ObjectivesCounting intraepithelial lymphocytes (IEL) is central to the histological diagnosis of coeliac disease (CD), but no definitive ‘normal’ IEL range has ever been published. In this multicentre study, receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off between normal and CD (Marsh III lesion) duodenal mucosa, based on IEL counts on >400 mucosal biopsy specimens.DesignThe study was designed at the International Meeting on Digestive Pathology, Bucharest 2015. Investigators from 19 centres, eight countries of three continents, recruited 198 patients with Marsh III histology and 203 controls and used one agreed protocol to count IEL/100 enterocytes in well-oriented duodenal biopsies. Demographic and serological data were also collected.ResultsThe mean ages of CD and control groups were 45.5 (neonate to 82) and 38.3 (2–88) years. Mean IEL count was 54±18/100 enterocytes in CD and 13±8 in normal controls (p=0.0001). ROC analysis indicated an optimal cut-off point of 25 IEL/100 enterocytes, with 99% sensitivity, 92% specificity and 99.5% area under the curve. Other cut-offs between 20 and 40 IEL were less discriminatory. Additionally, there was a sufficiently high number of biopsies to explore IEL counts across the subclassification of the Marsh III lesion.ConclusionOur ROC curve analyses demonstrate that for Marsh III lesions, a cut-off of 25 IEL/100 enterocytes optimises discrimination between normal control and CD biopsies. No differences in IEL counts were found between Marsh III a, b and c lesions. There was an indication of a continuously graded dose–response by IEL to environmental (gluten) antigenic influence.
Cystic lesions of the thyroid are common findings. Although many thyroid cysts are of benign, some cases of hemorrhagic degenerative changes occur in neoplastic nodules, mostly follicular neoplasms and papillary carcinomas. The occurrence of hemorrhagic changes in medullary carcinomas has never been documented with aspirative cytological and histological pictures to the best of our knowledge. A case of medullary thyroid carcinoma with a large central hemorrhagic cyst is described, and the literature regarding the pathogenesis of this regression and the occurrence of cystic neoplasms in the thyroid is reviewed.
Introduction: Collagenous colitis (CC) is a rare condition that is known to complicate inflammatory bowel diseases, but its relationship with celiac disease (CD) is more controversial. Aims: To report a case of CC that developed in a patient with CD and was manifested by rectal erosions at onset. Case report: A 46-year-old woman was diagnosed with CD and placed on a gluten-free diet. After an initial phase of improvement, her diarrhea resumed, and she began to lose weight. Despite strict adherence to the diet, the patient's diarrhea worsened. One year after diagnosis, colonoscopy was performed and mucosal biopsies were collected, but the findings were inconclusive. Two months later, the previously watery diarrhea became bloody, and a second colonoscopy was performed. Histological examination of the biopsy specimens revealed rectal erosions and CC. The patient was treated with oral prednisone plus mesalazine for 6 weeks, and her symptoms immediately disappeared. Mesalazine was continued, and the prednisone was then gradually replaced with budesonide. Six months after the CC diagnosis, the patient was asymptomatic, and a second colonoscopy revealed no macroscopic or microscopic signs of CC. She continues to take mesalazine and budesonide. An attempt to taper the dosage of the latter drug from 6 to 3 mg/day caused the reappearance of the diarrhea. Conclusion: CC is rarely associated to CD and can cause bloody diarrhea. Excellent results were obtained in this case with prednisone plus mesalazine followed by maintenance therapy with budesonide plus mesalazine.
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