Discovery of
Helicobacter pylori (
H.
pylori) in 1983 instigated the development of studies on the role of this
bacterium in the pathogenesis of diseases of the gastrointestinal tract, the
search for new
Helicobacter species and for sources of infection in humans
(1, 2). Dent et al. in 1987 and Stolte et al. in 1994 described in the stomach
of man a spiral bacterium different from
H. pylori which is contemporarilly
named
Helicobacter heilmannii (
H. heilmannii) initially termed
Gastrospirillum hominis (3, 4). Various species of
Helicobacter
have been described in animals:
H. heilmannii in pigs, dogs and cats,
H. felis in dogs and cats,
H. mustelae in ferrets, H
. muridarum
in rodents (5-9). It has been suggested that cats and dogs could act as animal
reservoirs in the transmission of
H. heilmannii and other
Helicobacter
spp to humans (3, 7, 8, 10-12). In humans, similar to
H. pylori,
H.
heilmannii is accompanying the pathogenesis of chronic gastritis, peptic
ulcer disease, gastric cancer and MALT-lymphoma (mucosa associated lymphoid
tissue) (13-16).
H. heilmannii is a Gram-negative bacterium resembling corkscrew (spiral shaped microorganisms) two to three times larger than
H. pylori; 4 to 10 µm in length and 0.5 to 0.8 µm in diameter, has four to eight tight spirals. There are typically 8 to 12 tufts of bipolar flagella (10, 16, 17). It possesses the greatest number of hosts in mammals. It is present in the stomach of dogs, cats, leopards, rats, pigs and various species of primates. It rarely settles gastric mucosa of man. Haesebrouck et al. suggested using the name
H. heilmannii sensu stricto to refer to the novel
Helicobacter species and the name
H. heilmannii sensu lato to refer to the whole group of non
H. pylori Helicobacters (18). The prevalence of
H. heilmannii infection in humans varies from 0.1% to 0.9% in patients presenting for upper gastrointestinal endoscopy, although it is reportedly higher in China (4%) and in Thailand where it is as high as 6% (14-16, 19, 20).
H. heilmannii infection has an asymptomatic course, however it may lead to chronic gastritis, gastric and duodenal peptic ulcer and to other diseases in humans and animals. Diagnosis of
H. heilmannii infection is made on the basis of bacterial morphology in direct microscopy of the specimen of the gastric mucosa and polymerase chain reaction (PCR). Attempts of cultures
in vitro failed, but it is possible to sustain
in vivo culture in laboratory animals (21).
The aim of the study was a clinical analysis of
H. heilmannii infection in children, and the assessment of the incidence of
H. heilmannii infection in children over a period of 18 years (1992-2010) according to age, sex, clinical symptoms and living environment.
MATERIAL AND METHODS
Clinical analysis encompassed 22 children aged 4 to 18 years (11 girls and 11
boys) admitted and diagnosed in our clinic due to dyspeptic symptoms in whom
H. heilmannii infection was diagnosed. The studied children were divided
into two groups depending on the age. Into the first group nine children aged
4 to 13 years were included and into the second group children aged 14 to 18
years. In the studied children we analyzed a place of living (city, country),
contact with domestic pets (dog, cat), clinical symptoms (epigastric pain, nausea,
vomiting, heartburn) and the presence of concomitant diseases. In all children
esophagogastroduodenoscopy was performed and specimens of mucosa from antrum
were sampled for microbiology and histology studies. Erosive esophagitis, gastritis,
duodenitis and ulcerative disease of the stomach and/or duodenum were taken
into consideration in endoscopic diagnosis. The collected samples were studied
by the mean of direct microscopy, microbiologic culture and in two children
by PCR. Additionally in a part of the children urea test, IgG antibodies against
H. pylori and study of
H. pylori antigen in stool were performed.
The specimens for direct microscopic examinations were stained using Gram stain
method. Bacterial culture was conducted on medium containing Columbia agar with
7% of hemolyzed horse blood. The plates were incubated at 37°C in microaerophylic
atmosphere (5% O
2, 10%CO
2,
85% N
2) for 6 days. Anti
H. pylori IgG
antibodies were detected using ELISA test (enzyme linked immunoabsorbent assay)
by Microgen-recom commercial kit. Concentration of antibodies above 24 u/ml
was treated as positive.
