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The strong association of giardiasis with dysgammaglobulinemia is such that a careful search should be made in the small bowel for the characteristic nodular pattern of lymphoid hyperplasia (Figs. 9.11 and 9.12A-D). These tiny 2 to 3 mm nodules may be found throughout the small intestine and are not related to giardiasis, but instead are lymphoid follicles and Peyer's patches that have become hyperplastic in their attempt to produce as much gamma globulin as possible (Fig. 9.13). Giardia lamblia cysts are present in the stools of most of these patients with the syndrome of dysgammaglobulinemia, nodular lymphoid hyperplasia, recurrent respiratory and urinary tract infections, chronic sprue-like diarrhea, and other clinical and radiographic evidence of malabsorption. The generally lowered resistance of these patients permits the usually innocuous G. lamblia to flourish in the small bowel.

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Fig.9.12 Giardiasis and nodular lymphoid hyperplasia of the small bowel in a 24-year-old woman with dysgammaglobulinemia, recurrent respiratory infections, and constant sprue-like diarrhea. (A) Mucosal pattern within the duodenal bulb and C loop is coarse with some edema of the folds. Duodenal sweep failed to fill out normally on multiple spot films, indicating slight spasm. (B) Abnormal motor activity and sprue-like changes are seen with dilatation of multiple loops of jejunum and ileum, together with segmentation of the barium column and coarsening of the mucosal folds in some areas. (B and C) Mucosa of the entire jejunum and ileum is uniformly studded with numerous tiny, round, polypoid lesions 2 to 3 mm in diameter. These nodules are well outlined in the areas of air-barium contrast. (D) Nodules of lymphoid hyperplasia are also present in the terminal ileum. (From Maurice M. Reeder: Radiology 93:427, 1969).

Fig 9.13 A,B (A) Gross specimen of the small intestine of a patient with nodular lymphoid hyperplasia in which innumerable small uniform 2 mm to 3 mm polypoid lesions stud the mucosal surface. These nodules account for the multiple round filling defects noted on small bowel series of patients with hypo- or dysgammaglobulinemia. AFIP 69-5421. (B) Photomicrograph of a jejunal biopsy of a patient with dysgammaglobulinemia and nodular lymphoid hyperplasia. Note the circumscribed collections of lymphoid tissue within the lamina propria, causing elevation of the mucosal surface that produces a "polypoid" appearance. The overlying villi are flattened. Higher magnification reveals a mantle of lymphocytes around the germinal centers with only an occasional plasma cell present. The intervening jejunal mucosa is normal. x50. AFIP 68-1025.

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