Extraosseous Aneurysmal Bone Cyst

A 73-year-old man developed an enlarged cystic lesion located in the soft tissues surrounding the left hip. The lesion was surgically removed. The patient was well 1 year after surgery. The lesion was histologically identical to an aneurysmal bone cyst, therefore it was diagnosed as an extraosseous aneurysmal bone cyst. The differential diagnoses and a review of the literature are presented.

Splenic Mucinous Cystadenocarcinoma Arising in Heterotopic Pancreatic Tissue

A mucinous cystadenocarcinoma along with remnants of normal pancreatic tissue was discovered in the spleen of a 21-year-old woman. Extensive clinical, radiological, ultrasound and computed tomography investigation revealed that the patient's pancreas and ovaries were unremarkable. We presume an origin from heterotopic pancreatic tissue for this neoplasm and present a review of the literature in this regard.

SETD2 and histone H3 lysine 36 methylation deficiency in advanced systemic mastocytosis

The molecular basis of advanced systemic mastocytosis (SM) is not fully understood and despite novel therapies the prognosis remains dismal. Exome sequencing of an index-patient with mast cell leukemia (MCL) uncovered biallelic loss-of-function mutations in the SETD2 histone methyltransferase gene. Copy-neutral loss-of-heterozygosity at 3p21.3 (where SETD2 maps) was subsequently found in SM patients and prompted us to undertake an in-depth analysis of SETD2 copy number, mutation status, transcript expression and methylation levels, as well as functional studies in the HMC-1 cell line and in a validation cohort of 57 additional cases with SM, including MCL, aggressive SM and indolent SM. Reduced or no SETD2 protein expression—and consequently, H3K36 trimethylation—was found in all cases and inversely correlated with disease aggressiveness. Proteasome inhibition rescued SETD2 expression and H3K36 trimethylation and resulted in marked accumulation of ubiquitinated SETD2 in SETD2-deficient patients but not in patients with near-normal SETD2 expression. Bortezomib and, to a lesser extent, AZD1775 alone or in combination with midostaurin induced apoptosis and reduced clonogenic growth of HMC-1 cells and of neoplastic mast cells from advanced SM patients. Our findings may have implications for prognostication of SM patients and for the development of improved treatment approaches in advanced SM.

First Report of Lavender Wilt Caused by Fusarium sporotrichioides in Croatia

In May 2011, samples of lavender plants (Lavandula × intermedia) showing wilt symptoms were collected from two commercial plantings in Slavonia County. Disease was observed on 20 to 30% of the plants. Symptoms of the disease consisted of chlorosis, stunting, wilting, and death. Vascular tissue of stems and roots exhibited brown discoloration. Isolations of the pathogen were made from the discolored tissues on potato dextrose agar (PDA). Colonies were initially white, but with age became red, and red pigments were produced in agar. Microconidia were pear shaped, oval, and fusoid, and ranged from 4.5 to 14.0 × 2.8 to 4.7 μm. Macroconidia were curved, mostly three septate, and ranged from 21.8 to 24.3 × 2.9 to 3.9 μm. Morphology of colonies and conidia matched the description of Fusarium sporotrichioides Sherb. (1). Identity of the fungus was confirmed by examining a portion of the EF1-α gene using the degenerated primers EF1 and EF2 (2). BLAST searches of the obtained sequences showed a 100% homology with several isolates of F. sporotrichioides from GenBank. Pathogenicity tests were conducted on 20 4-month-old rooted cuttings under greenhouse conditions. Each plant was planted in a separate pot containing 0.7 liter of sterile soil. Inoculum for artificial infection was prepared with sterilized mixtures of wheat and barley seeds (10 g of each). Seeds were inoculated with a F. sporotrichioides spore suspension (10⁶ conidia/ml) and incubated at 22°C for 10 days. Noninoculated seeds served as controls. Ten seeds were placed under the soil surface around the root of each plant. Plants were irrigated and placed in a greenhouse (22°C and a 12-h day/night photoperiod). Sixteen days after inoculation, 80% of inoculated plants were wilted. Symptoms on infected plants were similar to those observed in the field. The pathogen was reisolated and confirmed from the infected vascular tissue, thus fulfilling Koch's postulates. A previous paper reported lavender as host of F. solani in China (4) and F. oxysporum in Saudi Arabia (3). To our knowledge, this is the first report of Fusarium wilt of lavender caused by F. sporotrichioides. References: (1) J. F. Leslie and B. A. Summerell. Page 256 in: The Fusarium Laboratory Manual. Blackwell Publishing Professional, Hoboken, NJ, 2006. (2) K. O'Donnell et al. Appl Biol. Sci. 95:2044, 1998. (3) K. Perveen and N. Bokhari. Plant Dis. 94:1163, 2010. (4) Y. Z. Ren et al. New Dis. Rep. 15:55, 2007.

