A258 ROSAI-DORFMAN0-DESTOMBES DISEASE: A RARE CAUSE OF OBSTRUCTIVE JAUNDICE

Background

Rosai-Dorfman-Destombes Disease (RDD) is rare histiocytic disorder that is most frequently seen in children and young adults. Gastrointestinal involvement is reported in <1% of cases and typically involves the small bowel and colon. Pancreatic and hepatic involvement has been previously reported but is extremely rare.

Aims

To describe a case of obstructive jaundice in the setting of a very rare histiocytic disorder known as RDD.

Methods

Case Report

Results

A 59-year old previously healthy male of Asian descent presented with obstructive jaundice. Initial imaging demonstrated intra and extrahepatic biliary duct dilation with concurrent diffuse enlargement of the pancreas compatible with autoimmune pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) was performed with stenting and biopsy. ERCP demonstrated a distal common bile duct stricture with biopsies suggestive of low grade reactive changes and inflammation. Subsequent endoscopic ultrasound (EUS) guided biopsy of the pancreas showed active and chronic inflammation, necrosis, and atrophic pancreatic tissue, with no definitive evidence of autoimmune pancreatitis (Figure 1). Ca-19-9 and IgG4 were normal. He was treated with a course of prednisone and responded well, with repeat CT imaging showing almost complete resolution of the previously demonstrated pancreatic changes. A diagnosis of autoimmune pancreatitis was made. He re-presented 6-months later, however, with fatigue and repeat imaging now displayed lymphadenopathy in the neck, chest, and abdomen, and a bulky pancreatic head with associated hepatomegaly. Lymph node excisional biopsy confirmed the diagnosis of RDD with the presence of scattered histiocytic cells showing emperipolesis with a low number of IgG4 positive cells (Figure 1). The patient was promptly initiated on prednisone and rituximab and has since then had excellent clinical response.

Conclusions

RDD is a rare non-Langerhans cell histiocytosis of unknown etiology that has a prevalence of 1:200 000. RDD clinically presents with painless bilateral cervical lymphadenopathy and can manifest with both nodal and extra nodal involvement. The most common sites of extra nodal disease are the skin and central nervous system, but rarely, can also present with pancreatic involvement. The use of fine needle guided biopsy in diagnosing RDD with extra nodal disease can be limited by low yield, sclerotic tissue, or non-diagnostic findings. For this reason, RDD with pancreatic involvement can masquerade as autoimmune pancreatitis, pancreatic malignancy and IgG4-related disease.This case report raises awareness about RDD with pancreatic and biliary involvement, a rare entity, that can present with obstructive jaundice.

Figure 1: Histological sections of lymph node(left) with hystiocytic cells showing emperipolesis(arrow) and pancreas(right) showing active and chronic inflamation, necrosis and atrophy

Funding Agencies

None

A101 BLASTIC PLASMACYTOID DENDRITIC CELL NEOPLASM OCCURRING POST-LIVER TRANSPLANT FOR PSC WITH CLINICAL REMISSION OF ULCERATIVE COLITIS AFTER STEM CELL TRANSPLANTATION

Background

Primary sclerosing cholangitis (PSC) is a rare autoimmune fibroinflammatory disease that is associated with inflammatory bowel disease (IBD) and can progress to end-stage liver disease (ESLD) requiring liver transplantation (LT). Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a highly aggressive and rare hematologic malignancy (HM) that usually affects elderly males. High-dose chemotherapy followed by allogenic stem cell transplantation (SCT) offers the best chance of long-term remission in BPDCN. While it is well described that there is an increased risk of de-novo cancer development after solid organ transplantation (SOT), these are less commonly HMs. There are currently no documented cases of BPDCN in post-SOT patients in the literature.

Aims

To describe one of the first cases of BPDCN in a patient post-SOT, and subsequent clinical resolution of UC post SCT.

Methods

Case Report

Results

A 19-year-old previously healthy male initially presented with cholangitis and was diagnosed with PSC. Two years after the diagnosis of PSC, he progressed to ESLD and underwent live donor LT in India. He subsequently presented with episodes of bloody diarrhea and a colonoscopy then revealed diffuse mucosal edema, erosions, and spontaneous bleeding, with scattered inflammatory polyps throughout the colon. UC was diagnosed and Infliximab therapy was started. He later presented with a UC flare and Vedolizumab therapy was initiated. A liver biopsy showed recurrent sclerosing cholangitis and ultimately the patient required a second liver transplant. After the second LT he developed weight loss, arthralgias, and progressive splenomegaly following which BPCDN was diagnosed. His Vedolizumab was subsequently stopped. He received induction chemotherapy followed by a single antigen mismatched allogenic SCT. Whilst he had numerous complications associated with his chemotherapy induction, his UC appeared to be in clinical remission. No repeat colonoscopies were completed, however, on follow-up assessments, he denied abdominal pain and reported having formed, non-bloody stools. Unfortunately, he suffered an aggressive relapse of his BPCDN, and he was palliated.

Conclusions

The development of de-novo cancers after LT is common, and patients with PSC are at particularly high risk. PSC-LT patients have also been found to have the highest rate of hematological malignancies post LT; however, these are most commonly post-transplant lymphoproliferative disorder. Additionally, there have been a few reports of complete resolution of IBD after allogenic mismatched SCT. Here we describe one of the first cases of BPCDN post-LT in a PSC-UC patient and display another example of UC clinical remission post allogenic SCT. These findings emphasize that close follow-up of these patients after LT is imperative.

