Evidence for eosinophil activation in eosinophilic cystitis

[A CASE REPORT: EOSINOPHILIC CYSTITIS PRESENTED WITH DEEP VEIN THROMBOSIS]

A 76-year-old man presented with gross hematuria and reported the use of anticoagulant for deep vein thrombosis (DVT). Blood tests revealed eosinophilia and thrombocytopenia. Urine cytology revealed a class I specimen with a few eosinophils in the urine. We performed cystoscopy, which revealed bladder masses with friable mucosa diffusely throughout the bladder. Magnetic resonance imaging revealed possible invasion of the bladder muscle by the masses. We performed transurethral resection of the bladder masses, and histopathological examination revealed eosinophilic infiltration of the bladder wall stroma without cancerous tissue. Therefore, the patient was diagnosed with eosinophilic cystitis.Eosinophilia and thrombocytopenia promptly resolved, and the bladder masses disappeared following the administration of prednisolone for eosinophilic cystitis. DVT also improved without recurrence of eosinophilic cystitis.

Possible pathophysiology of ketamine-related cystitis and associated treatment strategies

Ketamine-related cystitis is characterized by ketamine-induced urinary frequency and bladder pain. It has become a serious problem in recent years. The most typical grossly pathological bladder change with ketamine related cystitis is a contracted bladder and bladder wall thickening. Ulcerative cystitis with an easily bleeding mucosa is a common cystoscopic finding. Microscopically, the urothelium is denuded and is infiltrated by inflammatory cells, such as mast cells and eosinophils. The pathogenesis of ketamine-related cystitis is complicated and involves many different pathways. Past evidence suggests a direct toxic effect, bladder barrier dysfunction, neurogenic inflammation, immunoglobulin-E-mediated inflammation, overexpression of carcinogenic genes, abnormal apoptosis and nitric oxide synthase-mediated inflammation contribute to the pathogenesis of ketamine-related cystitis. The first step to managing ketamine-related cystitis is always asking patients to cease ketamine. Medical treatment might be helpful in patients with early ketamine-related cystitis and abstinence from ketamine. Several case studies showed that the intravesical installation of hyaluronic acid and intravesical injection of botulinum toxin type A were effective for symptom relief in selected patients. For patients with irreversible pathological change, such as contracted bladder, augmentation enterocystoplasty might be the only solution to increase bladder capacity and relieve intractable bladder pain.

Elevated serum IgE may be associated with development of ketamine cystitis

PURPOSE

Previous studies revealed bladder mast cell and eosinophil cell infiltration in patients with ketamine cystitis. Due to possible hypersensitivity in those with this condition we investigated the association of serum Ig, histology findings and symptoms in patients with ketamine cystitis.

MATERIALS AND METHODS

We evaluated patients with ketamine cystitis for maximal bladder capacity, serum IgE, IgG and IgM, and pain visual analog scale score. Bladder biopsies were assessed for mast cells and eosinophils. Patients with interstitial cystitis/bladder pain syndrome, acute bacterial cystitis and controls were also studied. We used the Mann-Whitney U test for nonparametric data to compare serum IgE among groups with p <0.017 considered significant.

RESULTS

Median serum IgE was significantly higher in the 20 patients with ketamine cystitis (205.5 IU/ml, IQR 36.9, 514.0) than in the 10 controls (33.4 IU/ml, IQR 13.5, 71.7, p = 0.015) and the 15 with acute bacterial cystitis (34.6 IU/ml, IQR 24.2, 101.9, p = 0.015). It was marginally higher than in the 13 patients with interstitial cystitis/bladder pain syndrome (65.8 IU/ml, IQR 11.9, 133.0, p = 0.029). Of patients with ketamine cystitis the median visual analog scale pain score was significantly higher in those with serum IgE greater than compared to less than 200 IU/ml. Maximal bladder capacity was significantly less in patients with ketamine cystitis who had higher IgE. Patients with severe or moderate bladder eosinophil infiltration had a greater visual analog scale score, higher serum IgE and smaller maximal bladder capacity than patients with no or mild eosinophil infiltration. Serum IgE and the visual analog scale score correlated significantly (r(2) = 0.318, p = 0.01).

