A Combined Deposition of Lanthanum and β2-Microglobulin-Related Amyloid in the Gastroduodenal Mucosa of Hemodialysis-Dependent Patients: An Immunohistochemical, Electron Microscopic, and Energy Dispersive X-Ray Spectrometric Analysis

Review of the diagnosis of gastrointestinal lanthanum deposition

Lanthanum carbonate is used for treatment of hyperphosphatemia mostly in patients with chronic renal failure. Although lanthanum carbonate is safe, recently, lanthanum deposition in the gastrointestinal mucosa of patients has been reported in the literature. This review provides an overview of gastroduodenal lanthanum deposition and focuses on disease’s endoscopic, radiological, and histological features, prevalence, and outcome, by reviewing relevant clinical studies, case reports, and basic research findings, to better understand the endoscopic manifestation of gastrointestinal lanthanum deposition. The possible relationship between gastric lanthanum deposition pattern and gastric mucosal atrophy is also illustrated; in patients without gastric mucosal atrophy, gastric lanthanum deposition appears as diffuse white lesions in the posterior wall and lesser curvature of the gastric body. In the gastric mucosa with atrophy, lanthanum-related lesions likely appear as annular or granular whitish lesions. Moreover, these white lesions are probably more frequently observed in the lower part of the stomach, where intestinal metaplasia begins.

Lumbar vertebral osteomyelitis and psoas abscess caused by Actinomyces israelii after an operation under general anesthesia in a patient with end-stage renal disease: a case report

Background

Actinomycosis is a chronic, slowly progressive infection caused by the Actinomyces species. Lumbar vertebral involvement of Actinomyces israelii is extremely rare; this is the first case report of lumbar vertebral osteomyelitis and psoas abscess caused by Actinomyces israelii after an operation under general anesthesia.

Case presentation

A 66-year-old Japanese man with end-stage renal disease was admitted to our hospital for an operation for cervical canal stenosis. After the operation under general anesthesia, during which tracheal intubation and nasogastric tube insertion were performed, he developed low back pain. During a second hospitalization, computed tomography revealed osteolysis of the lumbar endplates of L2 and L3, swelling of the intervertebral disk of L2/L3, and swelling of the left psoas major muscle. Percutaneous drainage of the intervertebral disc was performed, and the culture of the aspirate grew Actinomyces israelii. Based on the susceptibility, ampicillin was administered but his condition did not improve. We changed the antibiotics to ampicillin-sulbactam for coverage of unidentified oral commensals, and his symptoms and signs finally improved.

Conclusion

Our patient’s long-term end-stage renal disease had made the oral and gastrointestinal mucosal barriers very fragile. Under these conditions, even mildly invasive procedures such as tracheal intubation and nasogastric tube insertion could be the cause of infectious complication by oral commensals, including Actinomyces.

Frequent Involvement of the Duodenum with Lanthanum Deposition: A Retrospective Observational Study

Objective This study aimed to investigate the endoscopic features of lanthanum-associated duodenal lesions and the prevalence of duodenal involvement among patients with pathologically proven lanthanum deposition in the gastrointestinal tract. Methods We retrospectively reviewed 24 patients with pathologically proven lanthanum deposition in the gastrointestinal tract. Patients were subdivided into three groups: Group A, patients with pathologically-proven lanthanum deposition in the duodenum; Group B, patients without lanthanum deposition in the duodenum; and Group C, patients without a biopsy of the duodenum. Results A biopsy examination of the duodenum was performed in 19 patients, and lanthanum deposition was detected in 17 patients (17/19, 89.5%). In group A (n=17), whitish duodenal villi were detected in 15 patients during esophagogastroduodenoscopy (15/17, 88.2%). While the other two patients showed no whitish villi, a biopsy of the duodenal mucosa revealed lanthanum deposition. The deposition of a white substance showing a clear margin was visible within multiple villi under magnified observation in some patients of group A. Group B patients (n=2) also showed whitish villi. However, the whitish color was faint in one case and sparse in the other case. Conclusion Lanthanum deposits in the duodenum may resemble white villi. However, in some cases, these deposits may be unrecognizable during esophagogastroduodenoscopy due to the subtle degree of deposition. Endoscopists should biopsy the duodenum as well as the stomach, regardless of the presence or absence of white villi, for an accurate determination of lanthanum deposition in the gastrointestinal tract.

Lanthanum deposition corresponds to white lesions in the stomach

OBJECTIVE

Although lanthanum deposition in the stomach has been most frequently reported to occur as white lesions, no study has investigated whether the white lesions observed during esophagogastroduodenoscopy are truly lanthanum-related. Here, we retrospectively investigated the amount of lanthanum in endoscopic biopsy specimens.

METHODS

We reviewed four patients showing gastric white spots or annular whitish mucosa in the gastric white lesions (Bw) and peripheral mucosa where the white substance was not endoscopically observed (Bp) during biopsy. We also reviewed three patients with diffuse whitish mucosa and three patients with no whitish lesions. We performed scanning electron microscopy and energy dispersive X-ray spectrometry to quantify the lanthanum elements (wt%) in the biopsy specimens.

RESULTS

The amount of lanthanum in the Bw ranged from 0.15-0.31 wt%, whereas that of Bp was 0.00-0.13 wt%. The difference was statistically significant (P < 0.05). The amount of lanthanum in the Bw, endoscopically presented with white spots or annular whitish mucosa, was significantly higher than that of no whitish lesions (0.05-0.14 wt%, P < 0.05). The amount of lanthanum was also higher in the diffuse whitish mucosa (0.21-0.23 wt%) compared with no whitish lesions (P < 0.01).

CONCLUSIONS

This study is the first to reveal that pathological lanthanum deposition corresponds to the endoscopically observed white lesions in the gastric mucosa. Therefore, during esophagogastroduodenoscopy, physicians should pay attention to possible presence of white lesions in patients treated with oral lanthanum carbonate to ensure prompt identification of associated issues.