Andrew Field

Treatment of HIV-1-associated microsporidiosis and cryptosporidiosis with combination antiretroviral therapy

BACKGROUND Enterocytozoon bieneusi and Cryptosporidium parvum cause chronic antimicrobial-resistant gastrointestinal infections in HIV-1-infected individuals. HIV-1 reverse transcriptase inhibitors delay the onset of opportunistic infections, but are not known to reverse established infections. HIV-1 protease inhibitors are more effective across a broader range of HIV-1-infected immune cells. Combination antiretroviral therapy that includes a protease inhibitor could improve immunity to E bieneusi and C parvum. METHODS HIV-1 infected patients with chronic microsporidiosis (five), cryptosporidiosis (three), or dual infection (one), were treated with combination therapy that included at least one HIV-1 protease inhibitor. Outcome measures were symptoms, weight, use of antidiarrhoeal and antimicrobial drugs, T-lymphocyte subsets, HIV-1 viraemia, stool microscopy, and biopsy by endoscopy. FINDINGS All patients had complete clinical responses, gained a median 15 kg in weight, and ceased all antidiarrhoeal and antimicrobial therapies. Biliary cryptosporidiosis responded in both affected patients. Neither pathogen was detected in follow-up stool microscopy (eight of eight patients) or in biopsy samples by endoscopy (five of five). Intestinal architecture returned to normal in three patients. There was a dense CD8 lymphocyte and macrophage infiltrate and staining of intraepithelial E bieneusi with interferon-gamma before and after treatment, but little staining for CD4 or B lymphocytes, interleukin 10, or HIV-1 gp41. Five patients remained symptom-free after a median 13 months follow-up. Four patients had recurrent diarrhoea at 7-13 months (one with positive stool microscopy), associated with declining CD4 counts. INTERPRETATION Combination antiretroviral therapy that includes a protease inhibitor can restore immunity to E bieneusi or C parvum in HIV-1 infected individuals, and result in complete clinical, microbiological, and histological responses. The persistent CD8 cell and macrophage infiltrate, and the rapid time to relapse in patients with declining CD4 lymphocyte counts, suggest that neither infection was eradicated.

Low oestrogen receptor α expression in normal breast tissue underlies low breast cancer incidence in Japan

Among white Australians without breast cancer, the median of the percentage of oestrogen receptor alpha positive cells was 12% for women younger than 50 years and 17% for those 50 years or older; among Japanese women who had no breast cancer and are generally at low risk for this disease, the corresponding values were both significantly lower and around 9%.

Development and ultrastructure of Trachipleistophora hominis n.g., n.sp. after in vitro isolation from an AIDS patient and inoculation into athymic mice.

Continuous culture was achieved in several cell lines of a microsporidium obtained from the skeletal muscle of an AIDS patient. Development in COS-1 and RK13 cells was prolific. Spores from the original biopsy were also inoculated into athymic mice by i.m. and i.p. routes. Infection was found in several organs as well as in skeletal muscle after a few weeks. All stages were surrounded by an electron-dense surface coat. Meronts had 2-4 nuclei and divided by binary fission. In sporogony the surface coat became separated from the plasma membrane to form a sporophorous vesicle, within which division into sporoblasts was effected by repeated binary fissions. The number of sporoblasts (and later spores) within the sporophorous vesicles varied from 2 to > 32 and the sizes of the vesicles varied, according to the number of spores contained therein, from 5 microns diameter to 14.0 x 11.0 microns. Spores measured 4.0 x 2.4 microns and had a prominent posterior vacuole. The parasite differs from the genus Pleistophora in that it does not form multinucleate sporogonial plasmodia and that the sporophorous vesicle enlarges during sporogony and its wall is not a multilayered structure. It is proposed to place it in a new genus and species Trachipleistophora hominis n.g., n.sp.

Early studies on the safety and efficacy of thalidomide for symptomatic inflammatory bowel disease

Background and Aim Thalidomide is clinically effective in the treatment of graft versus host disease in bone marrow transplantation and aphthous ulceration in HIV infection. It appears to exert a selective effect on tumor necrosis factor‐α (TNF‐α) production. Tumor necrosis factor‐α is implicated in the pathogenesis of inflammatory bowel disease (IBD). The aim of this study was to assess the efficacy and safety of thalidomide in symptomatic IBD.