CONCLUSIONS

Patients with ketamine cystitis had higher serum IgE than patients with interstitial cystitis/bladder pain syndrome or acute bacterial cystitis, or controls. Serum IgE and the severity of eosinophil infiltration were associated with bladder pain severity and small maximal bladder capacity.

Rare cause of dysuria: eosinophilic cystitis

Eosinophilic cystitis is an inflammatory condition characterized by eosinophilic infiltration of whole layers of the bladder wall. The condition occurs more commonly in adults. We report a case of eosinophilic cystitis mimicking a bladder tumor in a 5-year-old boy with symptoms of dysuria and urinary incontinence. The diagnosis was confirmed by histopathology and he underwent clinical treatment with trimethoprim-sulfamethoxazole and antihistamine (cetirizine). The symptoms fully resolved in follow up, which is continuing. Although very rare, eosinophilic cystitis should be considered in cases of dysuria and increased bladder wall thickness but no identified urinary tract infection.

Case of eosinophilic cystitis treated with suplatast tosilate as maintenance therapy

Eosinophilic cystitis is a rare inflammatory lesion of the bladder, characterized by massive eosinophilic infiltration of the bladder wall. Its cause is not known definitely. A 49-year-old man consulted our department with a miction pain, gross hematuria, and frequent micturition. Urinalysis showed combined hematuria and pyuria, but urine culture was sterile. Abnormal findings of laboratory examination included an elevated white blood cell (WBC) count (15,700/μL) and the proportion of eosinophils in the peripheral blood was 12% of the WBCs (normal 0–5%). Cystoscopy revealed a solid mass with severe edematous mucosa. Magnetic resonance imaging (MRI) also indicated marked bladder wall thickening, which was suspected for invasive bladder cancer. Transurethral biopsy of the bladder mass was performed with pathological examination revealing features of eosinophilic cystitis. After administration of a combination of prednisolone and suplatast tosilate, followed by monotherapy with suplatast tosilate, regression of the bladder mass, and normalization of the count of peripheral eosinophils were achieved. Fourteen months after steroid therapy, under treatment with suplatast tosilate, there was no relapse of urinary symptoms and the bladder mass.

Marked infiltration of eosinophils in necrotizing granulomas in the resected hepatic bed after cholecystectomy resulting from gallbladder cancer and metastatic liver cancer is associated with peculiar peripheral eosinophilia

It is known that after transurethral resection of the prostate (TUR-P) or a bladder tumor (TUR-BT), necrotizing granuloma formation associated with massive eosinophil accumulation can be detected at the site of the scar, revealing marked eosinophilia. This condition is called post-TUR prostatitis or cystitis. In the present study, we noticed a similar phenomenon in five patients who underwent cholecystectomy, of whom four had gallbladder adenocarcinoma and one had metastatic liver cancer originating from the rectum. We detected necrotizing granulomas with massive eosinophil accumulation, associated with marked eosinophilia. To induce these phenomena, the interval between the first operation (i.e., cholecystectomy) and the second operation (i.e., resection of the hepatic bed and extrahepatic bile duct) is very important. If the interval was 1 week, no granuloma formation was detected. On the other hand, if it was more than 2 weeks, the resected hepatic bed contained necrotizing granulomas with substantial eosinophil accumulation combined with an increase in peripheral eosinophilia (up to 34% in one case). Secondary resection was necessary to induce eosinophilia after cholecystectomy. In this sense, malignancies possessed a relationship with delayed eosinophilia. In the granulomas, some foreign body-type multinucleated giant cells were positive for both anti-interleukin (IL)-5 and CD68 antibodies. In sharp contrast, no eosinophilia was detected after cholecystectomy, with or without hepatic resection consequent to severe adhesion. Clinicians as well as pathologists should keep in mind that these peculiar phenomena of eosinophil accumulation surrounding the necrotizing granulomas and peripheral eosinophilia after cholecystectomy could occur.

