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C O N F E R E N C E 22 18 April 2018 Joint Pathology Center Veterinary Pathology Services WEDNESDAY SLIDE CONFERENCE 2017-2018 C o n f e r e n c e 22 18 April 2018 Amy Durham MS, VMD, DACVP Associate Professor, Department of Pathobiology University of Pennsylvania, School of Veterinary Medicine MJR-VHUP, Room 4041 3900 Delancey Street, Philadelphia, PA 19104 CASE I: 15L-2067C (JPC 4066542). blastic cells are negative. CD79a positive cells represent <5% of the Signalment: 3-year-old, male, Warmblood lymphoid cells recognized. (Equus caballus), equine. • CD20: Large blastic cells are diffusely negative for CD20 antibody. History: Acute signs of colic, poor general CD20 positive cells represent <5% of condition the lymphoid cells recognized. Gross Pathology: Diffuse thickening and white discoloration of the caudal 2/3 of the small intestine, evident from the serosal surface. Laboratory Results (clinical pathology, microbiology, PCR, ELISA, etc.): • CD3: Diffusely well-differentiated small lymphocytes show moderate to strong immunopositivity for CD3. Large blastic cells show diffuse moderate membranous positive signal for CD3. CD3 positive cells represent >95% of the lymphoid cells Ileum, horse. A neoplastic infiltrate extends from the recognized. Peyer’s patches into the surrounding mucosa and • CD79a: Scattered very rare small submucosa. (HE, 4X) well-differentiated lymphocytes are positive for CD79a antibody. Large 1 • Synaptophysin: An intense strong cytoplasmic positive stain is detected in the scattered remaining neurons of the Auerbach’s and Meissner’s plexuses Microscopic Description: Ileum – The intestinal epithelium is diffusely effaced by amorphous eosinophilc material and nuclear debris (post mortem autolysis – artifact). Multifocally, some crypts are expanded by eosinophilic and basophilic amorphous material (cellular and nuclear debris/crypt abscesses) with occasional areas characterized by granular basophilic material Ileum, horse. There is a significant reduction of numbers (mineralization – dystrophic). The autonomic of neurons within the Auerbach’s and myenteric plexi. Remaining neurons exhibit chromatolysis. (HE, 400X) ganglia of the submucosa (Meissner’s) and (Photo courtesy of: of Liverpool, Leahurst Campus, tunica muscularis (Auerbach’s) exhibited a Chester High Road, Neston, Wirral, UK, CH64 7TE.) marked reduction in numbers of neuronal bodies which occasionally appear hyper- submucosa, muscularis and serosa. Scattered eosinophilic with rounded cell margins and basophilic, star-shaped bodies peripheralized hyperchromatic nuclei (mineralization – asteroid bodies) are (chromatolysis). Within the plexuses an recognized within the intima of medium increased number of satellite cells is also sized to large submucosal arteries (incidental recognized. Expanding from the submucosal finding). gut associated lymphoid tissue (GALT), and diffusely infiltrating and effacing the Contributor’s Morphologic Diagnosis: mucosa, submucosa and occasionally Ileum, diffuse sub-acute severe Meissner’s reaching the superficial tunica muscularis of and Auerbach’s plexuses chromatolysis and the ileum there is a densely cellular, poorly neuron loss. demarcated, unencapsulated and infiltrative Ileum, atypical lymphoproliferative disorder proliferation of round cells arranged in sheets consistent with intestinal lymphoma. within a fine fibrous stroma. Cells are 20-25 Name of the condition: Equine dysautonomia μm in diameter, round with distinct cell Name of the disease: Equine grass sickness borders. They exhibit scant to moderate lightly basophilic cytoplasm and central Contributor’s Comment: In the present round nuclei with finely stippled to vesicular case, the submucosal (Meissner’s) and chromatin and one to three nucleoli. The myenteric (Auerbach’s) plexuses showed follicular structure of GALT is diffusely severe neuronal chromatolysis (de- effaced or lost. Mitotic index is 1-4 mitosis generation) consistent with equine grass per high power field and occasional bizarre sickness (equine dysautonomia). Immuno- mitoses are recognized. Large numbers of histochemical staining with an anti- small well-differentiated lymphocytes are synaptophysin antibody revealed a marked infiltrating in between the atypical blastic reduction in numbers of neurons within the cells. Large numbers of atypical lymphoid neuronal ganglia of the Meissner’s and cells are found infiltrating lymphatic vessels Auerbach’s plexuses and a highly increased and/or veins of the lamina propria, 2 immune-signal within the soma of remnant also reported in stomach, duodenum, neurons indicative of neuronal jejunum, caecum, large colon, small colon degeneration.3,20 and rectum,17 and the duodenum has been identified as the best location to identify Equine grass sickness is a