Cardiac death after autologous stem cell transplantation (ASCT) for treatment of systemic sclerosis (SSc): no evidence for cyclophosphamide-induced cardiomyopathy

In patients with systemic sclerosis (SSc) treatment-related mortality after autologous stem cell transplantation (ASCT) appears to be increased as compared to patients with hematological malignancies. In our phase I/II study on ASCT in autoimmune diseases a patient with SSc died on day 2 after ASCT. Here we report the results of the autopsy which revealed advanced pulmonary and cardiac fibrosis as the most probable cause of death. In spite of detailed technical examination before enrollment, the cardiopulmonary function tests did not reflect the advanced stage of the disease. We conclude that in selected patients with SSc, biopsies should be performed to reduce mortality after ASCT.

Grading of tumors and tumorlike lesions of bone: evaluation by FDG PET

Clinical diagnosis of skeletal tumors can be difficult, because such lesions compose a large, heterogeneous group of entities with different biologic behaviors. The aim of this prospective study was to assess the value of PET in grading tumors and tumorlike lesions of bone.

METHODS

Two hundred two patients with suspected primary bone tumors were investigated using FDG PET. Uptake of FDG was evaluated semiquantitatively by determining the tumor-to-background ratio (T/B). All patients underwent biopsy, resulting in the histologic detection of 70 high-grade sarcomas, 21 low-grade sarcomas, 40 benign tumors, 47 tumorlike lesions, 6 osseous lymphomas, 6 plasmacytomas, and 12 metastases of an unknown primary tumor.

RESULTS

All lesions, with the exception of 3 benign tumors, were detected by increased FDG uptake. Although sarcomas showed significantly higher T/Bs than did latent or active benign lesions (P < 0.001), aggressive benign lesions could not be distinguished from sarcomas. Using a T/B cutoff level for malignancy of 3.0, the sensitivity of FDG PET was 93.0%, the specificity was 66.7%, and the accuracy was 81.7%.

CONCLUSION

FDG PET provides a promising tool for estimating the biologic activity of skeletal lesions, implicating consequences for the choice of surgical strategy.

Langerhans cell deficiency in reticular dysgenesis

Reticular dysgenesis is a rare inherited immunodeficiency characterized by the lack of blood monocytes and neutrophils and low lymphocyte counts, contrasting with normal red blood cell counts and normal or decreased platelet counts. Whether dendritic cells or macrophages, both of which derive primarily from blood monocytes, are affected in this condition remains unknown. We studied 7 patients with reticular dysgenesis. Macrophages were present in normal numbers in the dermis and in the atrophic lymphoid tissues of these patients, proving that at least some subsets of macrophages can differentiate despite very low monocyte counts. By contrast, Langerhans cells, which are CD1a-positive epidermal dendritic cells, were absent in all (n = 5) patients before bone marrow transplantation. After bone marrow transplantation, Langerhans cells were present (n = 2), suggesting that the defect is not related to keratinocyte dysfunction. A split chimeric reconstitution, characterized by the presence of autologous blood monocytes able to differentiate in vitro into CD1a-positive dendritic cells, was observed in a patient who underwent successful engraftment. These results suggest that an intrinsic cell defect is unlikely and that a bone marrow-derived factor may be defective in reticular dysgenesis; it may be responsible for the Langerhans cell defect but not involved in macrophage differentiation.

Fluorodeoxyglucose positron emission tomography of soft tissue tumours: is a non-invasive determination of biological activity possible?

Since musculoskeletal tumours comprise a large heterogeneous group of entities with different biological behaviour, clinical diagnosis of such lesions can be very difficult. The aim of this prospective study was to assess the usefulness of 2-[F-18]-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) in the non-invasive evaluation of soft tissue tumours. One hundred and two patients with suspected soft tissue neoplasms were investigated by FDG-PET. The uptake of FDG was evaluated semiquantitatively by determining the tumour to background ratio (TBR). All patients underwent biopsy, resulting in the histological detection of 39 high-grade sarcomas, 16 intermediate-grade sarcomas, 11 low-grade sarcomas, 25 benign tumours, 10 tumour-like lesions such as spontaneous myositis ossificans (n = 6) and one non-Hodgkin lymphoma. All lesions except for two lipomas disclosed an increased FDG uptake. Sarcomas showed significantly higher TBR values than latent or active benign lesions (P<0.001) and aggressive benign lesions (P<0.05). Using a TBR cut-off level of 3.0 for malignancy, sensitivity of FDG-PET was 97.0%, specificity 65.7% and accuracy 86. 3%. From our data there are three main conclusions: (1) Except for patients with pseudotumoral myositis ossificans, lesions with a TBR >3 were sarcomas (91.7%) or aggressive benign tumours (8.3%). (2) Tumours with a TBR <1.5 were latent or active benign lesions, exclusively. (3) The group with intermediate TBR values (<3 and >1. 5) comprised primarily latent or active benign lesions, but also four aggressive benign tumours and two low-grade sarcomas. Our data suggest that FDG-PET represents a useful tool for the evaluation of the biological activity of soft tissue neoplasms.

