Research Article JOJ uro & nephron Volume 3 Issue 2 - April 2017 Copyright © All rights are reserved by Sierra Pablo DOI: 10.19080/JOJUN.2017.03.555607 Malacoplakia in Urologic Specimen Sierra Pablo*, Henao Matilde, Gaviria Federico and Velez Alejandro Department of Urology and Pathology, Hospital Pablo Tobón Uribe, Universidad CES, Colombia Submission: March 30, 2017; Published: May 30, 2017 *Corresponding author: Sierra Pablo, Department of Urology and Pathology, Hospital Pablo Tobón Uribe, Universidad CES, Colombia, Email: Abstract abnormal macrophage function in response to a bacterial infection. This rare entity is characterized by one o multiple tumoral growths in any part Malacoplakiaof the body and is anis usuallyinflammatory misdiagnosed condition as characterizeda malignant condition. by yellow–brown The genitourinary plaques with tract granulomatous is frequently involved lesions. It(up probably to 75%). results Pathologic from studiesThere of these is a very lesions sparse show evidence tissue infiltrated published by in macrophagesthe literature, and mostly hystiocytes case reports. with intracytoplasmic Previously in 2006 inclusions we reported (Michaelis-Gutmann 6 cases of malakoplakia, bodies). now we present an update with six additional cases to a total of twelve events in the same institution during a period of 17 years. Keywords: Malacoplakia; Urinary Tract infections; Prostatitis Abbreviations: MLP: Malacoplakia; MGB: Michaelis–Gutmannbodies; UTI: Urinary Tract Infection; ATB: Antibiotics Introduction visible changes on ultrasound, CT and MRI of the involved organ Malakoplakia is extremely rare granulomatous and promote thickening of the bladder wall forcing erroneous treatments and in some cases radical surgeries [7-9]. musculoskeletal, respiratory, and gastrointestinal and specially inflammatory condition that can affect many systems including the urinary tract, most commonly the bladder. It is considered to Patients and Methods develop as a result of a defective immune response to bacterial A retrospective review to identify patients with a diagnosis agents, the most common Escherichia coli [1-3]. Although more of malacoplakia of the urinary tract was performed, 12 patients commonly affects genitourinary tract, isolated cases have been were found to have this diagnosis along 17 years in Hospital Pablo reported in colon, stomach, lung, liver, bone, uterus and skin [4]. Tobon Uribe and Dinamica IPS in Medellin, Colombia. All cases In the histopathological examination, malakoplakia is where evaluated by the same uropathologist and challenging characterized by the presence of foamy histiocytes with cases where reviewed by and experienced uropathologist in a distinctive basophilic inclusions, which are known as Michaelis– reference center in US. Records were retrieved and complete Gutmannbodies (MGB), this name after whom described the clinical history reviewed and described in this case series as condition in 1902 [5]. It was Von Hansemann in 1903 who employed the word malakoplakia (from the greekmalakós, soft, images were included were available. This study was conducted well as laboratory findings, pathology specimen and radiology under the Hospital Pablo Tobon Uribe institutional review board macroscopic aspect. and plakos, plaque) [6] to define this process according to its Malakoplakia of the genitourinary system is more commonly and Apatients systematic confidentiality MEDLINE/Pubmed was assured. review was performed on the 27th of may 2016 according to the PRISMA guidelines. The and seventh decades of life but is has been described also in main search terms were “malakoplakia” and“urinary tract”. 267 diagnosed in women. It is usually observed between the fifth pediatric and other unique group such as kidney transplant articles were retrieved, 77 articles remained after applying immunosuppressed patients. limits for papers published after 2000. The search result was It is a challenging clinical diagnosis that is usually mistaken Spanish literature, abstracts were read and 33 publications for malignancy, it could lead to a formation of a mass anywhere in first screened for relevance by title and limited to English and of interest were selected for full text review. The search was the urinary tract, elevate prostate specific antigen (PSA), cause JOJ uro & nephron 3(2): JOJUN.MS.ID.5555607(2017) 001 JOJ Urology & Nephrology non responsive to pharmacologic therapy. Interestingly, 3 suggested by important publications until no additional patients had PSA elevation and a transrectal ultrasound guided complemented with own files articles, hand search and articles papers were retrieved. The search sensitivity was evaluated by biopsy was performed, all evidenced MGB in the pathologic to the