CMV. Inclusions predominantly in endothelial cells. Immunostaining greater sensitivity than H&E alone.

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Florence Perry
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2 CMV Inclusions predominantly in endothelial cells. Immunostaining greater sensitivity than H&E alone.

3 CMV inclusions are often present in a very patchy distribution Carefully examine all levels CMV

4 CMV reactivation in UC Looked at resection specimens from UC patients (H&E and CMV immuno) Severe UC 25% Refractory 8.3% Dysplasia (control) 0% Kojima T et al. Cytomegalovirus infection in ulcerative colitis. Scand J Gastroenterol. 2006;41(6):

5 CMV reactivation in UC Looked at resection specimens from UC patients (H&E and CMV immuno) Severe UC 25% Refractory 8.3% Dysplasia (control) 0% Association of CMV with active disease. Kojima T et al. Cytomegalovirus infection in ulcerative colitis. Scand J Gastroenterol. 2006;41(6):

6 Infective intestinal pathology in the immunocompromised patient.

7 Diarrhoea post BMT

8 CMV re-activation in an immunocompromised patient

9 ? Appendicitis

10 ? Appendicitis CMV

11 CMV appendicitis AIDs patient CMV

12 BMT patient colonic biopsies -?GVHD

14 Adenovirus colitis in immunocompromised patient

15 Deep penetrating rectal ulcer -? Cause.

16 CMV EBV EBV-associated ulceration

19 Fungal colitis Typically neutropaenic patients (chemotherapy for haematological malignancies). Mucor and aspergillus species

20 UK HIV/AIDs population Men who have sex with men (MSM). Intravenous drug abusers. Migrants from high risk countries. Blood transfusion / blood product recipients.

21 UK HIV/AIDs population Men who have sex with men (MSM). Intravenous drug abusers. Migrants from high risk countries. Blood transfusion / blood product recipients. Most HIV+ve cases will be stable on treatment but some patients still get AIDs: Health migrants. Unknown HIV infection. HIV patients who have failed HAART.

22 CD4 count and opportunistic infections >500 cells/mm3: Not considered at risk cells/mm 3 : Candidiasis Kaposi sarcoma cells/mm 3 : Pneumocystis, Histoplasmosis and coccidoidomycosis. Progressive Multifocal Leukoencephalopathy (PML) cells/mm 3 : Toxoplasmosis, Cryptococcosis and Cryptosporidiosis. Patient s with AIDs often have a CD4 count 50 cells per mm 3

23 Mycobacterium avium complex

24 Visceral Leishmaniasis Leishmania donovani Amastigotes 1.5 3mm

25 H&E D/PAS Histoplasmosis Histoplasma capsulatum 2-4mm yeast form Immunocompromised and immunocompetant.

26 Histoplasmosis Grocott Leishmaniasis Grocott

28 Cryptococcosis Cryptococcus neoformans 4 7mm (+ capsule 3-5mm)

29 Cryptosporidia in colon

Difficult to see on H&E In enterocytes - not basophilic blobs in goblet cells!

30 Encephalitozoon intestinalis Microsporidiosis Enterocytozoon bieneusi Now considered to be fungi Enterocytozoon bieneusi + others. Difficult to see on H&E In enterocytes - not basophilic blobs in goblet cells! Warthin-Starry staining +/- polarized light (spores polarize). PCR-based stool assay. ANDREW S. FIELD. Pathology (2002) 34, pp

31 What is the most frequent GI infection in western HIV patients?

32 What is the most frequent GI infection in western HIV patients? Helicobacter-associated gastritis

33 Parasitic infections

34 Giardiasis D2 biopsies

35 D2 biopsies TI biopsies Giardiasis

36 Classical flask-shaped ulcer Amoebiasis (Entamoeba histolytica)

37 Schistosomiasis (S. Mansoni)

38 Schistosomiasis (S. Haematobium)

40 Strongyloides stercoralis Nematode Predominantly infects patients in tropical and subtropical areas. May get fatal systemic dissemination in AIDs

41 Pinworm Enterobious Vermicularis

45 Diphyllobothrium latum

46 Conclusions Most cases of infective colitis can be differentiated from IBD on routine H&E sections. Atypical infective colitis can mimic IBD. Consider STDs in the differential diagnosis of proctitis in MSM patients. In refractory UC exclude a superimposed infective colitis. In the immunocompromised patient there may be little in the way of an inflammatory response. In known HIV +ve patients check the CD4 count.

Infections in immunocompromised host

Infections in immunocompromised host Immunodeficiencies Primary immunodeficiencies Neutrophil defect Humoral: B cell defect Humoral: Complement Cellular: T cells Combined severe immunodeficiency Secondary