Anaemia, thrombocytopenia and coagulopathy due to occult diffuse infantile haemangiomatosis of spleen and pancreas

Diffuse infantile haemangiomatosis of the spleen is a very rare lesion. Large haemangiomas may cause trapping of platelets and coagulation disorders known as Kasabach-Merrit syndrome. We here report the case of an infant with splenic and pancreatic haemangiomatosis presenting with life-threatening thrombocytopenia, anaemia and intravascular coagulation. Diagnosis was hampered by reactive erythroblastosis and non-conclusive radiological findings. While treatment with corticosteroids was ineffective, administration of antithrombin III improved coagulation parameters. After splenectomy the child recovered promptly and has remained free of disease for 3 years to date.

CONCLUSION

Occult visceral haemangiomatosis without visible cutaneous haemangiomas should be included in the differential diagnosis of thrombocytopenia, anaemia and consumption coagulopathy. Antithrombin III treatment may be considered to overcome bleeding problems in patients with Kasabach-Merrit syndrome.

[Color Doppler controlled needle biopsy in diagnosis of soft tissue and bone tumors]

In a prospective study we investigated 168 patients with musculoskeletal tumors, including 71 sarcomas, by core needle biopsy using the high-speed device Autovac. Monitoring with colour-coded duplex sonography allowed a well-aimed puncture of smaller or deeply localized lesions and also permitted the discrimination of necrotic and viable parts of the tumor. Adequate material for histologic diagnosis including grading and determination of tumor subtype was obtained from soft tissue sarcomas, soft tissue metastases, malignant lymphomas, plasmacytomas, and osteolytic skeletal secondaries. In contrast, in benign soft tissue and bone tumors the diagnosis could be established in only 66% of cases. Although skeletal sarcomas were identified as malignant mesenchymal lesions, a complete histologic classification of tumor subtype frequently was not possible due to an insufficient tissue specimen. With an accuracy of 97% for the diagnosis of malignancy and of 94% for the diagnosis of soft tissue sarcoma the results of core needle biopsies were comparable to those of incisional biopsies, the reference standard in the diagnosis of musculoskeletal tumors. Regarding the known disadvantages and the oncological risks of incisional biopsies, needle biopsy should replace the open procedure as the primary means of diagnosis in soft tissue and osteolytic bone tumors.

Clonal origin of tumor cells in a plexiform neurofibroma with LOH in NF1 intron 38 and in dermal neurofibromas without LOH of the NF1 gene

LOH at the NF1 locus was investigated in 38 neurofibromas of 26 NF1 patients. Only in one of these tumors LOH was observed. In this plexiform neurofibroma of a NF1 patient with a constitutional one base-pair insertion in NF1 exon 4b, a non-random X-inactivation pattern was found, strongly suggesting a clonal origin of the tumor cells. The analysis of X-inactivation patterns allowed the classification of some of the other neurofibromas with regard to the detectability of clonal LOH. In 3 of 6 neurofibromas without LOH amenable to this analysis, a comparable X-inactivation pattern was found in constitutional and neurofibroma derived DNA. A clonal LOH would not have been detected in these tumors. However, we observed a nonrandom pattern in 3 of the 6 neurofibromas, suggesting a clonal origin of the tumor cells. LOH was not detected in these tumors, but could, however, have occurred by mutational events below the level of large somatic deletions, loss of a whole chromosome 17 or somatic recombination.

[A case of sarcoidosis of the mastoid]

BACKGROUND

Sarcoidosis is a common granulomatous systemic inflammatory disease mainly affecting the interstitial lung tissue and perihilar lymph nodes. Since its first description by Bernier 1889 its etiology has remained obscure.

METHOD

Sarcoidosis of the right middle ear in a 38-year-old woman was diagnosed by biopsy.

RESULT

After mastoidectomy and treatment with prednisolone the patient has been free of relapse for two years.

CONCLUSION

According to our knowledge this is the second reported case of sarcoidosis of the middle ear. In both cases the interstitial lung tissue has been involved as well. This finding increases the importance of excluding sarcoidosis in differential diagnosis of chronic otitis media.

Histomorphological examination of endoluminal stent grafting in the descending aorta in a sheep model

Experiments were designed to examine the wound healing characteristics at the aorta-endograft interface. Thoracic aneurysms were induced in sheep and excluded by endovascular placement of a selfexpanding stent graft (Corvita Endovascular Graft). After a follow-up of 1, 4, or 12 weeks sheep were sacrificed and the corresponding segments of the aorta were subjected to histological examinations. Histomorphological evaluation of all groups underlined sufficient exclusion of lesions of the aortic wall by endovascular grafting. There was no evidence of proximal or distal leakage, graft dislocation or migration. The results appeared to be evidence that the endoluminal stent graft may be incorporated by the host aortic tissue.

