, . 183: 233–236 (1997)

FULL THICKNESS EOSINOPHILIA IN OESOPHAGEALLEIOMYOMATOSIS AND IDIOPATHIC EOSINOPHILIC

OESOPHAGITIS. A COMMON ALLERGICINFLAMMATORY PROFILE?

. 1*, 1, 2, 2 . 1

1Department of Histopathology, Royal Brompton Hospital, London, U.K.2Department of Surgery, Royal Brompton Hospital, London, U.K.

SUMMARY

Oesophageal leiomyomatosis and idiopathic eosinophilic oesophagitis are both extremely rare. The former is a diffuse proliferation ofsmooth muscle in the muscularis propria, whilst the latter is an idiopathic inflammatory condition, thought to be associated withbackground atopy and characterized by an infiltrate of eosinophils throughout the full thickness of the oesophagus. However, two recentcases of oesophageal leiomyomatosis showed similar full thickness infiltration of the oesophageal wall by eosinophils and thisinflammatory cell infiltrate was investigated in conjunction with one case of idiopathic eosinophilic oesophagitis. All three had a similarallergic profile characterized by CD45RO-positive primed T-lymphocytes, EG2–positive (i.e., activated) eosinophils, and tryptase-positive mast cells, together with gene expression for interleukin 4. Previous descriptions of leiomyomatosis describe an association withsystemic mastocytosis and urticaria and the possibility that there is a common underlying allergic component to both disorders is raised.? 1997 John Wiley & Sons, Ltd.

J. Pathol. 183: 233–236, 1997.No. of Figures 4. No. of Tables 0. No. of References 26.

KEY WORDS—oesophagus; eosinophilia; idiopathic eosinophilic oesophagitis; oesophageal leiomyomatosis

INTRODUCTION

The presence of eosinophils in an oesophageal biopsyis usually associated with gastro-oesophageal reflux,1with rarer associations including distal obstruction,2recurrent vomiting,3 and infections. In addition, if thereis a clinical background of atopy and/or a co-existentperipheral eosinophilia, idiopathic eosinophilic oeso-phagitis (IEO), a very rare disorder that is probably partof the spectrum of eosinophilic gastroenteritis, shouldalso be suspected.3–5We have recently encountered two patients with

another extremely rare condition, oesophageal leiomyo-matosis, in which we found marked eosinophiliathroughout the full thickness of the oesophageal wall.A third patient presenting with rupture secondary toidiopathic eosinophilic oesophagitis prompted us toinvestigate the inflammatory component of all threecases. The results demonstrate an allergic profile ofinflammatory cells and gene expression for thepro-inflammatory cytokine interleukin (IL) 4.

MATERIALS AND METHODS

In each case, the resected oesophagus was fixed in 10per cent formalin and representative blocks were embed-

ded in paraffin wax. Immunohistochemistry was per-formed using antibodies to CD20 (Dako; 1/100 dilution),CD3 (Dako; 1/150 dilution, CD45RO (Dako; 1/100dilution), desmin (Dako; 1/50 dilution), smooth muscleactin (Dako; 1/100 dilution), S-100 (Diagnostic ProductsCorporation; 1/1 dilution), EG2 (Kabi PharmaciaDiagnostics, Uppsala, Sweden), and mast cell tryptase(kindly donated by A. Walls, Southampton, U.K.).A standard streptavidin–biotin technique was usedfor detection of CD20, CD3, desmin, and S-100.For CD45RO (which detects primed/activatedT-lymphocytes), EG2 (which identifies ‘activated’eosinophils by marking the cleaved form of cationicprotein),6 and mast cell tryptase,7 we applied the alkalinephosphatase/anti-alkaline phosphatase (APAAP) tech-nique,8,9 using New fuchsin (Dako) as the chromogen.As a negative control, the primary antibody was omitted.In-situ hybridization was performed to detect IL-4,

using a previously described technique.10 For this, a500 bp human IL-4 cDNA fragment11 was subclonedinto pGEM 4Z (Promega, Southampton, U.K.) andpropagated in JM109 cells (Promega). After lineariza-tion with EcoR I and Sph I, sense and antisense RNAprobes were transcribed in vitro with 35S-UTP and CTP,GTP and ATP (Amersham, Bucks, U.K.), using SP6and T7 RNA polymerase (Promega) respectively. Afterhybridization, the sections were washed in decreasingconcentrations of standard saline citrate (SSC) from 4#to 0·1# at 42)C. Unhybridized single-stranded RNAprobe was removed by incubation with 20 ìg/ml RNaseA (Sigma Chemical Co. Ltd., Poole, U.K.) in 0·5

*Correspondence to: Dr A. G. Nicholson, Department of Histo-pathology, Royal Brompton Hospital, Sydney St, London SW3 6NP,U.K.

