Bronchoalveolar lavage in the assessment of pulmonary Hodgkin's disease

Abnormal chest radiographs in patients with Hodgkin's disease are occasionally due to pulmonary Hodgkin's disease. The fluids recovered from bronchoalveolar lavages (BALs) from 50 patients prior to autologous bone marrow transplantation for advanced Hodgkin's disease were examined. Abnormal chest roentgenograms were present in 24 patients (48%); 4 (17%) of these had Reed-Sternberg cells or their mononucleated variants in the lavage fluid and an alveolar lymphocytosis averaging 31.4% (normal: 11.5%). The lymphocytes were small and monotonous. Of the 20 patients with abnormal chest roentgenograms but no Reed-Sternberg cells in the lavage fluid, the lymphocyte count was 10.88%, with only 3 patients exceeding 17%. Two patients with normal chest roentgenograms had Reed-Sternberg-like cells in their lavage fluids and averaged 23% lymphocytes in their lavage differential count. Eosinophils averaged 1% or less of the lavage differential and were not predictive of pulmonary Hodgkin's disease. This experience suggests that pulmonary Hodgkin's disease can be diagnosed by BAL. Reed-Sternberg cells and their mononucleated variants can be recognized by their characteristic cytomorphologic features, although care must be taken not to misinterpret reactive binucleated macrophages as neoplastic cells. In patients with Hodgkin's disease, Reed-Sternberg cells should be sought when an alveolar lymphocytosis is present.     

Cytopathologic and genetic diagnosis of pulmonary amebiasis: a case report

BACKGROUND: Amebiasis is a parasitic infection with Entamoeba histolytica. Pulmonary amebiasis is rare since the infection is commonly manifested as amebic colitis or liver abscess. Most pleuropulmonary amebiasis is seen in patients with amebic liver abscesses. A pulmonary amebic lesion without either a liver abscess or amebic colitis is extremely rare. Thus, reported cases of sputum cytologic diagnosis of a pulmonary amebic lesion from a patient without a liver abscess are also very rare. CASE: A 53-year-old man presented with a dry cough and mild fever. Chest radiography revealed an abnormal solitary mass lesion in the right upper lung field. The clinical diagnosis was a bacterial lung abscess. Sputum cytologic examination demonstrated many trophozoites of E. histolytica. Following sputum cytodiagnosis, serologic tests revealed a slightly high but almost normal titer of IgG antibodies to E. histolytica, indicating the possible presence of the pathogen. Polymerase chain reaction (PCR) using E. histolytica-specific primers for DNA extracted from the sputum sample revealed specific DNA product. CONCLUSION: Pulmonary amebiasis without either a liver abscess or amebic colitis must be distinguished from bacterial abscesses and neoplastic disease. A sputum cytologic examination combined with PCR for DNA extracted from a sputum sample is a good approach to the diagnosis of a pulmonary amebic abscess.     

A note on indirect hemagglutination (IHA) antibody titers among hospitalized patients in Thailand with amebic liver abscesses

Amebic hepatic abscess is a tropical disease with a wide spectrum of clinical presentations. A retrospective case review was performed on 39 hospitalized patients in Thailand with the diagnosis of amebic liver abscess. A total of 23 men (59%) and 16 women (41%), with a mean age of 44.56 +/- 21.81 years (range, 10 to 88 years), were involved in the study. The average duration of present illness was 7.33 +/- 0.83 days. Abscesses were discovered in the right lobe in 29 patients (74.4%), in the left lobe in 3 patients (7.7%), and in both lobes in 7 patients (17.9%). Thirty patients had single abscesses (76.9%) and 9 patients had multiple abscesses (23.1%). On admission, the average white blood count was 17.37 +/- 6.34 x 1000 WBC/mm3, serum albumin was 2.86 +/- 0.61 g/dL, prothrombin time was 16.52 +/- 5.8 seconds, serum aspartate transaminase (AST) was 92.62 +/- 118.74 U/L, serum alanine transaminase (ALT) was 83.74 +/- 107.84 U/L, serum alkaline phosphatase (ALP) was 407.68 +/- 343.42 U/L, and serum bilirubin was 2.44 +/- 2.08 g/dL. Average indirect hemagglutination (IHA) titer of the cases was 1:1190.35 +/- 895.42 (range, 1:256 to 2048). Concerning the multiple logistic regression analysis, no significant correlation was found between antibody titer and the other parameters. Of interest, pathogenic organisms were detected in stool in only 2 cases. This study shows the usefulness of serologic study in diagnosis of amebic liver abscess.     

