Adult polyglucosan body disease: a postmortem correlation study

Autopsy of a 50-year-old woman with adult polyglucosan body disease and missense mutations (Arg515His, Arg524Gln) in the glycogen branching enzyme gene (GBE) revealed accumulation of polyglucosan bodies in the heart, brain, and nerve. GBE activity was decreased in the morphologically affected tissues but was normal in unaffected tissues. GBE mRNA transcripts were similar in all tissues and in controls, which confirms the lack of tissue-specific GBE isoforms.

[Plaque morphology of the carotid bifurcation and incidence of embolisms in relation clinical stage of cerebrovascular insufficiency]

Vascular morphology and determination of plaque surface structure are getting more and more matter of interest before revascularisation procedures are performed. One reason may be the increase of interventional treatment (PTA). For that we investigated the value of ultrasound duplex scanning to predict preoperatively the vascular surface and plaque structure. 368 patients operated on obstructing stenosis of the carotid artery could be enrolled in this investigation. In all patients duplex ultrasound scanning was performed preoperatively. In 127 patient an analysis of TC-Doppler curve was possible. During some operations (eversion endarteriectomie) we performed experimental stent implantation. The evaluation was performed with statistical methods.

[Recurrent tumor--pathologic-anatomic findings]

Based on pathological-anatomical findings, early (2 months) and late (2 years) local and distant recurrencies are presented, considering topographic aspects following surgery of primary pulmonary tumours, metastatic pathways and time intervals. Morphological criteria for differentiating two tumours from metastases, systemic recurrencies of the basic disease following early micrometastatic spread, as well as the grading of tumour regression in surgical samples following radio chemotherapy are shown.

[Why to operate on the carotid artery?]

AIM, METHODS, PATIENTS: In a prospective interdisciplinary study of 468 carotid artery stenoses we compared the ultrasound plaque morphology with the histological diagnosis.

RESULTS

For detection of soft plaques and hard plaques by preoperative ultrasound examination we found a sensitivity of 80%. The accuracy for the estimation of the degree of the stenosis was 98%. In case of stroke in progression and completed stroke we found ulcerations by histological examination in 72%. By ultra-sound these ulcerations were detected only in 53%. We found a significant higher figure for TIA and stroke in soft plaque patients than in asymptomatic stage, in which hard plaque formation was seen more often.

CONSEQUENCES

Patients with a soft plaque seem to have a higher risk of a postoperative permanent neurological deficit. However, the dangerous plaque formation with thrombosis or ulceration was not be detected with appropriate accuracy. Therefore the risk of embolisation cannot be predicted sufficiently by means of duplex scanning. This would be extremely important for the indication for stenting in this area. The number of HITS (high intensity transient signals) is 8 to 20 times higher in carotid stenting.

Adaptation of the Ras-recruitment system to the analysis of interactions between membrane-associated proteins

Interactions of membrane-associated proteins play important roles in many cellular processes. The yeast two-hybrid assay is of limited utility for the analysis of such interactions, due to the need for soluble protein partners, whose interaction is assessed in the nucleus. The advent of the Ras-recruitment system (RRS) has enabled the study of membrane-associated proteins interacting with cytoplasmic proteins fused to Ras. Constitutive membrane association of the Ras fusion protein is expected to complement the growth defect of the yeast strain CDC25-2, assayed in the RRS, independent from the interaction with a membrane-bound partner. We describe the adaptation of the RRS to the analysis of interactions between two membrane-associated proteins using a model system. These results may facilitate the study of protein-protein interactions between membrane-bound proteins and further increase the utility of the RRS.

Comparison of in vivo selection and rational design of heterodimeric coiled coils

To investigate how electrostatic interactions restrict the associations of coiled coils, we improved a heterodimeric coiled coil (WinZip-A1B1) by in vivo selection and, alternatively, by rational design. Selection from libraries encoding variable edge (g and e) residues enriched g/e' ion pairs, but the optimum selected heterodimers unexpectedly retained two predicted repulsive g/e' pairs. The best genetically selected heterodimer displayed similar thermodynamic stability and specificity as a rationally designed dimer with predicted ion pairs at all edge positions. This rationally designed pair, however, was less effective than the best genetically selected pair in mediating dimerization in vivo. Thus, the effects of predicted charge pairs depend on sequence context, and complementary charges at the edge positions rationalize only a fraction of the sequences that form stable, specific coiled coils.