H. pylori antigen in stool specimens was detected
by EIA method using the Amplified IDEIA
TMHpSTAR
TM
test (DACO) according to the manufacturer's instruction.
RESULTS
In the period between 1992-2010 the number of 13,124 esophagogastroduodenoscopic
studies were performed in children aged 4 to 18 years in the examination of
11,023 sampled specimens of gastric mucosa for
Helicobacter infection.
H. heilmannii infection was diagnosed in 22 children based on the examination
of 11,023 samples, direct microscopic examination and culture (
Fig. 1).
The frequency of
H. heilmannii infection was in 0.2% in direct microscopy
of gastric mucosa specimens.
|
Fig. 1. Gram-stained direct
smear of the antral mucosa infected with H. helmannii in examined
patient (magnification 1000). |
Table 1 presents the data of the patients, clinical symptoms and endoscopic
diagnosis. No sex difference in frequency of
H. heilmannii infection
was demonstrated (p>0,05). Most children lived in urban areas. 54.5% of the
children had domestic contact with a dog and/or a cat. Most of the children
belonged to the group aged 4 to 13 years. In all children chronic epigastric
pain was observed, nausea in 45.4%, vomiting in 27.2% and heartburn in 13.6%.
Nausea, vomiting and heartburn were observed more frequently in older children.
Among endoscopic diagnoses dominated chronic nodular gastritis of antrum (77%),
in 22.7% duodenitis. In single cases gastric or duodenal ulcer without
H.
pylori infection as well as erosive esophagitis were diagnosed. In three
children (13.6%) endoscopic studies of the esophagus, stomach and duodenum did
not reveal any changes but in microscopic study chronic inflammatory changes
were observed. In children with endoscopic changes of histopatologic mucosa
studies revealed chronic inflammatory process, which in half of the cases was
active, infiltration of mononuclear cells or neutrophils were observed. In two
children bronchial asthma was diagnosed, in three lactose intolerance and in
four food allergy.
Table 1. Patients,
symptoms and results of esophagogastroduodenoscopy. |
|
In
Table 2 the results of
Helicobacter diagnostic tests are presented.
In three children mixed infection with
H. pylori and
H. heilmannii
was diagnosed. In these children
H. pylori infection was confirmed in
direct microscopy of stomach biopsy specimen, positive culture and the presence
of anti
H. pylori IgG antibodies in serum.
H. heilmannii infection
was confirmed based on morphologic traits of
Helicobacter in direct microscopy,
negative culture for
H. pylori and in some cases PCR, the lack of antibodies
anti-
H. pylori and the lack of
H. pylori antigen in stool. All
children with
H. pylori and/or
H. heilmannii infection were treated
with proton pump inhibitor - omeprasole, amoxicillin and clarithromycin (OAC)
for 7 days or with proton pump inhibitor, amoxicillin and metronidazole (OAM)
for 10 days. Alternatively, instead of proton pump inhibitor - bismuth salts,
amoxicillin and metronidazole (BAM) were administred. The result of eradication
was examined after 8 weeks in 11 patients (50%). In all examined children eradication
was successful. In 11 children the effect of eradication was not controlled.
Table 2. The results
of Helicobacter species identification. nt-not tested, O- proton
pump inhibitor, A-amoxicillin, C-clarithromycin, M-metronidazole, B-bismuth
subcitrate potassium. |
|
DISCUSSION
H. heilmannii infection in children occurs relatively rarely. Based on
earlier observations, the frequency of infections in children with dyspeptic
symptoms was 0.5% (14). The present study on
H. heilmannii infection
based on a very large material demonstrated a rate of
H. heilmannii infection
to be 0.2% in direct microscopic examination of gastric mucosa specimens. Our
results are similar to those in Europe: 0.3% in Bulgaria and 0.9% in Czech Republic.
