Case 3 -

Granulomatous Cholecystitis and Sclerosing Cholangitis Associated with Trichosporon Infection and Natural Killer Cell Deficiency Jose Jessurun University of Minnesota Minneapolis, MN

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Clinical History An 8-year-old previously healthy white girl presented with abdominal pain and vomiting of a month's duration with recent weight loss and jaundice. She was the product of first-degree consanguinity. Family history was non-contributory. Physical examination revealed a thin, jaundiced child. A firm, non-tender liver edge was noted two centimeters below the right costal margin. Laboratory tests showed normal leukocyte count and hemoglobin, total bilirubin of 9 mg/dL (0.2 – 1), direct 6.5 mg/dL, ALT 155 IU/L (8-20), AST 116 IU/L (8-20), alkaline phosphatase 931 IU/L (30-115), lipase 5094 IU/L (2.3-50) and amylase 612 IU/L (35-118). Computerized abdominal tomography demonstrated multiple gallstones. Endoscopic retrograde cholangiopancreatography (ERCP) revealed multiple stenotic lesions in the distal biliary tree without evidence of ductal stones. Colonoscopy to the ileum was normal. A cholecystectomy was performed, during which a 1.5 cm stone and exudate were found in the cystic duct. Further evaluation included an immunologic profile. The patient was deficient in suppressor/cytotoxic T (CD8) cells and natural killer (NK) cells (CD16+CD56). Cytotoxic testing of NK cell lytic activity showed complete absence of NK cell function. A quantitative immunoglobulin (Ig) panel showed elevation of IgE. Lymphocyte and neutrophil function, leukocyte adhesion, and complement studies were all normal. Autoimmune antibody titer for anti-saccaromyces cerevisiae antibody, anti-neutrophilic cytoplasmic antibody, and anti-nuclear antibody were negative. Smooth-muscle antibody was minimally elevated with a titer of 40 (normal titer <20). Genetic testing was negative for chromosomal deletions, duplications, or translocations. Evaluations for human immunodeficiency virus, histoplasmosis, blastomycosis, leptospirosis, Epstein-Barr Virus, Hepatitis Virus A, B, and C, and tuberculosis were negative. Case 3 - Slide 1 Gallbladder showing granulomatous inflammation. Click to view with ImageScope Click to view with a Web-Based Viewer Case 3 - Slide 2 A GMS stain highlights organisms within granulomas. Click to view with ImageScope Click to view with a Web-Based Viewer Pathological/Microscopic Findings and any Immunohistochemical or Other Studies: Microscopic examination of the gallbladder and cystic bile duct shows numerous non-necrotizing granulomas with abundant giant cells and eosinophils. Fungal forms are highlighted by a GMS stain. Differential Diagnoses: Infectious granulomatous cholecystitis: - Histoplasmosis - Aspergillosis - Blastomycosis - Cryptococcosis - Tuberculosis - Q fever - Brucellosis - Salmonellosis Non-infectious granulomatous cholecystitis: - Crohn's disease of the gallbladder - Sarcoidosis - Bile granulomas - Suture granulomas Final Diagnosis: Granulomatous cholecystitis and sclerosing cholangitis associated with Trichosporon infection and natural killer cell deficiency. Case Discussion: Trichosporon, a basidiomycete characterized by a spore-bearing organ, was first described by Beigel in 1865, who identified it as the cause of white piedra, a disease of the hair follicle and shaft, which manifests as soft, mucilaginous, white to light brown hair nodules. The infection may cause the hair shaft to break but produces no other signs or symptoms. Gueho et al. reported that the species that cause deep-seated and disseminated infections are distinct from the agents of superficial infections. Sugita et al. proposed in 1999 six pathogenic Trichosporon species:T. asahii and T. mucoides, responsible for deep-seated and disseminated infections, T. asteroids and T. cutaneum for superficial infections, and T. ovoides and T. inkin for white piedra [1]. In the present case the pathogen was T. beigelii, which under the new classification corresponds to T. asahii. Disseminated infection has been reported in both adults and children, and more recently in premature neonates . The infection may involve the meninges, lungs, heart, esophagus, liver, biliary tree, urinary tract, peritoneum, and uterus [2, 3, 4]. Most patients have an underlying immunodeficiency, and the infection commonly occurs after surgical intervention, such as the placement of an indwelling prosthesis. This patient was not neutropenic or on immunosuppressive medication and was thought to be healthy. The role of the NK cell deficiency and dysfunction in her infection is not clear. NK cells appear to play a role in the control of tumor growth and are fundamental in