Epstein-Barr-virus-associated lymphoproliferative syndrome in severe combined immunodeficiency: establishment of a lymphoblastoid cell line as an in vitro model for biological and therapeutic studies

Patients with primary or secondary immunodeficiency are at high risk for B cell lymphoproliferative syndromes (LPS) that are generally Epstein-Barr virus (EBV)-associated. We established a cell line, termed JuWa, from an immunoblastic lymphoma that developed in a child with severe combined immunodeficiency. JuWa cells were representative of the original lymph node as shown by a similar IgH gene rearrangement pattern. The cell line exhibited the typical features of a lymphoblastoid cell line (LCL): (1) growth pattern in large clumps, (2) lack of structural chromosome abnormalities, (3) type III latency with expression of EBV-associated EBNA2 and LMP, as well as B cell activation markers CD23 and CD30, thereby showing characteristics of an EBV producer cell line, i.e. a latent infection with a small subpopulation of cells spontaneously entering the lytic cycle, (4) inducibility of the lytic cycle by IdU and TPA, leading to an increase of early antigen and viral capsid antigen-positive cells from 1 to 15-20%, and (5) elimination of the linear viral genomes by treatment with acyclovir (ACV), without affecting the circular episomal genomes. After withdrawal of ACV, viral replication resumed within 7 days. Thus, JuWa cells support the concept of the LCL-like features of LPS and lymphomas occurring in the setting of immunodeficiency. In our in vitro model, ACV treatment could effectively suppress the viral replication but not cure EBV infection of B cells.

Intestinal cytomegalovirus disease in immunocompromised patients may be ruled out by search for cytomegalovirus DNA in stool samples

Cytomegalovirus (CMV) PCR from stool specimens was adopted as a diagnostic tool for patients with suspected CMV colitis. After being established, the method was evaluated in 17 AIDS patients and 19 other immunocompromised patients by comparison of PCR results with clinical, histological, and microbiological or virological data. CMV PCR was positive in 4 symptomatic patients with proven CMV colitis and negative in 15 of 16 patients without characteristic histopathology. Neither CMV immunoglobulin G seropositivity nor intestinal symptoms alone were significantly associated with positive PCR results, but severe active systemic CMV infection may lead to a positive PCR. Absence of CMV DNA in stool samples may prove useful in ruling out CMV related colitis.

A fatal infection with Alternaria alternata and Aspergillus terreus in a child with agranulocytosis of unknown origin

Alternaria alternata and Aspergillus terreus were isolated from cutaneous nodules in a 5-year-old girl with agranulocytosis of unknown origin. Histopathological examination supported the diagnosis of an infection with two opportunistic moulds. Aspergillus terreus was also isolated from the secretions of the maxillary sinuses of the patient. In spite of antimycotic therapy, the child eventually died from respiratory failure.

Hepatitis C virus infection is a risk factor for liver failure from veno-occlusive disease after bone marrow transplantation

The contribution of hepatitis C virus (HCV) infection to liver disease after bone marrow transplantation (BMT) was retrospectively evaluated in 61 patients treated with BMT. HCV genome, as well as antibodies to HCV, was analyzed in sera collected before and serially after BMT. Six patients had been infected with HCV before BMT and three patients acquired the infection during or shortly after BMT. All patients infected before BMT died within 10 weeks after transplantation. Five of these six patients (83%) died of veno-occlusive disease (VOD), compared with nine of 52 patients (17%) not infected with HCV (P < .005). Risk factors for VOD other than HCV were not more prevalent in these patients compared with uninfected patients. Parallel to the development of VOD, replication of HCV increased, as demonstrated by rising concentrations of viral RNA in serum. HCV infection acquired during or after BMT caused only mild acute hepatitis C, which progressed to chronic hepatitis C in one patient surviving 10 years after BMT. These data suggest that patients with liver disease caused by HCV infection are at high risk of developing lethal VOD after BMT.

A symptomatic papillary fibroelastoma of the left ventricle removed with the aid of transesophageal echocardiography

A papillary fibroelastoma, causing amaurosis fugax and paresis of the right arm, was detected by echocardiography as a free floating mass in the left-ventricular outflow tract. Based on the exact localization of the tumor by intraoperative transesophageal echocardiography the initial indication for ventriculotomy was disregarded and an atraumatic transvalvular approach was chosen.

Experimental Yersinia enterocolitica infection in euthymic and T-cell-deficient athymic nude C57BL/6 mice: comparison of time course, histomorphology, and immune response