First Report of Cane Blight on Blackberry Caused by Diaporthe eres in Croatia

A cane disease of blackberry (Rubus sp.) cv. Thornfree was observed in May and June 2010 in two growing regions in the eastern part of Slavonia in Croatia. Symptoms consisted of bleached areas between and around cane nodes with some canes showing wilt symptoms. Infected areas were covered with numerous, black pycnidia immersed in the epidermal tissue. Disease occurrence in orchards growing cv. Thornfree ranged between 1 and 15%. Thirty disease samples were collected, disinfected (1 min in 70% ethanol and 2 min in 1% NaOCl), and placed in a moist chamber for 4 days. Fungal sporulating structures were then picked off and placed on potato dextrose agar (PDA). Fungal isolates obtained were identified as a Phomopsis sp., the conidial state of Diaporthe (3), on the basis of cultural and morphological characteristics. Alpha conidia were unicellular, hyaline, fusiform, sometimes tapering toward one or both ends, biguttulate (sometimes with several guttules), and 5.2 to 9.7 × 1.4 to 2.7 μm (average 6.5 × 2.1 μm). Beta conidia were hyaline, aseptate, filiform, hamate, and 16.6 to 28.2 × 0.5 to 1.5 μm (average 24.0 × 1.1 μm). The teleomorph was not observed. Biomolecular analysis was performed to identify the fungal species by sequencing the internal transcribed spacer (ITS) region spanning ITS 1, 5.8S rDNA, and ITS 2 of two isolates (Phk1 and Phk2). The amplified product was sequenced (GenLab-Enea, Rome, Italy) and a BLAST search of the NCBI nucleotide database was performed. Sequences from Phk1 and Phk2 (GenBank Accession Nos. HQ533144 and HQ533143, respectively) were identical to authentic and vouchered Diaporthe eres Nitschke (GenBank DQ491514, BPI 748435, and CBS 109767) ITS sequences in GenBank. Fungal isolates for pathogenicity tests were grown on PDA at 25°C for 7 days (12 h light/dark regimen). Inoculations were made on 30 to 40 cm long green shoots of potted plants of the blackberry cv. Thornfree. One-centimeter long wounds were made with a sterile scalpel and mycelia of D. eres were placed in the wounds. Inoculation sites were covered with a piece of wet cotton wool and aluminum foil to retain moisture. Three replications of 10 plants each were inoculated and these plus 10 control plants (inoculated with plugs of PDA only) were maintained in a growth chamber at 25°C. After 25 days, lesions developed on all 30 inoculated plants that averaged 15 mm long and control plants remained symptomless. D. eres was reisolated from inoculated plants, thus completing Koch's postulates. Phomopsis spp. have previously been reported on blackberry canes in Serbia (1) and Yugoslavia (2,4), however, to our knowledge, this is the first report of the occurrence of D. eres (anamorph P. oblonga) on blackberry in Croatia. References: (1) M. Arsenijevic. Biljni Lekar 34:117, 2006. (2) M. Muntanola-Cvetkovic et al. Zast. Bilja 36:325, 1985. (3) B. C. Sutton. Page 569 in: The Coelomycetes. CMI, Kew, Surrey, UK, 1980. (4) M. Veselic et al. Zast. Bilja 49:76, 1998.

First Report of Leaf Blight and Root and Foot Rot of a Strelitzia Caused by Phytophthora nicotianae in Italy

Bird of paradise, also known as crane flower (Strelitzia reginae Aiton), is a monocotyledonous flowering plant indigenous to South Africa. It is commonly grown and commercialized as an ornamental plant and it is appreciated for its beautiful flowers. In October of 2008, dark leaf spots and leaf blight associated with a severe root and foot rot were observed on several plants of S. reginae grown in a private garden located in Fiumicino, Italy. Small fragments of tissues (approximately 3 mm) collected from the base of leaves and roots and the margins of brown lesions, previously surface disinfected with 0.5% NaOCl, were plated onto potato dextrose agar (PDA) and incubated at 22°C in the dark. White, web-like, slow-growing colonies with coenocytic mycelium and hyphal swellings consistently developed from all plated tissue samples. Sporangia were ovoid or ellipsoid with prominent papillae (including some bipapillate) and frequently caducous with a short stalk. The dimensions of sporangia were 27 to 64 × 23 to 45 μm (average 43 × 35 μm). Chlamydospores were terminal or intercalary and approximately 30 μm in diameter. Isolates were considered heterothallic because they did not produce gametangia in vitro or in planta. On the basis of morphological features, isolates were identified as Phytophthora nicotianae (Breda de Haan). The identity was confirmed by internal transcribed spacer (ITS) sequence comparison in NCBI database with 99% identity with sequences available in GenBank (e.g., EU331089) and with cytochrome c oxidase subunit I (Cox I) with 99% identity with AY564196 by Kroon et al. (2). The sequences of one isolate, AB177, were deposited in GenBank (Accession Nos. FN430681 and FN552051 for ITS and Cox I, respectively). Pathogenicity tests were conducted in the greenhouse on leaves of a 1-year-old potted S. reginae plant by placing 5-mm-diameter mycelial plugs, cut from the margins of 10-day-old actively growing cultures, with mycelium in contact with plant tissues gently wounded with a needle. Controls were treated as described above, except that PDA sterile plugs were used. Plants were misted with water and placed in sealed plastic bags for 48 h. After 10 days, artificially wounded strelitzia leaves showed lesions (approximately 1 cm long). Controls remained symptomless. All inoculated leaves showed the same leaf symptoms as observed on naturally diseased plants. The pathogen was consistently reisolated from lesions. P. nicotianae has been reported as the causal agent of leaf blight and stem, collar, and root rot on several plants (1). It has been reported as an agent of Phytophthora blight on strelitzia in Japan (3). To our knowledge, this is the first report of P. nicotianae on strelitzia in Italy. References: (1) D. C. Erwin and O. K. Ribeiro. Phytophthora Diseases Worldwide. The American Phytopathological Society, St. Paul, MN, 1996. (2) L. P. N. M. Kroon et al. Fungal Genet. Biol. 41:766, 2004. (3) S. Uematsu et al. Ann. Phytopathol. Soc. Jpn. 60:746, 1994.

First Report of Diaporthe phaseolorum on Sunflower (Helianthus annuus) in Croatia