polyneuronopathy degenerated neurons in chronic cases.13 of the central and peripheral nervous system Neuronal lesions have been documented in that only affects grazing horses, ponies and the following ganglia of the autonomic donkeys. It is a seasonal disease with peak of system: ciliary ganglion, cranial cervical incidence between April-July in the northern ganglion, caudal mesenteric ganglion, hemisphere. This pathological condition was stellate ganglion, thoracic and abdominal first described in Scotland in 1909, since then sympathetic trunk, celiaco-mesenteric, equine grass sickness has been described in caudal mesenteric ganglion and numerous Northern European countries, parasympathetic terminal cardiac ganglion.17 Cyprus, Falkland Islands and Australia.17 Additionally, loss of interstitial cells of Cajal Although the etiology is still unknown, toxins have also been reported in cases of acute produced by Clostridium spp. are suspected grass sickness, suggesting the loss of these to play a role in the disease as low serum pacemarkers may also contribute to antibody levels for this bacterium were found development of the dysmotility.6 The only to be a risk factor.10 The most common gross way to diagnose equine grass sickness ante pathological manifestations are fluid mortem is by mean of an ileal biopsy which distention of the proximal gastrointestinal allows the identification of neuronal loss and tract (stomach and small intestine) and large / or neuronal chromatolysis with 100% intestine impaction with dry and corrugated sensitivity and specificity.12 Anti- digesta often coated by copious mucus.1 synaptophysin immunostaining has been Histologically the main findings consist in proposed as a good diagnostic tool to identify neuronal chromatolysis of the peripheral degenerating neurons which show an nervous system and central nervous system, increase of synaptophysin signal within the with changes particularly severe in the cytoplasm.3,20 peripheral autonomic ganglia and enteric neurons. Whilst less significant, different studies also have identified involvement of the central nervous system including degeneration of cranial nerves (III, V, VI, VIII, XII), dorsal motor nucleus of the X, accessory cuneate nucleus, red nucleus and reticular formation.17 The histological appearance of the chromatolytic neurons consists in swelling of cell body (soma), loss and/or peripheralization of Nissl substance, central eosinophilic spheroid bodies, foamy cytoplasm and peripheral margination and flattening of the nucleus.9 The best gastrointestinal location to identify these Ileum, horse. Enhanced synaptophysin immunopositivity changes is the ileum (submucosal and is consistent with neuronal degeneration. (HE, 400X) (Photo courtesy of: University of Liverpool, Leahurst myenteric plexuses), especially in acute Campus, Chester High Road, Neston, Wirral, UK, CH64 13 cases. Nonetheless, chromatolysis has been 7TE.) 3 Associated with the typical features of equine H&E the tumor was provisionally classified dysautonomia, an atypical proliferation of the as a T-cell rich B-cell lymphoma. lymphoid tissue arising from the GALT was also recognized in this case, that can explain Immunohistochemichal results however the grossly observed focally extensive identified a constant CD3 positivity in both thickening and white discoloration of the small and blastic lymphoid cells, with lack of intestine, which is not a usual feature of positivity for B markers (CD79a / CD20). equine grass sickness per se. In our opinion CD3 positive cells were also detected within there are several features that support the vessels. On this basis a T cell lympho- diagnosis of a lymphoma against a lymphoid proliferative disorder consistent with a T cell hyperplasia: grossly the intestinal wall was lymphoma was the final diagnosis in this diffusely severely thickened and white in case. Unfortunately no other organ was color. Histologically the blastic lymphoid available for examination to further cells exhibited features of atypia (large investigate the possible leukemic phase of the cellular size, with vesicular to finely stippled neoplasm as suggested by the vascular chromatin, occasional nuclear membrane invasion, in distant organs. A clonality test indentations and scattered bizarre mitotic was not available to test the clonality of the figures) and the infiltrative behavior proliferation. (invasion of the lamina propria and vessels) with loss of follicular structure of numerous Alimentary lymphoma is a commonly GALT areas. On the basis of the reported tumor of the gastrointestinal system 1 morphological appearance provided by the in horse. The mean age of presentation of Ileum, horse. The presence of small numbers of large lymphocytes in a sea of smaller mature T-cells is consistent
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