Gastric mucosa-associated lymphoid tissue in autoimmune thyroid diseases

Is Helicobacter pylori colonization associated with chronic tonsillitis? - A meta-analysis and systematic review

PURPOSE

The aim of this study was to investigate the correlation between Helicobacter pylori colonization of tonsillar tissue in chronic tonsillitis and in noninfectious hyperplastic tonsils.

MATERIALS AND METHODS

All included studies investigated the presence of Helicobacter pylori in tonsillar tissue removed for infectious or noninfectious factors. Included studies must have used an accepted method of testing for Helicobacter pylori. We pooled six eligible studies to perform a traditional meta-analysis.

RESULTS

Six studies were included, including 462 patients. Helicobacter pylori does have a significant role in chronic tonsillitis compared with noninfectious indications for tonsillectomy for children population. Detection methods had effects on results.

CONCLUSION

The positive rate of Helicobacter pylori in chronic tonsillitis group was significantly higher than that in simple noninfectious group for the pediatric population, but not for adults. We suspected that chronic tonsillitis is likely to be relevant to Helicobacter pylori.

To Evaluate the Role of H. pylori in Patients with Chronic Recurrent Tonsillitis

The usual indication for surgical resection of tonsils is chronic recurrent tonsillitis. Literature also does not indicate the reason behind the fact that only part of the population suffers from recurrent chronic tonsillitis in spite being exposed to similar conditions. This was a prospective study, in which 50 tonsil biopsy samples obtained from chronic tonsillitis patients. Specimens were analysed with rapid urease broth test, HelicotecUT PLUS assay and Toluidine blue staining for presence of Helicobacter pylori. The age ranged from 4 to 34 years. The median age for patients with chronic recurrent tonsillitis was 9.5, 23 (46%) patients were male while 27 (54%) were female, presence of H. pylori by rapid urease broth test, HelicotecUT PLUS assay and Histopathology was 4%. Our analysis revealed that H. pylori did not significantly colonize the tonsils and does not play a role in the pathogenesis or development of chronic tonsillitis. The heterogeneity in study population and methodology may have contributed to the non significant results.

Helicobacter pylori infection and endocrine disorders: Is there a link?

Helicobacter pylori (H pylori) infection is a leading world-wide infectious disease as it affects more than half of the world population and causes chronic gastritis, peptic ulcer disease and gastric malignancies. The infection elicits a chronic cellular inflammatory response in the gastric mucosa. However, the effects of this local inflammation may not be confined solely to the digestive tract but may spread to involve extra-intestinal tissues and/or organs. Indeed, H pylori infection has been epidemiologically linked to extra-digestive conditions and diseases. In this context, it has been speculated that H pylori infection may be responsible for various endocrine disorders, such as autoimmune thyroid diseases, diabetes mellitus, dyslipidemia, obesity, osteoporosis and primary hyperparathyroidism. This is a review of the relationship between H pylori infection and these endocrine disorders.

Maltoma of the thyroid and Sjögren's syndrome in a woman with Hashimoto's thyroiditis

We report the case of a 70-yr-old woman with maltoma of the thyroid, Sjögren's syndrome, and a history of Hashimoto's thyroiditis. The patient underwent a total thyroidectomy for a recently growing mass of the thyroid, while being treated with L-thyroxine for Hashimoto's thyroiditis. Postoperatively, routine histologic examination was consistent with the diagnosis of chronic lymphocytic thyroiditis of autoimmune etiology. Three years later, the patient presented with high temperature, anorexia, and coughing. This time, a microscopic examination of deeper thyroid tissue sections and an immunohistochemical study revealed a low-grade, non-Hodgkin lymphoma, MALT type. Simultaneously, the diagnosis of Sjögren's syndrome was established and the patient is currently under investigation for generalized lymphoma. This case clearly demonstrates the difficulty in differentially diagnosing Hashimoto's thyroiditis from low-grade MALT lymphoma by the use of routine histologic examination.