Sunflower (Helianthus annuus L.) is a crop that is grown worldwide for the production of edible oil. In Croatia, it has considerable economic significance. From 2004 to 2007, sunflower stems showed light-to-dark brown lesions of different sizes and shapes. The lesions were observed for the presence of pycnidia in affected areas. Isolations from infected tissue on potato dextrose agar (PDA) yielded in two fungal species. One, which was isolated in most cases, was the well known sunflower pathogen Diaporthe helianthi Munt. Cvet. Morphological characteristics, stromata pattern, formation of alpha and beta conidia, and ascostromata characteristic of the other isolated fungus matched the description of D. phaseolorum (Cooke & Ellis) Sacc. (2). D. phaseolorum frequency was 5%. On PDA, the fungus formed white, floccose, aerial mycelium that filled a petri dish (9 cm) in 6 days. D. phaseolorum produces conidiomata in black stromatic structures, which consist of pycnidia with alpha and beta conidia. The alpha conidia were unicellular, hyaline, ellipsoidal to fusiform, and 5.6 to 10.0 × 1.9 to 4.8 μm. The beta conidia were hyaline, elongated, filiform, straight, curved at one or both ends, and 11.7 to 27.6 × 0.7 to 2.0 μm. After 50 days, perithecia were formed. Asci were clavate and 27.64 to 40.1 × 5.70 to 8.2 μm. Eight ascospores formed within asci. Ascospores were two-celled, elliptic, hyaline, and slightly constricted at the septa, and 8.93 to 13.5 × 2.1 to 4.0 μm. Amplification and sequencing of the internal transcribed spacer (ITS) rDNA region were performed with ITS4 and ITS5 universal primers (3) on two isolates (Su9 and Su10) and data were deposited in GenBank (Accession Nos. GQ149763 and GQ149764). Comparison of sequences available in GenBank revealed that the ITS sequence was identical to D. phaseolorum found on Stokesia laevis Hill (Greene) (U11323/U11373) and identical to the strain CBS 116020 isolated from Aster exilis Elliot. (AY745018). On the basis of the obtained results of morphological characteristics and molecular approaches, the pathogen was identified as D. phaseolorum. Pathogenicity evaluation consisted of artificial infections on field-grown sunflower plants at the full button stage as described by Bertrand and Tourvielle (1). A leaf test was done by placing a mycelial plug of 5 × 5 mm from a cork borer of two isolates (Su9 and Su10) on the tip of the main vein. The inoculation site was covered with moistened, cotton wool and wrapped in aluminum foil to prevent the inoculum from drying out. Ten plants of each of the four replications were inoculated. Control plants were inoculated with pure PDA plugs. Lesions of 12 to 40 mm long were observed on the sunflower leaf 10 days after inoculation. Control plants did not develop symptoms. The pathogen was reisolated from the infected plants. To our knowledge, this is the first report of the finding of D. phaseolorum on sunflower in Croatia and we have no literature data about the occurrence of this fungus on sunflower in the world. References: (1) F. Bertrand and D. Tourvielle. Inf. Tech. CETIOM 98:12,1972. (2) E. Punithalingma and P. Holliday. No. 336 in: Descriptions of Pathogenic Fungi and Bacteria. CMI/CAB, Kew, Surrey, England, 1972. (3) T. J. White et al. Page 315 in: PCR Protocols: A Guide to Methods and Applications. M. A. Innis et al., eds. Academic Press, Inc., New York, 1990.

First Report of Vascular Wilt Caused by Fusarium redolens on Lentil in Italy

Lentil (Lens culinaris Medik.) is a traditional crop in Sicily, Italy. Near Villalba (Caltanissetta), a local lentil landrace, "Lenticchia di Villalba", is commonly grown. From 2002 to 2004, wilt was observed in five lentil fields (≈1 ha each) at rates from 5 to 20%. Affected plants were yellow and stunted with discoloration in the vascular tissue of stems and crowns. Pieces of brown vascular tissue from stems were disinfested in 2% sodium hypochlorite for 2 min, rinsed with sterile distilled water, placed on potato dextrose agar, and incubated at 23°C. Isolates with morphological characteristics of Fusarium oxysporum Schlecht.:Fr. (2) were consistently recovered from affected plants. For molecular identification of five isolates, the rDNA internal transcribed spacer (ITS) region and a portion of the elongation factor EF-1α were sequenced using ITS5/4 and EF1/2 primers, respectively (1). Two sequences of the ITS region were obtained: a 468-bp sequence from isolates ER1259, ER1260, and ER1275 (submitted as GenBank Accession No. EU159118) and a 483-bp sequence from isolates ER1274 and ER1276 (submitted as GenBank Accession No. EU281661). The two sequences shared 93% similarity. A sequence homology search using the NCBI BLAST program revealed that the first sequence had 100% homology with the ITS sequences of more than 50 F. oxysporum isolates of various formae speciales in GenBank and the second shared 100% homology with the ITS sequences of five isolates of F. redolens Wollenw. (e.g., GenBank Accession No. X94169 of the strain CBS 360.87). Amplification of the EF-1α produced a sequence from isolates ER1274 and ER1276 (submitted as GenBank Accession No. EU281660) with 99 to 100% homology to sequences of F. redolens and a sequence from strains ER1259, ER1275, and ER1260 (submitted as GenBank Accession No. EU281659) with 100% homology to that of more than 50 F. oxysporum strains in GenBank. Although F. redolens and F. oxysporum are morphologically similar, recent molecular studies have shown that they are distinct and phylogenetically distant species (3). On the basis of genetic sequences, isolates ER1274 and ER1276 were identified as F. redolens. These isolates were evaluated for pathogenicity on lentil. For each isolate, 10 2-week-old seedlings of "Lenticchia di Villalba" were inoculated by submerging roots in a suspension of 2.5 × 10⁶ conidia/ml for 10 min. Plants were put into separate tubes containing 70 ml of a nutritional liquid medium (7 ml of HydroPlus Olikani per liter; Yara, Nanterre, France) and incubated in a growth chamber at 20°C with 12 h of light per day. Seedlings dipped in sterile water served as the control treatment. The pathogenicity test was repeated twice. Inoculated seedlings started to wilt 1 week after inoculation and developed root rot and vascular discoloration. After 2 weeks, 70% of the inoculated plants were affected by both isolates and 40 and 10% died when inoculated with ER1274 and ER1276 isolates, respectively. F. redolens was consistently reisolated from the stems of wilted plants. Noninoculated plants remained healthy. Currently, only F. oxysporum f. sp. lentis Vasud. and Sriniv. has been reported as the cause of Fusarium wilt of lentil. To our knowledge, this is the first report of F. redolens as a pathogen on lentil. References: (1) R. P. Baayen et al. Phytopathology 91:1037, 2001. (2) P. E. Nelson et al. Fusarium Species: An Illustrated Manual for Identification. The Pennsylvania State University Press, University Park, 1983. (3) K. O'Donnell et al. Mycologia 90:465, 1998.

