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CASE REPORT

H. heilmannii of the stomach

Helicobacter heilmannii of the Stomach--A Case Report

Jeh-En Tzeng, Ying-Lung Lin , Yi-Tsui Chu, Sue-Mei Chung

Department of Pathology, Family Medicine , Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan

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ABSTRACT

Helicobacter heilmannii is a rare pathogen of the human stomach. Its natural hosts are domestic animals. The animal-to-human transmission might be the cause of infections in clinical cases. We herein report a case, which might be the first such case reported in Taiwan, and discuss this rare pathogen with regard to the literature. (Tzu Chi Med J 2004; 16:59-62) Key words: Helicobacter heilmannii, Helicobacter pylori, stomach, zoonosis

INTRODUCTION

Chronic Helicobacter infection of the stomach might increase the risk for development of gastroduodenal disease, such as gastritis, peptic ulcer, and some malignancies [1-3]. The majority of human Helicobacter infections are from Helicobacter pylori. But rare incidences, ranging between 0.01% and 6.2% [4,5], of Helicobacter heilmannii in different areas and populations have continued to be reported since the first case was reported by Dent et al in 1987 [6]. We herein report on another case and discuss this rare pathogen with regard to the literature. This is the first case reported in Taiwan as far as we know.

CASE REPORT

A 58-year-old male who complained of epigastragia and heartburn sensation for months had a health examination at our hospital. Neither a contributory history nor significant findings on physical examination was noted except for domestic dog contact for more than 10 years. The laboratory studies were all within normal limits in-

cluding a negative serologic test for syphilis screening. He received upper gastrointestinal (UGI) endoscopy. Endoscopically, the stomach showed multiple small, shallow, red-based ulcers with marginal erythema and hemorrhage over the erythematous antrum (Fig. 1). Ten pieces of gastric mucosa were biopsied for CLO test and submitted for pathological study. The CLO test was positive. Microscopically, the gastric mucosa was infiltrated by plasmalymphocytic cells and some scattered neutrophils with focally intestinal metaplasia. A moderate amount of spiral microorganisms, measuring 5-8 micrometer (µm) in length and 0.5 µm-1.0 µm in diameter, with tight spirals were found. The spirochetes existed in gastric glandular pits and lumens and were immersed in mucin (Fig. 2). The surface of the gastric mucosa was relatively intact. There was no concomitant H. pylori infection found. The spiral microorganisms positively stained for Giemsa stain (Fig. 3) but negatively stained for periodic acid Schiff (PAS) stain. Chronic active gastritis with focal intestinal metaplasia and H. heilmannii infection was diagnosed. He received a course of triple therapy (amoxicillin, clarithromycin, and esomeprazole). Symptom-free was achieved after one-week medical therapy. Three months later, there was only mild chronic gastritis, and no spiral microorgan-

Received: June 13, 2003, Revised: June 27, 2003, Accepted: July 17, 2003 Address reprint requests and correspondence to: Dr. Jeh-En Tzeng, Department of Pathology, Buddhist Dalin Tzu Chi General Hospital, 2, Min Sheng Road, Dalin, Chiayi, Taiwan

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ism was found in the follow-up biopsy.

DISCUSSION

Helicobacter heilmannii, previously called Gastrospirillum hominis, is a spiral bacterium. It was first reported in the human stomach by Dent et al in 1987 [6]. Histologically, the spiral organism is about 3.5 µm-7.5 µm long and 0.9 µm in diameter with 3-8 tight coils. Under electronic microscopy, this microorganism shows spiral coils, truncated ends flattened at the tips, and up to 12 sheathed flagella 28 nanometers in diameter at each pole. This culturable Gram-negative bacterium can be seen by hematoxylin-eosin, Giemsa, and Warthin-Starry silver stains [7]. Like H. pylori, H. heilmannii has urease and can show a positive CLO test. There is no serological test to distinguish between H. pylori and H. heilmannii [8]. To the present, the only diagnostic method for H. heilmannii is microscopic examination including histology and touch cytology [9,10] in routine practice. The natural hosts of this spiral microorganism are domestic animals, such as dogs, cats, and pigs. The animal-human transmission hypothesis was reported by some previous studies. About 70.3% of H. heilmanniiinfected patients had had contact with one or more animals. On the contrary, only 37.0% of H. heilmanniifree patients had had an animal-contact history [11]. The animal-human contact is generally more common in rural areas than in towns, and people living in rural areas have a significantly higher prevalence of H. heilmannii infection than those in towns [12]. Feline-human and canine-human transmissions were also reported in 1994 [13,14]. Up to the present, the animal-human transmission can explain most cases infected by H. heilmannii. The symptoms of H. heilmannii infection have many variations from being symptom-free to epigastric pain, nausea, vomiting, decreased appetite, and dyspepsia. UGI endoscopy discloses erythematous gastritis, erosion, or ulceration. Its histological picture demonstrates relatively milder gastritis or ulceration than with H. pylori infection. The animal model of Helicobacter infection inducing atrophic gastritis was established by Lee et al in 1993 [15]. As with H. pylori, H. heilmannii-infected cases have higher occurrences of mucosal atrophy, metaplasia, and dysplasia than Helicobacter-negative cases [5]. It was hypothesized that, over a long time, gastritis leads to mucosal atrophy, which is associated with an increased risk for subsequent development of gastric cancer. Gastric cancer combined with H. heilmannii infection was documented in some cases [16].

Fig. 1.