Entamoeba histolytica: antibody responses and lymphoreticular changes in gerbils (Meriones unguiculatus) in response to experimental liver abscess and amebic extract infection

Antibody responses and histological changes in hepatic lymph nodes and spleen of gerbils (Meriones unguiculatus) during the course of experimental hepatic amebiasis (5-60 days), or in those injected with extracts of Entamoeba histolytica, are described. Lymph node and spleen responses in infected animals paralleled the proliferation of the amebic liver abscess. However, spleen follicle responses were similar in animals that received low or high doses of the amebic extract and differed histologically from those with amebic liver abscess. Liver abscesses, up to 30 days postinfection (pi), doubled in weight between 10 and 15 and between 20 and 30 days pi. Early changes (10 days pi) in the lymphoreticular tissues were characterized by increased size and weight of the organs, hyperplastic follicles, and blastogenesis in the T-dependent areas. At 20 and 30 days pi, the size of spleen follicles increased and there was depletion of lymphocytes from the periarterial area (PAA), as well as gross extension of the red pulp, accompanied by extramedullary erythropoiesis and megakaryocytosis. The paracortical areas (PCA) of lymph nodes were depleted of lymphocytes and histiocytosis throughout the organ, and there was intense plasma cell activity in the medulla. At 60 days pi, lymphocyte repopulation was noted in the PCA and PAA; germinal centers were depleted of blast cells and the spleen red pulp had contracted. Antiamebic antibody titers were low throughout the infection. Changes in the cellularity of the lymphoid organs are discussed in relation to the proliferation of the amebic liver abscesses in infected animals and in those which were injected with the amebic extract.     

Entamoeba histolytica: identification of a distinct beta2 integrin-like molecule with a potential role in cellular adherence

Entamoeba histolytica infection causes dysentery, intestinal colitis, and hepatic abscess in an estimated 50 million people worldwide. Attachment of E. histolytica trophozoites to intestinal epithelium and vascular endothelium during liver metastasis results in an inflammatory process. We report the identification of a distinct amebic beta2 integrin (CD18)-like molecule which affords adherence to TNF-alpha-activated endothelial cells. Data from flow cytometry and indirect immunofluorescence assays suggest the amebic beta2 integrin was localized to focal adhesion plates and was present in both E. histolytica and Entamoeba dispar. The amebic beta2 integrin appeared to be distinct from the amebic Gal/GalNAc lectin based on recombinant expression, amebic colocalization, and ELISA studies. Trophozoite adherence to endothelial cells expressing ICAM-1 (CD54) following activation with TNF-alpha or ICAM-1-transfected CHO cells was specifically inhibited with anti-CD18 or anti-CD54 MAbs. In summary, evidence in support of a distinct beta2 integrin-like molecule participating in amebic adherence to TNF-alpha-activated endothelial cells expressing ICAM-1 is presented. The presence of integrin-dependent binding may allow trophozoites to opportunistically adhere to activated intestinal epithelium or vascular endothelium expressing ICAM-1 during amebic colitis or hepatic abscess.     

Monoclonal antibodies directed against the galactose-binding lectin of Entamoeba histolytica enhance adherence.