Weight loss and fatigue in an elderly patient

We report a recent clinical case of an elderly patient who presented with weight loss and fatigue and who was diagnosed with hyperthyroidism. Some time later, he was discovered to have underlying oesophageal lymphoma. The latter diagnosis was believed to contribute, at least in part, to his symptoms at the time of initial presentation. The case illustrates the potential difficulties associated with establishing the diagnosis of oesophageal lymphoma. Furthermore, symptoms of weight loss and fatigue are commonly encountered in general medical patients. This case reminded us that even when a diagnosis of hyperthyroidism has been established, these symptoms may be attributable to other pathology.

Is there anything to the reported association between Helicobacter pylori infection and autoimmune thyroiditis?

Higher serological prevalence rates of Helicobacter pylori (Hp) infection have been reported in patients with autoimmune thyroiditis (AT), and it has been suggested that monoclonal antibodies against Cag-A positive Hp strains can cross-react with follicular cells of the thyroid gland. We studied the prevalence of AT and thyroid functional status in patients who underwent gastroscopy for dyspeptic symptoms. Patients were tested for TSH, free thyroid hormones, and antithyroglobulin and antithyroperoxidase antibodies (ATPO). Hp positivity was determined using urea breath test (UBT). Serum samples from 302 patients (59.9% women) were evaluated. One hundred ninety-one subjects (63.2%) were Hp-negative, and 111 of 302 (36.8%) were Hp-positive. Forty-three of 191 Hp-negative patients (22.5%; 95% CI, 17.1-29.0%) had an increase of either antibody, compared to 30 of 111 (27.0%; 95% CI, 19.6-36.0%) Hp-positive patients (P = 0.40). Similar results were obtained using positivity for both antibodies (7.3 vs. 7.2%; P = 1) or for ATPO (18.8 vs. 21.6%; P = 0.54). The prevalences of hypothyroidism (4.7 vs. 5.5%) or hyperthyroidism (5.8 vs. 5.5%) were also similar (P = 0.95). Hormonal levels were not different in the two groups (P > 0.22 in all cases). The previously reported association between AT and Hp infection was not observed in our study. Infection by Hp does not appear to increase the risk of AT in individuals with dyspeptic symptoms, and screening for this condition in patients with a positive UBT is not indicated.

Disappearance of gastric mucosa-associated lymphoid tissue in hepatitis C virus-positive patients after anti-hepatitis C virus therapy

OBJECTIVE

Mucosa-associated lymphoid tissue, which has a follicular structure closely resembling Peyer patches, is absent in the normal gastric mucosa, but it can develop in several chronic conditions. Since we recently detected hepatitis C virus-RNA in gastric mucosa-associated lymphoid tissue of patients with chronic hepatitis C, we tried to treat hepatitis C virus infection to evaluate the effect of antiviral therapy on gastric mucosa-associated lymphoid tissue.

METHODS

Eighteen patients (12 men and 6 women; mean age: 52 years, range: 33-71 years) affected by chronic hepatitis C virus and with gastric mucosa-associated lymphoid tissue were enrolled. We enrolled only patients hepatitis C virus-positive, mucosa-associated lymphoid tissue-positive, and Helicobacter pylori-negative (8 patients) or hepatitis C virus-positive patients in whom anti-H. pylori therapy did not obtain disappearance of gastric mucosa-associated lymphoid tissue (10 patients). Hepatitis C virus was evaluated by hepatic biopsy with histologic evaluation and serologic examination; Gastric mucosa-associated lymphoid tissue was scored using Wotherspoon score. All patients were treated with recombinant leukocyte interferon-alpha-2b plus oral ribavirin for 6 months. The hepatitis C virus RNA was assayed at entry and at 3 months after stopping treatment. Virologic response was defined as undetectable levels of serum hepatitis C virus RNA 3 months after stopping treatment; esophagogastroduodenoscopy was repeated at this time to evaluate the effect of anti-hepatitis C virus therapy on acquired gastric mucosa-associated lymphoid tissue.

RESULTS

Two (11.11%) patients were withdrawn from the study. Hepatitis C virus cure was obtained in 11/16 patients (68.75%), and in all of them we obtained disappearance of gastric mucosa-associated lymphoid tissue (P < 0.01). Hepatitis C virus infection persisted, but with very lower levels, in 5 of 16 patients (31.25%): in 3 patients gastric mucosa-associated lymphoid tissue persisted (but in 2 it decreased from grade 3 to grade 2), while in 2 it disappeared.