[Inflammatory pseudopapilloma after recurring aspiration of fruit stones as rare differential diagnosis of bronchogenic cancer]

We present the case of a 51-year old man with drug-resistant pneumonia in the upper right lobe, weight loss and a 50-pack year history of cigarette smoking who underwent bronchoscopy. By clinical and radiological findings bronchogenic cancer was assumed. Fiberbronchoscopy showed an exophytic tumor-like mass obliterating the right upper lobe. Biopsies revealed an epithelial pseudopapillomatous tumor with multiple mucosal dysplasia and metaplasia. A second bronchoscopy in order to remove the lesion revealed a foreign body embedded in the tissue which could be removed easily. The foreign body proved to be a cherry stone, after its removal pneumonia resolved completely. In the same patient this lesion was recurrent one year later after aspiration of a grape seed. We present this case to emphasize the relationship between foreign body aspiration and inflammatory pseudopapilloma as a sequela of the inflammatory insult provoked by foreign bodies. Bronchoscopy is mandatory and may obviate misdiagnosis and thoracotomy. The use of inhaled and systemic steroids can be used to facilitate successful endoscopic extraction.

Tuberculous involvement of the oesophagus with oesophagobroncheal fistula

Tuberculous involvement of the oesophagus is a rare disease. Even if it is suspected, diagnosis is often difficult though dysphagia and chest pain are the most common symptoms without any other specific signs of tuberculosis. The diagnosis is based on oesophagography, oesophagoscopy, bronchoscopy, and computed tomographic scan. Suspected tuberculosis can be confirmed with histology, smear, and culture. The two most common differential diagnoses are Crohn's disease and carcinoma. The case is reported of a female patient with tuberculous involvement of the oesophagus, who developed an oesophagobroncheal fistula during steroid treatment started for suspicion of Crohn's disease. The patient was immunocompromised due to treatment with azathioprine that she was receiving for multiple sclerosis. The fistula was successfully treated by antituberculous chemotherapy alone.

[Fatal cardiomyopathy in adult in polyglucosan body disease]

Adult polyglucosan body disease (APBD) is a rare genetic disorder, inherited in an autosomal recessive mode. The disease is caused by mutations of the gene coding for the glycogen-branching enzyme, which is essential for branching of polyglucose chains in the normal glycogen molecule. The age of clinical manifestation of the disease mostly is between 40 and 60 years and its course is slowly progressive. Characteristic globular deposits (polyglucosan bodies, PGB) can be detected in biopsies of skin and skeletal muscle as well as in the peripheral and central nervous system. Biochemically, PGBs consist of poorly branched glycogen molecules with abnormally long polysaccharide chains. We report the case of a 50-year-old female patient with APBD who suffered from neurological symptoms such as spastic tetraparesis, urinary incontinence, hypesthesia and dementia. She died unexpectedly of cardiac failure. At autopsy a severe cardiomyopathy with abundant PGBs in the heart muscle fibres could be proven as the cause of death. This observation shows that in addition to the known deposition of PGBs in nervous system and skeletal muscle, an involvement of the heart has to be considered in APBD as well.

Fibre-years, pulmonary asbestos burden and asbestosis

The relations between cumulative asbestos fibre doses at the work-places and asbestos burden of the lung evaluated by lung dust analyses have been tested on 3 different groups of patients of the German Mesothelioma Register: 1. total collective (n = 366), 2. collective without elevated asbestos burden of the lungs (n = 193), 3. collective with asbestoses/minimal asbestoses (n = 64). The relations between the above mentioned parameters are in general only weak. The limit value of > 25 fibre-years is found in 19.6% of persons without increased pulmonary asbestos burden. In spite of reaching or exceeding the cumulative doses of 25 fibre-years, 24% of the whole collective also show no elevated asbestos-concentrations in their lung tissues. By contrast, 42% of patients with asbestos-associated lung fibroses do not attain 25 fibre-years at their work-places. Considering our data it is doubtful that the postulated limit value of 25 fibre-years can be an adequate parameter for the evaluation of asbestos-associated lung fibroses.