To elucidate the role of T lymphocytes in primary infection with Yersinia enterocolitica, we investigated the elimination rate of this pathogen, the histomorphology of tissue lesions, and the immune responses of athymic T-cell-deficient C57BL/6 nude mice and their euthymic littermates after parenteral infection with Y. enterocolitica of serotype O:8. While a low inoculum of 3 x 10(2) Y. enterocolitica cells (about 0.01 times the median lethal dose for normal C57BL/6 mice) was cleared by normal C57BL/6 mice within 7 to 10 days, athymic nude C57BL/6 mice developed progressive infections after this inoculum, leading to death on days 20 to 25 postinfection (p.i.). While normal C57BL/6 mice experienced short-term transient infections, nude mice exhibited a biphasic, progressive infectious process. Thus, in the early phase (days 1 to 7 p.i.), a rapid influx of CD11b/18-positive cells (Mac-1 antigen) and natural killer cells was evident in the spleens and livers of the nude mice. The late phase (from day 8 p.i. onward) was characterized by a rapid progression of the infection and a further influx of CD11b/18-positive cells into the liver accompanied by an increase in bacterial counts and development of tissue lesions particularly in the liver and spleen. In normal mice, granuloma-like lesions composed of CD11b/18-, CD4-, and CD8-positive cells could be observed. However, granulomata were not found in nude mice. Yersinia-specific immunoglobulin G antibodies appeared on day 15 p.i. in the sera of normal mice, while nude mice failed to develop significant antibody titers. Adoptive transfer of Yersinia-specific T cells into athymic nude mice mediated resistance to Y. enterocolitica infection and restored both the ability of granuloma formation and the production of specific antibodies. In summary, the data presented herein strongly suggest that T lymphocytes play an essential role in the defense of C57BL/6 mice against Y. enterocolitica.

The cellular immune response against Yersinia enterocolitica in different inbred strains of mice: evidence for an important role of T lymphocytes

Resistance of mice against infection with Yersinia enterocolitica has been shown to be related neither to the Ity locus coding for resistance against infection with Salmonella typhimurium and other pathogens nor to the H-2 locus. From other mouse infection models, e.g., murine leishmaniasis, there is evidence that a different T cell-dependent regulation of the host immune response in various inbred strains of mice determines the susceptibility to the infectious agent. However, until recently, little was known about the cellular immune response against Y. enterocolitica. Thus, in a first approach we used the highly virulent Y. enterocolitica strain WA of serotype O:8 and different inbred strains of mice (C57 BL/6, Balb/c and athymic T cell-deficient C57 BL/6 nude mice) to investigate the cell-mediated immunity against parenteral infection. Comparison of the median lethal dose and of the net-bacterial growth in the spleens of infected mice indicated that Balb/c mice could be considered as Yersinia-susceptible whereas C57 BL/6 mice were relatively resistant. However, in contrast to normal C57 BL/6, athymic T cell-deficient C57 BL/6 nude mice have proved to be highly susceptible to Yersinia infection suggesting that T cells are required for the elimination of the pathogen. This conclusion was supported by histomorphological and immunohistological results indicating that T lymphocytes were present in Yersinia-induced tissue lesions. Moreover, the adoptive transfer of Yersinia-specific T cell lines and clones into naive animals mediated significant protection against the pathogen in both Yersinia-resistant C57 BL/6 and in Yersinia-susceptible Balb/c mice. These findings emphasize an important role of T lymphocytes in the host response against Y. enterocolitica infection.

[Idiopathic ulcer of the small intestine]

The authors report on a female patient, 32 years old, suffering for eight years from recurrent and progressive abdominal pain, combined with chronic anemia, due to iron deficiency. Neither anamnesis and clinical course, nor technical examinations elucidated the etiology. Finally an explorative laparotomy with segmental resection of the small intestine led to diagnosis and healing of the rare "idiopathic small bowel ulcer". Possible differential diagnoses were lacking. This case report demonstrates the need of an invasive and aggressive diagnostic approach after excluding all common causes of disease, related to the symptoms, in order to prevent patients from suffering for years.

Immunohistological characterization of the cellular immune response against Yersinia enterocolitica in mice: evidence for the involvement of T lymphocytes

Previous work from this laboratory has demonstrated that cloned T lymphocytes from spleens of Yersinia-infected mice can transfer immunity against Y. enterocolitica into naive animals. In this study, we investigated the cellular immune response to parenteral infection of Yersinia-resistant C57 BL/6 mice with the highly virulent Y. enterocolitica strain WA of serotype O:8 employing immunohistological methods. In the course of the infection the spleen and the liver were the organs most extensively affected. Histologically, three different patterns of inflammatory reactions could be observed: (i) small non-pyogenic granuloma-like lesions (in the liver only), (ii) microabscesses lacking a sharp outline, and (iii) larger abscesses disclosing a distinct cellular border (spleen and liver). Immunohistologically, Y. enterocolitica was detectable within abscesses but not in the small granuloma-like lesions present in the liver. CD11b/18 positive cells (= Mac-1-antigen expressed on macrophages, monocytes, granulocytes and NK-cells) could be shown in Yersinia-induced lesions. The number of these cells correlated with the extent of tissue alterations induced by Y. enterocolitica. More strikingly, we were able to demonstrate for the first time that both CD4 (helper) and CD8 (cytotoxic) T lymphocytes are present in Yersinia-induced lesions. In summary, we could demonstrate for the first time that granuloma-like lesions can be induced by Y. enterocolitica. Moreover, we supported our recent study suggesting that T lymphocytes are probably involved in the immune response against Y. enterocolitica in mice.

