Hsal 1 is related to kidney and gonad development and is expressed in Wilms tumor

Townes-Brocks syndrome (TBS) is a human genetic disorder with features including urogenital, limb, anal and cardiac malformations associated with mutations of the TBS gene, Hsal 1. To begin to understand the role of the Hsal 1 protein (p140) in both normal development and disease pathogenesis, both message and protein expression were evaluated in specific tissues associated with TBS. DNA sequence information for Hsal 1 predicts that this homeotic, Drosophila homologue (Sal) encodes a zinc-finger protein consistent with a transcription factor. mRNA for Hsal 1 was highly expressed in fetal kidney and brain, with detectable production in thymus and heart. p140 was found in fetal ureteric bud, fetal and postnatal renal tubular epithelium, and renal blastema. In the 14-week fetal testis, the Hsal 1 protein was specifically expressed in the testosterone producing Leydig cells while in adult gonads Hsal 1 was also found in both Leydig and Sertoli cells, spermatogonia of the testis, and granulosa cells of the ovary. Evaluation of Wilms tumor revealed consistently high expression of the gene product in the epithelial and blastemal components. These spatial and temporal patterns of expression for Hsal 1, and the phenotypic effects associated with TBS, suggest that Hsal 1 plays an important role in the development and functional maintenance of the kidney and gonads. Furthermore, the Hsal 1 gene product may play a part in the pathogenesis of specific neoplasms occurring in these organs in addition to its specific role in Townes-Brocks syndrome.

The placenta in pseudoxanthoma elasticum: clinical, structural and immunochemical study

Pseudoxanthoma elasticum (PXE) is a rare genetic disorder clinically characterized by skin, cardiovascular and eye manifestations, mainly due to calcification and fragmentation of elastic fibres. Although infrequent, complications during pregnancy in women affected by PXE have been reported. The aim of the present study was to compare structural features of placentae at term from 14 control and 15 PXE-affected women, in order to better understand if and how abnormal mineral and/or matrix accumulation might affect placental function in PXE. In all cases, pregnancy, fetus growth and delivery were normal. Both gross and light microscopy examination did not reveal dramatic differences between placentae of PXE patients and controls, with regard to weight, dimensions, infarcts, thrombi, inflammatory lesions or vessels. However, necrotic changes and mineralization appeared statistically more pronounced in PXE. By electron microscopy the most remarkable differences between PXE and control placentae were observed in the localization and morphology of mineral precipitates; a significant higher deposition of mineral precipitates was observed associated with the "matrix"-type fibrinoid and among collagen fibrils, especially on the maternal side. Immunocytochemistry revealed the presence of vitronectin and fibronectin associated with the PXE-specific mineralizations and the absence of mineralization on the small and scarce elastic fibres in either controls or in PXE.

Asplenic-hyposplenic overwhelming sepsis: postsplenectomy sepsis revisited

Absence of the spleen or splenic function predisposes individuals to risk of overwhelming infection. These infections are most often due to encapsulated organisms, especially pneumococcus, Haemophilus influenzae type b, and meningococcus, but any bacterial agent may cause the rapid onset of septicemia, meningitis, pneumonia, and shock characteristic of the asplenic-hyposplenic condition. The risk is greatest in infants and young children, but asplenic-hyposplenic adults also have an increased risk of infection. Prophylactic antibiotics and immunization with polyvalent pneumococcal, H. influenzae type b, and meningococcal vaccines have reduced the incidence of infections in asplenic-hyposplenic individuals, but even these measures have not eliminated the risk. Surgeons have adopted techniques to save as much splenic tissue as possible and some splenic functions, such as pitting red cells, have been preserved, but conservative surgery has not provided total protection against overwhelming infection. Therapies designed to interrupt the cascade of overwhelming sepsis have not yet been successful. In those cases in which the spleen is surgically removed, the underlying disease or condition leading to splenectomy influences the risk of sepsis. Splenectomy incidental to other operations, such as gastrectomy, results in the lowest risk for overwhelming infection, but this is still some 35-fold greater than the risk for overwhelming infections in the general population. In increasing order of risk, the other main indications for surgical removal of the spleen are idiopathic thrombocytopenia purpura, trauma, transplantation procedures, hereditary spherocytosis, staging Hodgkin's disease, portal hypertension with hypersplenism, and thalassemia. Pathologists should comment on the risk of overwhelming sepsis when spleens are processed as surgical specimens, and should carefully weigh all splenic tissue, including accessory spleens and splenic implants (splenosis), in autopsy cases with and without overwhelming sepsis.

