Helicobacter heilmannii is a species of the recently ALIMENTARY TRACT

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1 GASTROENTEROLOGY 2000;118: ALIMENTARY TRACT Helicobacter heilmannii Associated Primary Gastric Low-Grade MALT Lymphoma: Complete Remission After Curing the Infection ANDREA MORGNER,* NORBERT LEHN, LEIF P. ANDERSEN, CHRISTIAN THIEDE,* MADS BENNEDSEN, KARLHEINZ TREBESIUS, BEATRIX NEUBAUER, ANDREAS NEUBAUER, MANFRED STOLTE, # and EKKEHARD BAYERDÖRFFER* *Medical Department I, Technical University, Dresden, Germany; Institute of Medical Microbiology, University of Regensburg, Germany; Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark; Institute for Medical Microbiology, University of Munich, Germany; Centre for Internal Medicine, University of Marburg, Germany; and # Institute for Pathology, Klinikum Bayreuth, Germany Background & Aims: Cure of Helicobacter pylori infection may lead to complete remission of associated low-grade mucosa-associated lymphoid tissue (MALT) lymphoma in stage EI. This study investigated whether Helicobacter heilmannii infection associated primary gastric MALT lymphoma will regress after cure of the infection. Methods: H. heilmannii induced gastritis was diagnosed histologically, by a new specific immunoglobulin G enzyme-linked immunosorbent assay, and with 16S ribosomal RNA amplification and sequencing in 5 consecutive patients with primary gastric MALT lymphoma clinical stage EI. Patients received 40 mg omeprazole and 750 mg amoxicillin 3 times per day for 14 days. Polymerase chain reaction (PCR) was used to detect rearrangement of immunoglobulin heavy-chain genes before treatment and during follow-up. Results: Five patients (3 men, 2 women; mean age, 65 years; range, years) were studied. H. pylori was not detected by culture, histology, serology, or PCR. Treatment resulted in the cure of H. heilmannii infection in each case and complete histological and endoscopic remission of the tumors. Three of 5 patients showed monoclonal B cells before treatment, 2 of whom remained PCR positive. Within a median follow-up period of 24 months, no relapse of the lymphoma or reinfection with H. heilmannii occurred. Conclusions: These data suggest that gastric MALT lymphoma may arise in patients with H. heilmannii infection. Cure of this infection may lead to complete remission of the MALT lymphoma. Helicobacter heilmannii is a species of the recently discovered genus Helicobacter that is found both in humans and animals. 1 6 Infection with H. heilmannii is a rare event, and transmission from animals has been suggested. 3,7,8 Its absolute prevalence is very low, about 300 times lower than that of Helicobacter pylori. 9 Despite the low prevalence, an association with gastric carcinoma has been described, and a possible role of H. heilmannii in the pathogenesis of gastric mucosa-associated lymphoid tissue (MALT) lymphoma has been suggested. 9 In this study we describe the clinical, pathological, microbiological, and molecular features including a 2-year follow-up of primary gastric low-grade MALT lymphoma associated with H. heilmannii infection in 5 patients. Recent epidemiological 10 and clinical investigations 11,12 have established a possible link between primary gastric MALT lymphoma, which has been classified as marginal zone B-cell lymphoma in the REAL classification, 13 and chronic H. pylori infection. 14 Clinical trials have shown that about 70% 80% of low-grade primary gastric MALT lymphomas respond with complete remission after cure of H. pylori infection. 11,15,16 We sought to determine whether MALT lymphomas seen concomitantly with H. heilmannii infection would also respond to cure of the infection, which has not been reported so far. Patients and Methods We investigated 5 patients with primary gastric lowgrade MALT lymphoma associated with H. heilmannii (former Gastrospirillum hominis) infection. Lymphomas were detected in routine biopsy specimens sent to our central pathologist (M.S.). At that time, the referring physicians were asked to enroll the patients according to the study protocol, as described previously. 15 Briefly, at all endoscopic examinations before and after treatment, 2 biopsy specimens were obtained from the antrum and 2 from the corpus to grade the gastritis, and H. heilmannii infection was diagnosed by histological analysis. Six samples were taken from the tumor for histopathologic and another 6 Abbreviations used in this paper: ELISA, enzyme-linked immunosorbent assay; MALT, mucosa-associated lymphoid tissue; PCR, polymerase chain reaction by the American Gastroenterological Association /00/$10.00 doi: /gg