Also in other countries
H. heilmannii infection is diagnosed rarely,
for example 0.1% in Japan, with the exception of China - 4% and Thailand - 6.2%
(15, 16, 20, 22). However,
H. heilmannii infection is frequent in the
animals. Interesting studies on
Helicobacter spp infection in
cats in our region have been conducted by Kubiak et al. (11). The authors studied
species of
Helicobacter in the stomach of 35 cats of European breed aged
1 to 10 years. Depending on the symptoms the cats were divided into two groups:
the first one containing 10 cats without symptoms (control group) and the second
group consisting 25 cats with dyspeptic symptoms (chronic nausea,
fetor ex
ore, lack of appetite, abdominal pain). Gastric biopsy samples taken from
animals during endoscopy were analyzed by PCR. In the control group
H. heilmannii
infection was identified in seven cats (70%) including four cats with mixed
infection with two species:
H. heilmannii and
H. felis. In the
second group
Helicobacter spp infection was found in 18 out of
25 animals (72%).
H. heilmannii was present in five cats (27.8%), mixed
infection with two species,
H. heilmannii and
H. felis or other
species not identified by PCR, were observed in 13 cats (72.2%). The authors
demonstrated a very frequent
H. heilmannii infection in cats, both healthy
and sick. Also in other studies frequent
H. heilmannii infection in animals
was demonstrated. Hwang et al. using PCR assay showed the presence of
H.
heilmannii in 85% and
H. felis in 95% of cats (23). By contrast,
in dogs
H. heilmannii was observed in 76% of the cases while H. felis
only in 4.8% (23). Moreover, the possibility of transmission of
H. heilmannii
infection from domestic animals to humans was proven. Gosciniak et al. described
14 years old girl living in a rural area in whom gastrointestinal endoscopy
was conducted due to chronic abdominalgia (8). Chronic nodular gastritis and
H. heilmannii infection has was diagnosed. Endoscopic study was also
conducted in the dog and the cat with which the girl had had everyday contact.
Endoscopic and histologic studies in the animals showed inflammation of the
gastric mucosa with erosions and infection with the same species of
H. heilmannii,
which was proven by PCR, in the animals and the girl. The results of that study
confirmed that
H. heilmannii infection in the girl might have been of
zoonotic origin (8). Other routes of infection also exist. Kato et al. documented
H. heilmannii infection in 11-years-old boy three years after successful
eradication of
H. pylori and the healing of duodenal ulcer. The patient
had had no contact with domestic animals, such as cats and dogs (24). In the
material analyzed in our study 13 children (59.1%) with
H. heilmannii
infection had contact with a dog and/or a cat, however 9 children (40.1%) did
not have any contact with domestic animals and the majority of them lived in
urban area.
Diagnosis of
H. heilmannii infection is based on morphology of biopsy specimens of the gastric mucosa, positive rapid urease test, and PCR. Culture, serum IgG anti-
H. pylori antibodies test and stool test produced negative results. Our diagnostic studies allowed for diagnosis of mixed
H. pylori and
H. heilmannii infection in three children. Besides chronic modular gastritis, gastrointestinal examination of the patients infected with
H. heilmannii revealed duodenitis (in five children) and gastric and duodenal ulcers (in two children). Histopathologic studies of the biopsy specimens from the prepyloric part of the stomach demonstrated a chronic inflammatory process of mild grade and in some of the children active inflammation of gastric mucosa. Previous experience in the treatment of
H. heilmannii infection has indicated that
H. heilmannii is sensitive to antibiotics used in the eradication of
H. pylori (14, 15, 24). In our study on children
H. heilmannii infection was successfully eradicated by the treatment with proton pump inhibitor, amoxicillin, clarithromycin or metronidazole.
In summary,
H. heilmannii infection may be one of the causes of chronic gastritis and ulcerative disease in children. The diagnosis of
H. heilmannii infection is generally made by the detection of its characteristic morphology in gastric biopsy specimens, since culture is extremely difficult and up till now has not been accomplished succesfully.
H. heilmannii infection should be differentiated from
H. pylori infection based on morphologic traits in direct microscopy, negative culture and absence of
H. pylori antigen in stool.
Conflict of interests: None declared.
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