Atypical squamous metaplastic cells: reproducibility, outcome, and diagnostic features on ThinPrep Pap test

BACKGROUND

Atypical squamous metaplastic (ASM) cells are associated with high-grade squamous intraepithelial lesions (HGSIL) in many cases. The reproducibility of the diagnosis and biopsy follow-up results of cases designated as ASM were studied at Women and Infants' Hospital of Rhode Island.

METHODS

Of 180 patients with ASM who the authors examined from January 1, 1998 to September 30, 1998, 147 (81.7%) had subsequent biopsies. Results of the biopsies were tallied. Twenty cases were rescreened in a blinded fashion to determine intra- and interobserver agreement and to identify diagnostic features.

RESULTS

Sixty-five (44.2%) cases of ASM had HGSIL on biopsy, 26 (17.7%) had low-grade squamous intraepithelial lesion, and 56 cases (38.1%) were benign. Overall individual consistency is 8 of 16 (50%), and overall agreement is 13 of 64 (20%).

CONCLUSIONS

Sixty-two percent of cases designated as ASM cytologically were associated with SIL, primarily HGSIL, at biopsies. The findings underscore the importance of this subcategory of atypical squamous cells. However, poor reproducibility suggests the need for refined criteria and/or continuing education, and obtaining second opinion. Cancer (Cancer Cytopathol)

Beta-cell hyperplasia in macrosomic infants and fetuses of nondiabetic mothers

The objective of this study was to test the hypothesis that macrosomic infants of nondiabetic mothers have beta-cell hyperplasia in their pancreases. Pancreatic tissues were examined from 10 macrosomic fetuses and liveborn infants and from 10 comparison cases matched for gestational age and gender. None of the mothers had a history of diabetes and all had normal glucose screening during pregnancy. Tissues were stained with hematoxylin and eosin and a monoclonal antibody against beta cells and were analyzed using an image analysis program to evaluate the size and surface area of beta-cell clusters. Brain/liver weight ratios were calculated and compared. The total surface area and cluster size of beta cells in the pancreases of macrosomic subjects were significantly larger than in the comparison pancreases. The study subjects lacked macroscopic and histopathologic findings expected in infants of diabetic mothers. We conclude that some macrosomic fetuses and infants of nondiabetic mothers manifest beta-cell hyperplasia. This corresponds to the higher insulin levels in macrosomic infants of nondiabetic mothers described in previous clinical studies. In macrosomic fetuses the stimulus for beta-cell hyperplasia may not involve aberrant maternal glucose levels.

Hepatic subcapsular hematomas in fetuses and neonatal infants

In fetuses and neonates hepatic subcapsular hematomas are relatively common lesions and may be life-threatening. Conditions previously associated with these hematomas include trauma, coagulopathies, hypoxia, sepsis, pneumothorax, maternal diseases, and placental lesions. In this study of 755 perinatal autopsies, hepatic subcapsular hematomas were found in 52 (6.9%) cases, including 31 stillborn fetuses and 21 liveborn infants. The average body weight was 690 g. A comparison group consisted of 52 temporally proximal autopsies of fetuses and neonates without hematomas. Body weights, gender, maternal age, and stillbirth or postnatal survival were matched as closely as possible while evaluating the presence or absence of sepsis, pneumothorax, cerebral germinal matrix hemorrhage, trauma, coagulopathy, placental lesions, and maternal diseases. Sepsis was associated with 62% of the cases with hepatic subcapsular hematomas and with 25% of the comparison group (P =.0001). Group B streptococcus infection was the most common cause of sepsis, but many different organisms were isolated. Cerebral germinal matrix hemorrhages were present in 35% of the cases with hematomas and in 14% of the comparison group (P =.0001). No other lesions or conditions were statistically different in the study group versus the comparison group. The delicacy of the hepatic capsule and its connections to the collagen along the sinusoids provide insight for the pathogenesis of hematomas in premature fetuses and neonates. We conclude that sepsis is present in most perinatal cases of hepatic subcapsular hematomas and that such patients also frequently have cerebral germinal matrix hemorrhages. Each of these lesions is a greater hazard among very small premature fetuses or neonates than among older fetuses and neonates.