CONCLUSIONS

We showed clearly that there is a strict correlation between hepatitis C virus infection and acquired MALT, obtaining the disappearance of this acquired immunologic acquired gastric tissue curing hepatitis C virus infection. However, further studies are needed to clarify there is the same correlation between hepatitis C virus infection and gastric mucosa-associated lymphoid tissue lymphomas in hepatitis C virus-positive patients.

Early cancer of the stomach arising after successful treatment of gastric MALT lymphoma in patients with autoimmune disease

BACKGROUND

Extranodal marginal zone B-cell lymphoma of the mucosa associated lymphoid tissue (MALT lymphoma) arises in lymphoid tissue acquired through chronic antigenic stimulation as exemplified by Helicobacter pylori. Secondary development of gastric cancer, however, is thought to be a rare event. The detection of a signet ring cell carcinoma during follow-up endoscopy after successful therapy of MALT lymphoma in a patient with Sjögren's syndrome prompted us to analyse the frequency of subsequent gastric cancer in patients with underlying autoimmune disease (AD).

METHODS

Patients with early stage MALT lymphoma and an underlying AD were evaluated for the occurrence of a secondary gastric cancer during the course of follow-up. Data analysed included the type of AD, stage of MALT lymphoma, H. pylori status, treatment for MALT lymphoma and response, follow-up, the presence of a secondary cancer, and time to development of cancer. In all patients, histologic samples were reassessed for the extent of gastritis, presence of intestinal metaplasia or focal atrophy at the time of lymphoma diagnosis.

RESULTS

A total of eight patients with overt AD at the time of diagnosis of MALT lymphoma were identified. All patients were women aged between 56 and 77 years; 5 had Sjögren's syndrome, 2 had autoimmune thyroiditis (1 along with psoriasis) and 1 suffered from polymyalgia rheumatica. All patients had early stage MALT lymphoma restricted to the mucosa and submucosa at the time of diagnosis, and the presence of H. pylori was found in all cases. Two of these patients achieved complete remission (CR) of the lymphoma following H. pylori eradication, while six were judged unresponsive and underwent chemotherapy, resulting in CR in all cases. One patient died from stroke while being in CR for 2 months following chemotherapy. Two patients (25%) developed early cancer limited to the gastric mucosa while being in CR from lymphoma for 9 and 27 months, respectively, and underwent partial gastrectomy. Final staging of gastric cancer revealed pT1pN0M0 in both cases. Of the remaining 5 cases, 1 patient had a local lymphoma relapse 18 months after CR and was salvaged with radiotherapy. In the remaining 4 patients, no evidence of lymphoma recurrence or a second malignancy has been found so far by regular follow-up every 3 months for a time-span between 52 and 63 months after initial diagnosis.

CONCLUSION

Patients with concurrent MALT lymphoma and an underlying autoimmune condition show not only an impaired response to H. pylori eradication but might also be at increased risk for the development of gastric cancer. In view of this, such patients should be followed closely by regular endoscopies after remission of MALT lymphoma.

Detection of HCV RNA in gastric mucosa-associated lymphoid tissue by in situ hybridization: evidence of a new extrahepatic localization of HCV with increased risk of gastric malt lymphoma

OBJECTIVES

Mucosa-associated lymphoid tissue (MALT) is absent in the normal gastric mucosa but it can develop in several conditions, such as Helicobacter pylori infection. A certain correlation between hepatitis C virus (HCV) infection and low grade MALT lymphomas has recently been reported. The aim of this study was to investigate the presence of HCV RNA in acquired gastric MALT of HCV-infected patients using the in situ hybridization technique.

METHODS

Twenty-five patients (16 male and nine female, average age = 56.6 yr [range = 33-75]) affected by chronic HCV hepatitis and with gastric MALT were studied. Giemsa stain and the rapid urease test were also used to evaluate the presence of H. pylori. A polymerase chain reaction product corresponding to the complete 5' noncoding region of the HCV genome was cloned directly in the pCR 1000 vector on gastric biopsies with acquired MALT.

