I 993;22:2 1-42. 8. Lee A, Eckstein RP, Fevrc DI, Dick E, ... Dubois A, Tarnawski A, Newell DG, ct al. Gastric injury and ... Dick E, Lee A, Watson G, et al. Use of.
BRIEF COMMUNICATION
Gastritis induced by the helicobacter 'Gastrospirillum horninis' SANDER JO V ELDI IUY?EN VA NZANT EN MD Ph D FRCPC, D ICKRAN
A
MALATJALIAN MD r:ACP,
LEON M DESORM EAU MD FRCPC, LEO V PEREIRA MD ~\Sc r:RCPC
SJO VELDHUYZEN VANZANTEN, DA MALATJAUAN, LM DESORMEAU, LV P EREIRA. Gastritis induced by the helicobacter 'Gastrospirillum hominis'.
J Gastroenterol 1994;8(4):257-259. A patien t with a 'Gastrospirillum homi nis' infection in the stomach is described. 'Gascrospirillum hominis' belongs co the genus 1-lelicobacr.er and is a rare cause o f gastritis in th e human stomach . le
Can
can be recognized by its d isti nct ive morphological a ppearance o n histology. Key Words: Gastritis, GastrosJ>irillum, Helicobact.er
Gastrite provoquee par Helicobacter Gastrospirillum hominis RESUME: U n patient atte int d'une infection aGastrospirillu.m hominis au niveau de l'estomac csLdecri t ici. Le Gastms/>irillum hominis appartient au genre f-lelicobacter et est une rare cause de gastrite chez l'homme. O n peu t la reconnaitre par son appare nce morphologique distinctive a l'histologie.
H
ELICOBACTER PYLO H/ IS NO W
accepted as the most common cause fo r h istologica l evidence of gastrit is (I ). Using rouLinc he matoxylin ,ind eosin staining H pylori organ isms often ca n be easily recognized histologically by their charac te rist ic curvedspiral morrhology. I loweve r, some-
Limes special histological stains are required for identifi cation of th e organism. W e describe a patie nt with 'Gastrospirillum hominis' infec tion co promote awaren es:, t hat infecti ons by spiral organisms o ther than H /Jy/ori ca n occur in the stomac h. These organisms have a distinctive mo rphological a p-
Division of Gmcroencernlogy and Dc/1arunent of Pathology, Dalho11sie Unii,ersic y, Vicwria General Hos/1ical, I lalifax, Nova Scotia; and De/>anmem of Pathology and lncemal Medicine, Sc Mcirclia's Hos/>ical , Antigonis/i , Nova Scotia Correspondence: IJr SJO Veu.lh11yzen van Zamen, Diuision of Gasn-cienwrology, Victorin General Hos/1ical, RC Dickson Cencrc, Room 4087, 1278 T ower R1xul, Halifax, Nom Scotia
133H 2¥9 Recciwd for publication March 30, 1994. Accepwd A1n·il 21, 1994 CAN
J GA!>'TROENT EROL V OL 8 N L) 4 JULY/A UGUST 1994
pearance on gastric biopsies and can be dist inguished fro m H pylori on rouLinc hematoxylin and eosin staini ng.
CASE PRESENTATION A 36-year-old male underwe nt upper gastro intesLina l endoscopy because of chron ic dyspepsia. The re was no prior history of peptic ulce r d isease. He smoked a pack of c igarcLtes a day for 15 years. T he on ly tra ve l h isrory outside C anada was a trip to Florida in the previous year. The patient had two hea lthy cats, and previously had a dog. I le regula rly hunted deer, ra bbits and raccoons. Upper gast roin testinal endoscopy revea led mild antral gastrit is. Biopsies o ( the annum demonstrated a mild ch ron ic gastritis with an inc reased number of lymphocytes a nd a few po lymorrhonuc lear ce lls. A rapid urease test lll assess t he urease act ivity of biorsies was no t perfo rm ed. Spira l microorganisms consistent with 'Gascrospirillum homin is' were idemi fied at h igher magni fication on h emarnxyli n and eosin staining ( Figure l ). S ubsequen tly e lectron microscopy was perfo rmed using the ava ilable biopsy material (Figure 2). No H /Jylori organ isms
257
VELDHUYZEN VANZANTEN er
al
Figure 1) Gastric biopsy (hematox:ylin and eosin, XI 250) demonstrating ~et•crnl long corkscreiu-like rn-ganisms ty/Jical for 'Gastrospiri/111111 /10minis' overlying the mucosa
Figure 2) Eleen-on micrograph (x20,000) showing tigl11ly coiled 'Gascros/Jirillum hominis' m·ganisms tuirlt corkscrew appearance. Dark stained gasn·ic mucus dro/>lets are seen on the left
were seen. No biopsies were taken from the body of the stomach. The patient was treated with bismuth subsalicylate but because of side effects he subsequently received m11oxicillin 500 mg rid and metronidazole 500 mg rid for l Odays. The dyspepsia symptoms resolved. A repeat endoscopy three months later was normal and biopsies from the gastric antrum and body were histologically normal. No 'Gastrospirillum hominis'
258
organisms were seen. Cultures of gastric biopsies were negative. Serology for immunoglobul in (lg) G antibodies aga inst H pylori was negative (2).