First trimester pregnancy loss associated with varicella zoster virus infection: histological definition of a case

Pathological demonstration of varicella infection in first trimester aborted tissue is reported. A 24-year-old primigravida manifested chickenpox infection about 38 days after her last menstrual period or at 24 days age of the embryo. The conceptus survived another 4 to 5 weeks. The macerated embryo and placental tissue revealed nuclear changes consistent with varicella infection. Immunohistochemical stains and electron microscopy were confirmatory.

Central nervous system malformations in a perinatal/neonatal autopsy series

Congenital malformations of the central nervous system (CNS) are among the most common anomalies, but data on the incidence of CNS malformations in autopsy populations are scant. We examined 4122 autopsies between the years 1958 and 1995. There were 363 cases (8.8%) with CNS malformations; 235 were neonates and 128 stillborns. The overall gender ratio was 1:1, although more male neonates and more female stillborns had malformations. The body weights ranged from 24 to 6440 g. Neural tube defects were the most common types of malformations (45.5%) and included anencephaly, meningoencephalocele, meningocele/meningomyelocele, craniospinal rachischisis, and spina bifida occulta. The incidences of other malformations were: congenital hydrocephalus (12.4%), neuronal/glial proliferation disorders such as micro- and macrocephaly (8.8%), neuronal migration disorders (8.8%), prosencephalon growth disorders such as holoprosencephaly and arhinencephaly (8.5%), abnormalities of the midline structures such as agenesis of corpus callosum (4.1%), developmental cysts (3.3%), cerebellar malformations (3%), and vascular malformations (2%). Miscellaneous malformations (3%) consisted of acephalia in four cases with twin reversed arterial perfusion (TRAP), two cases of hydranencephaly, and four cases of rare degenerative and metabolic encephalopathies.

Reference values for singleton and twin placental weights

The largest series of normal singleton placental weights was collected in the Collaborative Perinatal Study between the years 1959 and 1966 but values for normal twin placental weights were not published. In our study we examined 787 singleton and 514 twin normal placentas. Placentas with associated conditions known to affect the weights of placentas were excluded. After establishing the normal values for singleton and twin placental weights, we concluded that weight gain of twin placentas appears to accelerate between 24 and 36 weeks but reaches a plateau after 37 weeks, whereas singleton placentas appear to gain weight more uniformly throughout gestation. The mean values of twin placental weights for each gestational age are less than double those of singleton placental weights for the same duration of gestation. Our singleton and twin placentas are heavier than those from previously published data and may reflect a generational or nutritional change over the 30 years since the original numbers were compiled.

Pathology of the lung in surfactant-treated neonates

Respiratory distress syndrome (RDS) is associated with prematurity-related deficiency of surfactant. Surfactant replacement therapy has been used in premature infants to prevent RDS or reduce its severity. In this study we describe the pathology of the lungs after surfactant replacement therapy. All the neonatal autopsies during the years 1989 and 1990 (n = 235) were examined. Infants > or = 31 weeks gestation, with congenital anomalies or who lived more than 2 weeks were excluded from the study. Infants who had received intratracheal Survanta, a modified surfactant extracted from cow lung (n = 14), were compared with infants who did not receive exogenous surfactant (n = 20). The two groups were statistically comparable in terms of weight, gestational and postnatal age, gender, and clinical management. H&E-stained lung sections were examined independently by two pathologists without knowledge of surfactant treatment status; any discrepancies in histological evaluation were resolved by joint review. Nine histological features were evaluated including hyaline membranes, necrosis of the epithelium, hemorrhage, edema, inflammation, metaplasia, arteriolar muscular hyperplasia, interstitial fibrosis, and pulmonary interstitial emphysema (PIE). Histological changes were graded from 0 to 3+. When it was present, cerebral periventricular-intraventricular hemorrhage (PVH-IVH) was graded 1-4. The presence or absence of sepsis and necrotizing enterocolitis (NEC) were also determined. Comparisons between patient groups were performed using the Mann-Whitney U, Student's t and chi 2 tests. The severity of hyaline membrane disease, PIE, and epithelial necrosis was less severe in the surfactant-treated group than in the untreated group. There were no differences between the two groups in the degree of pulmonary hemorrhage or in the incidence of PVH-IVH, sepsis, or NEC.