RESULTS

Twenty patients showed grade 2 gastric MALT and five showed grade 3, and H. pylori's presence was detected in 18 of 25 patients (72%). Using in situ hybridization, we detected HCV RNA in gastric acquired MALT of seven of 25 patients (28%): five showed grade 2 gastric MALT (two of these were H. pylori negative and the other three were positive), whereas two patients showed grade 3 gastric MALT (without H. pylori infection).

CONCLUSIONS

This study shows that HCV not only may colonize gastric MALT but also may permit the development of a grade of acquired MALT, which may represent the first step toward a MALT lymphoma. However, further studies are needed to demonstrate the antigenic role of HCV in the progression of acquired MALT into MALT lymphoma.

Monoclonal gammopathy of undetermined significance predisposing to Helicobacter pylori-related gastric mucosa-associated lymphoid tissue lymphoma

Gastric mucosa-associated lymphoid tissue (MALT)-associated B-cell proliferation may range from benign to malignant, and Helicobacter pylori is the only identified critical antigenic stimulus to the development of gastric MALT. Monoclonal gammopathy of undetermined significance (MGUS) is characterized by B-cell hyper-activation and clonal expansion and is know to predispose to B-cell malignancies. We report a patient with MGUS and H. pylori infection in whom we noted the progression of gastritis to acquired gastric MALT and gastric MALT to MALT lymphoma during a 3-year follow-up.

Impaired response of gastric MALT-lymphoma to Helicobacter pylori eradication in patients with autoimmune disease

BACKGROUND AND AIMS

Gastric MALT-lymphoma is thought to be related to chronic antigenic stimulation provided by Helicobacter pylori (HP). As clonal expansion of gastric B cells not related to HP has been demonstrated in patients with autoimmune disease (AD), we have analysed whether AD adversely influences response of MALT-lymphoma following HP-eradication.

PATIENTS AND METHODS

Retrospective analysis of all patients with early stage gastric MALT-lymphoma treated with HP-eradication was performed. The presence of AD was evaluated by personal questioning for specific symptoms and serologically by analysis of rheumatoid factor, antinuclear antibodies and thyroid autoantibodies.

RESULTS

A total of 22 patients were identified receiving only antibiotic treatment for initial management, and six presented with an autoimmune condition: three had Sjögren's syndrome, one polymyalgia rheumatica, one autoimmune thyroiditis along with psoriasis, and one patient had only autoimmune thyroiditis. Successful eradication of HP was achieved in all patients, and 15 of 22 patients (68%) achieved complete response of the lymphoma, while none out of the six patients with an autoimmune disorder responded to HP-eradication.

CONCLUSION

Apart from questioning the role of HP in the development of lymphoma in such patients, these results suggest that patients with autoimmune disease might not be optimal candidates for HP-eradication even in case of early stage lymphoma.

Extranodal lymphoma of MALT-type: perspective at the beginning of the 21st century

Extranodal lymphomas arising from mucosa associated lymphoid tissue (MALT) have become a focus of interest in recent years due to their unique pathological and clinical properties. The link between Helicobacter pylori and the development of gastric MALT-type lymphoma has revolutionized treatment options as up to 80% of patients with early gastric MALT-type lymphoma achieve complete remission of the tumor following eradication of H. pylori. As opposed to surgical intervention, which has been the preferred form of treatment in the past, organ conserving approaches are increasingly being applied, as both irradiation and chemotherapy have given excellent results. However, mature data from prospective, randomized studies taking into account the concept of MALT lymphoma as a distinct entity are still lacking in order to define the optimal approach to the management of MALT-type lymphoma.

Acquired gastric mucosa-associated lymphoid tissue (MALT): a review with special emphasis on association with extragastric diseases and management problems of gastric MALT

Mucosa-associated lymphoid tissue is absent physiologically in normal gastric mucosa, but it can develop in some pathologies (dyspepsia, celiac disease, autoimmune diseases) due to certain (Helicobacter pylori, gluten) or uncertain (viruses?) antigenic stimuli. Its importance is related to the consideration that it is the background for the development of gastric mucosa-associated lymphoid tissue (MALT) lymphoma, and its histologic progression to MALT lymphoma may be diagnosed using Isaacson's score. Monoclonal bands can be diagnosed in acquired gastric MALT as well as in gastric MALT lymphoma, but its role is unknown. To prevent development of MALT lymphoma from acquired MALT, currently anti-H. pylori treatment in all H. pylori- and MALT-positive patients is not suggested--only in patients with grade 3 of acquired MALT--due to the high risk of developing MALT lymphoma in these patients. At the same time, the etiology of gastric MALT in autoimmune extragastric diseases is not clear. Additional studies are needed to clarify this relation and its possible causes.