First Report of Phomopsis longicolla on Cocklebur (Xanthium strumarium) in Croatia

Cocklebur (Xanthium strumarium L.; family Asteraceae) is a widespread weed species in eastern Croatia found especially in arable crops including soybean. Symptoms of disease appear after the plants reach physiological maturity. Stems and branches are completely blighted, and on the surface, are covered with minute, black pycnidia embedded in the epidermal tissue of the host and are especially numerous around nodes. More than 100 plants with symptoms were examined. From each plant with symptoms, three pieces of symptomatic tissues (5 to 10 mm) were disinfected and placed on potato dextrose agar (PDA), pH 4.5 and 25°C with a 12/12 h of light/dark regimen. The cultural and morphological characteristics of the fungi isolated from X. strumarium corresponded with those described (1) for Phomopsis longicolla Hobbs isolated from soybean. P. longicolla frequency was 3%, while other isolates belonged to other Phomopsis species. To confirm the morphological identification of isolates, molecular identification was performed. DNA of four isolates was extracted from 7-day-old monoconidial cultures grown on PDA. The internal transcribed spacer (ITS) regions of ribosomal DNA were amplified with universal primer ITS4 and ITS5 and sequenced (M-Medical Genenco, Rome). The sequences were aligned with the multiple sequence alignment program ClustalW, showing 100% similarity among them, and a sequence (GenBank Accession No. EF026104) was compared with the ITS sequences available on the database, revealing that it is identical to many P. longicolla isolates. To confirm Koch's postulate, cocklebur plants were infected in the field by applying mycelial plugs (5 mm in diameter) from the margin of 6-day-old cultures to the plant stem. The inoculation point was internodal at the mid-stem. After inoculation, plugs were covered with a piece of cotton wool and aluminum foil. Stem lesions were measured 10 days after inoculation. Mean stem lesions were 15 to 21 mm. A pathogenicity test was also done on soybean cv. Tisa (21-day-old) seedlings by applying mycelium plugs (5 mm) with a sterile scalpel on previously wounded hypocotyls. The inoculate point was covered with wet cotton wool and aluminum foil. After 10 days, mean stem lesions were 18 to 30 mm. The pathogen was always reisolated from the stem lesions. Control plants inoculated by PDA plugs did not exhibit any symptoms. There is a report of P. longicolla on cocklebur in the United States (2) and on other plants from the Asteraceae family. Other weeds such as Abutilon theophrasti Med., were shown to be a host of fungal pathogens belonging to the Phomopsis/Diaporthe complex of soybean (3). Our results also confirm that cocklebur could be a natural inoculum source for Phomopsis seed decay of soybean caused primarily by P. longicolla. However, to our knowledge, this is the first report of P. longicolla being isolated from naturally infected cocklebur in Croatia. References: (1) T. W. Hobbs et al. Mycologia 77:535, 1985. (2) K. W. Roy et al. Can. J. Plant Pathol. 19:193, 1997. (3) K. Vrandecic et al. Plant Pathol. 53:251, 2004.

Follicular baso-squamous melanocytic tumour of the skin

AIMS

We describe a previously unrecognized pigmented tumour of the skin and suggest a possible relationship with the follicular bulb.

METHODS AND RESULTS

A pigmented epithelial neoplasm clinically simulating a malignant melanoma of the skin was present in a 92-year-old woman, on her left leg. It was composed of three cell types: squamous cells with trichilemmal keratinization, basaloid cells and dendritic melanocytes. The presence of three cell types was confirmed by immunohistochemistry and electron microscopy.

CONCLUSIONS

The tumour showed differentiation towards the hair follicular bulb and the descriptive term of follicular baso-squamous melanocytic tumour is suggested.

[The sentinel lymph node in melanoma: utilization of molecular biology (RT-PCR) to detect occult metastases]

Sentinel lymph node (SLN) analysis allows the detection of occult metastases in patients with melanoma. The use of serial sections and immunohistochemical investigations (ICH) increases the chance of identifying metastases. Nevertheless, detection of mRNA of the tyrosinase gene through reverse transcription-polymerase chain reaction (RT-PCR) is the most sensitive tool for detection of occult melanoma cells in SLN. From September 1999 to August 2001, in the Anatomic Pathology Unit of M. Bufalini Hospital of Cesena, 489 SLNs from 332 patients with primary melanoma in clinical stages I and II (according to AJCC) were examined. There were 66 (13.5%) SLNs and 58 (17.4%) cases with metastasis revealed by histology and ICH. A single case with metastatic SLN was found in patients with melanomas < or = 1 mm in thickness. The percentage of cases with metastases in SLN correlated with thickness of the primary melanoma (p < 0.0001). RT-PCR for tyrosinase was carried out in 448 SLNs from of 308 cases. Overall, the RT-PCR results were positive in 149 (48.4%) patients and in 169 SLNs (37.9%). RT-PCR results showed a strong positive correlation with tumor thickness of primary melanoma (p < 0.0001) and with the clinical stage (p < 0.0001). Of the RT-PCR-positive cases, 18 showed intracapsular aggregates of nevus cells. Besides the percentage of positive cases, once those with nevus aggregates were excluded, overall, the RT-PCR revealed the presence of tyrosinase mRNA in 34.5% of patients with negative histology and ICH. Ongoing monitoring is necessary to define the real prognostic implication of the presumed presence of occult melanoma deposits disclosed by RT-PCR in SLNs.

Response of Italian elite subterranean clover genotypes to Fusarium avenaceum and Fusarium oxysporum under artificial conditions

Breeding programs of subterranean clover in southern Europe have traditionally set low priority on selection against major pathogens, in part because there have been no major disease outbreaks in this region. However, root-rot causing fungi, such as Fusarium spp., occur frequently on other crops and can therefore also represent a threat to clover. Thus, the breeding program carried out in Sardinia, Italy, took note of this disease. This study reports the results of 2 trials carried out in 2 consecutive years following artificial infestation with Fusarium spp. The first trial included 45 genotypes, of which 37 were Sardinian lines under advanced breeding and 8 were commercial varieties. To validate the variation observed in disease response, a subset of 27 genotypes was further evaluated in the second trial. In both trials, 3 pathogen treatments were applied, in addition to a control, uninoculated treatment - F. avenaceum, F. oxysporum, and an equal mixture of both fungi. One-month-old clover seedlings were scored in all treatments for shoot-growth vigour (1-9 scale), then excavated for scoring root-rot symptoms (1-5�scale), and finally weighed after oven drying. Analysis of variance tested differences among treatments, among genotypes, and between subsp. subterraneum and brachycalycinum of Trifolium subterraneum. On the common set of genotypes to both trials, a cluster analysis was applied using, as original variables, the average disease score across the 3 inoculated treatments in the 2 trials. Confirming previous evidence, F. avenaceum proved more pathogenic than F. oxysporum. The results suggested that high seedling vigour may play a role in limiting root-rot effects, and this may also contribute to the relatively better tolerance of subsp. brachycalycinum over subsp. subterraneum observed. Despite some inconsistency of response in the 2 trials both at the treatment and genotype level, some Sardinian genotypes demonstrated a consistent level of tolerance especially in relation to the performance of the commercial varieties tested. Among them were the lines `125 brachy C', `56 sub D', `22 brachy G', `56 sub B' (=Campeda), and `19 brachy E' (=Antas).