[Morphological changes after lung trauma]

Post traumatic pleuro-pulmonary lesions can be divided into 3 phases: Acute phase I--several days to one week--with superficial pleuro-pulmonary defects as a main cause for pneumo-hematothorax, intrapulmonary hematoma from rhexis bleeding of parenchymal vessels, tearing of bronchi and vessels. Latency phase II--1-4 weeks with complications caused by inflammatory overlap, contusion pneumonia, development of fistulae, internal aspiration. Late phase III--1 month to years--special variant of rounded hematoma, pleural inflammation for example in fistulae up to scarring fibrosis. Inflammatory complications and development of ARDS with subsequent complications in the traumatically pre-damaged pulmonary organ.

[Iatrogenic "metalloma" (titanoma) caused by implant failure in "metal-backed" patellar joint surface replacement]

Patellofemoral problems frequently provide the cause for revisions after total knee replacements (TKR). Problems with metal-backed patellae, in particular, have been reported on in the past, with a failure rate of 33%. As a result of implant failure, there is an increase of polyethylene and metallic wear, which eventually leads to a synovialitis and metallosis. We report a case of a iatrogenic induced metallosis of the knee joint resulting from failure of a metal-backed patella component with the formation of a substantial pseudotumor within the popliteal fossa. Intraoperatively, a browny-grey, knotted and hard structure was to be seen, which histologically imposed as a hyalinated scar tissue with black particular deposits. Energy dispersive X-ray microanalysis showed a high level of titanium within the intra- and extracellular deposits. In differential diagnosis these findings were postulated as "metalloma" (titanoma). In cases of periprosthetic pseudotumors, particular those with implant failure, a iatrogenic-induced metalloma should be considered.

Low malignant epithelioid peritoneal mesothelioma: successful treatment with surgical therapy alone

A 31-year-old man presented with malignant peritoneal mesothelioma. His past medical history was uneventful, specifically there was no personal or environmental asbestos exposure. The patient was treated by complete tumor resection including peritonectomy. Because of the histologic diagnosis of a low malignant, unusual highly differentiated epithelioid tumor with very low proliferative activity a postoperative chemotherapy was not administered. After a follow-up of 20 months, the patient is in excellent clinical condition and there is no evidence of disease by computed tomography. The present paper reports a case of this rare variant of malignant peritoneal mesothelioma.

[Late pulmonary manifestation of ovarian and breast cancer--which contribution provide immunohistochemical techniques?]

The two case studies are describing 2 females with tumor-suspicious lung opacities including pleural effusions. Both patients have had a smoking history of more than 20 packyears and both underwent surgery for a breast respectively an ovarian cancer 10/15 years before. Conventional staining of the biopsies does not allow in most cases the differentiation between a primary lung carcinoma or the metastasis of an extrapulmonary tumor. Immunohistochemical techniques can give clues as to the origin of the primary tumor. The contribution of these methods in finding the correct diagnosis in the two presented cases is discussed. The cooperation between clinician and pathologist should be emphasized. The transfer of all important information is essential.

[Reaction patterns to cutaneous particulate and ornamental tattoos]

Particulate matter incorporated into the skin of former miners was compared to ornamental tattoos with regard to composition and cutaneous reaction pattern. The specimens were examined histologically and immunohistochemically followed by scanning electron microscopy and element analysis. In the skin biopsies containing dirt particles, silicon and aluminium were regularly found and the particles were positively birefringent under the light microscope. Even years after the initial foreign particle incorporation strong reactions against quartz-containing substances deposited perivascularly and perifollicularly continued to take place. Reactions ranged from strong macrophage activation to pre-granulomatous changes. Anthracotic pigment was demonstrated in all layers of the dermis depending on the degree of traumatic insult and the colour pigments of the ornamental tattoos showed a variable spectra of elements depending on the type of dye used. Fibrous reactions were only discrete, however, strong macrophage activation and sometimes capillary proliferation as well as non-specific lymphocytic infiltration could still be confirmed even decades after the initial incorporation. In conclusion, the cutaneous incorporation of ornamental tattoo dyes and accidental dirt particles is not an inert process. Even years later, non-specific macrophage activation as well as discrete inflammatory changes in an attempt to degrade the foreign material can still be documented. A clear correlation between subcutaneous incorporated quartz particles and progressive systemic sclerosis was not found in this study.