Presenting manifestations of eosinophilic cystitis in two Filipino children

Eosinophilic cystitis is a very rare clinical disease entity in the pediatric population. We report two cases of Filipino children with eosinophilic cystitis who presented with irritative voiding symptoms, gross hematuria, peripheral eosinophilia, and hydroureteronephrosis and urinary bladder wall thickening visualized on ultrasonography and CT urography. Cystoscopy and transurethral biopsy confirmed the diagnosis. Both patients were started with corticosteroid with or without an antihistamine. Resolution from the signs and symptoms were observed in both patients as documented by disappearance of peripheral eosinophilia, normal urinalysis results, and resolution of the hydroureteronephrosis and urinary bladder wall thickening on ultrasonography on follow-up.

[Eosinophilic cystitis: review and two case reports]

Eosinophilic cystitis is a low frequency disease, with less than 200 reported cases in the world. It is characterized by a bladder wall inflammation, mainly by eosinophils, with fibrosis and muscle necrosis areas. Its origin seems to be immunological, although the triggers are not well known. Several predispose factor have been described such as allergic diseases, bladder injuries, drugs, infections, etc. It affects patient of all ages, mainly adults. It presents with frecuency, haematuria and suprapubic pain. Other less frequent symptoms are disuria, urinary retention, nicturia, and enuresis. The laboratory study (urinalysis, urinalysis and haemogram) and radiology (ultrasound, intravenous pyelography, computed tomography and nuclear magnetic resonance) are non specific. The lesions observed in the cystoscopy could emulate other diseases, that why the proper diagnostic is the histological analysis. The management could be observation o antihistaminic, anti-inflammatory and corticoid treatment. In refractory cases, surgery is an alternative. In this work, two male adult cases are reported with their symptoms, studies and management.

The Spectrum of Eosinophilic Cystitis in Males: Case Series and Literature Review

Context.—Eosinophilic cystitis (EC) is an inflammatory condition of the bladder that has been linked to food allergens, infectious agents, drugs, and other genitourinary conditions. Like interstitial cystitis, EC has a strong female predominance. It is characterized by an intense eosinophilic infiltrate in the acute phase and fibrosis in the chronic phase.

Objectives.—To document and focus on specific features of EC in males and highlight the relationship between clinical and histopathologic findings.

Design.—The bladder biopsies of male patients were reviewed. Eight cases of EC were selected.

Results.—Several known associations were noted as well as unreported features and associations such as Charcot-Leyden crystals, celiac disease, lupus anticoagulant, and additional viral and bacterial agents.

Conclusions.—Eosinophilic cystitis represents a response to a variety of agents and may often be overlooked. The temporally biphasic morphologic features are the hallmark of this condition. Because clinical and imaging studies are not specific, a high index of clinical suspicion is often crucial to the correct diagnosis and proper management of EC.

Oral mucosa lesions in hypereosinophilic syndrome--an update

Hypereosinophilic syndrome (HES) is a rare disorder characterized by persistent and marked eosinophilia. Some HES forms have a poor prognosis, either because of end-organ damage (particularly endomyocardial fibrosis), or because of associated myeloid leukemia or malignant T-cell lymphoma. Oral mucosa ulcerations can be early clinical signs in severe forms. They are discrete, round or oval, sometimes confluent ulcers or erosions, located on non-keratinized, unattached oral mucosa. In the last 15 years a better understanding of eosinophil biology has led to a new clinical classification of HES. The lymphocytic form is characterized by T-lymphocyte clonality, IL-5 production, and a possible progression to T-cell lymphoma. Oral lesions are more frequently associated with the myeloproliferative form, characterized by an increased risk of developing myeloid malignancies and a good response to a recent anti-tyrosine kinase therapy (imatinib mesylate). The target of imatinib is a novel kinase resulting from an 800-kb deletion on chromosome 4. Recently, the resulting FIP1L1-PDGFRalpha fusion gene was characterized as a marker of response to imatinib. Exclusion of other erosive ulcerative oral disease and early recognition of HES in patients with oral ulcerations, and precise characterization of the lymphocytic or myeloproliferative form are therefore important to rapidly initiate an effective therapy.

