Transitional cell carcinoma manifesting as acute cor pulmonale: cause of microscopic tumor embolism

Acute cor pulmonale is an uncommon manifestation of microscopic pulmonary tumor embolism. We describe the case of an 84-year-old man with a history of transitional cell carcinoma (TCC) of the urinary bladder who had acute cor pulmonale and died within a few hours after the onset of dyspnea. Autopsy showed that the right ventricle was dilated without hypertrophy. Microscopic examination of the lung showed that the small arteries, arterioles, and capillaries were filled with micrometastases of TCC. Microscopic pulmonary tumor embolism has rarely been reported with TCC, and to the best of our knowledge, such a fulminant course has not been previously described in the English language.

Acalculous gallbladder disease: US evaluation after slow-infusion cholecystokinin stimulation in symptomatic and asymptomatic adults

PURPOSE

To evaluate the measurement with ultrasonography (US) of the gallbladder ejection fraction after slow-infusion cholecystokinin stimulation in patients with biliary symptoms and in individuals without symptoms.

MATERIALS AND METHODS

Gallbladder volumes were calculated in 60 healthy volunteers after a 30-minute infusion of sincalide. The time to maximum response, the gallbladder ejection fraction, and the rate of initial contraction were obtained at US. A total of 100 symptomatic patients were evaluated with this technique. Reference standards included surgical outcome or results of clinical follow-up of at least 1 year.

RESULTS

The average ejection fraction +/- 2 standard deviations was 80% +/- 30. A fraction greater than 60% was considered to be a normal response to cholecystokinin stimulation. There was no statistically significant sex difference. Slow infusion did not produce any side effects. A sensitivity of 75% and a specificity of 100% for determination of gallbladder ejection fraction at US were obtained in patients with surgical and histopathologic proof of disease.

CONCLUSION

The slow-infusion method is reliable, safe, and reproducible in evaluating gallbladder contraction. The cholecystokinin-stimulated gallbladder ejection fraction test may be useful in determining which patients could benefit from surgery.

Clostridium innocuum endocarditis

Clostridial endocarditis is rare. We describe, to our knowledge, the first case of Clostridium innocuum endocarditis. The fatal case involved the tricuspid and pulmonary valves and was associated with multiple pulmonary emboli. We review the literature, which suggests the varied presentations and outcomes of clostridial endocarditis. Penicillin is the treatment of choice for this disease.

Osteosarcoma of the spermatic cord

Malignant tumors of the spermatic cord are rare but the vast majority of these tumors are sarcomas. We report on a patient with osteosarcoma arising in the spermatic cord. Left radical orchiectomy with high dissection of the spermatic cord was performed, and the patient remains free of recurrence 2 years postoperatively. We could find no previous discussion or report of this tumor.

Circulating mucin in Wilms' tumor and nephroblastomatosis. Effect on leukocyte counts

Two children with advanced Wilms' tumor and one with extensive nephroblastomatosis showed artifactually elevated white blood cell (WBC) counts due to circulating mucin. Wilms' tumor is known to produce mucin identifiable in serum, urine, and touch imprints. To our knowledge, circulating mucin has not been described in nephroblastomatosis. When patients' blood was mixed with lysing reagent in the Ortho ELT-800, mucin was precipitated by acetic acid; this was confirmed by microscopy. Precipitates were counted as nuclei, producing abnormal WBC counts and histograms. When measured by the Ortho ELT-8/ws using osmotic lysis, the WBC counts matched hemocytometer counts. Mucin was not seen on Wright-stained smears but was evident with alcian blue staining and was largely abolished by hyaluronidase. Treatment led to disappearance of the artifactual WBC elevation.