Fryns syndrome: a new definition

Fryns syndrome is a lethal, autosomal recessive syndrome of multiple congenital anomalies described by Fitch et al. in 1978 and Fryns et al. in 1979. As originally described, the major diagnostic criteria included abnormal facies; small thorax with widely spaced, hypoplastic nipples; distal limb and nail hypoplasia; and diaphragmatic hernia with pulmonary hypoplasia. Malformations involving other systems occurred irregularly in published reports. We reviewed 41 published cases of Fryns syndrome and added 4 cases of our own. The major diagnostic criteria described by Fryns were consistent in all cases with the exception of two criteria. Narrow thorax with hypoplastic nipples and gastrointestinal anomalies were present in less than 50% of the cases. Although for 16 of the 41 published cases there was no information on central nervous system findings, 21 of the 29 remaining cases (72%) had CNS malformations. These lesions were absence of corpus callosum, arhinencephaly, and heterotopia of cerebral and cerebellar tissue. Similarly, for 12 of the 41 published cases there was no information on cardiovascular findings but 29 of the 33 remaining cases (88%) had congenital heart disease. These lesions were ventricular septal defects, arterial septal defects, and persistent left superior vena cava. We conclude that central nervous system anomalies and congenital heart disease should be added to the major diagnostic criteria of Fryns syndrome.

Detection of human parvovirus B19 in early spontaneous abortuses using serology, histology, electron microscopy, in situ hybridization, and the polymerase chain reaction

OBJECTIVE

To determine whether there is an association between parvovirus B19 infection and early spontaneous abortion at less than 20 weeks' gestation.

METHODS

Eighty samples of early spontaneous abortions were analyzed. Each sample was examined histologically for the presence of viral inclusions, and selected cases were analyzed for parvovirus using electron microscopy and in situ hybridization. Polymerase chain reaction DNA amplification for the virus was done in each case. Maternal sera were analyzed for immunoglobulin (Ig) M and IgG parvovirus antibodies and compared with temporally matched controls.

RESULTS

Five cases in the study group had evidence of seroconversion for parvovirus, compared with two controls. Products of conception from two of these five cases were positive for virus by polymerase chain reaction amplification, and only one of these two had a characteristic inclusion of parvovirus histologically. Conversely, five chorionic vesicles from mothers who had not seroconverted had histologic changes suggesting parvovirus infection, but all of these cases were negative for parvovirus using in situ hybridization, polymerase chain reaction, and electron microscopy.

CONCLUSIONS

Parvovirus B19 DNA was found in two of 80 early spontaneous abortuses. Although viral DNA was detected in two cases, there was no clear evidence that the infections caused fetal death. Neither case showed erythroblastosis with large numbers of inclusions, as is seen in hydropic fetuses with parvovirus infection. In addition, in five cases in which parvovirus infection was not documented serologically or by the polymerase chain reaction, there was erythroid nuclear clearing suggestive of parvovirus B19 inclusions. This indicates that histologic evaluation for parvoviral inclusions is not always reliable in early spontaneous abortuses.

Estimating the time of death in stillborn fetuses: III. External fetal examination; a study of 86 stillborns

OBJECTIVE

To determine how accurately the time of fetal death can be predicted from the extent of external maceration in a stillborn fetus.