Anti-asthmatic potential of a D-galactose-binding lectin from Synadenium carinatum latex

Extracts from the plant Synadenium carinatum latex are widely and indiscriminately used in popular medicine to treat a great number of inflammatory disorders and although the mechanisms underlying these effects remain undefined, the lectin isolated from S. carinatum latex (ScLL) is thought to be in part responsible for these anti-inflammatory effects. In order to elucidate possible immunoregulatory activities of ScLL, we investigated the effects of ScLL administration in models of acute and chronic inflammation. Oral administration of ScLL significantly inhibited neutrophil and eosinophil extravasation in models of acute and chronic inflammation and reduced eosinophil and mononuclear blood counts during chronic inflammation. ScLL administration reduced IL(interleukin)-4 and IL-5 levels but increased interferon-gamma and IL-10 in an asthma inflammatory model, which suggested that it might induce a TH2 to TH1 shift in the adaptive immune response. ScLL also inhibited IkappaBalpha degradation, a negative regulator of proinflammatory NF-kappaB. Taken together, these results provide the first description of a single factor isolated from S. carinatum latex extract with immunoregulatory functions and suggest that ScLL may be useful in the treatment of allergic inflammatory disorders.

Eosinophil infiltration in post-transurethral resection prostatitis and cystitis with special reference to sequential changes of eosinophilia

Post-transurethral resection (TUR) status in the prostate and urinary bladder has been infrequently documented. Furthermore, sequential changes in eosinophil count in peripheral blood (PB) after TUR have not been investigated in detail. In the present study, eosinophil counts and changes in eosinophils in PB were examined before to after TUR of the prostate (P) in 20 patients with benign prostatic hyperplasia. Among them, 14 patients exhibited increased numbers of eosinophils, the greatest increase being 17%. After TUR to treat bladder tumor (BT), massive infiltration of eosinophils into the resected areas, peaking 1 month later, was also detected in 8 of 15 cases of post-TUR cystitis. The PB eosinophil counts increased by more than 5% in two of five cases of post-TUR cystitis in which eosinophil counts were obtained before and after surgery. Most infiltrating eosinophils reacted positively to antibodies to eosinophil cationic proteins. These results indicated that, in patients with post-TUR prostatitis, the number of eosinophils in PB increased, and peaked 1 month later, with infiltration by eosinophils observed. Pathologists and urologists should be aware of the potential for increase in eosinophils not only in regions of TUR but also in PB.

Eosinophilic cystitis: successful long-term treatment with montelukast sodium

We report a rare case of eosinophilic cystitis in a 6-year-old boy who presented with irritative voiding symptoms, peripheral eosinophilia, and a bladder mass initially visualized on ultrasonography. Cystoscopy and transurethral biopsy confirmed the diagnosis. Complete resolution of his symptoms occurred within 1 week of corticosteroid use and the x-ray findings improved within 6 weeks. At 6 months of follow-up, the patient continued to require a leukotriene receptor antagonist (montelukast sodium) despite several attempts to discontinue its use. We propose that eosinophilic cystitis in children who present with peripheral eosinophilia will often require long-term treatment.