CCC 0022–3417/97/100233–04 $17.50 Received 13 January 1997? 1997 John Wiley & Sons, Ltd. Accepted 29 May 1997

NaCl, 10 m Tris (pH 7·4), and 1 m EDTA for 30 minat 37)C. Autoradiography was carried out after coatingwith K-5 emulsion (Ilford, Knutsford, U.K.) and expo-sure at 4)C for 14 days. The slides were developed withKodak D-19 (Sigma), fixed with Hypam (Ilford), andcounterstained with haematoxylin. The sense probe wasused as a control and proved to be negative.

RESULTS

Clinical details

Case 1—A 27-year-old Asian male smoker presentedwith a 17-year history of dysphagia. There was nohistory of asthma. Examination revealed limited airentry into the left lung, but no other abnormal findings.Chest X-ray showed widening of the oesophagus, con-firmed by a barium swallow which also revealed severalfoci of narrowing. Computerized tomography showedthickening of the oesophageal wall at the level of thethird thoracic vertebra and narrowing of the trachea toa pinpoint at the level of the carina. Bronchoscopyshowed compression of the trachea and main bronchi,and oesophagoscopy showed large bosses of tumourextending into the lumen from all sides. An oesophagec-tomy was performed, together with resection of theinvolved posterior tracheal wall. The patient made agood recovery and was tumour-free at 1 year.

Case 2—A Caucasian male smoker gave a history oflong-standing asthma and of having an oesophagealleiomyoma resected in 1960, aged 28. His symptomsreturned in 1982, worsening until 1991 when he under-went oesophagectomy for advanced achalasia. Post-

operatively he made a good recovery and is currentlywell.

Case 3—A 26-year-old Caucasian man with a2-month history of progressive dysphagia presented withsevere, constant epigastric pain, presenting after a bolusof food had wedged in his lower oesophagus. There hadbeen two previous episodes of dysphagia since child-hood, and a history of both allergic rhinitis and penicil-lin allergy. The patient was shocked, with bilateralcervical surgical emphysema, a rigid abdomen, andno audible bowel sounds. Subsequent oesophagoscopydemonstrated a tight oesophageal stenosis immediatelybelow the hypopharynx, requiring bouginage to advancethe endoscope. At 25 cm, there was an 8 cm longitudinaltear on the right lateral wall of the oesophagus. Thedistal portion of the oesophagus and the cardia couldnot be satisfactorily assessed because of the stenosis anda subtotal oesophagectomy and cervical oesophago-gastric anastomosis were performed. Recovery was slow,with two subsequent elective admissions for dilation ofresidual cervical oesophagus giving good relief of minordysphagic symptoms.

Pathology and immunohistochemistry

Case 1—The entire wall of the oesophagus was thick-ened by nodular but confluent, hypertrophied muscu-laris propria (Fig. 1). The myocytes were enlarged andthere was variable replacement of the normal fibrepattern by irregular interweaving fascicles, but there wasneither cytological atypia nor mitotic activity. There wasno infiltration of myocytes into adjacent adventitia orsubmucosa. Nerves and ganglion cells were identified,

Fig. 1—Longitudinal section of resected oesophagus, showing nodular but continuous thickening of the muscularis propria throughoutits length

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the nerves appearing slightly prominent. Their anatom-ical distribution appeared normal, though this wassomewhat distorted by the muscular hypertrophy. EG2-positive eosinophils (Fig. 2), tryptase-positive mast cells,and moderate numbers of lymphocytes were present inthe surface epithelium and supporting lamina propria, aswell as being abundant throughout the thickened mus-cularis propria. There were perivascular accumulationsof EG2-positive cells and CD3-positive lymphocytes.Eosinophils and smooth muscle proliferation were alsopresent in the mucosa of the resected trachea. The latterwas felt to be smooth muscle proliferation of nativetracheal muscle, rather than extension of oesophagealmuscle into trachea.

Case 2—The resected oesophagus was grossly dilated,with a thickened wall which included circumscribednodules ranging from 30 to 50 mm. These proved to beleiomyomatous and multiple smaller nodules were alsoidentified within a hypertrophied muscularis propriaon microscopic examination. In addition, there weremany EG2-positive eosinophils and numerous tryptase-positive mast cells (Fig. 3) throughout the full thicknessof the specimen, in a distribution similar to that of case1, along with moderate numbers of lymphocytes and

plasma cells. Ganglion cells and nerves were identified ina similar fashion to case 1.

Case 3—Examination of the resected specimen con-firmed a longitudinal tear at the oesophagogastric junc-tion with rupture, abscess formation, and peritonitis.The wall of the oesophagus was thickened and itsmucosal surface was abnormally pale throughout thelength of the specimen. Microscopically, there was amixed eosinophil and neutrophil infiltrate involvingthe full thickness of the oesophagus, together with amoderate degree of fibrosis. Moderate numbers of EG2-positive eosinophils and tryptase-positive mast cells werepresent in the muscularis propria, with low to moderatenumbers in surface epithelium. There was no evidence ofinfection and a diagnosis of idiopathic eosinophilicoesophagitis was made.

