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Primary gastric actinomycosis: report of a case diagnosed in a gastroscopic biopsy.

Al-Obaidy K, Alruwaii F, Al Nemer A, Alsulaiman R, Alruwaii Z, Shawarby MA - BMC Clin Pathol (2015)

Bottom Line: The patient was admitted to the hospital with an impression of gastric outlet obstruction.Based on radiologic and gastroscopic findings, a non-infectious etiology was suspected, possibly adenocarcinoma or lymphoma.Subtle changes such as the presence of a pigmented inflammatory exudate should alert the pathologist to perform appropriate special stains to reveal the causative organism.

View Article: PubMed Central - PubMed

Affiliation: Pathology Department, College of Medicine, University of Dammam, P.O. Box 1982, Dammam, 31441 Saudi Arabia.

ABSTRACT

Background: Primary gastric actinomycosis is extremely rare, the appendix and ileocecal region being the most commonly involved sites in abdominopelvic actinomycosis. Herein, we report a case of primary gastric actinomycosis. The diagnosis was made on microscopic evaluation of gastroscopic biopsy specimens. To the best of our knowledge, this is the third case to be reported in the literature, in which the diagnosis was made in a gastroscopic biopsy rather than a resection specimen.

Case presentation: An 87-year-old Saudi male on medication for cardiomyopathy, premature ventricular contractions, renal impairment, hypertension, and dyslipidemia, presented to the emergency department with acute diffuse abdominal pain, abdominal distension, constipation and vomiting for two days, with no history of fever, abdominal surgery or trauma. The patient was admitted to the hospital with an impression of gastric outlet obstruction. Based on radiologic and gastroscopic findings, a non-infectious etiology was suspected, possibly adenocarcinoma or lymphoma. Gastroscopic biopsies showed an actively inflamed, focally ulcerated atrophic fundic mucosa along with fragments of a fibrinopurulent exudate containing brownish, iron negative pigment and abundant filamentous bacteria, morphologically consistent with Actinomyces.

Conclusion: Althuogh extremely rare, primary gastric actinomycosis should be considered in the differential diagnosis of radiologic and gastroscopic diffuse gastric wall thickening and submucosal tumor-like or infiltrative lesions, particularly in patients with history of abdominal surgery or trauma, or those receiving extensive medication. A high level of suspicion is required by the pathologist to achieve diagnosis in gastroscopic biopsies. Subtle changes such as the presence of a pigmented inflammatory exudate should alert the pathologist to perform appropriate special stains to reveal the causative organism.

No MeSH data available.


Related in: MedlinePlus

Filamentous and rod-like bacteria consistent withActinomycesin gastroscopic biopsies. a. H & E x 400 b. PAS x 1000 c. Gram x 1000 d. Grocott’s x 1000.
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Fig4: Filamentous and rod-like bacteria consistent withActinomycesin gastroscopic biopsies. a. H & E x 400 b. PAS x 1000 c. Gram x 1000 d. Grocott’s x 1000.

