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A Case of Urethral Malacoplakia Associated with Vesical Disease
0022-5347/79/1225-0705$02.00/0 Vol. 122, November
THE JOURNAL OF UROLOGY
Copyright© 1979 by The Williams & Wilkins Co.
Printed in U.S.A.
A CASE OF URETHRAL MALACOPLAKIA ASSOCIATED WITH VESICAL DISEASE J. MCCLURE From the Division of Tissue Pathology, Institute of Medical and Veterinary Science, Adelaide, South Australia
ABSTRACT
A case of recurrent urethral malacoplakia with coexisting disease of the bladder is described. This is compared to the single previously reported case of involvement of this site. The patient presented again 2 years later with dysuria and blood-staining. Examination revealed a urethral caruncle, which was removed and diagnosed as malacoplakia. The bladder was free of disease at this time. It has been 3 years since the second urethral lesion was removed and the patient is free of malacoplakia.
Malacoplakia of the bladder was described originally by Michaelis and Gutmann in 1902. 1 The condition is characterized by the accumulation of macrophage cells (von Hansemann cells) containing typical inclusion bodies called MichaelisGutmann bodies. These are round (5 to 10 µm. in diameter), show concentric laminations and usually contain easily demon-
Typical Michaelis-Gutmann bodies (arrowheads). H & E, reduced from Xl,000
strable calcium salts (iron is less frequently present). Usually, malacoplakia is associated with chronic bacterial infection (coliform) and the Michaelis-Gutmann bodies may represent end stage giant cytosegrosomes in macrophage cells persistently infected with organisms. Electron microscopic evidence purports to show bacilliform organisms in malacoplakic macrophages. 2' 3 While the most commonly reported site of malacoplakia is the bladder, cases of extravesical disease involving sites, such as the testis, prostate, kidney and colon, have been reported increasingly in the last 20 years. There is 1 case of urethral malacoplakia reported as a solitary apparently isolated lesion. 4 A case of a recurrent urethral malacoplakia associated with disease of the bladder is reported herein. CASE REPORT
A 59-year-old white woman presented with stinging pain and blood-staining of the urine on voiding. Clinical examination revealed a small urethral polyp, which was removed. Histologic examination revealed malacoplakia. Cystoscopy 5 months later showed the presence of malacoplakia of the bladder. Examination of the urine revealed moderate albumin and organisms. Culture yielded significant growths of Escherichia coli. Accepted for publication January 5, 1979.
TISSUE PATHOLOGY
The original urethral polyp was covered by stratified squamous epithelium deep to which was an accumulation of macrophage cells with abundant eosinophilic cytoplasm and containing typical Michaelis-Gutmann bodies (see figure). The subsequent bladder biopsy showed identical cells. The recurrent urethral lesion had a covering of transitional cells with focal squamous metaplasia. In the stroma numerous malacoplakia cells were seen with prominent Michaelis-Gutmann bodies, some of which lay free between the cells. The Michaelis-Gutmann bodies stained readily with alizarin red S (for calcium salts), von Kossa (for anionic companions of calcium ions) and periodic acid, Schiff. Occasional bodies reacted with Perl's Prussian blue, indicating the presence of iron. Special stains (Gram and Ziehl-Neelsen) failed to reveal the presence of bacteria in any of the specimens studied. COMMENT
This is the second reported case of urethral malacoplakia and, unlike the first case, there was associated disease of the bladder. The urethral lesion recurred but despite this the essentially benign nature of malacoplakia is emphasized. Pathologists should be aware that malacoplakia may give rise to urethral polypoid and caruncle-like lesions. It is noteworthy that malacoplakia of the testis and prostate has been confused 705
706
MCCLURE
with clear cell carcinoma. 5• 6 Identification of MichaelisGutmann bodies is facilitated by the use of alizarin red S. An obvious conclusion from the associations of this case is that disease of the remainder of the urinary tract should be excluded in cases of urethral rnalacoplakia.
3.
REFERENCES
4.
1. Michaelis, L. and Gutmann, C.: Ueber Einschliisse in Blasentumo-
5.
ren. Z. Klin. Med., 47: 208, 1902. 2. McClurg, F. V., D'Agostino, A. N., Martin, J. H. and Race, G. J.: Ultrastructural demonstration of intracellular bacteria in three
6.
cases of malacoplakia of the bladder. Amer. J. Clin. Path., 60: 780, 1973. Lewin, K. J., Harell, G. S., Lee, A. S. and Crowley, L. G.: Malacoplakia. An electron-microscopic study: demonstration of bacilliform organisms in malacoplakic macrophages. Gastroenterology, 66: 28, 1974. Serra, C. A., Grasso, R. L. and Dip Saade, J.: Malacoplakia: a case of unusual localization. J. Urol., 112: 762, 1974. Brown, R. C. and Smith, B. H.: Malacoplakia of the testis. Amer. J. Clin. Path., 47: 135, 1967. Ferreira, A. A. and Alvarenga, M.: Malacoplakia of the prostate confused with clear cell carcinoma. J. Urol., 116: 828, 1976.