The Entamoeba histolytica galactose-binding lectin is a surface glycoprotein composed of 170- and 35-kDa subunits. Inhibition of this lectin with galactose or anti-170 kDa subunit polyclonal antibody blocks amebic adherence to target cells and colonic mucin glycoproteins. We describe the properties of 10 mAb with specificity for the 170-kDa subunit. Based on competitive binding studies, six nonoverlapping antigenic determinants on the lectin were identified. The effect of the mAb on adherence of amebic trophozoites to both Chinese hamster ovary (CHO) cells and human colonic mucins was measured. Antilectin antibodies directed against epitopes 1 and 2 enhanced adherence, with the number of amebae having at least three adherent CHO cells increasing with the addition of epitope 1 mAb from 26 +/- 9 to 88 +/- 2% and the binding of colonic mucins increasing from 34 +/- 1 to 164 +/- 3 pg/10(5) amebae. Antibody-enhanced adherence remained 90 to 100% galactose inhibitable, occurred at 4 degrees C and was not Fc mediated. Univalent Fab fragments of epitope 1 mAb augmented mucin binding by 238% and CHO cell adherence by 338%. The binding of purified lectin to CHO cells was increased from 1.1 +/- 0.1 to 2.4 +/- 0.3 ng/10(3) CHO cells by mAb directed to epitope 1, demonstrating that enhanced adherence was due to direct activation of the lectin. mAb to epitope 3 bound to the lectin only upon its solubilization from the membrane and had no effect on adherence. Adherence to CHO cells and mucins was inhibited from 50 to 75% by mAb to epitopes 4 and 5; epitope 6 mAb inhibited amebic adherence to CHO cells but not mucins. The pooled sera from 10 patients with amebic liver abscess blocked the binding to the 170-kDa subunit of mAb directed to all six epitopes. Striking individual variations in the effects of immune sera on adherence were observed. Although the sera of all 44 South African patients with amebic liver abscess had high titer anti-lectin antibodies, 16 patients' sera significantly (more than 3 SEM) enhanced adherence whereas 25 patients' sera significantly inhibited adherence. Antilectin antibodies exert profound functional effects on the interaction of E. histolytica with target cells and human colonic mucins. Exploration of the clinical consequences of adherence-enhancing and inhibitory antibody responses may give insight into the role of antilectin antibodies in immunity to invasive amebiasis.     

Entamoeba histolytica: diffuse liver inflammation in gerbils (Meriones unguiculatus) with experimentally induced amebic liver abscess

The histopathological changes that occur in the uninfected liver lobes of gerbils with a localized amebic liver abscess (left lobe) were studied from 5 to 60 days after inoculation. Early parenchymal changes (10 days) in the right and median liver lobes showed a lymphocytic infiltrate and bile duct proliferation in the portal areas. Maximum alterations occurred at 20 to 30 days after inoculation and were characterized by a dense portal infiltrate, hepatocyte degeneration, granulocytic infiltrate and marked glycogen depletion. In drug-treated infections with metronidazole, the diffuse liver inflammation was terminated. The results of this study suggest that the diffuse liver injury was directly or indirectly induced by the presence of a proliferating amebic liver abscess and that the pathology caused by amebic liver abscess is more extensive than previously thought.     

Entamoeba histolytica: Diffuse Liver Inflammation in Gerbils (Meriones unguiculatus) with Experimentally Induced Amebic Liver Abscess

The histopathological changes that occur in the uninfected liver lobes of gerbils with a localized amebic liver abscess (left lobe) were studied from 5 to 60 days after inoculation. Early parenchymal changes (10 days) in the right and median liver lobes showed a lymphocytic infiltrate and bile duct proliferation in the portal areas. Maximum alternations occurred at 20 to 30 days after inoculation and were characterized by a dense portal infiltrate, hepatocyte degeneration, granulocytic infiltrate and marked glycogen depletion. In drug-treated infections with metronidazole, the diffuse liver inflammation was terminated. The results of this study suggest that the diffuse liver injury was directly or indirectly induced by the presence of a proliferating amebic liver abscess and that the pathology caused by amebic liver abscess is more extensive than previously thought.     

