Lipoma gigante bilobular en la mano: Caso clínico y revisión de la literatura

Los lipomas en la mano son infrecuentes y pueden asociar clínica compresiva de nervio mediano. Se denominan gigantes cuando superan los 5cm; en estos casos se debe hacer el diagnóstico diferencial con el liposarcoma. Describimos a continuación el caso de una paciente que presentó un lipoma gigante en la región palmar de la mano.

Prevalence and predictors of abnormal Papanicolaou smears in HIV-infected women

PURPOSE OF INVESTIGATION

To characterize the risk factors for abnormal cervical cytology among women with human immunodeticiency virus (HIV), and to determine the relationship between antiretroviral therapy (ART) and cytology results.

MATERIALS AND METHODS

Retrospective study of clinical data of 115 HIV-infected women between January 2008 and December 2011. Analysis of cervical smears history, as well as, epidemiologic, medical, and sexual factors, administration of ART, CD4 cells count, and HIV viral load were performed.

RESULTS

Mean age was 35.9 ± 6.5 years. Average time of HIV infection was 10.5 ± 4.5 years. HPV infection prevalence was 37.4%, the majority was high-risk. An abnormal Papanicolaou smear was found in 43.5%. Atypical squamous cell of undetermined significance (ASC-US) was reported in 7.8%, low-grade squamous intraepithelial lesions (LSIL) in 32.2%, and high-grade squamous intraepithelial lesions (HSIL) in 3.5%. HPV infection was the only statistical predictor of abnormal cytology (p < 0.001; OR = 0.042). ART, CD4 cells count, and HIV viral load did not correlate to regression of abnormal cytology.

CONCLUSION

These women should be followed-up according to current cervical cancer screening guidelines, independently of the therapy, CD4 cells count, and HIV viral load.

Moderate consumption of red wine, but not gin, decreases erythrocyte superoxide dismutase activity: a randomised cross-over trial

BACKGROUND AND AIMS

Several studies have shown that moderate alcohol consumption reduces the risk of coronary heart disease, a disease related to oxidative stress. However, the effects of different alcoholic beverages on antioxidant status are not fully known. Our aim was therefore to compare the effects of a moderate intake of an alcoholic beverage with high polyphenol content (red wine) and another without polyphenol content (gin) on plasma antioxidant vitamins, lipid profile and oxidability of low-density lipoprotein (LDL) particles.

METHODS AND RESULTS

Forty healthy men (mean age, 38 years) were included in a randomised cross-over trial. After a 15-day washout period, subjects received 30 g/ethanol/d as either wine or gin for 28 days. Diet and exercise were monitored. Before and after each intervention, we measured serum vitamins, malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione peroxidase activities, lipid profile, oxidized LDL and LDL resistance to ex-vivo oxidative stress. Compared to gin intervention, wine intake reduced plasma SOD activity [-8.1 U/gHb (95% confidence interval, CI, -138 to -25; P=0.009)] and MDA levels [-11.9 nmol/L (CI, -21.4 to-2.5; P=0.020)]. Lag phase time of LDL oxidation analysis also increased 11.0 min (CI, 1.2-20.8; P=0.032) after wine, compared to gin, whereas no differences were observed between the two interventions in oxidation rate of LDL particles. Peroxide concentration in LDL particles also decreased after wine [-0.18 nmol/mL (CI, -0.3 to-0.08;P=0.020)], as did plasma oxidized LDL concentrations [-11.0 U/L (CI,-17.3 to -6.1; P=0.009)].

CONCLUSION

Compared to gin, red wine intake has greater antioxidant effects, probably due to its high polyphenolic content.

Magnetic resonance imaging in the preoperative staging of endometrial carcinoma

PURPOSE OF INVESTIGATION

Magnetic resonance imaging (MRI) has emerged as an important imaging modality in the evaluation of the extension of endometrial carcinoma which is essential in planning treatment and predicting prognosis. This study aimed to assess the value of MRI in the preoperative staging of endometrial carcinoma.