authors and those cited in previous seminal reviews. If concurrent adenocarcinoma of the prostate and underwent a comparing the articles identified against those already known slides confirming malakoplakia, one patient was found with an article was missed, the title and abstract where carefully radical prostatectomy. One of the patients that did not have PSA reviewed to identify terms that would improve the sensitivity elevation was taken to transurethral resection of the prostate of the search. and was found with prostate cancer along with malacoplakia. Results The only pediatric patient is a 4 month old male with an enlarging testicular mass confounded with a neoplasia of the Twelve patients were found to have malakoplakia, median testis at doppler US, serum tumor markers were negative, he was age at presentation was 66.5 years, most patients being older than 35 years (11/12) and only one patient in the pediatric age. Most common organ involved was prostate, in fact taken to inguinal radical orchiectomy and the final pathologic lymphocytes, plasmocytes, giant cell and hystiocytes with MGB 7/12 patients had compromise of this gland, all of them had specimen showed a benign inflammatory process with abundant that suggest the diagnosis of MLP, he had a positive urine culture lower urinary tract symptoms (LUTS), all required surgical for E. Coli.Patients characteristics are listed on Table 1. intervention due to recurrent UTI and voiding obstruction Table 1: Malakoplakia cases clinical features. Age Micro Pathology and Sex Site Radiology Size (cm) Symptoms UTI Treatment Follow up (Years) organism lab MGB, Heterogeneous Scrotal M 0.3 Testicle 3x2 + E. Coli Orchiectomy Uneventful mass on US swelling cells inflammatory ABSCESSED Nephrectomy Kidney resection of MGB, F 52 Psoas 15 pain, fever + E. Coli psoas and 3rd Uneventful PERITONEAL Hystiocytes Duodenum MASS,RETRO- PSOAS weightRight flank loss portion of AND KIDNEY duodenum PSA 6.3 LUTS Prostate Glandular/ M 60 Prostate - urinary - - TURP Uneventful Enlargement stromal retention hyperplasia, MGB PSA 263 LUTS TRUS biopsy Prostate Hematuria Glandular/ M 67 Prostate - - - open Uneventful Enlargement urinary stromal retention prostatectomy hyperplasia, MGB PSA 10 LUTS Prostate urinary TRUS biopsy Hystiocytes M 70 Prostate - + E. Coli Uneventful Enlargement retention TURP chronic UTI MGB inflammation, TRUS Biopsy, Prostate Elevated Prostate M 70 Prostate - - - radical Uneventful Enlargement PSA Adenocarcinoma prostatectomy Thickened Recurrent F 76 Bladder irregular - + E. Coli ATB MGB Uneventful UTI, LUTS bladder wall How to cite this article: Sierra P, Henao M, Gaviria F, Velez Alejandro. Malacoplakia in Urologic Specimen. JOJ uro & nephron. 2017; 3(2): 555607. 002 DOI: 10.19080/JOJUN.2017.03.555607. JOJ Urology & Nephrology Prostate Prostate cancer M 66 Prostate - LUTS - - TURP Uneventful Enlargement and MGB Prostate M 62 Prostate - LUTS - - Prostatectomy MGB Uneventful Enlargement Prostate Radical M 68 Prostate - LUTS - - Prostate cancer Uneventful Enlargement prostatectomy Recurrent Recurrent F 38 Bladder VUR - + E. Coli TURBT - ATB MGB UTI UTI Cervix, Uterus, Functional F 85 Vagina, CT Pelvic mass 8x12x9 + E.Coli ATB MGB Uneventful decline Bladder, ureters Six of patients had E. Coli proven UTI by urine culture (50%), this percentage is expected be even higher but unfortunately showed yellow soft plaques with multiple foci affecting the cystogram revealed vesicourethral reflux (VUR) and cystoscopy some of the patients didn’t have urine culture reports previous bladder (Figure 1), biopsy showed MGB the patient received to the initiation of antibiotics. ATB, unfortunately symptoms recurred, at control cystoscopy we found larger lesions that required transurethral resection, Discussion Malakoplakia is a rare clinical entity, accurate diagnosis satisfactory with lower episodes of UTI after resection and pathologic examination confirmed the etiology. Outcomes were relies on biopsies or surgery specimen reviewed by experienced continuous prophylactic ATB. Other structures can be affected pathologists. MLP features Hansemanncells , which are by malakoplakia, Love et al. [10] described MLP of the urethra hystiocytes with small nuclei and granular acidophilic causing strictures and accounting as an exceptional etiology for cytoplasms and MGB, which are basophilic periodic acid- this disease, surgery was not necessary in this particular case. Schiff, diastase-resistant and calcific inclusions seen within search for the pathognomonic characteristics of the disease the hystiocytes8.This are not usual findings and requires active and a good clinical and pathological correlation. Apparently the pathogenesis is explained because impaired host defenses and a defect in phagocytosis