[Impact of an integrated treatment approach of the severely injured patients (ISS =/> 16) on hospital mortality and quality of care]

BACKGROUND

Outcome of severely injured patients is sharply influenced by the level of prehospital and hospital organization.

OBJECTIVE

To evaluate the impact of the re-organization of the trauma care process on the quality of care and final outcome of major trauma (ISS =/< 16) victims.

SETTING

the Emergency Department (ED) of a 1600 bedded tertiary care hospital.

INTERVENTION

a standardized approach to major trauma patients (MT) was implemented: Written protocols were established and trauma teams were organized. All anesthesiologists and trauma surgeons involved in trauma care were enrolled in an educational program including ATLS Courses and the Italian Resuscitation Council Prehospital Trauma Care Course. One of the targets was to assure the early orthopedic stabilization of limb and pelvis fractures.

METHODS

Data of all major trauma victims admitted to the ED during 3 comparable periods of time: before (Jan-May 1998), during (Jan-May 1999) and after (Jan-May 2000) the implementation of the process, were retrospectively and prospectively collected and analyzed.

RESULTS

MT patients admitted to the hospital increased from 39 in 1998 to 106 in 2000. For similar ISS (30.2 +/- 11.3 in 1998, 29.6 +/- 13.7 in 1999 and 30.5 +/- 12.9 in 2000) hospital mortality dropped from 42% in 1998 to 20.8%. The mean time from hospital admission to surgical orthopedic stabilization was 12 days in 1998, 4.6 in 1999 and 1.3 in 2000. In 2000, 86% of the patients with limbs fractures who required surgical stabilization, were treated within 36 hours from admission vs 11% in 1998.

CONCLUSIONS

The implementation of written protocols for trauma care, the organization of trauma teams, educational programs including ATLS and PTC-IRC Courses and a strategy of early stabilization of limb fractures are associated with a dramatic decrease in hospital mortality for major trauma.

Actin-rich desmoplastic malignant melanoma: report of three cases

We report three cases of desmoplastic malignant melanoma (DMM) rich in smooth muscle actin. They occurred in two men (Cases 1 and 3) and in one woman (Case 2). Cases 1 and 2 were recurrent lesions from common melanomas excised, respectively, 3 and 1 years previously. In Case 3, DMM was associated with lentigo maligna at the time of presentation. Morphologically, DMMs were composed of spindle neoplastic cells organized in haphazardly orientated long fascicles separated by collagen bundles. Perineural invasion was present and mitotic activity was prominent in all cases. The neoplastic spindle cells were intensely positive with S100 protein and smooth muscle actin antisera and negative with HMB45 and Melan-A (Mart-1) antibodies. Double staining for smooth muscle actin and S100 protein revealed no definite coexpression of the two antigens. Follow-up was available for patients 1 and 2 who had local recurrences and are still alive. It is possible that actin rich elements differentiate toward mesenchymal elements, paralleling the phenotypic changes seen in sarcomatoid carcinomas. Therefore, multidirectional differentiation may explain the mesenchymal (sarcomatoid) differentiation of neoplastic melanocytes and may be responsible for the different biologic behavior of DMMs, which is closer to mesenchymal tumors than to conventional melanomas.

IL-8, IL-6 and ICAM-1 in serum of paediatric patients undergoing cardiopulmonary bypass with and without cardiocirculatory arrest

BACKGROUND

The aim of the present study was to evaluate the systemic inflammatory response to CPB in paediatric patients undergoing surgical correction of congenital heart diseases.

METHODS

EXPERIMENTAL DESIGN

comparative investigation.

SETTING

paediatric cardiology hospital

INTERVENTION

ICAM-1, IL-8, and IL-6 production were analysed before and during CPB, and after surgery in 9 paediatric patients, submitted to cardiocirculatory arrest (Group A); and in 11 without cardiocirculatory arrest (Group B).

MEASURES

ICAM-1, IL-8, and IL-6 production were analysed from arterial samples before and during CPB, and after surgery.

RESULTS

In group A vs group B a significant increase of IL-8 was detected during (297+/-250 vs 11+/-19 pg x ml(-1), p<0.001) and after (100+/-230 vs n.d. pg x ml(-1)) surgery and was correlated with the duration of operation (r=0.759; p=0.0001) and clamping time (r=0.738; p<0.05). After surgery in group A, IL-6 levels (35+/-43 pg x ml) were higher than those in group B (2+/-5 pg x ml), and a good correlation was observed between IL-6 and duration of aortic clamping (r=0.714; p=0.048), cardiac arrest, (r=0.714; p=0.048), and length of surgery (r=0.867; p=0.04).

CONCLUSIONS

In children who underwent CPB with cardiocirculatory arrest cytokine production seems related to duration of operation and amplified by ischemia-reperfusion phenomena.

Extracorporeal circulation does not induce intra-alveolar release of Endothelin 1, but only a modest overproduction in pulmonary circulation

OBJECTIVE

To investigate whether ECC may produce regional liberation of inflammatory mediators capable of inducing vascular effects and organ damage.

EXPERIMENTAL DESIGN

Comparative study [corrected].

SETTING

Cardiac surgery department in a University hospital.

PATIENTS

Fifteen patients undergoing coronary artery bypass grafting (CABG, group A) and ten patients operated for infrarenal abdominal aortic aneurysm (controls, group B) have been studied.

MEASURES

Levels of Interleukin 1beta (IL1), Tumor Necrosis Factor alpha (TNF), Interleukin 6 (IL6), and Endothelin 1 (ET1) were measured in pulmonary capillary, arterial, and venous blood and in bronchoalveolar lavages (BAL) before, during and after extracorporeal circulation (ECC) or surgical intervention.