METHODS

We included in this study 162 patients with a histological diagnosis of endometrial carcinoma who underwent MRI pelvic imaging and surgical staging. MRI images were compared with pathological findings to measure MRI's sensitivity, specificity, positive and negative predictive values and diagnostic accuracy in what concerns myometrial, cervical and lymph node invasion.

RESULTS

MRI differentiation of deep myometrial invasion from superficial disease agreed with pathological findings in 77% of cases, with a sensitivity of 83%, a specificity of 72% and a diagnostic accuracy of 77%. Concerning cervical invasion, MRI had a sensitivity, specificity and diagnostic accuracy of 42%, 92%, 81% respectively. In assessing lymph node invasion, MRI presented a sensitivity of just 17%, a specificity of 99% and a diagnostic accuracy of 89%.

CONCLUSION

Our study confirmed the high accuracy of MRI imaging in assessing myometrial and cervical invasion in endometrial carcinoma. When evaluating lymph node invasion, micrometastases are responsible for the low sensitivy of MRI.

Classification of radical hysterectomy adopted by the Gynecological Cancer Group of the European Organization for Research and Treatment of Cancer

The Piver classification of radical hysterectomy for the treatment of cervical cancer is outdated and misused. The Surgery Committee of the Gynecological Cancer Group of the European Organization for Research and Treatment of Cancer (EORTC) produced, approved, and adopted a revised classification. It is hoped that at least within the EORTC participating centers, a standardization of procedures is achieved. The clinical indications of the new classification are discussed.

Patients with locally advanced cervical cancer should not undergo routine pretreatment surgical staging

The current FIGO staging system for locally advanced cervical cancer (Stages IIB to IVA) is considerably inaccurate, especially because lymph node metastases are ignored. Surgical staging has been used to overcome this insufficiency, allowing individualisation of therapy. However, this approach is controversial and should not be routinely undertaken considering the feasibility, adequacy and morbidity involved with the surgical procedure. Moreover, the survival benefit of surgical staging has yet to be proven and accurate non-invasive imaging alternatives, such as position emission tomography (PET) scanning, have become available. The management of patients with locally advanced cervical cancer based on PET and computed tomography (CT) imaging is proposed and discussed.

Estrogen receptor, progesterone receptor, and bcl-2 are markers with prognostic significance in CIN III

There are no known biological markers or technologies to predict the natural history of an individual CIN III. The probability of progression is considered greater with the persistence of high-risk human papillomavirus (HPV) infection and age. p53 polymorphism has been associated with cervical carcinogenesis. Hormone-induced cervical cancer is mediated by estrogen receptor (ER) and progesterone receptor (PR). In cervical cancer, increased bcl-2 and Bax immunoreactivity is generally associated with a better prognosis. The purpose of this study was to evaluate the value of HPV 16 and HPV 18 typing and p53 codon polymorphism genotyping by polymerase chain reaction and ER, PR, bcl-2, and Bax expression by immunohistochemistry in predicting the CIN III clinical behavior of CIN III lesions. We studied the expression of these prognostic factors in the CIN III adjacent to squamous cell microinvasive carcinomas of the cervix (MIC) from 29 patients with FIGO stage IA1 cervical cancer and in 25 patients with CIN III and no documented focus of invasion. In the MIC group, only the CIN III was considered at least 2 mm away from the microinvasive complex. The ER, PR, bcl-2, and Bax immunoreactivity was scored as positive (>10% staining cells) and negative (<10% staining cells). No significant difference was observed between MIC and CIN III group concerning HPV infection and p53 polymorphism. The ER, PR, bcl-2, and Bax immunohistochemical expression was stronger and more frequent in the CIN III group. After multivariable analysis, coexpression of ER, PR, and bcl-2 was the only independent factor in defining low risk of progression for CIN III. Our study suggests that coexpression of ER, PR, and bcl-2 may be a useful tool in identifying the CIN III lesions with low risk of progression to cervical cancer.