[Severe combined immune defect. Presentation of exfoliative dermatitis with eosinophilia and lymphadenopathy]

BACKGROUND

We report on 9 infants with severe combined immunodeficiency (SCID), who additionally showed signs of Omenn syndrome with an exfoliative dermatopathy, alopecia, enlarged lymph nodes, a hepatomegalia and a striking blood eosinophilia. The immunological evaluation revealed the characteristic abnormalities of SCID with cellular and humoral immunodeficiency. All patients however had the unusual finding of mature T cells in the peripheral blood. By HLA typing these cells were noted to be of maternal origin in 5 patients. In the other 4 patients the T cells were of host origin. We asked for additional differences between both patient groups.

METHOD

Both patient groups were analyzed and compared with regard to case histories, clinical, laboratory and histopathological parameters.

RESULTS

No clinical or laboratory differences could be detected. The histomorphologic analysis of patients with or without maternal T cells was identical. The skin biopsies showed dense cell infiltrations of lymphocytes, histiocytes and eosinophils, in the enlarged lymph nodes the latter two cell types predominated. Therefore the only difference between the 2 patient groups was the presence or absence of maternal T cells.

CONCLUSION

Since the Omenn syndrome is found in association with maternal as well as patient derived T cells, we postulate that the peculiar symptoms of this syndrome are the result of a T cell induced inflammatory reaction, similar but not identical to a graft versus host reaction, occurring on the basis of an inborn SCID.

Peripheral dentinogenic ghost cell tumor

A case of dentinogenic ghost cell tumor, that has originated peripherally in the jaw, is presented and the literature reviewed with particular reference to the origin of the tumor. The total number of central and peripheral cases reported in the English literature is 10 and although mucosal infiltration is common, peripheral origin of the neoplasm could be verified in only 3 cases.

Fatal B-cell lymphoproliferative syndrome in allogeneic marrow graft recipients. A clinical, immunobiological and pathological study

We have studied four cases of fatal B-cell lymphoproliferative syndrome (LPS) developing among 333 patients (incidence 1.2%) treated with allogeneic bone marrow transplantation (BMT). All four patients had received a T-cell depleted graft. Onset of the first clinical symptoms (palpable lymph node enlargement in three and IgA-lambda paraproteinemia in two patients) occurred between 41 and 188 days post-BMT (median 76 days). The course of the LPS was rapidly progressive in all cases, leading to death in 2-5 weeks. The peripheral blood showed progressive pancytopenia with disproportionally high numbers of activated NK cells, apparently compensating for the T-cell deficiency. Post-mortem histological studies disclosed polymorphic B-cell proliferations, most pronounced in the lymph nodes, spleen, liver, lungs and kidneys. Lymphohemopoietic cells were of donor origin in three patients. In the fourth patient, graft failure suggested a host origin for the proliferating cells. Immunophenotyping and gene rearrangement analysis revealed polyclonal proliferation in one patient, monoclonal proliferation in another patient, and an oligoclonal pattern in the other two patients. The clinical behavior of the LPS was independent of clonality. Immunohistologically, the proliferating cells showed characteristics of relatively mature B-cells in three cases, and pre-B-cell features in one case. Epstein Barr virus (EBV) serology indicated seroconversion (primary infection) in one child, and chronic active EBV infection in both adults. EBV DNA as well as EBV nuclear antigen (EBNA) were detected in infiltrated tissues of all four patients. The labeling pattern on in situ hybridization suggested a replicative EBV infection comparable to that in lymphoblastoid cell lines. We conclude that EBV-associated LPS developing as a result of post-transplant immunodeficiency is a distinct clinicopathologic entity, differing from non-Hodgkin's lymphoma (including Burkitt's lymphoma) and infectious mononucleosis of the immunocompetent host.

[Cytostatic-induced stomatitis]

45 patients with oral cancer preoperatively received regional intraarterial chemotherapy (RIAC). All patients developed stomatitis or glossitis limited to the region of cytostatic perfusion. Between 1 and 19 days (median 4 days) after RIAC the tumor was removed by hemiglossectomy, partial resection of the floor of the mouth etc. The tissue alterations induced by chemotherapy in these surgical specimens were analyzed histomorphologically. Stomatitis due to RIAC was characterized by necrosis, ulceration and severe epithelial dysplasia of mucous membranes. Approximately 2 weeks after chemotherapy both the inflammatory changes and the dysplasia had disappeared completely. The differences between spontaneous premalignant dysplasia of the oral cavity and dysplasia induced by RIAC are discussed.