THE JOURNAL OF UROLOGY
Copyright© 1979 by The Williams & Wilkins Co.
Printed in U.S.A.
A CASE OF URETHRAL MALACOPLAKIA ASSOCIATED WITH VESICAL DISEASE J. MCCLURE From the Division of Tissue Pathology, Institute of Medical and Veterinary Science, Adelaide, South Australia
ABSTRACT
A case of recurrent urethral malacoplakia with coexisting disease of the bladder is described. This is compared to the single previously reported case of involvement of this site. The patient presented again 2 years later with dysuria and blood-staining. Examination revealed a urethral caruncle, which was removed and diagnosed as malacoplakia. The bladder was free of disease at this time. It has been 3 years since the second urethral lesion was removed and the patient is free of malacoplakia.
Malacoplakia of the bladder was described originally by Michaelis and Gutmann in 1902. 1 The condition is characterized by the accumulation of macrophage cells (von Hansemann cells) containing typical inclusion bodies called MichaelisGutmann bodies. These are round (5 to 10 µm. in diameter), show concentric laminations and usually contain easily demon-
Typical Michaelis-Gutmann bodies (arrowheads). H & E, reduced from Xl,000
strable calcium salts (iron is less frequently present). Usually, malacoplakia is associated with chronic bacterial infection (coliform) and the Michaelis-Gutmann bodies may represent end stage giant cytosegrosomes in macrophage cells persistently infected with organisms. Electron microscopic evidence purports to show bacilliform organisms in malacoplakic macrophages. 2' 3 While the most commonly reported site of malacoplakia is the bladder, cases of extravesical disease involving sites, such as the testis, prostate, kidney and colon, have been reported increasingly in the last 20 years. There is 1 case of urethral malacoplakia reported as a solitary apparently isolated lesion. 4 A case of a recurrent urethral malacoplakia associated with disease of the bladder is reported herein. CASE REPORT
A 59-year-old white woman presented with stinging pain and blood-staining of the urine on voiding. Clinical examination revealed a small urethral polyp, which was removed. Histologic examination revealed malacoplakia. Cystoscopy 5 months later showed the presence of malacoplakia of the bladder. Examination of the urine revealed moderate albumin and organisms. Culture yielded significant growths of Escherichia coli. Accepted for publication January 5, 1979.
TISSUE PATHOLOGY
The original urethral polyp was covered by stratified squamous epithelium deep to which was an accumulation of macrophage cells with abundant eosinophilic cytoplasm and containing typical Michaelis-Gutmann bodies (see figure). The subsequent bladder biopsy showed identical cells. The recurrent urethral lesion had a covering of transitional cells with focal squamous metaplasia. In the stroma numerous malacoplakia cells were seen with prominent Michaelis-Gutmann bodies, some of which lay free between the cells. The Michaelis-Gutmann bodies stained readily with alizarin red S (for calcium salts), von Kossa (for anionic companions of calcium ions) and periodic acid, Schiff. Occasional bodies reacted with Perl's Prussian blue, indicating the presence of iron. Special stains (Gram and Ziehl-Neelsen) failed to reveal the presence of bacteria in any of the specimens studied. COMMENT
This is the second reported case of urethral malacoplakia and, unlike the first case, there was associated disease of the bladder. The urethral lesion recurred but despite this the essentially benign nature of malacoplakia is emphasized. Pathologists should be aware that malacoplakia may give rise to urethral polypoid and caruncle-like lesions. It is noteworthy that malacoplakia of the testis and prostate has been confused 705
706
MCCLURE
with clear cell carcinoma. 5• 6 Identification of MichaelisGutmann bodies is facilitated by the use of alizarin red S. An obvious conclusion from the associations of this case is that disease of the remainder of the urinary tract should be excluded in cases of urethral rnalacoplakia.
3.
REFERENCES
4.
1. Michaelis, L. and Gutmann, C.: Ueber Einschliisse in Blasentumo-
5.
ren. Z. Klin. Med., 47: 208, 1902. 2. McClurg, F. V., D'Agostino, A. N., Martin, J. H. and Race, G. J.: Ultrastructural demonstration of intracellular bacteria in three
6.
cases of malacoplakia of the bladder. Amer. J. Clin. Path., 60: 780, 1973. Lewin, K. J., Harell, G. S., Lee, A. S. and Crowley, L. G.: Malacoplakia. An electron-microscopic study: demonstration of bacilliform organisms in malacoplakic macrophages. Gastroenterology, 66: 28, 1974. Serra, C. A., Grasso, R. L. and Dip Saade, J.: Malacoplakia: a case of unusual localization. J. Urol., 112: 762, 1974. Brown, R. C. and Smith, B. H.: Malacoplakia of the testis. Amer. J. Clin. Path., 47: 135, 1967. Ferreira, A. A. and Alvarenga, M.: Malacoplakia of the prostate confused with clear cell carcinoma. J. Urol., 116: 828, 1976.