Estrogen receptor, progesterone receptor, and bcl-2 are markers with prognostic significance in CIN III

There are no known biological markers or technologies to predict the natural history of an individual CIN III. The probability of progression is considered greater with the persistence of high-risk human papillomavirus (HPV) infection and age. p53 polymorphism has been associated with cervical carcinogenesis. Hormone-induced cervical cancer is mediated by estrogen receptor (ER) and progesterone receptor (PR). In cervical cancer, increased bcl-2 and Bax immunoreactivity is generally associated with a better prognosis. The purpose of this study was to evaluate the value of HPV 16 and HPV 18 typing and p53 codon polymorphism genotyping by polymerase chain reaction and ER, PR, bcl-2, and Bax expression by immunohistochemistry in predicting the CIN III clinical behavior of CIN III lesions. We studied the expression of these prognostic factors in the CIN III adjacent to squamous cell microinvasive carcinomas of the cervix (MIC) from 29 patients with FIGO stage IA1 cervical cancer and in 25 patients with CIN III and no documented focus of invasion. In the MIC group, only the CIN III was considered at least 2 mm away from the microinvasive complex. The ER, PR, bcl-2, and Bax immunoreactivity was scored as positive (>10% staining cells) and negative (<10% staining cells). No significant difference was observed between MIC and CIN III group concerning HPV infection and p53 polymorphism. The ER, PR, bcl-2, and Bax immunohistochemical expression was stronger and more frequent in the CIN III group. After multivariable analysis, coexpression of ER, PR, and bcl-2 was the only independent factor in defining low risk of progression for CIN III. Our study suggests that coexpression of ER, PR, and bcl-2 may be a useful tool in identifying the CIN III lesions with low risk of progression to cervical cancer.

Plasma cell cheilitis

Plasma cell cheilitis is a rare inflammatory disorder of the lip with a characteristic band-like infiltrate of plasma cells in the upper dermis. Differential diagnosis should consider allergic/irritant contact cheilitis, candidiasis, syphilis, Queyrat's erythroplasia, granulomatous cheilitis, plasmoacanthoma, plasmacytoma, squamous cell carcinoma and exfoliative or factitious cheilitis. We observed plasma cell cheilitis in a 60-year-old Caucasian female who had a partial response to topical steroids and oral griseofulvin.

Acral necrosis by Stenotrophomonas maltophilia

BACKGROUND

Stenotrophomonas maltophilia (SM) has been considered a nosocomial pathogen. Nevertheless, community acquired infection may occur more frequently than usually recognized.

CASE

We describe distal necrosis of the fingers by SM in a farmer, contracted in the community and successfully treated with a combination of cotrimoxazole and ciprofloxacin. The patient was diagnosed with chronic lymphocytic leukaemia 6 months later.

CONCLUSIONS

This unusual presentation shows that infection with SM should be included in the differential diagnosis of the skin and soft tissue infection, even in apparently healthy patients.

Interanionic (-)O-H...O(-) interactions: a solid-state and computational study of the ring and chain motifs

The (-)O-H...O(-) interaction formed by the anions HCO3-, HCO4, HC4O4 and HC5O5- (HA-), obtained upon monodeprotonation of the corresponding carbonic, oxalic, squaric and croconic acids (H2A), has been investigated theoretically and experimentally. The ring (RING) and chain (CHAIN) hydrogen bond motifs established between these anions have been analysed in terms of geometry and energy and their occurrence in crystalline salts investigated by searching the Cambridge Structural Database (CSD) and the Inorganic Chemistry Structural Database (ICSD). It has been shown that hydrogen carbonates form RINGs, with the notable exception of NaHCO3, while only CHAINs are known for hydrogen oxalates. Hydrogen squarates and hydrogen croconates can form both RINGs and CHAINs. The structures of Rb- and Cs- hydrogen croconates, which present the two alternative motifs, have been discussed together with that of the hydrated salt NaHC5O5.H2O. The relationship between RING and CHAIN has been examined in the light of ab initio calculations. A rigorous quantum chemical study of the nature of the interanionic (-)O-H...O(-) interaction in both vacuum and condensed phase has shown that the interaction energy is dominated by the electrostatic component which becomes attractive at short O...O distances (less than 2.5 A) if the net ionic charge on the anion is delocalised away from the -OH group. It has been demonstrated that the RING motif is slightly metastable with respect to dissociation in the gas phase, but becomes stable in the crystal owing to the influence of the Madelung field. However, the CHAIN motif is unstable both in the gas phase and in the crystal. It is argued that interanionic (-)O-H...O(-) interactions ought to be regarded as stabilising bonding interactions rather than proper intermolecular hydrogen bonds because the RING and CHAIN aggregates are not energetically stable on an absolute scale of bonding energy (i.e., in the absence of counterions). The presence of very short non-hydrogen-bridged O...O contacts resulting from charge compression of polyatomic anions bridged by alkali cations is also discussed.