Localization of IL-4 gene expression

Cells positive for IL-4 were present in the surfaceepithelium and lamina propria of all three cases. In themuscularis propria, they were abundant in the cases ofleiomyomatosis, but few were seen in the case of IEO.The appearance of the radioactively labelled riboprobewas punctate and likely present in the inflammatory cellslocated between muscle fibres, with no evidence for itspresence in the muscle itself (Fig. 4).

DISCUSSION

Idiopathic eosinophilic oesophagitis is characterizedby full thickness eosinophil infiltration of the oesopha-gus. Most patients are male and have blood eosinophiliaand/or an allergic disorder. They usually present withdysphagia, most commonly due to stricture, and thedisease responds well to treatment with steroids.5,12 Ourpatient showed no blood eosinophilia, but gave a historyof atopy and oesophageal spasm related to specificfoods, consistent with an allergic aetiology. The presenceof immunopositive mast cells, ‘activated’ EG2 eosino-phils, and gene expression for IL-4 confirms an allergic

Fig. 2—Abundant EG2-positive eosinophils are present within themuscularis of case 1. (EG2)

Fig. 3—Tryptase-positive mast cells are present within both themucosa and the muscularis of case 2. (Mast cell tryptase)

Fig. 4—Autoradiogram of anti-sense 35S-labelled riboprobe for IL-4mRNA showing punctate positivity after in situ hybridization

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pattern of inflammation compatible with a T-helperlymphocyte (Th2) profile, similar to that described inasthma.13–15Diffuse oesophageal leiomyomatosis16–19 should be

distinguished from single or multiple leiomyomas.20,21 Itis not known whether diffuse leiomyomatosis is neoplas-tic or purely hypertrophic in nature. As demonstrated inother cases, there is loss of normal fibre pattern beyondthat of simple hypertrophy; conversely, there is noevidence of infiltration into submucosa or adventitia tosuggest neoplasia.18 Our two patients (cases 1 and 2)were diagnosed as leiomyomatosis on the basis of con-fluent smooth muscle hypertrophy throughout theoesophagus. Although there were foci of nodularitywhich suggested multiple distinct tumours, longitudinalexamination of the resection specimens confirmed theconfluent nature of the proliferation. Like IEO, bothpatients presented at an early age with chronic disease.Eosinophils have not been previously described as thedominant inflammatory cell in oesophageal leiomyo-matosis, although they have been noted as part of theassociated inflammatory cell infiltrate.16–18 The same istrue of mast cells, though in cases showing autosomaldominant familial inheritance, there is a strong associ-ation with systemic mastocytosis and urticaria.16 Thisassociation suggests a predisposition to atopy, a recog-nized aetiological factor in IEO, and with EG2-positiveeosinophils and mast cells present throughout the fullthickness of the oesophageal wall in both cases, a Th2profile was again observed.Within the (Th2) allergic pattern of inflammation,

IL-4 is thought to play a key role, recruiting eosinophilsfrom blood into tissue by enhancing endothelial expres-sion of the adhesion molecule VCAM, whose ligand(VLA-4) is present on the eosinophil.22,23 Our cases ofleiomyomatosis are clearly associated with this allergicpattern of inflammatory response, which could possiblyresult in the release of additional inflammatory media-tors that stimulate smooth muscle hypertrophy. In thisrespect, there are similarities between the smooth musclemass enlargement seen in leiomyomatosis and thatobserved in fatal asthma.24,25 This hypothesis is sup-ported by ‘in vitro’ experiments which show tryptase tobe a potent mitogen for tracheal smooth muscle.26However, it should be noted that there are differences

between oesophageal leiomyomatosis and IEO: bothpatients with oesophageal leiomyomatosis presentedwith dysphagia secondary to achalasia, whilst patientswith IEO usually present with dysphagia secondary tostenosis. There are also histological differences, with thecase of IEO surprisingly showing less intense eosino-philia, and the thickening of the oesophageal wall beingdue mainly to fibrosis rather than smooth muscle hyper-trophy. The eosinophilic infiltrate in oesophageal leio-myomatosis may possibly be secondary to severe refluxinto a redundant oesophagus,3 and considering thedegree of oesophageal dysfunction, is likely to be acontributory factor. However, it does not explain whythe eosinophilia is most marked in the thickened mus-cularis propria, nor why the inflammatory cell infiltrateextends into the trachea. The latter may conceivably bethe result of aspiration.

In summary, these two cases of oesophageal leiomyo-matosis show an intriguing pattern of inflammation thatis usually only found in IEO, suggesting a possible linkbetween two conditions generally regarded as distinct.Whether they share a common aetiology, at least in part,is uncertain, but the inflammatory profile of bothconditions supports this hypothesis.

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