METHODS

Autopsy photographs of 86 stillborns with well-timed deaths were studied retrospectively. Sixty randomly chosen fetuses (learning set) were assessed unblinded to develop proposed gross criteria for timing fetal death; 26 fetuses (test set) were then randomly and blindly assessed to test the accuracy of the proposed criteria.

RESULTS

The two earliest changes in the learning cases were areas of desquamation measuring at least 1 cm in diameter and brown-red discoloration of the umbilical cord stump. Both changes occurred primarily in fetuses with death-to-delivery intervals of 6 or more hours. Other early changes included desquamation involving the face, abdomen, or back (12 or more hours); desquamation involving 5% or more of the body surface (18 or more hours); brown skin discoloration (24 or more hours); and a moderate or severe extent of desquamation (24 or more hours). The only late change that correlated with a specific duration of intrauterine retention was mummification (2 or more weeks). When the 26 test fetuses were randomly and blindly assessed using these gross criteria, 18 (69%) were classified correctly with respect to the approximate time of fetal death.

CONCLUSION

External fetal examination is useful for estimating the time of death in many stillborns; this information may be helpful when a complete autopsy cannot be performed.

Undifferentiated small cell hepatoblastoma with a unique chromosomal translocation: a case report

Cytogenetic studies of pediatric tumors have revealed a number of reproducible karyotypic abnormalities, including del(p13) found in aniridia-Wilms' tumor association, t(8;14) in Burkitt's lymphoma, and t(11;22) in Ewing's sarcoma. To date, no consistent cytogenetic abnormality has been reported in association with hepatoblastoma. We report the case of a 7-month-old male infant with the undifferentiated small cell variant of hepatoblastoma. Immunohistochemistry revealed reactivity with antibodies to cytokeratin and vimentin throughout the tumor. Alpha-fetoprotein, neuron-specific enolase, and S100 stains were negative. Chromosomal analysis of metaphase cells from a culture of tumor tissue revealed a translocation of most of the long arm of chromosome 22 to the distal long arm of chromosome 10.

The urinary system in Down syndrome: a study of 124 autopsy cases

We examined 124 autopsy cases of Down syndrome for the presence of renal and urinary tract abnormalities. The cases were divided into three groups: (I) fetuses of 16-22 weeks gestation (n = 18), (II) stillborns or newborns who died on the first day of life (n = 9), and (III) Down patients 1 day to 25 years of age (n = 97). Kidney weight was reduced by a mean of 14.4% compared with expected values. Renal hypoplasia, defined as kidney weight less than two-thirds expected, was found in 18 cases. Glomerular microcysts were found in 23 of 97 cases in group III. Focal dilatation of tubules was found in 10, simple cysts in 7, and immature glomeruli deep in the renal cortex in 18 cases. Obstructive uropathy occurred in 2 of 18 (11.1%) in group I, 2 of 9 (22.2%) in group II, and 4 of 97 (4.1%) in group III. Obstructive uropathy with bilateral cystic dysplastic kidneys resulted in Potter's sequence. We suggest that obstructive uropathy is associated with Down syndrome. When severe, it results in Potter's sequence and an early perinatal death. A chromosomal analysis is recommended in any case of obstructive uropathy in the fetal or neonatal period.

Type-specific identification of herpes simplex and varicella-zoster virus antigen in autopsy tissues

To identify antigens of herpes simplex virus (HSV) types 1 and 2 and varicella-zoster virus (VZV) in human tissue, polyclonal antisera and an immunoperoxidase method were used to examine formalin-fixed, paraffin-embedded tissues from autopsy cases and experimentally infected animals. These antisera readily distinguished between HSV and VZV antigen, with no evident cross-reactivity. Antiser ato HSV-1 and HSV-2 were more strongly reactive with antigen of the homologous virus than with that of heterologous virus. This difference in immunoreactivity was used to discriminate between HSV-1 and HSV-2 antigens in experimentally infected animal tissues containing HSV antigens of known type and, by extrapolation, to distinguish between these antigens in human autopsy tissues. Thus, with appropriate antisera and tissue controls, HSV-1, HSV-2, and VZV can be identified in paraffin sections.