Characterization of soluble factors from cultures of premalignant cervical epithelium

PURPOSE

Immune responses within the cervical microenvironment are likely to play an important role in the natural history of premalignant lesions but the pattern of this response and how it is regulated has not been documented in detail.

METHODS

Explants of premalignant cervical epithelium were cultured in vitro for 24 hours. The culture supernatants were assayed for the presence of IL-1alpha, IL-10, IL-12 and TNF-alpha by ELISA. Aliquots of each supernatant were also added to a CD3-dependent T cell proliferation assay.

RESULTS

The pattern of cytokines found in different samples was heterogeneous and no significant correlation was observed between the various cytokines examined. The functional effects observed were also diverse, with some supernatants showing strong inhibitory T cell activity, while others were stimulatory.

CONCLUSION

Our results document the heterogeneity of the local cytokine microenvironment of premalignant cervical lesions, which may play a role in regulating the immune response associated with such lesions and hence influence clinical outcome.

The antigen-presenting environment in normal and human papillomavirus (HPV)-related premalignant cervical epithelium

The activation of HPV-specific T cells within the cervical microenvironment is likely to play an important part in the natural history of cervical intraepithelial neoplasia (CIN). The extent and the type of T cell activation will depend critically on the expression of MHC, costimulatory cell surface molecules and cytokines by keratinocytes and Langerhans cells within the cervical lesion. Expression of MHC class II (HLA-A-DR and -DQ), costimulatory/adhesion molecules (CD11a/18, CD50, CD54, CD58 and CD86) and cytokines (tumour necrosis factor-alpha (TNF-alpha) and IL-10) was therefore investigated by immunohistochemistry in normal squamous epithelium (n = 12), low-grade (n = 23) and high-grade (n = 18) squamous intraepithelial lesions of the cervix. CIN progression was associated with de novo expression of HLA-DR and CD54, and increased expression of CD58 by keratinocytes. However, significantly, there was no expression of any adhesion/costimulation molecule by epithelial Langerhans cells in any cervical biopsy studied. Furthermore, TNF-alpha, a potent activator of Langerhans cells, was expressed constitutively by basal keratinocytes in normal cervix (12+/12). but expression of this cytokine was absent in a number of CIN samples (20+/23 for low-grade, 12+/18 for high-grade CIN). Conversely, the suppressive cytokine IL-10 was absent in normal epithelium (0+/12), but was up-regulated in a number of CIN lesions (12+/23 for low-grade; 8+/18 for high-grade CIN). The restricted expression of costimulation/adhesion molecules and the nature of the cytokine microenvironment within the epithelium may act to limit effective immune responses in some CIN lesions.

Antigenic and genomic diversity of human rotavirus VP4 in two consecutive epidemic seasons in Mexico

In the present investigation we characterized the antigenic diversity of the VP4 and VP7 proteins in 309 and 261 human rotavirus strains isolated during two consecutive epidemic seasons, respectively, in three different regions of Mexico. G3 was found to be the prevalent VP7 serotype during the first year, being superseded by serotype G1 strains during the second season. To antigenically characterize the VP4 protein of the strains isolated, we used five neutralizing monoclonal antibodies (MAbs) which showed specificity for VP4 serotypes P1A, P1B, and P2 in earlier studies. Eight different patterns of reactivity with these MAbs were found, and the prevalence of three of these patterns varied from one season to the next. The P genotype of a subset of 52 samples was determined by PCR. Among the strains characterized as genotype P[4] and P[8] there were three and five different VP4 MAb reactivity patterns, respectively, indicating that the diversity of neutralization epitopes in VP4 is greater than that previously appreciated by the genomic typing methods.