Guidelines for cytopathologic diagnosis of epithelioid and mixed type malignant mesothelioma. Complementary statement from the International Mesothelioma Interest Group, also endorsed by the International Academy of Cytology and the Papanicolaou Society of Cytopathology.

To provide practical guidelines for the cytopathologic diagnosis of malignant mesothelioma (MM). Cytopathologists involved in the International Mesothelioma Interest Group (IMIG) and the International Academy of Cytology (IAC), who have an interest in the field contributed to this update. Reference material includes peer-reviewed publications and textbooks. This article is the result of discussions during and after the IMIG 2012 conference in Boston, followed by thorough discussions during the 2013 IAC meeting in Paris. Additional contributions have been obtained from cytopathologists and scientists, who could not attend these meetings, with final discussions and input during the IMIG 2014 conference in cape town. During the previous IMIG biennial meetings, thorough discussions have resulted in published guidelines for the pathologic diagnosis of MM. However, previous recommendations have stated that the diagnosis of MM should be based on histological material only.[12] Accumulating evidence now indicates that the cytological diagnosis of MM supported by ancillary techniques is as reliable as that based on histopathology, although the sensitivity with cytology may be somewhat lower.[345] Recognizing that noninvasive diagnostic modalities benefit both the patient and the health system, future recommendations should include cytology as an accepted method for the diagnosis of this malignancy.[67] The article describes the consensus of opinions of the authors on how cytology together with ancillary testing can be used to establish a reliable diagnosis of MM.

Suggestions for HER-2/neu testing in breast carcinoma, based on a comparison of immunohistochemistry and Fluorescence in situ hybridisation

Summary The arrival of Herceptin (Trastuzumab), an antibody against the HER‐2 oncogene found in a proportion of breast carcinomas and other carcinomas, has emphasised the need for a standardised technique for demonstrating overexpression of HER‐2. We compared the Dako A485 antibody and Dako HercepTest kit (HT) on a series of 122 breast carcinomas. Fluorescence in situ hybridisation (FISH) (Vysis) was performed on all cases with positive or equivocal immunohistochemical results. The Dako A485 showed HER2 overexpression in 53% of carcinomas, while the HT showed 21% positive (HT 2 + 8%, HT 3 + 13%) and 79% negative (HT 0 67%, HT 1 + 12%). FISH for HER‐2 gene amplification on all the HT 1 + and HT 2 + cases was negative, whereas FISH analysis of all HT 3 + cases was positive, with the exception of one case which could not be analysed for technical reasons. When histological subtype was analysed, only grade 3 infiltrating duct carcinomas were FISH‐positive, suggesting that histological grading and subtyping may be able to triage carcinomas suitable for HER‐2 testing. We suggest that the HT or a similar standardised immunohistochemical study for HER‐2 can be used to screen breast carcinomas. We then recommend FISH where the carcinoma is HT 2 +. FISH may also be appropriate in high grade, HT 1 + carcinomas where there are doubts regarding optimal tissue fixation or block storage conditions.

Rapid cytological analysis of endobronchial ultrasound-guided aspirates in sarcoidosis

Rapid on-site evaluation (ROSE) of endobronchial ultrasound-guided transbronchial needle aspirates (EBUS-TBNA) has not been compared to final detailed cytological analysis in patients with suspected sarcoidosis. To assess the diagnostic accuracy of EBUS-TBNA with ROSE in patients with suspected sarcoidosis, a prospective two-centre study performed EBUS-TBNA with ROSE of cellular material followed by transbronchial lung biopsy (TBLB) and endobronchial biopsy (EBB). The diagnostic accuracy of EBUS-TBNA with ROSE was compared to the final cytological assessment and to TBLB and EBB. Analysis confirmed 49 out of 60 cases of sarcoidosis. ROSE sensitivity was 87.8% (specificity 91%, positive predictive value 97.7%). ROSE slide interpretation in combination with the final fixed slide and cell block preparations had a sensitivity of 91.8% (specificity 100%, positive predictive value 100%). 67% of patients were confirmed as having sarcoidosis on TBLB and 29% on EBB. Interobserver agreement between cytotechnologists and pathologists was very good (&kgr;=0.91, 95% CI 0.80–1.0 and &kgr;=0.91, 95% CI 0.79–1.0, respectively). EBUS-TBNA with ROSE has high diagnostic accuracy and interobserver agreement and informs the bronchoscopist in theatre whether additional diagnostic procedures need to be undertaken. EBUS-TBNA with ROSE should therefore be considered as the first-line investigation of sarcoidosis. Rapid on-site evaluation of EBUS-TBNA should be first-line investigation in sarcoidosis http://ow.ly/nT9Mx