Gonadal agenesis in a 46,XY female with multiple malformations and positive testing for the sex-determining region of the Y chromosome

A full-term 46,XY female newborn presented with respiratory failure due to a right-sided diaphragmatic hernia. During surgical repair, exploration revealed isolated dextrocardia and hypoplasia of the right lung. Neither gonads nor wolffian or müllerian structures could be palpated. Cardiac catheterization demonstrated defects of the ventricular septum, hypoplasia of the right pulmonary artery, persistence of the left vena cava superior and a patent ductus arteriosus. Anthropometric data were normal at birth, but fell below the 3rd percentile during follow-up. Body proportions displayed a predominance of the upper compared to the lower segment. Endocrine studies indicated no defect of steroid biosynthesis and no functional gonadal tissue. Using genetic analyses of various loci within the testis-determining region of the Y chromosome, a mutation could not be detected. The patient died from pneumonia at the age of 19 months. Postmortem examination confirmed the diagnosis of gonadal agenesis.

[Pathology of thyroid diseases in children]

In the present survey the pathohistologic substrate of the major thyroid diseases (functional disturbances, goiters, inflammations, tumors) occurring in childhood is described. In this context the functional morphology (correlation of structure and function) and the immunohistology of the thyroid is reported in detail. Finally, it is discussed under which conditions histologic studies of the thyroid are meaningful for the diagnosis.

[Validity of immunohistology and in situ hybridization in the differential diagnosis of cytomegalovirus pneumonia and idiopathic interstitial pneumonia after allogenic bone marrow transplantation]

Interstitial pneumonia (IP) is currently the most frequent and severe complication of allogeneic bone marrow transplantation (BMT). Post-BMT-IP is due partially to infection by cytomegalovirus (CMV-IP) and partially to idiopathic induction (IIP). Because of the different therapeutic consequences it is important to distinguish between these two kinds of pneumonia. Therefore, the validity of immunohistochemistry (IHC) and in situ hybridization (ISH) for the differential diagnosis of CMV-IP and IIP was studied. The investigations were performed using postmortem tissue samples (lung) of 23 patients decreased after allogeneic BMT. In 22 of the 23 patients the primary cause of death was IP (CMV 13x, idiopathic 7x, pneumocystis 1x, toxoplasmosis 1x). One patient died from thrombopenic cerebral bleeding. All 3 CMV-detecting systems tested disclosed certain advantages and disadvantages. The sensitivity of routine histology was 12/13 (92.3%), of IHC 13/13 (100%), and of ISH 12/13 (92.3%). The specificity corresponded to the order: ISH greater than IHC greater than histology. The application of ISH and IHC did not change significantly the routine histologic classification of pneumonias into CMV-IP and IIP. The validity of the three procedures used for detecting CMV in patients after allogeneic BMT is discussed in detail.

[Reversible germ cell toxicity following aggressive chemotherapy in patients with testicular tumors: results of a prospective study]

The impact of aggressive chemotherapy on reproductive and endocrine gonadal function was prospectively studied in 44 patients with germ cell tumors. Diagnostic procedures to determine gonadal toxicity consisted of hormone determinations, semen analyses, interviews with a standardized questionnaire, and gonadal histology. After chemotherapy all patients showed elevated serum levels of follicle-stimulating hormone (FSH) and azoospermia due to germ cell and stem cell loss. Recovery of spermatogenesis, as indicated by normalization of serum FSH levels and sperm density, occurred in 77% of the patients 25-60 months after cessation of chemotherapy. In all patients serum testosterone and luteinizing hormone (LH) values remained within normal limits after therapy indicating resistance of Leydig cells to cytotoxic drugs. Three patients fathered four healthy children after completion of chemotherapy. These data suggest significant reproductive dysfunction in all men treated for germ cell tumors. However, most patients showed late and complete recovery of spermatogenesis. In contrast, endocrine gonadal function was unaffected after chemotherapy in all patients. FSH and LH are feasible markers to assess drug-induced gonadal toxicity.

Detection of human cytomegalovirus DNA and viral antigens in tissues of different manifestations of CMV infection

Biopsy and autopsy specimens from 22 patients with cytomegalovirus (CMV) infections were investigated by means of in situ hybridization (ISH) to detect viral DNA and by immunohistochemistry (IHC) to visualize viral proteins. Both methods proved to be valuable tools for histopathology. ISH sometimes recognized cells that did not show typical CMV inclusions. An antiserum against the full spectrum of viral proteins (non-infectious enveloped particles) detected most cytomegalic cells in disseminated and organ-limited infections. An antiserum against a recombinant polypeptide (XP1) was particularly useful in connatal CMV infections and organ-limited infections. We have demonstrated that IHC and ISH studies in parallel are the best approach to the detection of CMV infections in pathological specimens.

[Histomorphology and immunopathology of granulomatous inflammation]

Every inflammation has its morphological substrate, however, not every morphological substrate is specific for a particular disease. On one side, this is due to the limited reaction spectrum of the organism, on the other side, to the fact that completely different etiological agents are able to activate the same pathomechanism. Since this holds true for granuloma formation also, the term "specific inflammation" has to be restricted considerably today. On the other hand, recent progress in the field of mediators of inflammation frequently permits a pathogenetic classification of granulomatous inflammatory processes - even before the etiology has been clarified (e.g. Morbus Boeck). In addition, the possibility to identify "granuloma cells", in particular macrophage- and lymphocyte-subpopulations, in situ by immunohistological means (by monoclonal antibodies to surface markers) expands the scope of conventional histomorphological techniques significantly.