Evolution of IESs and scrambling in the actin I gene in hypotrichous ciliates

Germ-line (micronuclear) genes in hypotrichous ciliates are interrupted by numerous, short, noncoding, AT-rich segments called internal eliminated segments, or IESs. IESs divide a gene into macronuclear destined segments, or MDSs. IESs are excised from micronuclear genes, and the MDSs are spliced when a micronuclear genome is processed into a macronuclear genome after cell mating. In the micronuclear version of the actin I gene intramolecular recombination between IESs during evolution has put MDSs into a scrambled disorder in some but not all hypotrichs. Studies using rDNA sequences to define phylogenetic relationships among eight hypotrichs suggests that evolution of the micronuclear actin I gene proceeds by successive addition of IESs in earlier diverging species, without MDS scrambling. Continued addition of IESs and recombination among IESs in later diverging species produced actin I genes with scrambled MDSs. Subsequent to MDS scrambling, additional IESs were inserted into the more recently evolved species. Thus, IES insertions and gene scrambling occur in a progressive manner during species evolution to produce micronuclear actin I genes of increasing structural complexity.

[Pleural mesothelioma. I: History, epidemiology, clinical aspects (symptoms, diagnosis)]

EPIDEMIOLOGY

Although production and processing of asbestos have been prohibited for years, the incidence of mesothelioma of the pleura will rise in Western Europe. The incidence of mesothelioma will peak between the years 2010 and 2020. It will cause an estimated 250,000 deaths within the next 35 years.

PATHOGENESIS

The fact that exposure to asbestos fibers may result in mesothelioma was first described in 1960. The risk of developing mesothelioma depends mainly on the type of asbestos fibers and the way asbestos is manufactured. Environmental eronite fibers in Central Turkey are the cause of endemic mesothelioma. The pathogenetic role of infection with simian virus 40 is still not determined. Thoracic radiation is of minor importance in the etiology of pleural mesothelioma.

DIAGNOSIS

Between first symptoms of disease and diagnosis of mesothelioma often more than 6 months pass as clinical symptoms are rarely typical. Detection of early stages by invasive procedures and imaging is often very difficult. Histopathological distinction between adenocarcinoma and mesothelioma requires experienced pathologists. This implies that management of mesothelioma should only be performed in multidisciplinary cooperation in specialized centers.

[Minimally invasive percutaneous contrast-ultrasound guided thrombin occlusion of iatrogenic pseudoaneurysm]

BACKGROUND

Complicating femoral artery puncture aneurysms may occur resulting in the need for surgical or newer, non- or minimal-invasive therapy: A new minimal-invasive method is the percutaneous occlusion injecting bovine thrombin. The high thrombogenous potential of thrombin bears the risk of iatrogenic artery occlusion by artificial intravascular instillation.

AIM

Is the contrast-ultrasound guided thrombin injection safe and effective in occluding femoral aneurysms?

METHODS

During 1/99 to 12/00, 33 femoral artery aneurysms as a complication coronary catheterization were diagnosed. In 32 patients the aneurysm (mean dimensions 32 x 35 x 24 mm) was punctured during ultrasound guidance. By injecting ultrasound contrast medium, the flow pattern perfusing the aneurysm was documented. In the canula position where no contrast medium exited the aneurysm thrombin was injected.

RESULTS

Complete occlusion of the aneurysm was achieved in 96.9% (31 out of 32) of the patients by contrast-ultrasound guided thrombin occlusion. Follow-up for up to 3 months after the procedure revealed complete occlusion and no clinical or sonographical complications. In one case, a large aneurysm (50 mm x 62 mm x 27 mm) had already led to skin alterations and was only partly occluded by thrombin injection.

CONCLUSIONS

Contrast-ultrasound guided thrombin occlusion of femoral artery aneurysms is safe and highly effective.

[Association of primary sclerosing cholangitis and sarcoidosis]

BACKGROUND

Primary sclerosing cholangitis and sarcoidosis are rarely associated diseases.