2 822 MORGNER ET AL. GASTROENTEROLOGY Vol. 118, No. 5 for molecular analysis. All patients had to have stage EI lymphoma to be included in the study. Nodal lymphoma were excluded by physical examination and ultrasound examination of the abdomen, including liver and spleen. Computed tomography of the abdomen and thorax was performed in all patients. Histology For histopathologic analysis, biopsy samples were placed in neutral buffered formalin and mailed to the Institute for Pathology, Bayreuth, Germany. 17 Biopsy specimens were embedded in paraffin, and 4-µm sections were cut. H&E staining was used to grade gastritis. Warthin Starry staining was used to detect H. heilmannii, and the grading was performed according to the Sydney system, 18 with slight modifications. 17 For the diagnosis of MALT lymphoma, detection of lymphoepithelial destructions was required, as suggested by Wotherspoon et al. 11 The criterion for cure of the H. heilmannii infection was negative biopsy samples 4 weeks after the end of treatment. 17,19 Complete regression of lymphoma was diagnosed when posttreatment biopsy samples showed none of the previously detected atypical lymphoid cell infiltrations, and the tunica propria was completely free of lymphoid cells, as is commonly seen after chemotherapy. Complete regression was also documented by endoscopy. Immunohistochemical analysis was performed to proof B- cell morphology of the lymphomas. Briefly, 4-µm sections were cut and dewaxed in xylol and hydrated in graded ethanol. Endogenous peroxidase was blocked using 3% H 2 O 2 in methanol. The slides were preblocked and incubated with the primary antibody anti-human B cell CD20cy clone L 26 (Dako, Glostrup, Denmark). After incubation with secondarybiotinylated antibodies (Dako), the slides were developed using the avidin-biotin complex alkaline phosphatase system (Vector, Burlingame, CT). Positive-stained cells were graded blind and showed a red color. Molecular-Genetic Analysis For molecular analysis of rearranged immunoglobulin heavy-chain variable (VH) region genes, i.e., monoclonal proliferation of B cells, biopsy specimens were placed in transport medium (Specimen Collection Kit; Gen-Probe, San Diego, CA) and mailed to the central molecular laboratory (Dresden, Germany). Genomic DNA was extracted by phenolchloroform, and 100 ng genomic DNA was subjected to polymerase chain reaction (PCR) with primers specific to Fr2a, Fr3a, and LJH. A seminested PCR with 1:100 dilution of the first PCR with primers specific to Fr2a, Fr3a, and VLJH was performed afterward. 20 To ensure the integrity of the DNA, a control amplification of the interferon gene was performed. Monoclonal bands were cloned into a vector (pcr-ii; Invitrogen, Leek, Netherlands) for DNA sequencing. Sequencing was performed as reported previously. 21 Serology and Culture H. heilmannii was cultured on chocolate agar plates (7% lysed horse blood agar plates; SSI, Copenhagen, Denmark) for 4 days at 5% O 2, 10% CO 2, 85% N 2 in a water-jacketed CO 2 incubator (Forma Scientific Inc., Marietta, OH), harvested in sterile phosphate-buffered saline (PBS, ph 7.2), and centrifuged at 4000g in a Labofuge (Hereaus Sepatech, Hannover, Germany). 