Pulmonary malakoplakia in acquired immunodeficiency syndrome: An ultrastructural study of morphogenesis of Michaelis-Gutmann bodies

Malakoplakia is an unusual inflammatory reaction to a variety of infections, characterized by the accumulation of macrophages containing the target-like calcospherites, the Michaelis-Gutmann body (MGB). We report three patients with acquired immunodeficiency syndrome with pulmonary malakoplakia associated with Rhodococcus equi infection; two patients were diagnosed at autopsy and one by examination of a transbronchial biopsy specimen. All three patients had pulmonary bacterial cultures and light and electron microscopic examination. The patients were 33-, 41-, and 43-year old men, human imnaunodeficiency virus-positive for 2, 6, and 8 years, respectively. The two patients diagnosed at autopsy had cavitary lesions, and the patient diagnosed by biopsy specimen had nodular lesions on chest radiographs. Histologically, the lungs had well-circumscribed areas of infiltration with benign macrophages with granular cytoplasm, scattered MGBs, and numerous gram-positive coccobacilli. Electron microscopic examination showed intracellular coccobacilli, from 990 x 702 to 972 x 648 mm in diameter, with thick, homogenous cell walls, trilaminar cytoplasmic membranes, and dense cytoplasm with from one to five vacuoles. Electron microscopic studies showed that the bacteria within the pulmonary macrophages had thicker cell walls, less prominent nucleoid areas, and more vacuoles than the bacteria in cultures from the sputum and blood. The mature MGB ultrastructurally had a concentric, trilaminate structure with central mineralized core and was without recognizable bacterial forms. Early MGBs, however, consisted of a circular, electron-dense core containing bacteria, ultrastructurelly similar to the R. equi seen in the culture. Pulmonary malakoplakia in patients with the acquired immunodeficiency syndrome might thus represent an acquired macrophage dysfunction of the intracellular digestion of phagocytized bacteria. The bacteria within the macrophages, however, seemed to have thicker cell walls compared with those in culture, and thus might be protected from enzyme digestion. It seems that MGBs are formed around the undigested bacteria as an alternative pathway for bacterial destruction, because R. equi was identified within the cores of early MGBs but not the mature or late stage MGBs.