Detection of pathogenic Entamoeba histolytica DNA in liver abscess fluid by polymerase chain reaction.

, , and 1992. Detection of pathogenic Entamoeba histolytica DNA in liver abscess fluid by polymerase chain reaction. International Journal for Parasitology 22: 1193–1196. A sensitive method for detection of pathogenic Entamoeba histolytica DNA in drained fluids from liver abscess patients, using the polymerase chain reaction (PCR), has been developed. The PCR employs oligonucleotide primers specific for the gene encoding the 30 kDa molecule of pathogenic E. histolytica. Liver abscess fluids (19 samples), from 14 patients with a presumptive amebic liver abscess, were examined microscopically and by the PCR method. Only two of the 19 samples were positive microscopically, whereas all 19 samples tested positive by PCR. This technique can be used to confirm the diagnosis of amebic liver abscess.     

Patients treated for amebic liver abscess develop cell-mediated immune responses effective in vitro against Entamoeba histolytica

We studied the afferent and efferent cell-mediated immune response in 15 patients treated for amebic liver abscess. Patients had a lower T4 to T8 ratio (1.25 +/- 0.65) compared with age- and sex-matched controls (1.89 +/- 0.44, p less than 0.01) due to a decrease in T4-"helper" cells and an increase in T8-"suppressor" cells (p less than 0.01). The in vitro proliferative response of patient T lymphocytes to the plant mitogen concanavalin A (Con A) was depressed; responses to phytohemagglutinin were not. The proliferative response of patient lymphocytes to an amebic soluble protein preparation (SPP) was greater than the mitogenic response seen in control lymphocytes (mean of 68,300 delta cpm and 22,300 delta cpm, respectively, p less than 0.001), correlated with the T4 to T8 ratio (p less than 0.05) and the duration of time from initiation of antiamebic therapy (p less than 0.01). Supernatants from patient lymphocytes exposed to the amebic SPP activated normal monocyte-derived macrophages to kill virulent axenic E. histolytica trophozoites (p less than 0.001); patient monocyte-derived macrophages activated by Con A-elicited lymphokine could also kill amebae. Finally, when incubated with the amebic SPP for 5 days, T lymphocytes from patients were able to kill virulent amebae (p less than 0.005); patient T lymphocytes not exposed to the amebic SPP or control T lymphocytes incubated for 5 days with the amebic SPP were not cytotoxic to E. histolytica trophozoites. In summary, after cure of amebic liver abscess, specific cell-mediated immune mechanisms develop that are effective in vitro against the parasite.     

Evaluation of Hemoptysis in Patients With a Normal Chest Roentgenogram

Hemoptysis is a common presenting complaint in patients with pulmonary disease. Although controversial, many clinicians suggest that all patients with hemoptysis should be evaluated with bronchoscopy to exclude the presence of a serious pathologic condition. We reviewed records for an 18-month period, during which 113 patients had hemoptysis as their principal complaint. In all, 26 of the 113 patients had normal chest roentgenograms. All underwent bronchoscopy as part of their evaluations. Results of bronchoscopy in these patients neither altered therapeutic decisions nor led to diagnoses of specific pathologic processes. We conclude that close observation of patients with normal chest roentgenograms who have hemoptysis may be an acceptable clinical approach.     

Tissue invasion by Entamoeba histolytica: evidence of genetic selection and/or DNA reorganization events in organ tropism

Entamoeba histolytica infection may have various clinical manifestations. Nine out of ten E. histolytica infections remain asymptomatic, while the remainder become invasive and cause disease. The most common form of invasive infection is amebic diarrhea and colitis, whereas the most common extra-intestinal disease is amebic liver abscess. The underlying reasons for the different outcomes are unclear, but a recent study has shown that the parasite genotype is a contributor. To investigate this link further we have examined the genotypes of E. histolytica in stool- and liver abscess-derived samples from the same patients. Analysis of all 18 paired samples (16 from Bangladesh, one from the United States of America, and one from Italy) revealed that the intestinal and liver abscess amebae are genetically distinct. The results suggest either that E. histolytica subpopulations in the same infection show varying organ tropism, or that a DNA reorganization event takes place prior to or during metastasis from intestine to liver.     

