Intraepithelial lymphocytes, scores, mimickers and challenges in diagnosing gluten-sensitive enteropathy (celiac disease)

Figure 1 Plant taxonomy and celiac toxicity (red).

Figure 2 Intraepithelial lymphocytes and Marsh classification. A: Schema of the intraepithelial distribution of the intraepithelial lymphocytes (top, side and bottom, see text); B: Marsh 0, normal villous architecture with en-face cut (HE, × 100); C: Marsh I (HE, × 100); D: Marsh IIIA (HE, × 100); E: Marsh IIIB (HE, × 100); F: Marsh IIIC (HE, × 100). Marsh-Oberhuber classification is often shortened as Marsh.

Figure 3 Gluten-sensitive enteropathy and GSE mimickers. A, B: Variable destructive patterns of Marsh IIIC of GSE (A: HE, × 100; B: HE, × 200); C, D: Eosinophilic duodenitis (HE, × 400); E, F: Peptic duodenitis (HE, × 400). GSE: Gluten-sensitive enteropathy.

Figure 4 Gluten-sensitive enteropathy mimickers. A: Lymphocytic gastritis with involvement of the duodenum (HE, × 100); B: H. pylori gastritis (inset, Giemsa staining) (HE and Giemsa × 630); C: Giardiasis (HE, × 400); D: Cytomegalovirus (CMV) infection (HE, × 6300) and inset showing anti-CMV antibody reacting against viral proteins using an avidin-biotin complex immunoperoxidase immunohistochemical detection (× 100); E: Focal adenomatous change in duodenum (HE, × 50); F: Sickle cell disease-related duodenitis (HE, × 200).

Figure 5 Gluten-sensitive enteropathy mimickers. A-D: Post-transplant lymphoproliferative disorder, polymorphic type (A: HE, × 50 and inset HE, × 200) showing mononuclear epithelial and stromal infiltration with blasts and high CD20 (B, × 100) on CD3 (C, × 100) lymphocytes and high Epstein-Barr virus replication (in situ hybridization or Epstein-Barr encoding region, × 100); E: Burkitt lymphoma of the duodenum (HE, × 100); F: Tubular adenoma of the duodenum of a patient with familiar adenomatous polyposis (HE, × 200).

Figure 6 Synoptic report for gluten-sensitive enteropathy and gluten-sensitive enteropathy mimickers.