22 Bacteria were suspended in sterile PBS at a concentration of 1 g/ml and sonicated on ice for 5 45 seconds at 350 W, using a Rapidis 350 sonicator (Ultrasonics Ltd., Shipley, York, England). Further purification of the antigens was performed using a Hiload Superdex S-200 gel filtration column on an FPLC (fast protein liquid cromatography) system (Amersham Pharmacia Biotech, Uppsala, Sweden) for the H. heilmannii purified antigen enzyme-linked immunosorbent assay (ELISA). For the H. pylori purified antigen ELISA, antigens in the range of kilodaltons were used. Antigens for absorption of cross-reactive antibodies were a 1:1 mixture of whole bacteria and sonicated bacteria at a concentration of 0.5 g wet weight per milliliter of PBS. For ELISA antigen preparation, H. pylori was cultured on Wilkins Chalgren agar containing 10% horse blood, Dent supplement (Oxoid, Basingstoke, England) and 0.4 g KNO 3 per liter (Merck, Darmstadt, Germany), Pylori agar (BioMérieux, France), and nonselective Columbia chocolate agar (GCII, Becton Dickinson, Heidelberg, Germany) without antibiotics. The media were incubated for up to 10 days at 36 C in an microaerobic atmosphere generated by gas insufflation: 0.6 bar air were evacuated from a jar and replaced by a mixture of 15% CO 2,5%O 2, and 80% N 2, resulting in an atmosphere of 9% CO 2, 11% O 2, and 80% N 2. The presence of H. pylori was detected in a semiquantitative way as follows:, 10 colony-forming units (CFU);, 100 CFU; and, 100 CFU per one-third biopsy specimen. H. pylori was identified by colony morphology, Christensen urease (Bacto urea base; Difco, Augsburg, Germany), oxidase (Oxidase Dry Slide; Difco), catalase (3% H 2 O 2, Merck), and phase-contrast microscopy. Serum samples of the patients were frozen at 20 C in portions of approximately 0.5 ml until further use. Levels of immunoglobulin G (IgG) directed against H. pylori antigens were determined in a quantitative way by a second-generation ELISA according to the instructions of the manufacturer, with slight modifications (Cobas core; Roche, Grenzach, Germany). This assay uses antigens from a cytotoxin-positive patient isolate, and the antigens are purified by high-performance liquid chromatography. Ten microliters of a serum sample was used for the test. Antibodies were detected with a polyclonal goat anti-human IgG antibody, which was stained with peroxidase. To reduce interassay differences, a high (86 U/mL) and low (20 U/mL) internal calibrator was determined in each assay. All obtained values were corrected by a linear regression. Values up to 3 U/mL were interpreted as negative, 4 7 U/mL was indeterminate, 7 U/mL was positive, 8 23 U/mL was low, and 79 U/mL was highly positive. IgG antibodies to H. heilmannii were measured by an indirect cross-absorption ELISA. Sera from the patients were absorbed with sonicated H. pylori before being tested in a dilution of 1:500 against a partially purified H. heilmannii antigen, and the sera were

3 May 2000 H. HEILMANNII IN GASTRIC MALT LYMPHOMA 823 absorbed with sonicated H. heilmannii before being tested in a dilution of 1:500 against a partially purified H. pylori antigen. The chromogenic reaction was read on a Spectra III ELISAreader (SLT Labinstruments, Groedig, Austria) at 492 nm, using 620 nm as reference. Immunoblot An immunoblot recently developed with Mikrogen (Munich, Germany) using lysate antigens from H. pylori strain (ATCC 49503) as antigen was also used. Sera were diluted 1:100 in dilution buffer. After incubation for 2 hours, the strips were washed 4 times and incubated with conjugate for 1 hour. After washing the substrate 4 times, diaminobenzidine was added and incubated for minutes. Genus-Specific PCR For the identification of H. heilmannii using 16S ribosomal RNA (rrna) amplification and sequencing, DNA was extracted from paraffin-embedded tissue of the patients using the Qiagen Tissue Kit following the manufacturer s instructions (Qiagen, Hilden, Germany). Five microliters of DNA was then added to a genus-specific PCR reaction using primers (Helico 1 and Helico 2; Creatogen GmbH, Augsburg, Germany) that specifically amplify 172 base pairs of the Helicobacter 16S rrna gene. The protocol was as follows: denaturation for 5 minutes at 95 C; 35 cycles with 95 C for 30 seconds, 52 C