Serotype specificity of the neutralizing-antibody response induced by the individual surface proteins of rotavirus in natural infections of young children

The relative contribution of the rotavirus surface proteins, VP4 and VP7, to the induction of homotypic as well as heterotypic neutralizing antibodies (NtAbs) in natural infections was studied. The NtAb titers of paired sera from 70 infants with serologically defined primary rotavirus infections were determined with a panel of rotavirus reassortants having one surface protein from a human rotavirus (serotypes G1 to G4 for VP7 and P1A and P1B for VP4) and the other surface protein from a heterologous animal rotavirus strain. A subset of 37 children were evaluated for epitope-specific antibodies to the two proteins by an epitope-blocking assay. The infants were found to seroconvert more frequently to VP4 than to VP7 by both methods, although the titers of the seroconverters were higher to VP7 than to VP4. Both proteins induced homotypic as well as heterotypic NtAbs. G1 VP7 frequently induced a response to both G1 and G3 VP7s, while G3 VP7 and P1A VP4 induced mostly homotypic responses.

Cathepsin E expression by normal and premalignant cervical epithelium

We have investigated the expression of the aspartic proteinase cathepsin E and HLA-DR and the presence of HPV16 in normal squamous epithelium (n = 8) and low-grade (n = 21) and high-grade (n = 14) intraepithelial squamous lesions of the uterine cervix. Immunohistochemistry of cervical biopsies revealed that up-regulation of cathepsin E expression was related to increasing severity of the cervical intraepithelial neoplasia (CIN). Up-regulation of protein was associated with increased message as assessed by in situ hybridization. Langerhans cells and the majority of koilocytes did not express detectable cathepsin E levels. Although there was also an up-regulation of HLA-DR expression by cervical keratinocytes in cervical intraepithelial neoplasia lesions, as determined by immunohistochemistry, no significant correlation was found between HLA-DR and cathepsin E expression in these lesions; neither was expression of cathepsin E correlated to the presence of HPV16, detected by polymerase chain reaction. The expression of cathepsin E, an aspartic proteinase that is reported to play a role in antigen processing for presentation by class II major histocompatibility complex molecules, is associated with cellular dedifferentiation in cervical intraepithelial neoplasia.

Regulation of cathepsin E expression during human B cell differentiation in vitro

Cathepsin E is an aspartic proteinase which has been implicated in antigen processing in the class II major histocompatibility complex pathway. In this study we show that cathepsin E, measured at both the protein and message level, is up-regulated late in human B cell activation. The implications of this observation in terms of cathepsin E function are discussed.

[Control of diarrheal diseases in Mexico and Latin America]

Oral rehydration therapy (ORT), has been considered the major advance in the treatment of the diarrheal diseases, and has been the single most important factor in the decrease of mortality and decreased morbidity in childhood diarrheal. ORT, is not limited to the administration of oral rehydration solution; it also includes feeding techniques and community education and participation. In order to promote ORT, national programs have been developed and promoted in educational centers in strategic areas of the Latin America countries, where medical and paramedical staff attend. In México there have been two national surveys to evaluate the ORT program. This policy has allowed for participating countries to reduce the cost of treatment of diarrheal disease.