Endoscopically, the antral mucosa of the stomach showing a spottily hemorrhagic active ulcer and diffusely erythematous picture.

Fig. 2. A cluster of Helicobacter heilmannii immersed within mucin present in a glandular lumen of the stomach. The tight spirals are obvious. (H&E, 1000X)

Fig. 3.

Giemsa stain picture of Helicobacter heilmannii. (1000X)

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H. heilmannii of the stomach

However, the relationship of long-term H. heilmannii infection and gastric cancer still needs further investigation. Until now, 4 cases of gastric mucosa-associated lymphoid tissue (MALT) lymphoma combined with H. heilmannii infection have been reported [17]. Regression of this lymphoma after eradication of H. helmannii indicates that H. heilmannii infection correlated with gastric MALT lymphoma, like with H. pylori, should be considered. Only 1.6% of H. heilmannii-infected patients were concomitantly infected by H. pylori. This special phenomenon might indicate the possibility of H. heilmannii protecting one from infection by H. pylori [11]. Nevertheless, further such cases need to be collected to be able to accurately this phenomenon. Treatment of H. heilmannii is similar to that of H. pylori. Triple therapy (2 antibiotics with 1 proton pump inhibitor) will achieve satisfactory results with a symptom-free outcome and complete eradication of this spiral pathogen histologically [18]. However, since this is an animal-human transmitted disease, preventing further contact with infected animals is necessary to avoid reinfection by H. heilmannii. In conclusion, H. heilmannii is a spiral zoonosis. It could lead to dyspepsia, resulting in gastritis and might be related to gastric malignancies. Treatment is similar to that for H. pylori. Preventing further contact with infected animals is necessary to avoid reinfection by H. heilmannii.

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REFERENCES

1. Parsonnet J, Friedman GD, Vandersteen DP, et al: Helicobacter pylori infection and the risk of gastric carcinoma. N Engl J Med 1991; 325:1127-1131. 2. Stolte M, Eidt S: Healing gastric MALT lymphomas by eradicating H. pylori. Lancet 1993; 342:568. 3. Wotherspoon AC, Doglioni C, Diss TC, et al: Regression of primary low-grade B-cell gastric lymphoma of mucosa-associated lymphoid tissue type after eradication of Helicobacter pylori. Lancet 1993: 342:575-577. 4. Foschini MP, Pieri F, Cerasoli S, et al: Helicobacter heilmannii: Anatomo-clinical study of 14 new cases. Pathologica 1999; 91:18-24. 5. Yali Z, Yamada N, Wen M, Matsuhisa T, Miki M: Gastrospirillum hominis and Helicobacter pylori infection in

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Thai individuals: Comparison of histopathological changes of gastric mucosa. Pathol Int 1998; 48:507511. Dent JC, McNulty CA, Uff JC, Wilkinson SP, Gear MW: Spiral organisms in the gastric antrum. Lancet 1987; 2: 96. Andersen LP, Boye K, Blom J, Holck S, Norgaard A, Elsborg L: Characterization of a culturable "Gastrospirillum hominis" (Helicobacter heilmannii) strain isolated from human gastric mucosa. J Clin Microbiol 1999; 37: 1069-1076. Kubonova K, Trupl J: IgG antibodies to Gastrospirillum hominis and Helicobacter pylori. Cesk Epidemiol Mikrobiol Immunol 1993; 42:22-24. Debongnie JC, Mairesse J, Donnay M, Dekoninck X: Touch cytology. A quick, simple, sensitive screening test in the diagnosis of infections of the gastrointestinal mucosa. Arch Pathol Lab Med 1994; 118:1115-1118. Debongnie JC, Donnay M, Mairesse J: Gastrospirillum hominis ("Helicobacter heilmanii"): A cause of gastritis, sometimes transient, better diagnosed by touch cytology? Am J Gastroenterol 1995; 90:411-416. Stolte M, Wellens E, Bethke B, Ritter M, Eidt H: Helicobacter heilmannii (formerly Gastrospirillum hominis) gastritis: An infection transmitted by animals? Scand J Gastroenterol 1994; 29:1061-1064. Svec A, Kordas P, Pavlis Z, Novotny J: High prevalence of Helicobacter heilmannii-associated gastritis in a small, predominantly rural area: Further evidence in support of a zoonosis? Scand J Gastroenterol 2000; 35:925928. Lavelle JP, Landas S, Mitros FA, Conklin JL: Acute gastritis associated with spiral organisms from cats. Dig Dis Sci 1994; 39:744-750. Thomson MA, Storey P, Green R, Cleghorn GJ: Canine-human transmission of Gastrospirillum hominis. Lancet 1994; 343:1605-1607. Lee A, Chen M, Coltro N, et al: Long term infection of the gastric mucosa with Helicobacter species does induce atrophic gastritis in an animal model of Helicobacter pylori infection. Zentralbl Bakteriol 1993; 280:38-50. Morgner A, Bayerdorffer E, Meining A, Stolte M, Kroher G: Helicobacter heilmannii and gastric cancer. Lancet 1995; 346:511-512. Regimbeau C, Karsenti D, Durand V, et al: Low-grade gastric MALT lymphoma and Helicobacter heilmannii (Gastrospirillum hominis). Gastroenterol Clin Biol 1998; 22:720-723. Yoshimura M, Isomoto H, Shikuwa S, et al: A case of acute gastric mucosal lesions associated with Helicobacter heilmannii infection. Helicobacter 2002; 7: 322-326.

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