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CASE REPORT  
Year : 2023  |  Volume : 66  |  Issue : 1  |  Page : 165-167
Sarcina ventriculi associated gastritis: Mimicking lymphoma on endoscopy


Department of Pathology, J. N. U. Medical College and Hospital, Jaipur, Rajasthan, India

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Date of Submission11-Oct-2021
Date of Decision06-Jan-2022
Date of Acceptance07-Jan-2022
Date of Web Publication18-Jan-2023
 

   Abstract 


Sarcina Ventriculi is a gram-positive anaerobic coccus rarely reported in patients with delayed gastric emptying, emphysematous gastritis, gastric ulcers, and perforation. So far, less than 30 cases of sarcina isolated from the stomach have been reported. Herein, we describe a case of a 66-year-old male with a history of persistent epigastric pain and regurgitation. The upper gastrointestinal (GI) endoscopy revealed gastric erythema, edema, ulceration, and food bezoar. A gastric biopsy was done to rule out lymphoma. On histopathological examination, sarcina Ventriculi was identified. This organism is likely to get underreported as it may not be that obvious on routinely stained biopsies. Given its association with life-threatening illness such as emphysematous gastritis and perforation, awareness of this organism is important. It's presence in gastric biopsies must be mentioned in the report and should prompt the clinicians to investigate further for functional causes of delayed gastric emptying and gastric outlet obstruction like occult malignancy.

Keywords: Gastric ulcer, gastritis, perforation, sarcina ventriculi

How to cite this article:
Attri N, Pareek R, Dhanetwal M, Khan FM, Patel S. Sarcina ventriculi associated gastritis: Mimicking lymphoma on endoscopy. Indian J Pathol Microbiol 2023;66:165-7

How to cite this URL:
Attri N, Pareek R, Dhanetwal M, Khan FM, Patel S. Sarcina ventriculi associated gastritis: Mimicking lymphoma on endoscopy. Indian J Pathol Microbiol [serial online] 2023 [cited 2023 Feb 8];66:165-7. Available from: https://www.ijpmonline.org/text.asp?2023/66/1/165/367931





   Introduction Top


Sarcina ventriculi is a gram-positive, non-motile, anaerobic, spore-forming coccus normally found in acidic soil.[1],[2] An exclusive carbohydrate fermenter, it produces acetaldehyde, ethanol, hydrogen, and carbon dioxide.[3] Hematoxylin and eosin staining of gastric biopsies show tetrad packets of large (3 μm) basophilic spherical microorganisms with a refractile wall. This characteristic packing is because of the cell division occurring in two planes of growth.[4] Molecular diagnosis is done by PCR and sequencing of the 16S ribosomal ribonucleic acid (RNA) and pyruvate decarboxylase genes.[5]

Sarcina was first identified as a human pathogen in 1842 by John Goodsir.[6] Various reports in veterinary medicine have implicated sarcina in the development of 'abomasal bloating' and the death of livestock.[7] Sarcina has been increasingly reported in the feces of healthy individuals consuming a predominantly vegetarian diet in patients with a history of GI surgery and delayed gastric emptying. Patients infected with sarcina were found to have a frothy vomit termed as sarcinate vomit.[8] Endoscopic findings include retained food residue, gastric inflammation, ulcers, and erosions.[4]

Herein we report a case of sarcina ventriculi-associated gastritis mimicking lymphoma on endoscopy in a 66-year-old male.


   Case Report Top


A 66-year-old male presented to the medicine OPD with significant clinical symptoms of epigastric discomfort, pain, nausea, regurgitation malnutrition, and vomiting that lasted for a duration of four months.