for 45 seconds, and 72 C for 45 seconds; and a final extension at 72 C for 5 minutes using the 9700 Perkin Elmer thermocycler (Perkin Elmer, Norwalk, CT). The PCR product was then sequenced with oligonucleotides using the cycle-sequencing protocol (Perkin Elmer) and analyzed using the ABI-sequencer (Perkin Elmer). Therapy To cure H. heilmannii infection, patients received a 14-day course of omeprazole, 40 mg 3 times per day, and amoxicillin, 750 mg 3 times per day. 15,23 The first posttreatment endoscopic examination was performed after 6 weeks, i.e., 4 weeks after the end of treatment, and then every 4 weeks until complete endoscopic and histological tumor regression was noted. The study was approved by the local university ethics committees in Berlin and Erlangen, Germany. Results Clinical Data Five patients with H. heilmannii associated primary gastric low-grade MALT lymphoma aged 42, 60, 71, 75, and 79 years (3 men, 2 women) were studied (Table 1). All patients complied with the study protocol. Treatment Results The first course of treatment cured H. heilmannii infection in all 5 patients. The flat-polypoid tumors, which measured 1 4 cm in the largest endoscopically Table 1. Baseline Characteristics of 5 Patients With H. heilmannii Associated MALT Lymphoma Sex (M/F) 3/2 Median age, yr (range) 71 (42 79) Tumor stage EI 5 Localization of lymphoma Antrum 3 Corpus 2 Endoscopic appearance Tumor 5 Median tumor size, cm (range) 1 (1 4) visible dimension, were located in the antrum in 3 patients and in the lower part of the corpus in 2 patients; after treatment, all showed complete remission histologically and endoscopically. The posttreatment interval to complete remission was 1 month in 4 patients and 4 months in the fifth. After anti H. heilmannii therapy, patients have been followed up for a period of months. The median disease-free survival is 21 months (range, months), and median overall survival is 24 months (range, months). During this period, no reinfection with H. heilmannii was observed. In 1 male patient, 75 years old at entry into the study, colonic cancer with hepatic metastases was diagnosed 14 months later, and he refused further endoscopic controls for the MALT lymphoma. A female patient, 79 years old at entry into the study, refused further endoscopies after 1 year in remission, but she is still alive without clinical signs of relapse. Histological Examination Before treatment, the histological picture showed typical dense infiltrates of small centrocyte-like cells and lymphoepithelial destructions that met all the criteria of MALT lymphoma as described by Wotherspoon et al. 11,15 in all 5 patients (Figures 1 and 2). H. heilmannii infection was diagnosed by histomorphological analysis and consecutively confirmed by serology, culture, and sequencing of the genus-specific 16S rrna gene. The great morphological diversity of the genus Helicobacter enables us to distinguish clearly between different members of the genus. The S-shaped morphology of H. pylori resembles that of members of the genus Campylobacter, and could not be more different from the tight spiral shape of H. heilmannii (Figure 3). The Warthin Starry stain revealed bacteria localized in the mucus as well as in the depth of the gastric glands. The density of H. heilmannii colonization was higher in the antrum than corpus region, and correlated with the grade and the activity of the gastritis, being higher in the antrum than the corpus. Overall, the gastritis was mildly expressed as detailed in Table 2. After treatment, H. heilmannii colonization was not

4 824 MORGNER ET AL. GASTROENTEROLOGY Vol. 118, No. 5 Figure 1. Histological section of a low-grade MALT lymphoma stained with H&E showing mucosal infiltration with atypical lymphoid cells and lymphoepithelial destructions. Figure 2. Immunohistochemical analysis of a low-grade MALT lymphoma showing the B-cell morphology using an anti-human B-cell CD20cy antibody (clone L 26; Dako). Figure 3. Warthin Starry stain showing H. heilmannii on the surface of the epithelium.