Infections, preterm delivery, and perinatal death in midgestation

Amniotic fluid infection results in considerable pregnancy wastage in the second and early third trimesters. In our study of 1119 perinatal autopsies amniotic sac infection was associated with death in 133 fetuses and neonates in midgestation. These cases accounted for almost 12% of all perinatal autopsies and for 20% of all perinatal autopsies in midgestation at Women and Infants Hospital during the past decade. Gram-positive organisms, especially coagulase negative staphylococcus, group B streptococcus and Streptococcus viridans, were the most common pathogens isolated.

Streptococcus viridans infections in midgestation

During a 14-year period Streptococcus viridans was isolated at autopsy from 18 neonates or stillborn fetuses delivered in midgestation (18-28 weeks) at Women & Infants' Hospital in Providence, Rhode Island. Evidence of swallowed and/or aspirated, infected amniotic fluid by the fetus was found in 16 of 18 cases along with chorioamnionitis and funisitis. Of the 18 cases, maternal infection was documented in 6 cases; delivery was preceded by spontaneous rupture of membranes in 9 cases and vaginal bleeding in 7 cases. Poor maternal obstetric history was indicated by only 12 living children from 42 total pregnancies in the 12 multigravidas in the study. It is concluded that S. viridans may have a significant role in the pathogenesis of second trimester amniotic fluid infections with abortions and fetal and neonatal sepsis.

Abnormalities of diaphragmatic muscle in neonates with ventilated lungs

Several infants and neonates who had received long-term ventilatory assistance had subnormal diaphragmatic muscle mass on gross necropsy examination. We conducted a retrospective study of our hospital infant necropsy files to determine whether prolonged ventilatory support was associated with diminution in myofiber cross-sectional area selectively affecting the diaphragm. We found that long-term ventilatory assistance may predispose diaphragmatic myofibers to disuse atrophy or to failure or normal growth. This phenomenon may contribute to difficulties in weaning infants from ventilatory support.

Pregnancy-induced hypertension and congenital adrenal hypoplasia

Adrenal weights and histologic features in an autopsy population of 759 fetuses and neonates were correlated with the presence or absence of pregnancy-induced hypertension. Hypoplastic fetal adrenals with normal proportions of fetal and adult cortical layers (miniature histologic type) had combined adrenal weights less than 1 g, and were noted in 11 fetuses and neonates born to 39 mothers with pregnancy-induced hypertension, two born to 35 mothers with suggested pregnancy-induced hypertension, and 45 born to 685 mothers with no pregnancy-induced hypertension. Hypoplastic fetal adrenals were associated significantly with pregnancy-induced hypertension by chi 2 analysis (P less than .01). When a more stringent criterion for fetal adrenal hypoplasia was used (combined adrenal weight/body weight ratio of less than 1:1000), five cases were associated with pregnancy-induced hypertension, three with suggested pregnancy-induced hypertension, and seven with normal maternal blood pressures (P less than .001). This study confirms the relationship between pregnancy-induced hypertension and reduced fetal adrenal mass. We speculate that reduced production of dehydroepiandrosterone sulfate by the small adrenals may be related to maternal hypertension.

Parathyroid gland hemorrhage in perinatally lethal osteogenesis imperfecta

In four neonates with perinatally lethal osteogenesis imperfecta (OI) who survived for more than 9 days after birth, vascular congestion and acute hemorrhage were found in 10 of 11 parathyroid glands; in one neonate, all four parathyroid glands, including the only gland without acute hemorrhage, contained abundant deposits of stainable iron. One neonate had hypocalcemia, and one had both hyperphosphatemia and hypocalcemia. In four neonates with OI who died within 72 minutes of birth, all 10 parathyroid glands demonstrated were free of hemorrhage and hemosiderin deposition. Only minor foci of acute hemorrhage were seen in three of 170 glands in 113 comparison neonates and infants. We conclude that parathyroid gland hemorrhage is common in perinatally lethal OI with survival beyond the immediate period of birth, and is otherwise rare. We speculate that parathyroid hemorrhage may be related to difficulty in maintaining postnatal calcium homeostasis in the absence of adequate calcium reserves in bone. Acute parathyroid gland hemorrhage causes fluctuations in serum calcium levels that have on occasion proved fatal, and parathyroid hemorrhage may be a proximate cause of death in some neonates with OI.

