[Perianal precancerous conditions (Bowen disease, Paget disease, Carcinoma in situ, Buschke-Lowenstein tumor)]

Perianal premalignant lesions are rare. Any suspicious perianal lesion or any perianal exanthema, that does not heal by non-surgical treatment has to be biopsied for histology. Many premalignant lesions are diagnosed as an incidental finding after anorectal surgery: any anorectal specimen must be examined by the pathologist. Leukoplakia is a facultative premalignant condition. High-grade anal intraepithelial neoplasia (AIN) is an in situ squamous cell carcinoma, associated with papillomavirus infection. Bowen's disease and Bowenoid papulosis are clinical variations of high-grade AIN. Buschke-Löwenstein tumour (giant condyloma) is a locally destructive tumour, that does not infiltrate or cause metastases. Paget's disease is a premalignant lesion like AIN, associated with other malignancies.

Clostridium difficile-associated diseases. The clinical courses of 18 fatal cases

OBJECTIVE

Severe cases of Clostridium difficile-associated diseases with sepsis seem to be rare, as are case reports about the pathogen involved and sepsis. Our objective was to investigate the frequency and the clinical courses of severe cases of C. difficile-associated diseases with a fatal outcome in our hospital.

SETTING

Teaching hospital of the University of Kiel (650 beds).

DESIGN

We reviewed retrospectively all deceased patients' charts who had prior histological or microbiological evidence of C. difficile-associated diarrhea (CDAD) and revised the available histological specimens of the autopsies.

PATIENTS

Over a 4-year period (November 1994-October 1998) we diagnosed 304 cases of C. difficile-associated diseases in our hospital.

RESULTS

Eighteen of our cases with C. difficile-associated diseases had a fatal outcome. C. difficile was not likely to be the cause of death in two of the cases. Four of the fatal infections were community-acquired and the reason for admission to the hospital. CDAD is most prevalent in elderly patients with multiple or severe underlying diseases and tends to be overlooked. Sepsis was diagnosed in 15 of our 18 patients with C. difficile-associated diseases.

CONCLUSION

Our study shows that severe cases of CDAD or cases with C. difficile-associated sepsis are probably not rare. Routine testing of fecal specimens for the presence of C. difficile toxins should be considered not only in nosocomial gastrointestinal infections but also in community-acquired gastrointestinal infections of elderly people.

Keratoacanthoma in the differential diagnosis of anal carcinoma: difficult diagnosis, easy therapy. Report of three cases

Three male patients who had an anal keratoacanthoma are described. Anal keratoacanthoma is a rapidly growing skin tumor that invades the dermis but remains locally and can mimic clinically and histologically a squamous-cell carcinoma.

A case of cryptic miliary tuberculosis mimicking cholecystitis with sepsis

Miliary tuberculosis is a rare form of tuberculosis in industrialized countries. We report on a 69-year-old woman presenting a sepsis syndrome caused by cryptic miliary tuberculosis clinically mimicking a case of cholecystitis with sepsis. The patient died of a multi-organ failure on day 6 of her hospital stay.

[A database for thyroid diseases: evaluation with special reference to potential consequences of a nuclear power plant accident]

The concept of a thyroid disease register based on a relational database system with a structured query language (SQL) is reported. More than 5000 examination findings of benign and malignant thyroid disorders have been recorded so far, covering the period from 1986 to 1996. For epidemiological studies these population-based thyroid diseases data can be allocated to a digital data map by means of the five-digit German postal code. When evaluating the data with regard to the function of the thyroid gland as an indicator of preceding nuclear power plant disasters and fallout, we found neither indicators of an increased incidence of thyroid carcinoma as an aftermath of the Chernobyl disaster nor the occurrence of clusters. The data were supplemented by the results of a survey among all Schleswig-Holstein pathologists involved in the diagnosis of thyroid diseases. Data on childhood carcinoma of the thyroid were also provided by the Childhood Tumor Register of the Institute of Pathology, University of Kiel, and by the Childhood Cancer Register of the University of Mainz.

[Fatal pulmonary embolism after endoscopic embolization of downhill esophageal varix]

HISTORY AND CLINICAL FINDINGS

A 79-year-old man was admitted with a history of recent haematemesis and tarry stools. 4 years before he had undergone a subtotal thyroidectomy for hyperthyroidism.

INVESTIGATIONS

He was anaemic (haemoglobin 7.2 g/dl, haematocrit 23%). At the transition between the upper and middle third of the oesophagus gastroscopy revealed a bleeding oesophageal varix.