5 May 2000 H. HEILMANNII IN GASTRIC MALT LYMPHOMA 825 Table 2. Grade of Gastritis in H. heilmannii Infection Before treatment (antrum/corpus) After treatment (antrum/corpus) Density of H. heilmannii colonization 1 (1 4)/1 (0 1) 0/0 Grade of gastritis a 3 (2 3)/1 (1 2) 2 (1 2)/1 (1 2) Grade of activity of gastritis a 2 (1 2)/0 (0 1) 0 (0 1)/0 Replacement of foveolar epithelium 2/0 0/0 Grade of mucus depletion a 1 (1 2)/0 0/0 Lymphoid follicles (n) 5/1 4/0 NOTE. Grading of gastritis was performed in accordance with the Sydney system, 15 with slight modifications. 14 a Median (range). detectable and neutrophil infiltration had also disappeared, with the exception of one biopsy specimen (Table 2). Further histopathologic changes associated with gastritis, such as replacement of foveolar epithelium by regenerative epithelium, and mucus depletion also normalized after successful treatment of the infection (Table 2). The expression of the lymphoplasma cellular infiltration, i.e., the grade of gastritis, returned to a minimal level after treatment, and lymphoid follicles persisted after treatment in all patients (Table 2). Serological Investigation Using the recently developed ELISA for H. heilmannii, 22 H. heilmannii specific antibody levels were significantly higher in H. heilmannii positive patients than in H. pylori positive patients (P ) or Helicobacternegative patients (P 0.004) for all 5 patients. The anti H. heilmannii titer dropped below the cutoff level after therapy in 2 patients from whom serum was available. Anti H. pylori IgG antibodies were significantly higher in H. pylori positive patients (P 0.002) than in H. heilmannii positive and Helicobacter-negative patients (P 0.003). Western Blot Analysis In the Western blot analysis, IgG antibodies to the 54-kilodalton heat shock protein analogue flagellin A complex were detected in all patients (Figure 4, lanes 1G, 4G, and 6G). In addition, patient 1 with positive ELISA results showed antibodies to antigens with 72 (OMP 67), 62 (urease B), and 47 and 29 kilodaltons (urease A) (Figure 4, lane 1G). Patient 3 showed a weak reaction to 50 kilodaltons, the suspected catalase (Figure 4, lane 6G). All IgG bands were significantly weaker after 6 weeks and after 1 year (Figure 4, lanes 3G, 5G, and 7G). IgA antibodies to the urease B subunit were detected in all patients before and after treatment; the bands were weaker in patients 2 and 3 (Figure 4, lanes 1A 7A). In addition, patient 1 showed antibodies to antigens with 72 (OMP 67) and 29 kilodaltons (urease A) (Figure 4, lane 1A); the reaction to urease A was no longer detectable after 1 year (Figure 4, lane 3A). Molecular Data PCR with primers specific for the framework region 3a/2a and joining region LJH detected single Figure 4. Western blot analysis using lysate antigens from H. pylori ATCC Positive and negative controls are shown at the right margin, and corresponding molecular weights (MW) of known and suspected antigens are indicated. Lanes 1 7 indicate the individual patient sera with IgG conjugate (G) and IgA conjugate (A) of patient 1 before treatment (1), 4 weeks (2) and 1 year (2) after treatment; patient 2 before (4) and 4 weeks after (5) treatment; and patient 3 before (6) and 4 weeks after (7) treatment.