Lethal osteogenesis imperfecta associated with 46,XY,inv(7)(p13q22) karyotype

An infant who died of complications of osteogenesis imperfecta (OI) at 22 days of age had a 46,XY,inv(7)(p13q22) karyotype. His mother carried the same inversion. One breakpoint of the inversion was within the region of the gene for alpha 2(I) procollagen. The product of this gene is a component of type I collagen, the principal collagen synthesised by osteoblasts. Karyotypic abnormalities involving type I collagen gene sites have not previously been reported in association with OI.

Hydrocephalus of intrauterine onset in perinatally lethal osteogenesis imperfecta: clinical, sonographic, and pathologic correlations

Five neonates with perinatally lethal osteogenesis imperfecta (OI) have come to necropsy at Women & Infants' Hospital of Rhode Island in the past eight years. Four had true hydrocephalus, defined as enlargement of the lateral ventricles with thinning of the cortical mantle. In all 4 hydrocephalus was diagnosed by sonography before birth. All 4 died almost immediately after birth, whereas the neonate without hydrocephalus lived for 22 days. Significant necropsy findings in the 4 with hydrocephalus included healing occipital-bone fractures with stenosis of the foramen magnum, remote and recent cerebral parenchymal and intraventricular hemorrhage, and remote and recent subarachnoid hemorrhage. True hydrocephalus of intrauterine onset has rarely been described in perinatally lethal OI, but its high incidence (80%) in this population suggests that it may be a common phenomenon. Hydrocephalus of intrauterine onset in perinatally lethal OI may indicate relatively more severe disease.

Electron microscopic identification of parvovirus virions in erythroid-line cells in fatal hydrops fetalis

Intrauterine infection with parvovirus B19 may lead to fatal hydrops fetalis. Intranuclear particles, consistent with parvovirus virions, within erythroid cells were readily identified on transmission electron microscopy of formalin-preserved material obtained at necropsy from a neonate and two fetuses in whom clinical and light microscopic criteria for parvovirus B19 infection were met. No such particles were seen in similar material from a neonate and two fetuses with erythroblastosis fetalis due to alpha-thalassemia, maternofetal Rh incompatibility, and an erythrocyte membrane protein defect. When other means of investigation are impracticable transmission electron microscopy is widely available and easily performed and may be of value in establishing a diagnosis of parvovirus B19 infection.

Pseudomembranous colitis in a preterm neonate

This preterm female infant abruptly developed diarrhea and bowel distention at 25 days of age and died within 60 h with fulminating pseudomembranous colitis and proctitis. Toxin-producing C. difficile was recovered from the stool. The pseudomembranous colitis developed 12 days after the last dose of ampicillin was given to the baby. Necrotizing enterocolitis, a condition pathologically distinct from pseudomembranous colitis, was also present.

Neonatal sepsis due to nontypable Haemophilus influenzae

From August 1980 through July 1984, 19 neonates had sepsis due to Haemophilus influenzae. Onset of disease occurred within 48 hours after birth of all the neonates. One neonate was born at term and 18 were born prematurely, including seven neonates born before 28 weeks' gestation. Eight neonates and one fetus died, six of them within 24 hours of birth. Acute chorioamnionitis was present in the placentas. Those neonates with the most severe placental inflammation survived while all of those who died had moderate or only mild chorioamnionitis. Acute villitis was noted in the placentas of three neonates who died. Respiratory distress syndrome (in 15 neonates) and pneumonia (in 15 neonates) were noted in 18 liveborn patients. Nine mothers had fever, six of them with genitourinary infections and one with septicemia due to H influenzae. All isolates of H influenzae were submitted for serologic typing and none were typable. In 14 cases, isolates were biotyped yielding eight with biotype II, four with biotype III, and one each with biotypes IV and V. Neonatal sepsis due to nontypable H influenzae is now nearly as common as sepsis due to group B Streptococcus. Both organisms produce diseases with many features in common, especially fulminant courses with respiratory distress and pneumonia, and often have a fatal outcome.