DISCUSSION 11 pylori is the ca use of antral gastritis and is linked to duodenal ulcers and gastric cancer (1 ). A lthough it is by for the most common cause of antral gastritis other spiral organisms may colonize the human l.tomach. ApproxiCAN
matcly 60 cases of 'G~istrospirillum hominis' infection have been reported in the medical literature worldwide (3,4). The incidence of cases is low, varying from 0.25 co 0.4% (4,5). In most patients chronic dyspepsia w,1s the reason for endoscopy. The morphology of 'Gastrospirillum hominis' is distinctive and can be identified on routine hemacoxylin and eosin staining (Figure l ). Compared with I-I pylori, 'Gastrospirillum hominis' organisms are longer (7 to IO µM) and are more t ightly coiled, with six to eight coils per bacterium, giving it a corkscrew appearance (Figure 2) (4-6). In most cases of 'Gastrospirillum hominis' infection a chronic active gastritis is present, a lthough this is often less severe than the inf1ammation caused by I l /)ylori. Th..: number of organbms is a lso lower and they often tend to be seen in small groups ( 4, 7). Un like H J>ylori, 'Gastrospirillum hominis' is usually not in close contact with the mucosa! epithelial cells but is often found above the foveola r epithelial cells (4 ). Occasional invasion of parietal cells by 'Gastrospirillum hominis' has been seen (8,9). To date in vitro culture of 'Gastrospirillum hominis' has been unsuccessful, rendering the taxonomic identification of the organisms tentative (for this reason rhe name of the organism appears between single quotation marks). In vivo culture of 'Gastrospirillum hominis' is possible by inoculacing mice with scrapings from gastric biopsies obtai ned from infected patients. With this technique, colonization of 'Gastrospirillum hominis' can be established, maintained and transferred in the mouse (I 0). Sequencing the I 6S ribosomal RNA gene of 'Gastrospirillum hominis' showed 96% homology with Helicobacter felis, indicating that 'Gastrospirillum hominis' belongs to the genus I lelicobacier (l l ). Our serological assay for measuring IgG-antibodics against H pylori was negative in this patient. This suggests that there is no cross-reactivity of this assay with 'Gastrospiri llum hominis'. We can not exclude the possibility that cross-reactivity with H J>ylori may occur and that the lack of seropositivity in this case was
j 01\STROENTEROL VOL 8 No 4 JULY/AUGUST 1994
Gastritis due to 'Gastrospirillum hominis'
due to the low num ber of 'Gastrospiril ldm hom inis' organ isms resulting in a low systemic antibody response. Colonization of the gastric mucosa by 'Gasuospirillum hominis' is commonly ,een in cars, dogs and ocher animals such as monkeys :md pigs. Several human cases have been associated with pets {3,12-14). The case described here also had a history of exposu re co animals. Activity of the urease enzyme in 'Gastrospirillum hominis' infection has been demonstrated using a rapid urease test on gastric biopsies (3,4,13,15,16). However, not a ll in fected patients have a positive urease rest; the ir u rease
ACKNO WLEDGEMENTS: Dr Veldhuy"cn wm Znntcn holds a Career Award from the Pharmaceutical Manufacturer~ Assoc int ion of Canada/Medical Rc~earch
Council.