TREATMENT AND COURSE

The bleeding varix was sclerosed with polidocanol. 3 erythrocyte concentrates were administered. Massive bleeding 2 days later was controlled with intravaricose injection of cyanoacrylate (Histoacryl). The patient died 6 weeks later from progressive cardiovascular failure. Autopsy revealed the cause of death as right heart failure with extensive foreign-body pulmonary emboli identified as thrombotic material containing polymerized cyanoacrylate found in the previously injected oesophageal varix. Also discovered was a retrosternal goitre which had compressed the brachiocephalic vein. Cause of the "washing-out" of the cyanoacrylate embolus from the varix into the systemic circulation was an oesophago-varicose collateral circulation in a cranio-caudal direction; this had been formed by the pressure of the retrosternal goitre on the brachiocephalic vein.

CONCLUSION

Cyanoacrylate injection into a varix above the lower third of the oesophagus should only be done under strict indication. A similar risk as that described in this case potentially exists in the treatment of acute bleeding from a portosystemic varicose circulation.

Detection of fungemia from blood cultures using the BACTEC 9240 instrument

From January 1995 to November 1996, 14,623 resin-containing blood culture vials were tested with the BACTEC fluorescent series instrument. A total of 1560 microorganisms were recovered. 48 of the microorganisms were fungi. We could demonstrate the ability of the BACTEC 9240 to detect cases of fungemia with Candida species and moulds such as Aspergillus fumigatus (4 cases) and Fusarium solani (1 case).

Solitary fibromastocytic tumor arising in an inguinal lymph node: the first description of a unique spindle cell tumor simulating mastocytosis

A 77-yr-old man presented with a right inguinal mass. At herniotomy, an enlarged inguinal lymph node was also removed. Gross examination revealed a firm gray tumorous nodule measuring 3 cm in maximum diameter. On histological examination, the lymphatic tissue was found to have been almost completely replaced by spindle-shaped tumor cells arranged in whorls and bundles. In Giemsa-stained sections, about one-third of the tumor cells were seen to be strongly metachromatic tissue mast cells. The other tumor cells reacted only with a monoclonal antibody against vimentin out of a broad panel of antibodies directed against various antigens expressed by leukocytes, mesenchymal cells, and epithelial cells. A small fraction of the nonmetachromatic tumor cells reacted with the proliferation-associated antibody MIB1. Immunostaining with an antibody against p53 tumor-suppressor gene products was negative. Electron-microscopic examination revealed mast cells containing abundant granules, which were intermingled with fibroblasts that had bizarre, elongated nuclei. No myofibroblasts, desmosomes, or basement membrane material were detected. Clinical examination revealed no abnormalities, and blood and bone marrow findings were completely normal. A diagnosis of solitary (apparently benign) fibromastocytic tumor was established on the basis of the relative tumor cell numbers, the cytological features, and the clinical data. To the authors' knowledge, this is the first description of a solitary spindle cell tumor arising in a lymph node and simulating mastocytosis.

[Endogenous tracheobronchial foreign body. An indication for emergency bronchoscopy with a rigid bronchoscope]

We report two patients, a 3-year-old child and a 75-year-old woman, with a foreign body of the trachea, and of the entire tracheobronchial system respectively. We emphasise the importance of rigid endoscopes for foreign body extraction and for respiration. Also, we describe the differentiation of endogenous from exogenous foreign bodies of the tracheobronchial system.

[Diagnosis and control of therapy of thyroid disorders by TRH-test (author's transl)]

TSH-measurement before and after stimulation with TRH proved to be of good value in the diagnosis of thyroid dysfunctions, better than other parameters including J-131-test. During treatment of hypothyroid disorder TRH-test, often repeatable, allows estimation of T4 substitution dosis. In Graves disease therapy, furthermore, should be judged by in-vitro or clinical parameters.

[Thyroid tumours with a long clinical course: diagnostic and therapeutic aspects (author's transl)]

Thin-needle biopsy allows morphological examination which is free of complications. It is, therefore, suitable as a routine out-patient diagnostic measure in diseases of the thyroid. A biopsy should be taken whenever there is the slightest indication, so that clinical changes which have existed for prolonged periods can be included, even if there is no suspicion of tumour. In this way, thyroid tumours with an unusually long course will be diagnosed cytologically. Three such cases are reported: a papillary adenocarcinoma, a medullary carcinoma and a Hürthle-cell tumour.