[Acute non-bacterial interstitial tubular nephritis]

With the idea in mind to review the etiologic characteristics and evolution of nonbacterial acute tubulointerstitial nephritis, 29 cases seen at the Hospital Infantil de México between 1972 and 1978 were studied. The ages of patients fluctuated from 3 months to 14 years; 18 of them were males. The disease was associated with the administration of nephrotoxic agents, fundamentally antibiotics, being in order of frequency; gentamicin, kanamycin, ampicillin and streptomycin. The main initial manifestations were hematuria and oliguria. At the onset of the disease, acute renal failure was found in 5 of the patients. Two patients developed chronic renal failure, which in one of them was caused by diphenylhydantoin and was reversible on discontinuance of the drug. There were 3 deaths which in 2 cases followed infectious complication and in 1, renal failure. Considerations are made on the pathogenesis of the disease which is predominantly immunologic of following direct toxic action.

[Glomerulonephritis with mesangial IgA deposit (IgA mesangiopathy?)]

Clinical correlations and evolution were studied in 34 biopsies from patients with the following diagnosis: Henoch-Schönlein purpura in 17, monosymptomatic hematuria in 11, idiopathic nephrotic syndrome in 3, and Fanconi Syndrome, Systemic lupus erythematosus and tubulointerstitial nephritis, one for each diagnosis respectively. All these biopsies showed anti-IgA mesangial deposits, by immunofluorescence techniques with variable morphology by light microscopy. Endo and extracapillary proliferation was the most frequent lesions. Twenty cases had follow-up observation for over 2 years: 7 cases were in remission, hematuria and/or proteinuria persisted in 10 and 3 cases progressed to chronic renal failure. In conclusion, mesangial IgA deposits are not an infrequent finding in renal biopsies performed in the Hospital Infantil de México. Although the predominant clinical diagnosis was either Henoch-Schönlein purpura or monosymptomatic hematuria, other diagnosis were also found. Some cases with this mesangiopathy presented as idiopathic nephrotic syndrome or post-streptococcal glomerulonephritis, but with serum complement within normal levels. Long-term prognosis was related to glomerular morphology as in other glomerulopathies.

[Idiopathic nephrotic syndrome with diffuse mesangial proliferation]

The clinicopathologic correlation of 18 cases of idiopathic nephrotic syndrome (INS) with diffuse mesangial proliferation (MP), (over 3 cells per intercapillary space) showed clinical characteristics similar to INS with minimal glomerular lesions (MGL) in relation to age at onset, sex, period of evolution, intensity of proteinuria, hypercholesterolemia, hypoalbuminemia and edema. However, there was a greater incidence of cases with arterial hypertension, hematuria, azotemic retention and positive glomerular immunofluorescence. Out of the 18 cases, 10 were corticosensitive (group I) and 8 were corticoresistant (group II). Patients of I followed a similar course as those with MGL, while most cases of group II showed proteinuria through observation periods up to 5 years. No differences were found in the initial clinical presentation between these 2 groups. The only item with prognostic value was the intensity of the mesangial proliferation which in group I was of 3 to 5 cells per intercapillary space, while in group II, in the spaces of some glomeruli, there were up to 10 mesangial cells present. These findings suggest the convenience to practice renal biopsy before initiating treatment in children with INS and arterial hypertension, hematuria and/or azotemic retention in order to identify this group of patients that appears to be different from that with MGL.

[Immunopathological study in membranoproliferative glomerulonephritis]

In 39 renal percutaneous biopsies, practiced to 31 patients with membranoproliferative glomerulonephritis (GMP) with subendothelial deposits (DSE), a study with immunofluorescence technique and light microscopy was carried out. In all cases, heavy granular deposits of C3 were detected in the loops of the glomerular capillaries and in a variable proportion of cases, deposits of IgM, IgA, C3PA (factor B) and C1q of similar aspect and localizacion were found. These findings suggest immunologic pathogenesis. In the absence of C1q, no cases with factor B were found; thus, it is possible to assert that the activation of the complement system takes place exclusively through an alternate pathway, as was previously accepted. On the other hand, it was found that the presence of C1q was correlated with a faster evolution to chronic renal failure and with the presence of a higher percentage of glomeruli with extracapillary proliferation (crescents). Thus, it is concluded that activation of C1q in patients with MPG and SED, may play a role in formation of crescent and consequently, it is a sign of poor prognosis.