Mentions: An 87-year-old Saudi male on medication for non-ischemic cardiomyopathy, frequent premature ventricular contractions, renal impairment, hypertension, and dyslipidemia, presented to the emergency department with acute diffuse abdominal pain, abdominal distension, constipation and vomiting of two days duration, with no history of fever, abdominal surgery or trauma. Medications received by the patient for the last four years included, mainly, daily acetyl salicylic acid 81 mg, atorvastatin 40 mg, irbesartan 300 mg and hydrochlorothiazide 25 mg. Abdominal examination revealed stable vital signs along with positive findings of abdominal distension and mild epigastric tenderness. Laboratory investigations showed leucocytosis (16.6 k/μl with 89% segmented cells), mild normocytic normochromic anemia (Hgb 11.5 g/dl, MCV 93.7 fl, MCH 31.7 pg), elevated serum lipase (1123 U/L), amylase (269 U/L), and creatinine (1.4 mg/dl), and low potassium (3.1 mEq/L). Plain abdominal X-ray showed a markedly dilated stomach (Figure 1a). The patient was admitted to the hospital with an impression of gastric outlet obstruction. NGT was inserted & aspiration yielded a large amount of greenish fluid. The patient was then immediately put on empiric antibiotic coverage for 5 days with 2 doses of IV levofloxacin and 3 doses of IV metronidazole administered. Contrast CT-scan, performed to rule out an organic cause for the gastric outlet obstruction, showed a significantly distended stomach with thickened wall and abnormal configuration, and a single air-fluid level (Figure 1b). Two gastroscopies were then performed, 1 week apart, and revealed a deformed stomach with a hard mass infiltrating the greater curvature in the fundic area, covered by necrotic greenish brown material, along with absent peristaltic movement and no apparent organic obstruction to the gastric outlet (Figure 2). Based on the radiologic and gastroscopic findings, a non-infectious etiology was suspected, possibly adenocarcinoma or lymphoma. Biopsies obtained from the edge and the centre of the fundic mass during both gastroscopies were sent for pathological examination. Histologic examination showed an actively inflamed, focally ulcerated, atrophic fundic mucosa with variable, focal eosinophilic infiltration, edema, and variably dilated foveolae with focal regenerative epithelial atypia (Figure 3). There were also fragments of a fibrinopurulent exudate mixed with brownish, iron negative pigment (Perl’s stain) and abundant PAS, Grocott’s, and Gram positive rod-like and filamentous bacteria, morphologically consistent with Actinomyces (Figure 4). The organisms were overlooked in the first biopsy. The second biopsy was performed because a diagnosis of malignancy was still in suspicion, despite the negative result of the first biopsy. A revisit to the first biopsy confirmed negativity for malignancy but revealed the presence of organisms identical to those noted in the second biopsy. Culturing of gastric contents following the second gastroscopy, yielded only Streptococcus viridans with no Actinomyces identified. However, anaerobic culture was not specifically ordered by the clinician. Consequently Actinomyces, known to be strictly anaerobic, were not detected. Despite the negative culture, the typical morphology of the organisms in tissue sections confirmed by positive Grocott, PAS and Gram staining was considerd sufficient for diagnosis with no necessity for confirmation by repeat culturing under anaerobic conditions.Figure 1


Primary gastric actinomycosis: report of a case diagnosed in a gastroscopic biopsy.

Al-Obaidy K, Alruwaii F, Al Nemer A, Alsulaiman R, Alruwaii Z, Shawarby MA - BMC Clin Pathol (2015)

Filamentous and rod-like bacteria consistent withActinomycesin gastroscopic biopsies. a. H & E x 400 b. PAS x 1000 c. Gram x 1000 d. Grocott’s x 1000.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4359583&req=5