Breast cancer incidence and estrogen receptor α in normal mammary tissue—An epidemiologic study among Japanese women in Japan and Hawaii

We have undertaken a study to examine whether the difference in breast cancer incidence between 2 populations of similar genetic background is reflected in a similar pattern of estrogen receptor α expression in normal mammary gland. Study participants were 92 Japanese women from Sapporo, Japan (mean age 48.2 years) and 49 Japanese women from Honolulu, Hawaii (mean age 45.4 years), who underwent biopsy indicating normal breast tissue or benign, nonproliferative breast disease in hospitals in Sapporo, Japan and Honolulu, Hawaii. The breast tissue samples were formalin‐fixed and paraffin‐embedded. The estrogen receptor immunohistochemistry assays were conducted using Dako kits. Japanese women in Hawaii, who have a higher incidence of breast cancer compared with Japanese women in Sapporo, also had, as predicted, higher mean percentage of estrogen receptor α‐positive normal mammary cells (2‐tailed test, p ∼ 0.09). The results of our study are compatible with the hypothesis that estrogen receptor α expression in normal mammary tissue increases breast cancer risk and they also indicate that the expression of these receptors is dependent, at least in part, on nongenetic factors.

Guidelines for the Cytopathologic Diagnosis of Epithelioid and Mixed-Type Malignant Mesothelioma

Objective: To provide practical guidelines for the cytopathologic diagnosis of malignant mesothelioma. Data Sources: Cytopathologists with an interest in the field involved in the International Mesothelioma Interest Group (IMIG) and the International Academy of Cytology (IAC) contributed to this update. Reference material includes peer-reviewed publications and textbooks. Rationale: This article is the result of discussions during and after the IMIG 2012 conference in Boston, followed by thorough discussions during the 2013 IAC meeting in Paris. Additional contributions have been obtained from cytopathologists and scientists who could not attend these meetings, with final discussions and input during the IMIG 2014 conference in Cape Town.

Myositis due to the microsporidian Anncaliia (Brachiola) algerae in a lung transplant recipient

Microsporidia are obligate intracellular parasites, more closely related to fungi than protozoa on molecular phylogenetic analysis, and are known to be a rare cause of opportunistic infection in immune compromised patients including human immunodeficiency virus‐positive patients and solid organ transplant recipients. We report the first case to our knowledge of microsporidial myositis in a lung transplant recipient. He was 49 years old and had received a lung transplant in 2000 for cystic fibrosis. He presented in 2009 with fevers, chronic diarrhea, myalgia, and pancytopenia, and developed progressive weakness and neurological symptoms before his death 35 days after hospital admission. Multiple investigations, including stool culture, rectal biopsy, colonoscopy, cerebrospinal fluid examination, bone marrow biopsy, lung biopsy, and bronchoalveolar lavage, failed to reveal a definite cause for the patients deterioration. The diagnosis of microsporidial infection was made on post‐mortem light microscopic examination of tissue sections of the tongue and deltoid muscle. Light microscopy diagnosed a microsporidial myositis, confirmed by transmission electron microscopy, which suggested that the organism was Brachiola species. The identity of the organism was confirmed by polymerase chain reaction as Brachiola algerae (recently renamed Anncaliia algerae). The case highlights the need to consider protozoal organisms in the differential diagnosis of myalgia and multisystemic infections in immune compromised patients.