CASE REPORT

We report the case of an 42-year-old woman with primary sclerosing cholangitis confirmed by endoscopic cholangiography, biopsy of the liver and serum neutrophil cytoplasmatic antibodies. Furthermore radiological and histological signs of pulmonary and hepatic manifestation of sarcoidosis were observed, besides there were alopecia areata and choledocholithiasis.

CONCLUSION

The present case report gives a brief survey of the literature, reflects the theories to unknown etiology and reports actual aspects of diagnosis and therapy of both diseases.

Computed tomographic high-attenuation mediastinal lymph nodes after aluminum exposition

A case with increased computed tomographic densities of mediastinal lymph nodes with histologically proven aluminum storage is presented. We suggest consideration of aluminosis as differential diagnosis in patients with increased native CT densities beyond 50 HU.

Helix-stabilized Fv (hsFv) antibody fragments: substituting the constant domains of a Fab fragment for a heterodimeric coiled-coil domain

Antibody Fv fragments would in principle be useful for a variety of biotechnological applications because of their small size and the possibility to produce them in relatively large amounts in recombinant form; however, their limited stability is a drawback. To solve this problem, both domains are usually fused via a peptide linker to form a single-chain Fv (scFv) fragment, but in some cases this leads to a dimerization. We present an alternative format for stabilizing antibody Fv fragments. The C(H)1 and C(L) domain of the Fab fragment were replaced with a heterodimeric coiled coil (WinZip-A2B1), which had previously been selected using a protein-fragment complementation assay in Escherichia coli. This new antibody format was termed helix-stabilized Fv fragment (hsFv), and was compared to the corresponding Fv, Fab and single-chain Fv format. Bacterial growth and expression of the hsFv was significantly improved compared to the Fab fragment. The hsFv fragment formed a heterodimer of heavy and light chain with the expected molecular mass, also under conditions where the scFv fragment was predominantly dimeric. The hsFv fragment was significantly more stable than the Fv fragment, and nearly as stable as the scFv fragment under the conditions used (80 nM protein concentration). Thus, the format of a helix-stabilized Fv (hsFv) fragment can be a useful alternative to existing recombinant antibody formats, especially in cases where poor expression of Fab fragments or multimerization of scFv fragments is a problem.

[Complex pulmonary vessel alterations in an aorto-pulmonary window in adulthood]

An aorto-pulmonary window (aorto-pulmonary septal defect) is considered to be a rare congenital cardiac malformation. We report the case of a patient with an unrepaired congenital aorto-pulmonary window 1.4 cm in size which is the largest aorto-pulmonary septal defect yet reported. This patient died at the age of 58 not from the congenital cardiac malformation but from the after-effects of a pulmonary adenocarcinoma diagnosed 2 years previously. Interestingly, the long standing, persistent pulmonary hypertension correlated well with the varying pathomorphological changes seen in the pulmonary vessels. In addition to the complex morphological signs due to the pulmonary hypertension such as the extensive aneurysms found in the left and right main pulmonary arteries (first report of this size), pulmonary vessels with relatively few pathomorphological changes were also found. Hence this first report of such a long survival of a patient with a comparatively large aorto-pulmonary septal defect demonstrates a surprising variety of pathomorphological alterations seen in the pulmonary arteries in the face of excessive pulmonary hypertension. These alterations could be the result of peripheral aneurysmatic formations and thrombembolic stenoses of the lobular or segmental arteries and might provide an explanation for the long survival of this particular congenital cardiac malformation. All these varying findings in the pulmonary arteries emphasise the fact that the pathomorphological findings in lung biopsies might not be representative of the whole lung.

[Stent-induced changes of coronary morphology--pathologic-anatomic and experimental findings after balloon expansion]

BACKGROUND

Restenosis after coronary stenting still remains a major limitation of implanted endoluminal endoprostheses. To minimize-device related complications, a better understanding of the mechanisms leading to vessel wall alterations is needed.

AIM

To study the morphological effects of coronary stenting in correlation to design changes of the endoprostheses after intraluminal dilation.

METHODS

1) Postmortem analysis of the changes in coronary artery morphology and venous bypass specimens of 35 stents inserted in 27 patients (24 hours up to 4 years after implantation). 2) Standardized postmortem stenting of 20 highly stenosed (> 90% in postmortem selective coronary angiography) and calcified coronary artery segments. Artifact-free microscopical analysis and measurements were performed on cross sections obtained by methylmethacrylate embedding and hard-cut grinding histological preparation.