REFERENCES l. Veldhuyzcn van Z:mten SJO, Sherman PM. Hdicobacter /1ylori infection as a cause of gastritis, duodenal ulcer, gastric cancer, ,md non-ulcer dyspepsia: a systematic overview. Can Med Assoc ] 1994; 150:177-85. 2. Best LM, Vcldh uyzcn van Zantcn SJO, Bezanson GS, ct al. Serological detection of Helicobactcr pylori by Flow M icrosphcre I mmunotluorcscent Assay (FM IA). J Clin Microbial l992;30:23l l-7. 3. McN ulty CAM, Dent JC, C urry A, ct al. New spiral organism in gastric mucosa. J Clin P:uhol 1989;42:585-9 J. 4. Heilmann KL, Borchard F. Gastritis due to ~pirnl shaped bacteria ocher th:m Hclicobaccer /J)•friri: clinical, histologica l, anJ ultrastructural findings. Gut 1991;32:137-40. 5. 'Gastrospirillum hominis'. Lancet l 989;ii:252-3. (Et.lit) 6. The Hdicobaccer genus: now we are nine. Lancet l 992;3 W:840- l. (Edit)
enzyme activity may be less than in
H pylori. Treatment of 'Gastrospiri ll um hominis' is easier th an H pylori. A lthough combination therapy has been used (13) most patien ts are erad icated when bismuth subsa licy late was used as monorherapy for fou r weeks (4) . The chronic gastritis seen in infected patients disappears after the organism is eradicated ( 4). lf not treated the organism can persist in rhe human stomach fo r a long time, analogous to infection by H pylori (4). The organism has also been found in the duodenal mucosa with evidence of duodenitis ( 17). ln a few cases presence of 'Gastrospirillum 7. Lee A, O'Rourke J. Ga,Lric bacteria other than /-lelicohacwr /Jylori. Gastrocnterol Clin North Am I 993;22:2 1-42. 8. Lee A, Eckstein RP, Fevrc DI, Dick E, Kellow E. Non-Campylobacwr pylori spiral organisms in th e gastric ancrum. Aust N Z J Med 1989; l 9: l 56-8. 9. Dubois A, Tarnawsk i A, Newell DG, ct al. Gastric injury and invasion of parieta l cells by spiral bacteria in rhesus monkeys. Gastrocntcrology 199 l; 100:884-91. 10. Dick E, Lee A, Watson G, et al. Use of the mouse for the isolation and investigation of sromach-associnced, spiral-helical shaped bacteria from man and other animals. Med Microbiol 1989;29:55-62. l l. Solnick JV, O'Rourkc J, Lee A, er al. 'Gascrospirillum' is a new species of Hclicobactcr in humans. Gastroentcrology l 992; l 02:A699. (Abst) 12. Lee A, Dent J, Haze II S, ct al. Origin of spiral organisms in the h uman gastric amrum. Lancet l 988;i:300- l. 13. Dye R, Marshall BJ, Frierson HF, ct al. U ILrascructurc of another spiral organism associated wirh human gastritis. Dig Dis Sci l 989;34: 1787 -9 l. 14. Dye KR, Mnrsh::ill BJ, Frierson JR,
CAN J GASTROENTEROL Vt)L 8 No 4 JULY/AUGU~, 1994
hominis' was associated with a duodenal ulcer ( 18). ln teresLingly, i.n monkeys, basic acid output and peak acid output were increased in animals infec ted with 'Gastrospirillum hominis' compared with controls (9). Cninfec-
tion of 'Gasrrospi rill um hominis' and H pylori has also been described (4, 19). Finally, 'Gastrospirillum hominis' has a lso been reported in chi ldren; the youngest case was three years old (20). In summary, infection with 'Gastrospirillum hominis' is a rare cause of chronic gastri t is in man and can be recognized by the distinct morphology of the organism.
LS.
16.
17.
18.
19.
20.
Guerrnnc RL, McCallum RW. Ultrastructu re of another spiral urg,mism associated with human gastritb. Oig Dis Sci L989;34: 1787 -9 l. Morris A, Ali MR, Homsen L, Vanderwcc M. Tightly spiral shapcJ bacteria in gastric antrum: are they ureasc positive? J Clin Pacho! 1989;42:2 I 6. Figura N, Gugliclmcui P, Quaranta S. Spiral shaped bacteria in g,1stric mucosa. J Clin Pachol 1990;43: 173. Nakshahcndi IM, Peebles SE, Lee FD, Russell RI. Spiral shaped microorganisms in the human duodenal mucosa. Postgracl MeJ J 199 l ;67:846- 7. Borody T, George L, Brant.II S, cc al. Hdicobacter /Jy/ori negmive duodenal ulcer. Am J Gastrocmerol l99l;89:l l54-7. Quciroz OM, Carbral MM, Nogueira AM, Barbosa AJ, Rocha GA, McnJcs EN. Mixed gastric infection by 'Gastrospirillum h omin is' and Helicobac1er /Jylori. Lancet I 990;336:507 -8. Oliva MM, Lazcnhy AJ, Perman JA. Gastritis associated with 'Gastrospiril lum hominis' in children. Mod Parhol l 993;6:5 13-5.
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