RESULTS

TNF-alpha (never >35 pg/ml) and IL1beta (range 20-300 pg/ml) values did not change over time for both groups. IL6 concentrations in all samples of group A increased between five and twenty fold, during and after ECC (from 3-5 pg/ml up to 240 pg/ml, p<0.001). This trend was similar in controls after surgical stress. Endothelin 1 was always undetectable in the BAL fluid, with a modest, but significant increase in pulmonary capillary blood of group A, after ECC, (from 11+/-4 pg/ml to 18+/-5 pg/ml, p<0.001). This increment correlated well with the PVR increase, but was transient and after 24 hours, ET1 values returned to baseline levels. Mean values of ET1 increased also in controls, but not significantly.

CONCLUSIONS

ECC may induce ET1 liberation in pulmonary circulation with transient pulmonary vasoconstriction, but wihout intra-alveolar release, or lung damage. Augmented concentrations of IL6 probably express a response to surgical procedure rather than an effect exclusively related to ECC.

[Anatomo-pathologic study of sentinel lymph nodes in melanoma. Analysis of 200 cases]

Pathologic evaluation of sentinel lymph node represents a new technique for managing high-risk primary melanoma. We examined the sentinel lymph node biopsies of 200 patients affected by primary melanomas of trunk, limbs, head and neck, who had been operated at "M. Bufalini" Hospital between April 1996 and July 1998. The lymphatic mapping has been performed through the preoperative intradermal injection of vital blue dye and technetium-labelled albumin. 319 sentinel lymph nodes were harvested and the 11.3% (15% of patients) were positive for melanoma metastases. No metastases were found in melanomas < or = 1 mm. The percentage of positive sentinel lymph nodes in patients with melanomas > 1 mm in thickness was 16.3% (22% of patients). In 5 cases (2.5%) nodal nevi were found, 1 of which was associated with micrometastasis. All 30 patients with positive sentinel lymph nodes underwent regional lymph node dissection and 555 lymph nodes were harvested. Melanoma metastases were found in only 7 patients, in 31 lymph nodes. The procedure of SLN detection and biopsy is a feasible surgical approach to melanoma patients. It is extremely useful in finding early metastases and in effective pathologic staging. As a consequence of the very low incidence of metastases in the sentinel lymph nodes of patients with thin melanomas, we suggest the sentinel lymph node mapping should be offered to patients with primary melanomas at least 1 mm in depth.

Intramedullary melanotic schwannoma. Report of a case and review of the literature

A case of an intramedullary melanotic schwannoma located in the spinal cord at the T2-T3 level is described. The lesion occurred in a 44-year-old woman with a 10-year history of weakness and sensory numbness in both legs and feet. At operation the lesion appeared as a well-demarcated grey-brown intramedullary mass. Histologically, it was composed of interlacing bundles of spindle cells showing their cytoplasm filled with melanin. Among spinal cord neoplasms, melanotic schwannomas are rare tumours, which have apparently been reported only in three previous instances. The clinical, diagnostic and pathological features, as well as the possible aetiology of these rare tumours are discussed.

Application of SOFA score to trauma patients. Sequential Organ Failure Assessment

OBJECTIVE

To assess the ability of the SOFA score (Sequential Organ Failure Assessment) to describe the evolution of organ dysfunction/failure in trauma patients over time in intensive care units (ICU).

DESIGN

Retrospective analysis of a prospectively collected database.

SETTING

40 ICUs in 16 countries.

PATIENTS

All trauma patients admitted to the ICU in May 1995.

MAIN OUTCOME MEASURES AND RESULTS

Incidence of dysfunction/failure of different organs during the first 10 days of stay and the relation between the dysfunction, outcome, and length of stay. Included in the SOFA study were 181 trauma patients (140 males and 41 females). The non-survivors were significantly older than the survivors (51 years+/-20 vs 38+/-16 years, p < 0.05) and had a higher global SOFA score on admission (8+/-4 vs 4+/-3, p < 0.05) and throughout the 10-day stay. On admission, the non-survivors had higher scores for respiratory ( > 3 in 47% of non-survivors vs 17% of survivors), cardiovascular ( > 3 in 24% of non-survivors vs 5.7% of survivors), and neurological systems ( > 4 in 41% of non-survivors vs 16% of survivors); although the trend was maintained over the whole study period, the differences were greater during the first 4-5 days. After the first 4 days, only respiratory dysfunction was significantly related to outcome. A higher SOFA score, admission to the ICU from the same hospital, and the presence of infection on admission were the three major variables associated with a longer length of stay in the ICU (additive regression coefficients: 0.85 days for each SOFA point, 4.4 for admission from the same hospital, 7.26 for infection on admission).

CONCLUSIONS

The SOFA score can reliably describe organ dysfunction/ failure in trauma patients. Regular and repeated scoring may be helpful for identifying categories of patients at major risk of prolonged ICU stay or death.

Molecular Identification and Phylogenetic Grouping of Diaporthe phaseolorum and Phomopsis longicolla Isolates from Soybean

ABSTRACT Diaporthe phaseolorum and Phomopsis longicolla isolates from soybean were examined using traditional mycological characteristics and molecular methods. Cultural characteristics including types of fruiting bodies and conidia were assessed for isolates collected from soybean stems and seeds. Cultures were identified as P. longicolla, D. phaseolorum var. caulivora, D. phaseolorum var. meridionalis, or D. phaseolorum var. sojae. Molecular markers for these groups were developed and analyzed using polymerase chain reaction restriction fragment length polymorphisms (PCR-RFLP) and DNA sequencing in the internal transcribed spacer (ITS) and the 5.8S ribosomal DNA. The ITS(4) and ITS(5) primers amplified PCR products for all isolates studied. Gel electrophoresis of undigested PCR products and DNA sequencing produced various fragment lengths including 604 bp for P. longicolla, 602 and 603 bp for D. phaseolorum var. caulivora, 603 bp for D. phaseolorum var. meridionalis, and from 597 to 609 bp for D. phaseolorum var. sojae. Digestion of these PCR products with enzymes AluI, HhaI, MseI, RsaI, and ScrFI resulted in distinct bands for identification of P. longicolla and the varieties of D. phaseolorum I. All P. longicolla, D. phaseolorum var. caulivora, and D. phaseolorum var. meridionalis isolates were distinguished using AluI and HhaI with RsaI or ScrFI. The banding patterns of D. phaseolorum var. sojae isolates were complex and were separated into 11 subgroups after digestion with AluI, HhaI, MseI, RsaI, and ScrFI. Phylogenetic analysis of 20 isolates of D. phaseolorum and P. longicolla based on the DNA sequence of the ITS region resolved six clades termed A, B, C, D, E, and F. Clade A included all sequenced D. phaseolorum var. caulivora isolates, two from Italy and one from the United States. Isolates in clade B were exclusively associated with D. phaseolorum var. meridionalis. Clades A and B formed a well-supported monophyletic group. Isolates in clades C, D, E, and F were morphologically defined as isolates of P. longicolla, D. phaseolorum var. sojae, and Diaporthe spp. The ITS sequences similarity of seven geographically diverse P. longi-colla isolates illustrated that P. longicolla isolates have a similar genetic background, with some affiliations to some D. phaseolorum var. sojae isolates. Morphological characteristics of the isolates along with the terminal clades of the ITS phylogeny suggest that P. longicolla is an individual species, D. phaseolorum var. caulivora and D. phaseolorum var. meridionalis are varieties of D. phaseolorum, and D. phaseolorum var. sojae is either several varieties of D. phaseolorum or possibly several distinct species.