RESULTS

Light microscopy revealed inhomogeneous stent expansion in all artery cross sections resulting in twisted stent filaments. Calcified plaque areas were not deformed by the stent dilation. In eccentric stenoses only over-dilation of the fibrotic plaque segments led to enlargement of the vessel's cross section. Dissections were seen on the edges of atherosclerotic plaques reaching into the arterial medial lamina. Underlying vessel morphology and not implantation pressure determined stent symmetry. Ruptured stent filaments were a seldom but crucial complication of changes in stent design after balloon dilation.

CONCLUSIONS

The expansion pattern of coronary stents is determined mostly by the underlying degree of atherosclerotic disease, which is the major factor influencing results of coronary stenting and leading to limiting thrombotic and myofibroblastic stent occlusions.

Saline-irrigated, cooled-tip radiofrequency ablation is an effective technique to perform the maze procedure

BACKGROUND

We evaluated the effectiveness of the saline-irrigated-cooled-tip-radiofrequency ablation (SICTRA) to produce linear intraatrial lesions.

METHODS

Thirty patients with chronic atrial fibrillation and mitral valve disease were consecutively randomized to have mitral valve operation either with a Maze procedure (group A) or without (group B). Intraatrial linear lesions were made with an SICTRA catheter (20 to 32 W; 200 to 320 mL/h saline). An echocardiography and 24-hour electrocardiogram were obtained 12 months postoperatively.

RESULTS

The cumulative frequencies of sinus rhythm in group A and B were 0.80 and 0.27 (p < 0.01). Restored biatrial contraction was present in 66.7% (6 of 9) of the group A patients in sinus rhythm. One patient from each group received a permanent pacemaker because of bradycardia. A fatal renal bleeding and mediastinitis occurred in 2 group A patients, 6 weeks postoperatively. One group A patient had sudden cardiac death at home, 4 months after operation. One patient from each group had lethal respiratory failure, 7 and 10 months after operation. Survival after 12 months for group A and B was 73% and 93% (p = 0.131).

CONCLUSIONS

The SICTRA appeared to be an effective technique to perform the Maze procedure.

A structural and phylogenetic analysis of the group IC1 introns in the order Bangiales (Rhodophyta)

Our previous study of the North American biogeography of Bangia revealed the presence of two introns inserted at positions 516 and 1506 in the nuclear-encoded SSU rRNA gene. We subsequently sequenced nuclear SSU rRNA in additional representatives of this genus and the sister genus Porphyra in order to examine the distribution, phylogeny, and structural characteristics of these group I introns. The lengths of these introns varied considerably, ranging from 467 to 997 nt for intron 516 and from 509 to 1,082 nt for intron 1506. The larger introns contained large insertions in the P2 domain of intron 516 and the P1 domain of intron 1506 that correspond to open reading frames (ORFs) with His-Cys box homing endonuclease motifs. These ORFs were found on the complementary strand of the 1506 intron in Porphyra fucicola and P. umbilicalis (HG), unlike the 516 intron in P. abbottae, P. kanakaensis, P. tenera (SK), Bangia fuscopurpurea (Helgoland), and B. fuscopurpurea (MA). Frameshifts were noted in the ORFs of the 516 introns in P. kanakaensis and B. fuscopurpurea (HL), and all ORFs terminated prematurely relative to the amino acid sequence for the homing endonuclease I-Ppo I. This raises the possibility that these sequences are pseudogenes. Phylogenies generated using sequences of both introns and the 18S rRNA gene were congruent, which indicated long-term immobility and vertical inheritance of the introns followed by subsequent loss in more derived lineages. The introns within the florideophyte species Hildenbrandia rubra (position 1506) were included to determine relationships with those in the Bangiales. The two sequences of intron 1506 analyzed in Hildenbrandia were positioned on a well-supported branch associated with members of the Bangiales, indicating possible common ancestry. Structural analysis of the intron sequences revealed a signature structural feature in the P5b domain of intron 516 that is unique to all Bangialean introns in this position and not seen in intron 1506 or other group IC1 introns.