[Histomorphology of inflammation]

Progress in biochemistry of inflammation, particularly in the identification of mediators of inflammation, has considerably deepened our understanding of the histomorphology of inflammatory lesions. In surgical pathology, the traditional histologic differentiation between specific and non-specific inflammation still plays a certain role. This differentiation, on the other hand, has lost significance since it became evident that specific inflammatory reactions, such as epithelioid cell granuloma formation, can be observed in diseases of completely different etiology. Consequently, the histological picture does not reflect the activity of a particular etiologic agent but rather images the action of mediators of inflammation. Which mediators are released depends not only on the inducing agent but also on numerous other factors. This holds true for specific as well as non-specific inflammation and also for immunopathologic (allergic) reactions. In most instances the modulating effect of the fine structure of tissues (e.g. capillary angioarchitecture) on the intensity, type and course of inflammatory processes is covered by other predominating influences. The most important new aspect in the histomorphology of inflammation is the possibility--nowadays--of interpreting histological patterns of inflammation in terms of known pathomechanisms.

Histomorphology of experimental listeriosis

This paper is a survey of the histomorphology of experimental listeriosis based on cooperative studies performed within the past ten years. The influence of various parameters of the infectious agent (pathogenic Listeria monocytogenes serovar 4b, nonpathogenic Listeria innocua serovar 6b etc.) as well as of the host (euthymic NMRI-mice conditioned with dextran sulfate 500 or cyclosporin A, athymic nude mice etc.) on the course, morphology and outcome of the Listeria infection was investigated. From the experimental models used and the studies performed much could be learned concerning the factors that determine the histomorphological manifestations of listeriosis in humans.

Alteration of non-specific resistance to infection with Listeria monocytogenes

The experimental infection of murine hosts with Listeria monocytogenes is often used as a model for cell-mediated immunity. However, the natural immunity or non-specific resistance to listeriosis can be influenced by the parasite itself and also by a wide array of endogenous and exogenous host factors. The most important host factor in inbred mouse strains is their genetically determined susceptibility or resistance to Listeria monocytogenes. Secondly, the age of the mice is crucial for the outcome of infection. Resistance is only slowly developed by newborn mice, while aged mice possess an increased non-specific resistance as compared to young adult animals. Resistance is further influenced by the nutritional status, by pregnancy or by a simultaneous second antigenic stimulation. Regarding exogenous factors, macrophage blocking agents can totally abolish the resistance to listeriosis, while a lot of immunomodulating agents, such as BCG, killed Bordetella pertussis or Propionibacterium acnes organisms, lipopolysaccharides, suramin etc., can either increase or decrease the resistance. The mononuclear phagocyte system seems to be the main target of all these immunomodifiers. The timing between listeria infection and application of the immunomodulator determines the effect on non-specific resistance. A simultaneous injection of parasite and immunomodulator results in a decrease of resistance, while the application of immunoadjuvants several days before infection can dramatically increase the resistance to listeriosis. The delicate equilibrium of the mononuclear phagocyte system must therefore be taken into account, when infection with Listeria monocytogenes is used to test for immune-modifying agents, which are intended for use in humans or animals.

Testosterone-secreting adrenocortical tumor in a pubertal girl. Case report and review of the literature

A girl aged 12 years and 10 months presented with deepening of the voice first noted 7 months earlier. Pubertal development was almost completed. The girl had regular monthly menses and no signs of hirsutism, clitoris enlargement or Cushing's disease. Serum testosterone was about threefold above normal, whereas dehydroepiandrosterone was in the upper normal range. The 17-ketosteroids as well as the gas-chromatographically analyzed 5 alpha and 5 beta derivatives of testosterone from urine were slightly increased. Other serum and urinary steroids were normal. Dynamic tests of the endocrine function exhibited inconclusive results. Ultrasonography revealed no ovarian cysts. A small, left-sided adrenal mass was identified by computed axial tomographic scan and removed by surgery. There were no signs of local metastasis nor of vascular extension. The histopathological diagnosis was adrenocortical carcinoma. 5 months after surgery, the preoperatively elevated steroid levels had returned to normal.

Benign testicular tumors: a case for testis preservation?

Between June 1980 and June 1986, 345 inguinal explorations for intrascrotal space-occupying lesions were performed. In 47 patients benign testicular tumors were diagnosed (13.5%). In 32 of the 47 tumors (68%), the testis could be preserved by excision or enucleation of the tumor. In the remaining 15 patients a high semicastration was carried out: in 12 cases macroscopic examination or frozen section revealed doubtful benignity (6 Leydig cells tumors, 5 dermoid cysts and 1 epidermoid cyst), in 3 patients because of extensive involvement of the testis. In a follow-up period of 1-7 years none of the patients has shown evidence of tumor recurrence or metastasis. Changing the concept of not incising the parietal tunica of the testis and regarding clear-cut macroscopic and histological criteria of benignity on frozen section will safely lower the testicular loss rate from up to 80% to about 30% when benign tumors are encountered.