Fig4: Filamentous and rod-like bacteria consistent withActinomycesin gastroscopic biopsies. a. H & E x 400 b. PAS x 1000 c. Gram x 1000 d. Grocott’s x 1000.
Mentions: An 87-year-old Saudi male on medication for non-ischemic cardiomyopathy, frequent premature ventricular contractions, renal impairment, hypertension, and dyslipidemia, presented to the emergency department with acute diffuse abdominal pain, abdominal distension, constipation and vomiting of two days duration, with no history of fever, abdominal surgery or trauma. Medications received by the patient for the last four years included, mainly, daily acetyl salicylic acid 81 mg, atorvastatin 40 mg, irbesartan 300 mg and hydrochlorothiazide 25 mg. Abdominal examination revealed stable vital signs along with positive findings of abdominal distension and mild epigastric tenderness. Laboratory investigations showed leucocytosis (16.6 k/μl with 89% segmented cells), mild normocytic normochromic anemia (Hgb 11.5 g/dl, MCV 93.7 fl, MCH 31.7 pg), elevated serum lipase (1123 U/L), amylase (269 U/L), and creatinine (1.4 mg/dl), and low potassium (3.1 mEq/L). Plain abdominal X-ray showed a markedly dilated stomach (Figure 1a). The patient was admitted to the hospital with an impression of gastric outlet obstruction. NGT was inserted & aspiration yielded a large amount of greenish fluid. The patient was then immediately put on empiric antibiotic coverage for 5 days with 2 doses of IV levofloxacin and 3 doses of IV metronidazole administered. Contrast CT-scan, performed to rule out an organic cause for the gastric outlet obstruction, showed a significantly distended stomach with thickened wall and abnormal configuration, and a single air-fluid level (Figure 1b). Two gastroscopies were then performed, 1 week apart, and revealed a deformed stomach with a hard mass infiltrating the greater curvature in the fundic area, covered by necrotic greenish brown material, along with absent peristaltic movement and no apparent organic obstruction to the gastric outlet (Figure 2). Based on the radiologic and gastroscopic findings, a non-infectious etiology was suspected, possibly adenocarcinoma or lymphoma. Biopsies obtained from the edge and the centre of the fundic mass during both gastroscopies were sent for pathological examination. Histologic examination showed an actively inflamed, focally ulcerated, atrophic fundic mucosa with variable, focal eosinophilic infiltration, edema, and variably dilated foveolae with focal regenerative epithelial atypia (Figure 3). There were also fragments of a fibrinopurulent exudate mixed with brownish, iron negative pigment (Perl’s stain) and abundant PAS, Grocott’s, and Gram positive rod-like and filamentous bacteria, morphologically consistent with Actinomyces (Figure 4). The organisms were overlooked in the first biopsy. The second biopsy was performed because a diagnosis of malignancy was still in suspicion, despite the negative result of the first biopsy. A revisit to the first biopsy confirmed negativity for malignancy but revealed the presence of organisms identical to those noted in the second biopsy. Culturing of gastric contents following the second gastroscopy, yielded only Streptococcus viridans with no Actinomyces identified. However, anaerobic culture was not specifically ordered by the clinician. Consequently Actinomyces, known to be strictly anaerobic, were not detected. Despite the negative culture, the typical morphology of the organisms in tissue sections confirmed by positive Grocott, PAS and Gram staining was considerd sufficient for diagnosis with no necessity for confirmation by repeat culturing under anaerobic conditions.Figure 1

Bottom Line: The patient was admitted to the hospital with an impression of gastric outlet obstruction.Based on radiologic and gastroscopic findings, a non-infectious etiology was suspected, possibly adenocarcinoma or lymphoma.Subtle changes such as the presence of a pigmented inflammatory exudate should alert the pathologist to perform appropriate special stains to reveal the causative organism.

View Article: PubMed Central - PubMed

Affiliation: Pathology Department, College of Medicine, University of Dammam, P.O. Box 1982, Dammam, 31441 Saudi Arabia.

ABSTRACT

Background: Primary gastric actinomycosis is extremely rare, the appendix and ileocecal region being the most commonly involved sites in abdominopelvic actinomycosis. Herein, we report a case of primary gastric actinomycosis. The diagnosis was made on microscopic evaluation of gastroscopic biopsy specimens. To the best of our knowledge, this is the third case to be reported in the literature, in which the diagnosis was made in a gastroscopic biopsy rather than a resection specimen.

Case presentation: An 87-year-old Saudi male on medication for cardiomyopathy, premature ventricular contractions, renal impairment, hypertension, and dyslipidemia, presented to the emergency department with acute diffuse abdominal pain, abdominal distension, constipation and vomiting for two days, with no history of fever, abdominal surgery or trauma. The patient was admitted to the hospital with an impression of gastric outlet obstruction. Based on radiologic and gastroscopic findings, a non-infectious etiology was suspected, possibly adenocarcinoma or lymphoma. Gastroscopic biopsies showed an actively inflamed, focally ulcerated atrophic fundic mucosa along with fragments of a fibrinopurulent exudate containing brownish, iron negative pigment and abundant filamentous bacteria, morphologically consistent with Actinomyces.

Conclusion: Althuogh extremely rare, primary gastric actinomycosis should be considered in the differential diagnosis of radiologic and gastroscopic diffuse gastric wall thickening and submucosal tumor-like or infiltrative lesions, particularly in patients with history of abdominal surgery or trauma, or those receiving extensive medication. A high level of suspicion is required by the pathologist to achieve diagnosis in gastroscopic biopsies. Subtle changes such as the presence of a pigmented inflammatory exudate should alert the pathologist to perform appropriate special stains to reveal the causative organism.

No MeSH data available.


Related in: MedlinePlus