Eosinophilic cystitis and its management

Eosinophilic cystitis (EC) is a rare clinicopathological condition characterized by transmural inflammation of the bladder predominantly with eosinophils, associated with fibrosis with or without muscle necrosis. The cause of EC remains unclear, although it has been associated with various aetiological factors, such as allergy, bladder tumour, bladder trauma, parasitic infections and chemotherapeutic agents. EC is, probably, caused by the antigen-antibody reaction. This leads to the production of various immunoglobulins, which, in turn, cause the activation of eosinophils and initiates the inflammatory process. The most common symptom complex consists of frequency, haematuria, dysuria and suprapubic pain. Cystoscopy and biopsy are the gold standard for diagnosis. Additional laboratory evidence supporting the diagnosis includes proteinuria, microscopic haematuria and peripheral eosinophilia, the last one occurring in few patients. There is no curative treatment for this condition. Current treatment modalities include transurethral resection of the bladder lesion along with non-specific medical therapy, such as non-steroidal anti-inflammatory agents or steroids. Because the lesion tends to recur in spite of the above therapy, long-term follow-up is mandatory.

In situ eosinophil activation in 26 primary cutaneous T-cell lymphomas with blood eosinophilia

Blood and tissue eosinophils can be associated with Hodgkin and non-Hodgkin lymphomas in that they have prognostic value. Tissue eosinophils in T-cell lymphoma patients with blood eosinophilia have not been systematically assessed. The objective of this research was to study the presence, density, and activation of tissue eosinophils in patients with primary cutaneous T-cell lymphomas (CTCLs) with blood eosinophilia and a possible relationship between features of the disease and prognosis. With skin biopsy specimens from 26 CTCL patients with blood eosinophilia, tissue eosinophils were studied with electron microscopy, extracellular eosinophil peroxidase deposits, and interleukin-5 expression. Tissue eosinophils, found in 22 of 26 cases, were constantly activated. Both density and activation of tissue eosinophils were significantly related to disease progression. The state of activation of tissue eosinophils in CTCL might reflect inflammatory flare-ups associated with aggressive lymphomas. Further studies are needed to confirm the value of eosinophil density as a simple and reliable marker of CTCL progression.

Histochemical and immunohistochemical protocols for routine biopsies embedded in Lowicryl resin

Tissue processing and analysis require good preservation of both the shape and content of cells. Lowicryl resin is one of the few embedding media that allow good preservation of both tissue architecture and cellular contents. Therefore, different histochemical and immunohistochemical reactions can be applied to semithin sister sections from one biopsy. Further examination of a zone of interest can be carried out under the electron microscope. The hydrophilic property of Lowicryl resins makes possible different histochemical reactions; however, the technique used for paraffin sections must be adapted for each reaction. Antigenic preservation of cells by low temperature embedding allows immunolabeling on either semithin sections or in the zone of interest on ultrathin sections. We have shown the application and adaptation of different histochemical and immunohistochemical reactions on semithin and ultrathin sections from hepatic biopsies that were large, but thin. The variety of techniques that can be used on sister Lowicryl sections of a single biopsy makes this medium useful for extensive pathological studies of precious needle biopsies.

Cellular localization of interleukin-5 expression in rectal carcinoma with eosinophilia

Eosinophilia often occurs in malignant diseases. This report concerns a female patient aged 76 years, diagnosed with rectal carcinoma with eosinophilia. Sera were obtained at two different periods (at diagnosis and after the operation) for the evaluation of levels of interleukin-5 (IL-5). The serum IL-5 level increased to 264 pg/mL, and returned to an undetectable level after the operation. The serum at diagnosis enhanced the viability of normal eosinophils in vitro, and this activity was inhibited by antihuman IL-5 polyclonal antibody. Immunohistochemistry and in situ hybridization revealed that stromal eosinophils contained IL-5 protein and messenger RNA (mRNA), but no IL-5 transcripts were detected in eosinophils attached to carcinoma cells. In situ detection of apoptosis showed that several eosinophils attached to tumor cells underwent apoptosis and lost their eosinophil secreted cationic protein (ECP) and major basic protein (MBP). These results may suggest that activated eosinophils by IL-5 play an important role in host defense mechanisms, releasing their toxic granule proteins on adjoining tumor cells.