6 826 MORGNER ET AL. GASTROENTEROLOGY Vol. 118, No. 5 bands representing monoclonal B-cell proliferation 15 before treatment in 3 of 5 patients, which is similar to the frequency of detecting B-cell monoclonality in H. pylori associated MALT lymphoma. 15 In 1 of the 3 patients, the monoclonal bands changed to a polyclonal pattern 4 weeks after cure of H. heilmannii infection. In 2 patients, polyclonal bands were seen before treatment. Genus-Specific PCR The 16S rrna amplification was successful in 2 of 5 patients. Sequencing of the PCR product and alignment to published sequences using a common database showed in both cases a homology of up to 99.3% to H. heilmannii (former Gastrospirillium hominis I), reported by Solnick et al. 24 Discussion We report clinical, microbiological, and molecular results on primary gastric MALT lymphoma associated with H. heilmannii infection. Antibiotic treatment of the organism, as established for H. pylori infection, 23 resulted in its disappearance, and eradication of H. heilmannii resulted in complete remission of the MALT lymphoma in all 5 patients. According to recent studies that have linked chronic H. pylori infection to the development of MALT lymphoma, 9 11,14,15,21 this finding supports the hypothesis that primary gastric low-grade MALT lymphoma may also develop against the background of H. heilmannii associated gastritis. In view of the small number of patients with H. heilmannii associated lymphomas in this study, it could be argued that the association between the bacterium and the lymphomas was an incidental finding; however, well-established animal models have shown a high incidence of lymphomas induced by H. heilmannii infection. 25 Epidemiologically, the association between the low prevalence of H. heilmannii infection and primary gastric MALT lymphoma is much closer than that between H. pylori infection and MALT lymphoma. From 1988 to 1998, we diagnosed 543 patients with H. heilmannii infection at the Institute for Pathology in Bayreuth; among them, 8 patients (1.47%) had primary gastric MALT lymphoma. In comparison, we diagnosed 263,680 patients with H. pylori gastritis during the same period, and 1745 (0.66%) of them had a primary gastric MALT lymphoma. Therefore, the development of a gastric MALT lymphoma caused by H. heilmannii infection shows a much higher ratio than that of gastric MALT lymphomas in H. pylori infected patients. We were able to exclude H. pylori infection in our patients by serology, culture, and histology. H. heilmannii infection was also diagnosed analyzing the 16S rrna sequence that showed a homology of up to 99.3% to G. hominis I, former H. heilmannii. It might be argued further that H. heilmannii usually causes very mild gastritis compared with H. pylori, and is thus unlikely to play a major role in the pathogenesis of lymphoma. However, this interpretation is not supported by a recent study comparing the severity and distribution of H. pylori gastritis in different H. pylori associated diseases; the grade of H. pylori gastritis was relatively low in patients with gastric MALT lymphoma compared with those having gastric carcinoma. 26 It was also shown that H. heilmannii gastritis is generally less severely expressed than H. pylori gastritis. 27 In the present study as well, gastritis caused by H. heilmannii showed medium- or low-grade expression in both the antrum and corpus, using the grading system established for H. pylori gastritis. The observation that MALT lymphoma seems not to be associated with severely expressed gastritis is also supported by studies in a mouse model of H. felis infection. Enno et al. 28 described that H. felis infection in the model caused only little inflammation after 22 months of infection and minimal lymphoid cell proliferation. Approximately 25% of the infected mice developed a low-grade MALT lymphoma compared with none in controls. 28 When the same model was investigated with H. heilmannii, which has a more widespread host range, including humans, 47 of 79 (59%) mice infected with H. heilmannii isolated from different species developed MALT lymphomas after 24 months of infection. Like the infection with H. felis, H. heilmannii caused little inflammation, but after 15 months, a significant pathology started to develop that was morphologically similar to a high-grade lymphoma. The grade and expression of the pathological changes found in mice did not correlate with the grade of gastritis, but seemed to vary with different isolates. 25 We observed monoclonal bands in 3 of 5 cases by using PCR. The PCR was performed using primers specific for the FR2 and FR3 regions. However, the histopathology clearly demonstrated lymphoepithelial destruction in all 5 patients, which is the hallmark of low-grade MALT lymphomas 11 (Figures 1 and 2). In a previous study of MALT lymphomas associated with H. pylori infection, monoclonal bands were detected in 76% of the cases. 15,21 That only 3 of 5 cases were monoclonal in the present study may indicate that both consensus primers (FR2 and FR3) may have been inadequate to start the PCR reaction as a result of mismatches within the 3 region of the primer. This may point to a somatic mutation within this genomic region, as has been observed in gastric MALT lymphomas, 29 which may have led to false-negative