Ischemia in experimental acute amebic liver abscess in hamsters.

In experimental acute amebic liver abscess, produced in hamsters by the intraportal inoculation of 1 x 10(6) axenic trophozoites of Entamoeba histolytica strain HM-1, we examined the blood perfusion of the lesions 5, 10, 24 and 72 h after injection of the parasites. India ink introduced into the portal circulation filled all liver vessels but was systematically excluded from even the earlier amebic lesions. The absence of serum proteinase inhibitors from the lesions may allow the participation of amebic proteinases in the causation of tissue necrosis.     

Fractures on the chest radiograph in detection of alcoholic liver disease.

The presence of fractures seen on routine chest radiography was assessed in patients with liver disease to see whether it might provide a useful marker of alcoholism. Chest radiographs taken at the time of liver biopsy were examined in 149 patients--72 with alcoholic liver disease (32 (44%) cirrhotic) and 77 with various forms of non-alcoholic liver disease (15 (19 . 5%) cirrhotic)--and in 149 controls. Fractures (85 rib, two clavicular) were much more common in patients with alcoholic liver disease (20 subjects; 28%) than in patients with non-alcoholic liver disease (1; 1 . 3%) or controls 10; 6 . 7%). In alcoholic liver disease rib fractures were significantly more likely to be bilateral or multiple (more than two) or both (p less than 0 . 01). Of patients with alcoholic liver disease, those with fractures were significantly older than those without, but there was no difference in sex, social class, the proportion with cirrhosis, or the proportion known to be alcoholic at the time of the radiograph. In liver disease fractures on the chest radiograph diagnosed alcoholism with 95% specificity and 28% sensitivity. These often overlooked or ignored findings in the chest radiograph may have a wider role in the detection of alcoholism.     

Efficacy and safety of paromomycin for treating amebiasis in Japan

The clinical management of amebiasis is a growing concern, particularly among human immunodeficiency virus (HIV)-infected individuals who are predisposed to severe illness. Treatment with a luminal amebicide is strongly recommended following acute-stage treatment with a nitroimidazole. In 2004, the Japanese Research Group on Chemotherapy of Tropical Diseases introduced paromomycin, which was not nationally licensed, and offered it to a number of patients. From 2004 to 2011, 143 case records of amebiasis (123 with amebic colitis, 16 with amebic liver abscess, and 4 with both) in which patients were treated with paromomycin, mainly 1500 mg/day for 9 or 10 days following metronidazole treatment, were submitted. Among 123 evaluable cases, 23 (18.7%) experienced possible adverse effects, the most common being diarrhea (17/123, 13.8%) and other gastrointestinal problems that were resolved after the completion or discontinuation of treatment. In addition, single cases of bloody stools associated with Clostridium difficile colitis, skin rash, and the elevation of liver enzymes were also reported, although the causal relationship was not clear. HIV infection did not appear to increase the incidence of adverse drug effects. Each of the 11 asymptomatic or mildly symptomatic amebic colitis cases became negative for stool cysts after paromomycin treatment. Paromomycin was shown to be safe and well tolerated, as well as effective in a special subset of amebic colitis cases.     