Upper GI endoscopy revealed gastric erythema, edema, ulceration, and food bezoar. [Figure 1] Keeping in mind all these findings of delayed gastric emptying, the differential diagnosis of lymphoma and adenocarcinoma was made. Gastric biopsy revealed marked inflammation with ulcer bed formation along with the multiple foci of sarcina ventriculi tetrads along with the vegetable matter. The sarcina organisms were identified on routine hematoxylin and eosin stain, which revealed large tetrad packets of basophilic spherical microorganisms of approximately 3 μm in size. The gram stain highlighted the red-stained tetrad structures consistent with sarcina. [Figure 2] Biopsies were negative for helicobacter pylori or any malignancy. The patient was treated with metronidazole 250 mg thrice daily and ciprofloxacin 250 mg twice daily for one week along with daily sucralfate. Subsequent follow-up with a repeat esophagogastroduodenoscopy two months later showed improvement of gastric erythema and absence of food bezoar. Repeat biopsies from the stomach were negative for sarcina organism and showed features of chronic gastritis. Clinically, the patient's overall health improved with the above treatment, and he continued to be free of gastrointestinal symptoms.
Figure 1: Esophagogastroduodenoscopy (a) Esophagus- Normal mucosa (b) Stomach- Fundus- Large food bolus seen. Body- Gastric edema, diffuse erythema (c) Stomach- Antrum- Gastric edema, diffuse erythema, food bezoar, and bulging seen. (d) Duodenum- Normal

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Figure 2: (a) Basophilic-stained and cuboid-shaped sarcina organisms arranged in tetrad packs adjacent to the ulcer bed [H&E stain, 20 × magnification]. (b) Basophilic-stained and cuboid-shaped sarcina organisms arranged in tetrad packs adjacent to the ulcer bed [H&E stain, 40× magnification]. (c) The cuboid-shaped organisms were tightly packed in a tetrad formation embedded in gastric mucin [H&E stain, 40× magnification]. (d) Gram's stain- Noted the characteristic red staining of tetrads or octets with individual bacterial cells measuring up to 3 microns; the resulting tetrads were comparable to the size of a lymphocyte nucleus [Gram's stain, 40× magnification]

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   Discussion Top


Sarcina ventriculi was first identified in 1842 by John Goodsir and was isolated in 1911 using strict anaerobic cultures.[7],[9] It is a gram-positive, anaerobic, acid-tolerant coccus associated usually with GI surgery.[1] It exhibits a 2:1 female to male ratio.[4] The patient, in this case, was a male with no prior history of GI surgery.

Hematoxylin and eosin staining show a tetrad arrangement measuring 1.8-3 μm in diameter.[4] It is usually located at the mucosal surface without any invasion into the underlying glands.[2] There are only two organisms that are morphologically similar to sarcina ventriculi, namely Micrococcus spp. and Sarcina maxima. Micrococcus spp. are gram-positive cocci which also grow in tetrads and tight clusters, but they measure 0.5 μm in diameter. Micrococcus is catalase-positive aerobic cocci whereas, sarcina ventriculi are catalase-negative and anaerobic.[4] In contrast to sarcina maxima, sarcina ventriculi possesses a thick cellulose layer on the outer wall that measures 150–200 nm in thickness.[1]

Sarcina ventriculi have also been reported in cases of gastric adenocarcinoma and pancreatic adenocarcinoma.[9] Cases of Sarcina ventriculi often develop food bezoars due to delayed gastric emptying. In a previous study of eight cases of sarcina associated gastritis, five patients presented with delayed gastric emptying and retained food bezoar during gastric endoscopy.[3],[9],[10] Hence, sarcina ventriculi can be used as a marker of delayed gastric emptying.[2] While all these patients presented with various gastrointestinal symptoms, only a few had life-threatening complications like emphysematous gastritis and gastric perforation.[4] Our patient had mainly epigastric pain with regurgitation, and sarcina was found incidentally when a gastric biopsy was performed for erythematous mucosa.

As sarcina might cause life-threatening emphysematous bloating in animals, it is quite possible that its human gastric association is not due to the direct mucosal invasion but because of the fermentation byproducts produced by the organism. However, so far, no correlation has been made between the deadly gastric bloating in animals and colonization of human stomachs, although a few cases of gastric perforation have been reported. Hence, the clinical importance of sarcina ventriculi in human gastric specimens remains uncertain. However, it is also unlikely that its presence is merely an incidental finding and without sequelae.