First Report of Colletotrichum coccodes on Soybean in the United States

Anthracnose symptoms were observed on soybean (Glycine max (L.) Merr.) cv. Yale in Illinois in September 1996. Lower stems were girdled by lesions that contained black fungal stroma. Colletotrichum coccodes (Wallr.) S. J. Hughes was isolated from surface-sterilized portions of diseased stems incubated on potato dextrose agar (PDA). Cultures produced abundant black sclerotia and acervuli with setae. Acervuli produced straight and fusiform conidia (15 to 23 × 3 to 4 μm) in honey-colored masses. Ovate or long clavate appressoria were formed on slide microcultures. Pathogenicity tests were carried out in the greenhouse on soybean plants, cvs. Panda and Pony at the V4 growth stage, by (i) spraying a conidial suspension (2 ×10⁶ conidia per ml) on seedlings and (ii) placing a mycelial PDA plug above the first two nodes of the stem, previously wounded with a sterile needle. Plain sterile water and plugs without mycelia were used as controls. Six plants per cultivar and per treatment were used. Plants were covered with polyethylene bags for 3 days. Anthracnose symptoms gradually appeared near maturity and plants senesced prematurely with both inoculation methods. Averaged over both cultivars, 100 and 50% of the plants showed symptoms when inoculated with a conidial suspension and mycelial plugs, respectively. Control plants did not have any symptoms. C. coccodes was consistently reisolated from stems, leaves, petioles, and pod peduncles with symptoms, and was not reisolated from noninoculated plants. Seeds collected from plants inoculated with either method showed infection rates up to 14 and 8% on cvs. Panda and Pony, respectively, while seeds collected from control plants showed 0% infection rate. The most common pathogen associated with soybean anthracnose is C. truncatum (Schwein.) Andrus and W. D. Moore, but other species have been reported to cause anthracnose. C. coccodes was reported on soybean in Italy (1). This pathogen has a wide host range and causes serious damage, mostly on solanaceous crops. This is the first report of the presence of the pathogen on soybean in the United States. Reference: (1) G. Conca et al. Petria 4:193, 1994.

Palmar cutaneous hamartoma

We report a case of a complex hamartomatous lesion of the skin which presented in a 75-year-old woman as a painful nodule of the palm. Histology showed eccrine glands, fat, angiomatous vessels, and neurovascular glomic-like bodies, variously admixed and immersed in a cellular, fibroblastic stroma. The name palmar cutaneous hamartoma is proposed for this unusual lesion.

Using PCR to Distinguish Diaporthe phaseolorum and Phomopsis longicolla from Other Soybean Fungal Pathogens and to Detect Them in Soybean Tissues

Restriction fragment length polymorphism analyses of polymerase chain reaction (PCR) amplified DNA were used to distinguish Diaporthe phaseolorum and Phomopsis longicolla isolates from other soybean fungal pathogens. Primers made to the conserved sequences of nuclear ribosomal DNA amplified the internal transcribed spacer (ITS) regions of D. phaseolorum var. meridionalis and P. longicolla. The PCR products were cloned and then sequenced. Specific-primers, Phom.I and Phom.II, were designed from the polymorphic regions of D. phaseolorum and P. longicolla isolates from soybean to distinguish them from other soybean fungal pathogens. These ITS-derived primers amplified a 337-bp-specific DNA fragment from P. longicolla, D. phaseolorum var. meridionalis, D. phaseolorum var. caulivora, D. phaseolorum var. sojae, and Phomopsis spp. from 20 different hosts. No amplified product was observed using DNA of seven other soybean fungal pathogens or soybean DNA. The detection limit of PCR using primers Phom.I and Phom.II was 2.5 × 10^-7 dilution of fungal DNA extracted from samples of 10 pooled seeds and as low as a 1:15 (Phomopsis:soybean) ratio when using 10 ng of DNA per μl from each P. longicolla and soybean. PCR did not produce products using primers Phom.I and Phom.II with DNA extracted from noninfected seeds, but specific bands were observed from samples of 10 pooled seeds and from individually infected seeds. A specific band was observed as well from DNA extracts of tissue samples from symptomless plants inoculated with P. longicolla and D. phaseolorum var. sojae.

Poorly differentiated myoepithelial cell rich carcinoma of the breast

Three unusual cases of invasive breast carcinoma are reported, each comprising a dual malignant cellular proliferation consisting of 'ordinary' epithelial cells as well as myoepithelial cells haphazardly intermingled. The cases displayed features which did not match any of the four main types of invasive malignant breast tumours containing myoepithelial elements, i.e. adenomyoepithelioma, adenoid cystic carcinoma, pure myoepithelioma and low-grade adenosquamous carcinoma. The designation of 'poorly differentiated myoepithelial cell rich carcinoma' (PDMC) is proposed for these tumours.

