16 September Case of the Week #157
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(1) We have updated the in situ carcinoma section of the Breast-Malignant chapter, which is now in our new format with thumbnails of most images.
(2) Thanks to the following contributors of images:
- Dr. Asmaa Gaber Abdou, Menoufiya University, Egypt - Uterus chapter: Dysfunctional Uterine Bleeding
- John Irlam, D.O., University of Toledo Medical Center (Ohio) - Skin-Nonmelanocytic tumors chapter: Cylindroma, Trichilemmoma, Sebaceous Hyperplasia, Eccrine Poroma and Sebaceous Carcinoma; and Skin-Melanocytic tumors chapter: Blue Nevus.
- Ed Uthman, MD., Texas, Cervix chapter - Squamous Cell Carcinoma, Lymphomas: B cell chapter - Burkitts Lymphoma, Oral Cavity chapter - Infectious Mononucleosis and Placenta chapter - Incomplete / Partial Hydatiform mole
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Thanks to Drs. Suhail Muzaffar and Bilal Karim Siddiqui, City Hospital, Sandwell & West Birmingham NHS Trust (United Kingdom), for contributing this case and part of the discussion. To contribute a Case of the Week, email NatPernick@Hotmail.com with the clinical history, your diagnosis and diagnostic microscopic images (textbook quality) in JPG, GIF or TIFF format (send as attachments, we will shrink if necessary). Please include any other images (gross, immunostains, etc.) that may be helpful or interesting. We will write the discussion (unless you want to), list you as the contributor, and send you $35 (US dollars) by check or PayPal for your time after we send out the case. Please only send cases with high quality images and a diagnosis that is somewhat unusual (or a case with unusual features).
Case of the Week #157
A 20-year-old Asian woman presented with dyspepsia. An upper GI endoscopy was followed by a gastric antral biopsy, which revealed a moderate acute and chronic inflammatory infiltrate in the lamina propria. There was no evidence of atrophic gastritis, intestinal metaplasia, dysplasia, or malignancy.
H&E stain, 200x H&E stain, 400x
What is your diagnosis?
A large number of giardial trophozoites were identified along the surface of foveolar epithelial cells (Fig 1). The trophozoites appeared as pear or sickle shaped, lying opposed to the gastric surface and foveolar epithelium (Fig 2). No H. pylori organisms were identified.
Giardia lamblia is the most prevalent pathogenic intestinal protozoan and a major contributor to the burden of diarrheal disease worldwide. Giardia can be contracted from contaminated streams or pools, through food or by poor hygienic practices resulting in fecal-oral contact. The trophozoites colonize and reside in the lumen of the small intestine, causing severe diarrhea, vomiting, abdominal cramps and fever. These can lead to anorexia, malaise and fatigue.
In a cohort of 41 cases of gastric giardiasis, it was found that all patients showed moderate to severe chronic atrophic gastritis, with mild to severe activity associated with intestinal metaplasia. Though not seen in this case, concomitant H. pylori infection is common in patients with gastric giardiasis (J Clin Pathol 1992;45:964). In one study, H. pylori was found in 75% of patients with giardiasis (J Egypt Soc Parasitol 1996;26:481). Helicobacter produce urease, which breaks down urea to neutralize the acidic pH of the stomach. This produces a comparatively alkaline environment better suited for H. pylori survival. Thus, higher pH may induce a permissive local environment for Giardia and stimulate excystation and subsequent release and survival of trophozoites. Patients treated for ulcers who have recurring upper gastrointestinal tract symptoms should be examined for signs of Giardia (Indian J Pathol Med 2006;49:519).
Diagnosis can be made by simple examination of stool for ova and parasites, searching for teardrop or sickle shaped trophozoites. Treatment consists of a multi-day course of antibiotics, such as Metronidazole.
Based on the endoscopic findings, a differential diagnosis of H. pylori associated follicular gastritis and maltoma was given in this case. Histopathological examination was used to make the diagnosis.
Additional references: PathologyOutlines.com, eMedicine, Koss, LG: The gastrointestinal tract. Diagnostic pathology and histopathological bases; JB Lippincott, 1979:834-5.
Nat Pernick, M.D., President,
and Kara Hamilton, M.S., Assistant Medical Editor
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