defense against some cytopathic viruses, but there is no evidence that NK cells provide protection against fungal infections. NK cell dysfunction is associated with some genetic syndromes, particularly Chediak-Higashi and Griscelli, both of which are autosomal recessive. Some studies indicate that lower NK cell function can be inherited as a recessive trait. NK cell dysfunction is also associated with illnesses such as systemic lupus erythematosus, lymphoproliferative disorders, malignancies, sclerosing cholangitis, and hepatitis, and has been reported in association with postoperative bacterial wound infection and sepsis, and with mycobacterial infections and aspergillosis [5, 6]. Infections have been implicated previously in the development of sclerosing cholangitis. Bucuvalas et al. described a case of cholangitis associated with Cryptococcus neoformans in an young patient with cirrhosis. [7] There are other reported cases of biliary tree fungal infections with Candida, Histoplasma, Aspergillus and Blastomyces. Most of these infections also developed in immunodeficient hosts. The reports collectively conclude that fungal cholangitis carries a poor prognosis, especially in patients who are either immunocompromised or have a second, underlying condition (e.g. cancer, diabetes). [8, 9, 10] Review of the Literature/Treatment Options (if applicable): The current case illustrates an unusual fungal infection of the gallbladder and bile ducts that developed in an immunocompromised patient. This case was chosen to discuss some pertinent aspects of infectious diseases of the gallbladder and extrahepatic bile ducts. Because of their clinical relevance, the participation of infectious agents in the following three conditions will be discussed. 1. Infections in calculous cholecystitis. 2. Infections in acalculous cholecystitis. 3. Infectious cholecystitis in the immunocompromised patient. 1. Infections in calculous cholecystitis: Symptomatic cholecystitis is most frequently caused by gallstones. The most common type of gallstone in the western world is the cholesterol gallstone. The two types of non-cholesterol or pigmented gallstones are black and brown. In the US, black pigment stones develop in patients with other diseases such as chronic hemolysis and cirrhosis and are not associated with biliary infections. By contrast, infections participate in the genesis of brown stones. This type of gallstones, which are very common in Asia, may develop within the bile ducts and gallbladder. Bacteria directly alter the composition of bile by the production of B-glucuronidase, cholyl-glycyl hydrolase and phospholipase A1 which promote the formation of calcium salts of uncojugated bilirubin, deconjugated bile acids and saturated long-chain fatty acids thereby promoting the formation of brown pigment stones. Organisms related to the formation of brown pigment stones include E. coli and parasites such as Clonorchis sinensis, Opisthorchis viverrini, and Ascaris lumbricoides. [11, 12] Although bacteria have been implicated in the formation of cholesterol gallstones, a definitive cause-and-effect relationship have never been established. In patients with acute calculous cholecystitis, when bile cultures are obtained early enough bacteria can be isolated in 42 to 72% of the cases. Intestinal organisms predominate: Escherichia coli, other Gram-negative aerobic rods, enterococci and anaerobes. In contrast, bacteria, mostly E. coli and enterococci, are cultured in less than third of the cases of chronic cholecystitis. [13] Certainly, the identification of bacteria in the gallbladder does not mean that these organisms caused the gallstones. Most authorities postulate that changes in bile composition, mucosal inflammation and biliary dysmotility favor bacterial colonization. Supporting this hypothesis is the observation in experimental mouse models that colonization of the gallbladder by bacteria in not required for the formation of cholesterol gallstones. [14] Recent studies have suggested a possible association between Helicobacter pylori and cholesterol gallstones. Several groups have identified H. pylori DNA in biliary tissue and gallstones. [15, 16] However, some samples were obtained through endoscopic retrograde cholangiopancreatography which could contaminate them with gastric bacteria. The 16S ribosomal RNA genus-specific primers that are frequently used to identify these organisms in PCR analysis can amplify other non-H pylori helicobacters. Finally, as mentioned before, these organisms may secondarily invade the biliary tree. [16] The presence of several bile resistant Helicobacter species such as H. bilis, H. pullorum and F. rappini has been convincingly demonstrated in the