Oncocytic meningioma

Six cases of meningioma showing oncocytic changes are described. The lesions were composed mostly of sheets, nests, and cords of large polygonal cells with finely granular eosinophilic cytoplasm rich in mitochondria. Neoplastic cells showed nuclear pleomorphism with prominent nucleoli. Necrosis and high mitotic rate were present in the majority of cases. Oncocytic differentiation was demonstrated by conventional histology, immunocytochemistry, electron microscopy, and Western-blot analysis. Oncocytic meningiomas showed an aggressive behavior; recurrences were observed in three cases, and invasion of brain cortex was evident in other two cases.

Primary non-Hodgkin's lymphoma of the sciatic nerve followed by localization in the central nervous system: case report and review of the literature

OBJECTIVE AND IMPORTANCE

A unique case of primary non-Hodgkin's lymphoma of the sciatic nerve followed by multiple loci in the central nervous system is described.

CLINICAL PRESENTATION

The lesion occurred in a 44-year-old immunocompetent man with a palpable mass in the left popliteal fossa and a 10-month history of progressive weakness and numbness of the left foot. The tumor was a diffuse large lymphoma of B-cell origin of an intermediate grade of malignancy according to the criteria of the International Working Formulation.

INTERVENTION

Because diagnosis of the malignant lymphoma was performed on frozen section, resection of the nerve trunk was avoided. The patient was treated with radiotherapy and chemotherapy. At 6 months after the discovery, biopsy, and treatment of the sciatic nerve lymphoma, other lesions demonstrating the same histological features were observed in the central nervous system. The patient died 4 years and 2 months after presentation as a result of the central nervous system lesions and without clinical evidence of systemic extraneural localization.

CONCLUSION

A review of the literature indicates that primary peripheral nerve lymphomas occur in the sciatic nerve. These cases, and the case described in our study, share common clinicopathological findings that justify discussing them separately as distinct entities.

Noninvasive positive-pressure ventilation via face mask during bronchoscopy with BAL in high-risk hypoxemic patients

STUDY OBJECTIVE

The aim of this study was to assess the feasibility and safety of noninvasive positive-pressure ventilation (NPPV) via a face mask to aid in performing fiberoptic bronchoscopy (FOB) with BAL in immunosuppressed patients with gas exchange abnormalities that contraindicate using conventional unassisted FOB.

STUDY POPULATION

Eight consecutive immunosuppressed patients (40 +/- 14 years old) with suspected pneumonia entered the study. Entrance criteria included the following: (1) PaO2/fraction of inspired oxygen (FIo2) of 100 or less; pH of 7.35 or more; and (3) improvement in O2 saturation during NPPV before initiating FOB.

INTERVENTION

Patients had routine application of topical anesthesia to the nasopharynx. A full face mask was connected to a ventilator (Servo 900C; Solna, Sweden) set to deliver continuous positive airway pressure (CPAP) of 4 cm H2O, pressure support ventilation of 17 cm H2O, and 1.0 FIo2. The mask was secured to the patient with head straps. NPPV began 10 min before starting FOB and continued for 90 min or more after the procedure was completed. The bronchoscope was passed through a T-adapter and advanced through the nose. BAL was obtained by sequential instillation and aspiration of 5 to 25 mL aliquots of sterile saline solution through a bronchoscope wedged in a radiographically involved subsegment. Oxygen saturation, heart rate, respiratory rate, and arterial blood gases were monitored during the study.

RESULTS

NPPV significantly improved PaO2/FIo2 and O2 saturation. FOB with NPPV was well tolerated, and no patient required endotracheal intubation. A causative pathogen was identified by BAL in all patients. Six patients responded to treatment and survived hospital admission. Two patients died 5 to 7 days after FOB from unrelated complications of the underlying illness.

CONCLUSIONS

NPPV should be considered during bronchoscopy of immunosuppressed patients with severe hypoxemia.

Solitary left ventricle metastasis by renal cell carcinoma with sarcomatoid features

A 64 year-old male presented with a mass of the left kidney, 9 cm across. A radical nephrectomy was performed and the pathological examination of the surgical specimen revealed a large papillary renal cell carcinoma (RCC). Five weeks after surgery, the patient died because of progressive cardiac failure. At autopsy, a whitish-gray subendocardial mass, measuring 6 cm in its main diameter, was discovered in the left ventricle. Histologically, the tumour, consisted of interlacing bundles of spindle cells, showing large vesicular nuclei, with prominent nucleoli. Rare gland-like structures lined by neoplastic cells were occasionally found. Neoplastic cells were focally immunoreactive to anti-cytokeratin and anti-epithelial membrane antigen antisera. The diagnosis was that of cardiac involvement by RCC with sarcomatoid features. Cardiac metastases by RCC are rare and their incidence ranges from 1.3% to 4.2%. In the present case, the sarcomatoid appearance of the cardiac lesion raises the problem of the differential diagnosis with primary cardiac sarcoma. The clinico-pathological features of this case are discussed and the literature on this topic is reviewed.

Leukotrienes and alpha tumor necrosis factor levels in the bronchoalveolar lavage fluid of patient at risk for the adult respiratory distress syndrome

OBJECTIVE

To examine bronchoalveolar lavage (BAL) fluid of patients at risk for Adult Respiratory Distress Syndrome in the attempt to provide evidence of an increased local production of Leukotrienes (LTS) and Tumor Necrosis Factor (TNF).

DESIGN

Prospective, comparative, clinical study.

SETTING

ICU in a university hospital.

PATIENTS

14 patients at risk for ARDS and 10 control patients undergoing mechanical ventilation, were studied.

INTERVENTION

BAL was performed in each patient at the time admission to the ICU (T0), and after 48 hours (T1).

RESULTS

Our controls never showed levels of TNF > 10 pg/ml and their LTS amounts were always below the detection limit. All patients at risk had levels of TNF ranging between 22 and 130 pg/ml, but no difference was noticed between patients who developed ARDS and those who did not, between survivors and non survivors, and between septic and non septic patients. LTD4 and LTB4 (ranging between 30 to 1365 pg/ml) were detected only in six of the 14 patients. Among these 6 patients, 4 developed ARDS. In these patients we could correlate LTB4 with TNF levels and the number of neutrophils recovered from the BAL fluid.

CONCLUSION

In our patients leukotrienes and TNF in the BAL fluid correlate well with the acute inflammatory phase of ARDS, as reflected by the increase number of leukocytes in the fluid retrieved, but they do not appear to be clearly predictive index for the syndrome.