Funding Agencies

None

A136 A RARE CAUSE OF AUTOIMMUNE ATROPHIC PANGASTRITIS COMPLICATED WITH GASTRIC OUTLET OBSTRUCTION

Background

Chronic gastritis comes in two well recognized forms: environmental, which is most commonly antral or multifocal in distribution and is typically caused by Helicobacter Pylori (HP) infection, and autoimmune gastritis(AIG), which affects the corpus and fundus. Presented here is a case of autoimmune atrophic pangastritis(AIAP).

Aims

To increase awareness of a rare condition with limited data on available treatment modalities.

Methods

Case Report

Results

A 68-year old female with autoimmune hypothyroidism, presented with weight loss and elevated anti-TTG serology. Index esophagogastroduodenoscopy (EGD) biopsies demonstrated chronic non-specific gastritis limited to the antrum. Strict gluten free diet adherence was initiated. Testing for HLA revealed HLADq2 and HLADq8 negativity but HLADq2.5 positivity. Subsequent EGD showed a markedly atrophic appearing gastric body. The corresponding biopsies demonstrated persistent moderately chronic active gastritis with severe atrophy now involving the body, fundus and antrum. The biopsies were negative for HP. Notably, there was a lack of ECL-cell hyperplasia and the number of antral G cells appeared decreased. Anti-parietal cell antibody serology was positive with a titre of 1:80. Despite combination therapy with budesonide and mesalamine and treatment for HP given persistent symptoms, the patient’s course was further complicated by gastric-outlet obstruction (GOO). Urgent EGD biopsies showed pyloric stenosis requiring dilation. Endoscopic Ultrasound (EUS) guided biopsies were negative for malignancy. The patient was started on corticosteroids and azathioprine(AZA). Most recently, an EGD on AZA, continued to demonstrate severe chronic active pangastritis now with intestinal metaplasia involving the body. Corticosteroid therapy was reinitiated with a plan to start mycophenolate mofetil (MMF).

Conclusions

AIAP is a rarely described entity, not well documented in the literature. An eight patient case series reported a distinctive form of atrophic gastritis that was independent of HP infection with the absence of neuroendocrine hyperplasia that involved the body and antrum. Thyroid disease, specifically Hashimoto thyroiditis is present in about 40% of patients with AIG. Additionally, AIG progression to atrophic gastritis with intestinal metaplasia confers an increased risk for gastric adenocarcinoma in more than 10% of patients.

Limited literature exists regarding the management of AIAP. Pediatric data suggests the use of prednisone and/or azathioprine for AIAP. Furthermore, a recent case report of AIAP demonstrated clinical and endoscopic remission with MMF. Currently, no guidelines exist for the treatment, screening and monitoring of patients with AIAP. This case report presents a rare case of AIAP refractory to AZA complicated with GOO and adds to the little literature that exists.

Funding Agencies

None

Chromosome-wide distribution of haplotype blocks and the role of recombination hot spots

Recent studies of human populations suggest that the genome consists of chromosome segments that are ancestrally conserved ('haplotype blocks'; refs. 1-3) and have discrete boundaries defined by recombination hot spots. Using publicly available genetic markers, we have constructed a first-generation haplotype map of chromosome 19. As expected for this marker density, approximately one-third of the chromosome is encompassed within haplotype blocks. Evolutionary modeling of the data indicates that recombination hot spots are not required to explain most of the observed blocks, providing that marker ascertainment and the observed marker spacing are considered. In contrast, several long blocks are inconsistent with our evolutionary models, and different mechanisms could explain their origins.

Mining SNPs from EST databases

There is considerable interest in the discovery and characterization of single nucleotide polymorphisms (SNPs) to enable the analysis of the potential relationships between human genotype and phenotype. Here we present a strategy that permits the rapid discovery of SNPs from publicly available expressed sequence tag (EST) databases. From a set of ESTs derived from 19 different cDNA libraries, we assembled 300,000 distinct sequences and identified 850 mismatches from contiguous EST data sets (candidate SNP sites), without de novo sequencing. Through a polymerase-mediated, single-base, primer extension technique, Genetic Bit Analysis (GBA), we confirmed the presence of a subset of these candidate SNP sites and have estimated the allele frequencies in three human populations with different ethnic origins. Altogether, our approach provides a basis for rapid and efficient regional and genome-wide SNP discovery using data assembled from sequences from different libraries of cDNAs.

Intrafamilial sexual abuse: family-of-origin and family-of-procreation characteristics of female adult victims

We examined connections between incest victims' family-of-origin and family-of-procreation characteristics in a sample of 40 American women who were in treatment for childhood or adolescent experiences of victimization. Retrospective data on their families-of-origin were collected along with their perceptions of current relationships with family members in the three-generational system. Results showed a close association between family-of-origin and family-of-procreation characteristics, especially in the areas of intergenerational intimacy, intergenerational fusion/individuation, and personal authority. A number of significant correlations were also found between subjects' past and present relationships with family-of-origin members and the dimensions of moral and religious orientation, achievement, and intellectual and cultural orientation, conflict, and control in their family-of-procreation. Some aspects of individual adjustment, including alienation, emotional discomfort, and defensiveness, were strongly related to various family-of-origin and family-of-procreation characteristics.