First report of Sarcina ventriculi in a pyloric and duodenal brushing specimen

Abstract

Dear Editor,Sarcina ventriculi is an anaerobic Gram-positive coccus that in tissue is arranged in a characteristic tetrad shape. It is usually incidentally found on gastric biopsy in the setting of gastric stasis. 1,2We present a case of Sarcina found by cytological examination of a pyloric and duodenal brushing.The patient is a 38-year-old male immigrant from Guatemala with a past medical history significant for Hodgkin's disease in remission. He presented to a local primary care provider for nausea, frothy emesis, occasional haematemesis and early satiety; he was then referred to a gastroenterologist for endoscopy. Upper endoscopy revealed a circumferential pre-pyloric ulcerative lesion and a separate pyloric ulcer extending into the duodenum. Biopsy of the circumferential lesion demonstrated poorly differentiated diffuse-type gastric adenocarcinoma with signet ring cells. A brushing of the pyloric/duodenal ulcer was prepared on a ThinPrep® 2000 Processor (Hologic). Papanicolaou stain showed non-malignant squamous, gastric and duodenal mucosa with rare acute and chronic inflammatory cells. Interspersed and loosely adherent to the mucosal surface were large, haematoxylinfast cuboidal cells arranged in tetrads and packets (Figure 1, 200×). These cuboidal cells stained prominently with Grocott's methenamine silver (Figure 1 inset, 400×). These findings are most consistent with S. ventriculi. To our knowledge, this is the first reported case of Sarcina in a pyloric/duodenal brushing specimen. A recent report did note Sarcina in an oesophageal brushing. 3 This patient's oesophageal biopsy taken simultaneously did not demonstrate the organism. First discovered in a dyspeptic patient in 1842 and first cultured in 1905, Sarcina is ubiquitous in the environment and is associated with bloating disease in livestock. 4 In humans, S. ventriculi is associated with gastric stasis of any aetiology, but evidence suggests that the organism does not directly injure gastric mucosae in humans and does not have a causative role in ulcerative or static disease. 1,4Rather, the organism is most likely to be able to grow only in the presence of gastric stasis or outlet obstruction. 1,4 This patient's gastric adenocarcinoma was probably the proximate cause of gastric stasis, which allowed Sarcina to flourish.Our findings also suggest that duodenal brushing cytology is sensitive enough to find Sarcina. In addition to upper gastrointestinal cancer diagnosis, 5 historical studies found brush cytology to be sensitive for detection of other bacteria 6 and yeast. 7 Micrococcus species are a potential morphological confounder and can sometimes be arranged in tetrads; however, this organism was significantly larger than expected for Micrococcus and was not arranged in large clusters, a characteristic of Micrococcus species. 4Currently, microbiological workup (culture, sensitivities, molecular genotyping/phenotyping) is not routinely performed for Sarcina because of the lack of causative relationship with disease. However, the presence of Sarcina...

Sarcina Ventriculi infection: a rare but fearsome event. A Systematic Review of the Literature

“…SV is diagnosed with an H-E stain through some essential morphologic features: intense basophilic staining, refractile nature (mimicking vegetable matter) (Lam-Himlin et al, 2011;Canale-Parola, 1970), cuboid shape (Canale-Parola et al, 1960), tetrad packet arrangement (Canale-Parola et al, 1960), 1.8 to 3 μm individual size (Lam-Himlin et al, 2011), and frequent flattening of the cell walls in areas of contact with adjacent cells (Tolentino et al, 2003). Some authors (19/56, 34%) used special ancillary stains such as Gram, Grocott's methenamine silver, Periodic acid-Schiff and/or May-Grumwald Giemsa to confirm the bacterial nature and to exclude the concomitant presence of additional microorganisms (Table 1) (Bommanet al, 2016;Bortolottiet al, 2019;Chanet al, 2020;Chougule et al, 2015;Dolganiucet al, 2017;Dumitruetet al, 2020;Elvertet al, 2018;Fanaroffet al, 2020;Heidingeret al, 2020;Louiset al, 2014;Medlicottet al, 2015;Minorovaet al, 2017;Perraultet al, 2021;Propst et al, 2020;Restelli et al, 2013;Rohr et al, 2019;Tintaraet al, 2019;Tuuminemet al, 2013;Zareet al, 2019). Additional methods, including polymerase chain reaction, sequencing of the 16S ribosomal RNA gene, pyruvate decarboxylase gene, or the IS-proTM technique, can confirm SV diagnosis (Table 1) (Bortolotti et al, 2019;De Meji et al 2017;Elvert et al, 2018;Heidinger et al, 2020;Lam-Himlin et al, 2011;Sauter et al, 2013;Tuuminem et al, 2013).…”

Non-operative Management of Sarcina ventriculi-Associated Severe Emphysematous Gastritis: A Case Report

“…The pathogenic role of Sarcina ventriculi in humans is not entirely understood despite an increasing number of reported cases. It has been isolated in blood [ 13 , 14 ], as well as esophageal, pyloric and duodenal brushings [ 15 - 16 ], fine-needle aspirations of the stomach [ 17 ], and tissue biopsies of the stomach [ 18 ]. It has also been implicated in esophageal stricturing [ 19 ] along with emphysematous gastritis and fatal perforations.…”

Sarcina ventriculi a rare pathogen

“…In the medical literature, the cases reported are associated with a variety of anatomical or functional conditions associated with gastric stasis, such as: gastric or esophageal adenocarcinoma in five cases, 9,19,24,34 laparoscopic gastric banding in four cases, 20,22,23,26 post gastrectomy with gastroenteroanastomosis and vagotomy, 10 psychomotor retardation or neurological deficit with gastrostomy for feeding in three cases, 28,42 benign pyloric or duodenal mass, 7,9,11,32 Schatzki's ring, 27 gastroparesis secondary to diabetes mellitus; 6,9,31 among other conditions.…”