Unfortunately, in our case, culture material was not available, but we believe the histologic features of sarcina are singular enough that a diagnosis can be made on hematoxylin and eosin stain. The organism, in this case, was associated with a gastric ulcer. Interestingly on Gram's stain, the organism stained red, which was again curious given that it should have stained purple (gram-positive). Possible reasons might be over-decolorization during the staining or cell wall damage due to the antibiotics. Additional special stains, such as Brown and Hopps, might help to stain the unique tetrad morphology, although it is not necessary for the diagnosis.[5]

Because sarcina ventriculi are difficult to grow on culture and molecular methods of confirmation are not available in routine practice, histopathological examination for the classic morphological features remains a key to diagnosis until specific microbiological diagnostic methods are established.[4] The clinicians must provide a detailed history of any delayed gastric emptying in the requisition form of the gastric biopsy submitted. This practice would alert the pathologist to look for the presence of sarcina along the gastric mucosa and investigate further for the functional causes of delayed gastric emptying like occult malignancy. It is of utmost importance that the pathologists must be aware of this rare organism and its uncertain significance.

Acknowledgments

Authors also acknowledge the immense help received from the scholars whose articles are cited and included in references. The authors are grateful to editors and publishers of all those articles, journals, and books from where the literature for this article has been reviewed and discussed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Canale-Parola E. Biology of the sugar-fermenting Sarcinae. Bacteriol Rev 1970;1:82–97.  Back to cited text no. 1
    
2.
Ratuapli SK, Lam-Himlin DM, Heigh RI. Sarcina ventriculi of the stomach: A case report. World J Gastroenterol 2013;14:2282–5.  Back to cited text no. 2
    
3.
Tolentino LF, Kallichanda N, Javier B, Yoshimori R, French SW. A case report of gastric perforation and peritonitis associated with opportunistic infection by Sarcina ventriculi. Lab Med 2003;7:535–7.  Back to cited text no. 3
    
4.
Al Rasheed MR, Senseng CG. Sarcina ventriculi: Review of the literature. Arch Pathol Lab Med 2016;140:1441-5.  Back to cited text no. 4
    
5.
Lam-Himlin D, Tsiatis AC, Montgomery E, Pai RK, Brown JA, Razavi M, et al. Sarcina organisms in the gastrointestinal tract: A clinicopathologic and molecular study. Am J Surg Pathol 2011;35:1700-5.  Back to cited text no. 5
    
6.
Goodsir J XXIII. History of a case in which a fluid periodically ejected from the stomach contained vegetable organisms of an undescribed form. J Nat Hist 1843;11:125-6.  Back to cited text no. 6
    
7.
DeBey BM, Blanchard PC, Durfee PT. Abomasal bloat associated with Sarcina like bacteria in goat kids. J Am Vet Med Assoc 1996;8:1468–9.  Back to cited text no. 7
    
8.
Ferrier D. The constant occurrence of Sarcina ventriculi (Goodsir) in the blood of man and the lower animals: With remarks on the nature of sarcinous vomiting. Br Med J 1872;1:98–9.  Back to cited text no. 8
    
9.
Sauter JL, Nayar SK, Anders PD, D'Amico M, Butnor KJ, Wilcox RL. Coexistence of Sarcina organisms and Helicobacter pylori gastritis/duodenitis in 14 pediatric siblings. J Clin Anat Pathol (JCAP) 2013;1:103.  Back to cited text no. 9
    
10.
Laass MW, Pargac N, Fischer R, Bernhardt H, Knoke M, Henker J. Emphysematous gastritis caused by Sarcina ventriculi. Gastrointest Endosc 1972;5:1101–3.  Back to cited text no. 10
    

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Correspondence Address:
Nisha Attri
D-16, D Block, Staff Quarters, ESIC Hospital, Sodala, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpm.ijpm_1007_21

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