Helicobacter pylori infection is markedly increased in patients with autoimmune atrophic thyroiditis

Infection by viral or bacterial pathogens has been suspected in playing a role in the development of autoimmune thyroid disease. Because Helicobacter pylori might be involved in the development of nongastrointestinal conditions such as rosacea, ischemic heart disease, and diabetes mellitus, we evaluated the prevalence of H. pylori infection in patients with autoimmune thyroid disease. Fifty-nine patients with autoimmune thyroid disease were included: autoimmune atrophic thyroiditis (n=21), Hashimoto's thyroiditis (n=18), and Graves' disease (n=20). Twenty patients with nontoxic multinodular goiter served as controls for nonautoimmune thyroid disease, and 11 patients with Addison's disease served as controls for nonthyroid endocrine autoimmune disease. The levels of anti-H. pylori immunoglobulin G (IgG) were determined, and a radiolabeled urea breath test were performed. The prevalence of H. pylori infection was markedly increased in the patients with autoimmune atrophic thyroiditis (85.7%), compared with the controls with nontoxic multinodular goiter (40%) and Addison's disease (45.4%). Infection by H. pylori resulted in increased levels of gastrin, pepsinogen I, and pepsinogen II in the H. pylori-positive groups, compared with the H. pylori-negative groups. A positive linear regression was found between the levels of microsomal autoantibodies and those of anti-H. pylori IgG in patients with autoimmune atrophic thyroiditis (n=21; r=0.79; p < 0.01). Finally, and although the overall prevalence of H. pylori infection was not increased, the anti-H. pylori IgG levels and the results from the breath test were higher in the patients with Graves' disease and Hashimoto's thyroiditis patients than in the controls. Clearly, the prevalence of H. pylori infection is increased in autoimmune atrophic thyroiditis and results in abnormalities of gastric secretory function. The strong relation between the levels of anti-H. pylori IgG and the levels of microsomal antibodies suggests that H. pylori antigens might be involved in the development of autoimmune atrophic thyroiditis or that autoimmune function in autoimmune atrophic thyroiditis may increase the likelihood of H. pylori infection.

Disappearance of gastric mucosa-associated lymphoid tissue in coeliac patients after gluten withdrawal

BACKGROUND

Mucosa-associated lymphoid tissue (MALT) develops in gastric mucosa in response to chronic antigenic stimulation, such as Helicobacter pylori infection. However, reactive lymphoid follicles have been found also in the stomach of H. pylori-negative coeliac patients, suggesting that other environmental factors may be involved in MALT genesis. The aim of our study was to evaluate the effects of gluten withdrawal in H. pylori-negative coeliac patients with gastric MALT.

METHODS

We studied 23 H. pylori-negative untreated coeliac patients with gastric MALT. All patients underwent determination of antigliadin (AGA) and antiendomysium antibodies (EMA) and upper endoscopy with multiple biopsies in duodenum, gastric corpus, and antrum. Lymphoid follicles and H. pylori status were assessed by histopathologic and enzymatic analysis. All patients were started on a gluten-free diet and were reevaluated after 12 months. To consider their adherence to the gluten-free diet we relied on direct patient questioning. Thirteen patients who had strictly adhered to the gluten-free diet constituted our study group. Ten patients who had not strictly adhered to gluten withdrawal from their diet constituted the control group.

RESULTS

Regression of MALT was obtained in 9 of 13 (69%) patients who strictly followed the gluten-free diet; in the control group MALT disappeared in 2 of 10 (20%) patients (P=0.0361).

DISCUSSION

Disappearance of reactive lymphoid follicles in the gastric mucosa of H. pylori-negative coeliac patients after gluten withdrawal suggests that antigens related to alimentary gluten may constitute persistent stimuli for development of gastric MALT in coeliac patients.