The rib cage in normal and emphysematous subjects: a roentgenographic approach

The configuration and motion of the bony rib cage were studied from lateral chest roentgenograms in 10 young normal subjects (YN), 12 elderly normal subjects, and 12 hyperinflated emphysematous patients [chronic obstructive pulmonary disease subjects (COPD), mean total lung capacity (TLC) 133% of predicted]. The acute angles formed by the fourth through seventh ribs with an axial reference plane were measured at residual volume, functional residual capacity, and TLC in both supine and standing positions and correlated with corresponding lung volumes. both rib angles (RA) and changes in RA with lung volume were greatest with the fourth rib and decreased progressively going down (caudad) the chest. At TLC the RA of upper ribs was significantly less in EN and significantly greater in COPD than in YN. RA's were greater supine than standing. When RA information was used together with autopsy data on the angles formed by intercostal muscles with adjacent ribs, intercostal muscle lengths in hyperinflation could be calculated. Computed intercostal muscle length data suggested that hyperinflation should not be associated with degrees of intercostal muscle shortening or overstretching, that would interfere seriously with tension generation.     

Entamoeba histolytica: the serine-rich gene polymorphism-based genetic variability of clinical isolates from Georgia

It is generally accepted that a majority of individuals infected by Entamoeba histolytica do not develop symptomatic disease. However, the parasite and the host factors contributing to the development of the disease, remain undetermined. It is also unclear why certain individuals develop extra-intestinal amebiasis without exhibiting apparent intestinal symptoms. An outbreak of amebic liver abscess in Tbilisi, Georgia in 1998-1999 suggested that the causative E. histolytica strain had an unusual propensity for extra-intestinal spread. To correlate the genetic differences with pathogenic potential of the parasite, we have examined the SREHP gene polymorphisms among Georgian E. histolytica isolates. Comparison of polymorphic patterns revealed the presence of several different genotypes of E. histolytica, thus preventing an association of a single genotype with hepatic disease, but supporting the previous finding of extensive genetic diversity among E. histolytica isolates from the same geographic origin.     

Entamoeba histolytica phagocytosis of human erythrocytes involves PATMK, a member of the transmembrane kinase family

Entamoeba histolytica is the cause of amebic colitis and liver abscess. This parasite induces apoptosis in host cells and utilizes exposed ligands such as phosphatidylserine to ingest the apoptotic corpses and invade deeper into host tissue. The purpose of this work was to identify amebic proteins involved in the recognition and ingestion of dead cells. A member of the transmembrane kinase family, phagosome-associated TMK96 (PATMK), was identified in a proteomic screen for early phagosomal proteins. Anti-peptide affinity-purified antibody produced against PATMK demonstrated that it was a type I integral membrane protein that was expressed on the trophozoite surface, and that co-localized with human erythrocytes at the site of contact. The role of PATMK in erythrophagocytosis in vitro was demonstrated by: (i) incubation of ameba with anti-PATMK antibodies; (ii) PATMK mRNA knock-down using a novel shRNA expression system; and (iii) expression of a carboxy-truncation of PATMK (PATMK(delta932)). Expression of the carboxy-truncation of PATMK(delta932) also caused a specific reduction in the ability of E. histolytica to establish infection in the intestinal model of amebiasis, however these amebae retained the ability to cause hepatic abscesses when directly injected in the liver. In conclusion, PATMK was identified as a member of the TMK family that participates in erythrophagocytosis and is uniquely required for intestinal infection.     

On the pathogenicity of Entamoeba histolytica. Part I: The role of bacterial associate on the modification of virulence of E. histolytica.

Of the 3 strains of Escherichia coli used, only Milner A strain was found capable of modifying the virulence of Entamoeba histolytica. None out of twenty-four hamsters inoculated with either 5 X 10(5) of axenically-cultured E. histolytica of NIH: 200 strain, or 1 X 10(7) of Esch. coli (A, B or C strains), was found to have amebic liver abscess. Whereas one out of six hamsters inoculated with the same number of amebae preincubated for 12 hrs with Esch. coli of Milner A strain was found to have abscess. The role of bacterial associate seems to be nothing but provides a more suitable environment for amebae, thus enable them to survive longer and endow them more time to adapt themselves to the given new environment. From liver abscess E. histolytica was recovered and successfully reaxenized. These amebae were capable of producing liver abscess, therefore the virulence seemed to be inheritable.