7 May 2000 H. HEILMANNII IN GASTRIC MALT LYMPHOMA 827 results. Furthermore, the absence of monoclonal bands in 2 patients may also be a result of the small patient number. One may argue against the specific association between H. heilmannii infection and MALT lymphoma as suggested in this study because the new H. heilmannii ELISA 22 may not be specific enough to exclude coincident infection with H. pylori. However, serological investigations failed to detect anti H. pylori antibodies using a second-generation ELISA in all patients. Also, Western blot analysis identifying immune response to specifically known H. pylori virulence correlated antigens such as CagA and specific antigens such as 50-, 33-, 25-, and 19-kilodalton was negative in all serum samples obtained from H. heilmannii infected patients. The only antigenspecific immune response common to both H. heilmannii infected patients and H. pylori infected controls was IgA to the urease subunit B (62 kilodaltons), which is also known to be present in H. heilmannii. What is morphologically described as H. heilmannii has so far been cultivated only from humans in one laboratory, 30,31 and the first DNA analyses that identified G. hominis as a new species of the genus Helicobacter 24 suggested that organisms with the same microscopic appearance might in reality be a group of different Helicobacter species. However, even if this were true, our report is the first to describe a very high relative risk of lymphoma developing on the background of this rare infection. Besides case reports reporting triple therapy as effective, 32 this is the first report showing that H. heilmannii infection can be cured with dual therapy, a regimen known to be successful in treating H. pylori. 23 Curing H. heilmannii infection is followed by remission of the associated lymphoma, similar to H. pylori associated lymphoma. 15,21 In addition to its clinical significance, we would like to emphasize the possible role of this close relationship between H. heilmannii infection and the incidence of lymphoma as a pathogenetic model for lymphoma development to be studied in an animal model. 25 In conclusion, the present data suggest that there may be a link between H. heilmannii infection and the development of primary gastric low-grade MALT lymphoma, as described previously for H. pylori. The development of lymphoma seems to be independent of the grade of gastritis, which has also been speculated for MALT lymphoma associated with H. pylori infection. 26 A comparative study of the host response observed in H. heilmannii gastritis associated MALT lymphoma with the host response observed in patients with H. pylori associated MALT lymphoma may provide a valuable human model to study the differential influence of host and bacterial factors in the pathogenesis of MALT lymphoma. MALT lymphomas may completely regress after cure of H. heilmannii infection. References 1. Dent JC, McNulty CAM, Uff JC, Wilkinson SP, Gear MWL. Spiral organisms in the gastric antrum [letter]. Lancet 1987;2: Lee A, Hazell SL. Campylobacter pylori in health and disease. An ecological perspective. Microbiol Ecol Health Dis 1988;1: Lee A, Dent J, Hazell S, McNulty C. Origin of spiral organisms in human gastric antrum. Lancet 1988;1: McNulty CAM, Dent JC, Curry A, Uff JS, Ford GA, Gear MW, Wilkinson SP. New spiral bacterium in gastric mucosa. J Clin Pathol 1989;42: Heilmann KL, Borchard F. Gastritis due to spiral shaped bacteria other than Helicobacter pylori: clinical, histological, and ultrastructural findings. Gut 1991;32: Stolte M, Wellens B, Bethke M, Ritter M, Eidt H. Helicobacter heilmannii (formerly Gastrospirillum hominis) gastritis: an infection transmitted by animals? Scand J Gastroenterol 1994;29: Solnick JV, O Rourke J, Lee A, Paster BJ, Dewhirst FE, Tomkins LS. An uncultured gastric spiral organism is a newly identified Helicobacter in humans. J Infect Dis 1993;168: Meining A, Kroher G, Stolte M. Animal reservoirs in the transmission of Helicobacter heilmannii. Scand J Gastroenterol 1998;33: Morgner A, Bayerdörffer E, Meining A, Stolte M, Kroher G. Helicobacter heilmannii and gastric cancer. Lancet 1995;346: Parsonnet J, Hansen S, Rodriguez L, Gelb AB, Warnke RA, Jellum E, Orentreich N, Vogelman JH, Friedman GD. Helicobacter pylori infection and gastric lymphoma. 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