hepatobliary system. [17] PCR based studies have detected these organisms in patients with chronic cholecystitis, gallstones and gallbladder carcinoma. It has been suggested that these organisms participate in the formation of cholesterol gallstones by inducing a calcium salt nidus, a hypothesis supported by the formation of cholesterol gallstones in experimental animal models infected with enterohepatic helicobacters and by the observation that urease-positive bacteria can precipitate calcium salts in vitro. [18] Chronic colonization with the causative agent of typhoid fever, Salmonella enterica ser Typhi, is associated with gallstones and gallbladder cancer. This organism forms a bacterial biofilm on the surface of cholesterol gallstones which favors chronic colonization and protects the organism during antibiotic therapy. The concomitant presence of gallstones and S typhi markedly promotes the risk of gallbladder cancer. [19] Despite the difficulty in ascribing a causative role to bacteria in the formation of gallstones, there is experimental evidence that, at least in some instances, this may be the case. When mice form the widely used animal model C57L/J are kept in pathogen-free conditions (free of enzootic Helicobacter spp) cholesterol gallstones develop in only 10% of the animals. However, purposeful infection with entrohepatic strains of Helicobacter spp increases the prevalence of gallstones to 80%. [14] 2. Infections in acalculous cholecystitis. Inflammation of the gallbladder in the absence of stones is referred to as acalculous cholecystitis (ACC). In the clinical literature this term is applied predominantly to a condition diagnosed in critically ill patients in whom visceral hypoperfusion, ischemia and reperfusion injury appear to play a role. As in calculous cholecystitis, bacteria (Enterobacteriaceae and other anaerobes) may produce secondary infections. [12] Acalculous cholecystitis has been described in numerous systemic bacterial infections including leptospirosis, chronic biliary tract carriers of typhoidal and nontyphoidal Salmonella, Campylobacter enteritis, tuberculosis, Q fever, and brucellosis. Viral pathogens such as hepatitis A, B, Epstein-Barr virus and dengue virus, and parasitic diseases including ascariasis, echinococcosis, cryptospodiosis and microsporidiosis may cause this condition. [20, 21, 22] The histopathologic features of ACC caused by these infections has been poorly characterized since the focus of most of these reports has been on the clinical presentation and response to therapy. A granulomatous response in common in tuberculosis, Q fever, brucellosis and less common in Salmonella. Multicellular parasites frequently produce an inflammatory response with a high content of eosinophils. A predominance of lymphocytes and plasma cells, indistinguishable from that seen in chronic calculous cholecystitis is present in most viral infections. 3. Infectious cholecystitis in the immunocompromised patient. Opportunistic infections of the gallbladder and extrahepatic bile ducts have been reported primarily in HIV infected patients and less frequently in transplant and cancer patients. Grouped under the rubric "acquired immunodeficiency syndrome cholangiopathy" are a diverse group of biliary infections causing biliary obstruction. The organism most commoly found is Cryptosporidium. Other infectious agents that have been identified include Cytomegalovirus, Mycobacterium avium-intracellulare complex, Isospora, Cyclospora, and the genera of Microsporidia. [23] By contrast, in transplant patients, Cytomegalovirus and fungal infections by organisms such as Candida and Cryptococcus appear to be the predominant infectious agents. [24] As mentioned before, fungal infections by Histoplasma, Aspergillus and Blastomyces have also been reported. The histopathologic features associated with these infections are identical to those that have been reported in other organs. Conclusion(s): Causative roles for infectious agents have been postulated for cholesterol gallstones. Many cases of acalculous cholecystitis are due to infectious organisms. In immunosuppressed patients a variety of opportunistic organisms have been reported as a cause of cholecystitis and sclerosing cholangitis. References: Sugita T, Nishikawa A, Ikeda R, et al. Identification of medically relevant Trichosporon species based on sequences of internal transcribed spacer regions and construction of a database for Trichosporon identification. J Clin Microbiol 1999;37:1985-1993. Panagopoulou P, Evdoridou J, Bibashi E, et al. Trichosporon asahii: an unsusual cause of invasive infection in neonates. Pediatr Infect Dis J 2002;21:169-70. 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