[Bilateral intrauterine testicular torsion]

Torsion of the testes is the most frequent urogenital emergency in childhood. Bilateral intrauterine torsion of the testes is a rare event. Only 15 cases have been reported up till now. We add two patients. Clinical findings, consequences and therapy of bilateral torsion of the testes are discussed. Etiology and symptomatology of testicular torsion in the newborn and the adult are different. Predisposing factors are lacking in the extravaginal torsion of the newborn but are present in the intravaginal torsion of the adult. The diagnosis is made by inspection, palpation, Doppler sonography and, if necessary, by immediate surgical exploration. Except for the local findings there are usually no symptoms in the newborn. Following bilateral torsion of the testes with consecutive bilateral orchiectomy the loss of exocrine function remains irreversible. Androgenic substitution therapy should begin at the age of 14. The full dose of hormone should not be given before the termination of bone growth. For psychological and cosmetic reasons a testicular prosthesis can be recommended.

[Ureteral stump metastasis of a hypernephroma. A case report]

Ureteral stump metastasis after tumor nephrectomy is very rare. To date 43 cases have been published. In our patient this type of metastasis was diagnosed 2 years after nephrectomy for renal adenocarcinoma with prominent rhabdomyosarcomatoid components. The pathogenesis of ureteral stump metastasis is discussed.

Effects of cyclosporin A on experimental infection with Listeria monocytogenes

The effects of cyclosporin A on primary and secondary infection of mice with Listeria monocytogenes was studied both at the microbiological and the histomorphological level. This drug, when given in a dose of 100 mg/kg/day, was found to inhibit the development of protective immunity after primary infection as well as the expression of acquired immunity to challenge infection as determined by counting of bacterial numbers in the spleen. The manifestation of delayed type hypersensitivity was also impaired. When the cellular immune system was functionally intact, the formation of granulomas composed of macrophages and lymphocytes enabled the animals to overcome the Listeria infection. In mice treated with cyclosporin A protective granulomatous reaction during secondary infection did not occur. Instead numerous necropurulent lesions developed in the reticuloendothelial organs, such as spleen and liver, of animals unable to control the lethal infection.

Causative agents, mediators and histomorphology of inflammation

The purpose of this survey on the interrelationship of causative agents, mediators and the histomorphology of inflammation is to show to what extent endogenous biochemical factors determine the inflammatory reaction. There is overwhelming evidence, today, that such factors are involved in the manifestation of acute as well as chronic, non-specific as well as well as specific inflammation. In fact, the histomorphological pattern of many inflammatory reactions more directly reflects the activity of the mediators than of the causative agents involved. Therefore, knowledge of the properties of mediators of inflammation does not only provide new insights into the underlying pathomechanisms but may also help in the understanding and interpretation of the histomorphology of inflammatory lesions.

Extramedullary haemopoiesis after bone marrow transplantation

44 patients underwent bone marrow transplantation (BMT) for treatment of severe aplastic anaemia or haematological malignancies. During their post-transplant phase all patients had erythroblasts and granulocytic precursors in their peripheral blood. 15 patients died between day +6 and +346 after BMT and autopsies were performed. The sections of all 15 patients revealed extramedullary haemopoiesis in the spleen. Extramedullary haemopoiesis in the liver was found only in those patients who died early (between d +6 and d +21 after BMT). Medullary haemopoiesis, normally only occurring in the vertebral body, was also observed in the shaft of the femur. The present data show that after BMT all tissues with a haemopoietic matrix in ontogenesis can be repopulated with haemopoiesis in the early phase of reconstitution, possibly to compensate for the haemopoietic insufficiency after conditioning therapy. The expansion of haemopoiesis in the later period of up to 1 year after BMT, remains to be explained.

[Parathyroid carcinoma]

The parathyroid carcinoma is a rare cause of primary hyperparathyroidism. It deserves special attention in regard to diagnosis and treatment. Within a period of 10 years we observed 117 patients with primary hyperparathyroidism (pHPT) at the University Hospitals of Ulm and Heidelberg. In five patients a parathyroid carcinoma was found, corresponding to an incidence of 4.4%. In four of five patients no clinical signs were evident preoperatively indicating a parathyroid malignancy.

Resistance of gnotobiotic nude mice to Listeria infection

Unlike the acute and short-term course of experimental listeriosis in phenotypically normal (nu/+) mice, Listeria monocytogenes infection in conventionally raised athymic Nude mice results in chronic inflammation with persistence of bacteria and lesions in the internal organs such as liver and spleen. Although it could be shown that germfree Nude mice had no intestinal microbial flora and lacked measurable serum immunoglobulins, neither the course nor the histomorphology of experimental listeriosis differed significantly from that of their conventionally raised littermates. The results indicate that the typical response of Nude mice to Listeria infection is primarily determined by inborn factors and not by prior antigenic stimulation.