Perinatal group B streptococcal infection in midgestation

In a series of 32 fetuses and neonates studied at autopsy at Women and Infants Hospital, group B streptococcus (GBS) was isolated from the right atrial blood or from the lung. Eleven or 34% (5 stillborn fetuses and 6 liveborn infants) were delivered in midgestation, between 18 and 28 weeks, and all weighed less than 1000 g. Maternal clinical features in GBS infection during midgestation included vaginal hemorrhage in 4 and premature rupture of membranes in 8. The high rate of fetal death associated with this infection in midgestation (45%) bears emphasizing. Reproductive loss among mothers with previous pregnancies seems to be a risk factor for subsequent perinatal loss due to GBS. Of 17 pregnancies among these 11 mothers, only 3 resulted in living children. Colonized mothers with GBS are usually treated late in the third trimester, if at all. This study indicates that attention must be directed to midgestation, at least among the high-risk group.

Hepatic erythropoiesis in infants of diabetic mothers: a morphometric study

Hepatic erythropoietic tissue is inversely proportional to the gestational age both in infants of diabetic mothers and in control cases. Hepatic erythropoietic and indices range from 17.8 in fetuses and babies before 28 weeks' gestational age to about 1.0 in fetuses and babies at 40-42 weeks' gestational age. The decline with gestational age is gradual in the last 10-12 weeks of in utero development. Infants of diabetic mothers who are normally grown have normal amounts of erythropoiesis in their livers. At term, large infants of diabetic mothers have excessive hepatic erythropoiesis. Hypoxia, a frequent feature in infants of diabetic mothers, is probably responsible for the increased erythropoiesis, but an alternate mechanism may be that hyperinsulinemia directly stimulates erythroid precursors or erythropoietin production.

Effect of insulin on the size of skeletal muscle fibers of fetal rhesus monkey

Increased body weight of insulin-treated fetuses is largely attributed to increased muscle mass. Skeletal muscle from fetal rhesus monkeys was analyzed for differences in the sizes of muscle fibers from monkeys treated in utero with high or low doses of insulin and compared to control (non-insulin-treated) animals. The results indicate no significant difference among the various groups studied and suggest that hyperplasia, not hypertrophy, of skeletal muscle fibers is responsible for the observed increase in muscle mass.

Hemorrhage in cardiac conduction tissue in premature infants

Six premature infants had hemorrhages that were limited to cardiac conduction tissues. Obstetric complications occurred in each; four were growth retarded, and four had perinatal asphyxia. Two babies survived beyond one week. Four survived less than 24 hours. Bradyrhythmias occurred in four. Extracardiac lesions included infections and renal failure in two infants, hyaline membrane disease in one, hypoplastic lungs in two (one with renal agenesis and placental amnion nodosum), and placental villous edema in two. Cardiac hemorrhage occurred in sinoatrial nodes (n = 1), atrioventricular nodes (n = 3), atrioventricular bundles (n = 3), left bundle branches (n = 5), and right bundle branches (n = 3). The lesions were macroscopic in five cases. These cases suggest that neonatal cardiac conduction tissues are vulnerable to hemorrhage, particularly if associated with perinatal insults. Such lesions may account for some idiopathic dysrhythmias in surviving babies.

Prepartum diagnosis of traumatic fetal-maternal hemorrhage

The diagnosis of significant fetal-maternal hemorrhage due to abdominal trauma was made upon detection of fetal red cells in the maternal circulation before delivery, and prompted immediate intervention despite an equivocal fetal monitor tracing. Histologic examination of the placenta identified the area of disruption of the fetal circulation, and the clinical condition of the neonate confirmed the diagnosis. A test for fetal-maternal hemorrhage would be appropriate in the evaluation of any pregnant woman sustaining trauma to the abdomen.

X-linked recessive myotubular myopathy: II. Muscle morphology and human myogenesis

The classification of centronuclear myotubular myopathies is controversial. Within this group of disorders, congenital X-linked recessive myotubular myopathy (XLMTM), characterized by marked cell hypotrophy and structural resemblance to fetal myotubes, represents a distinct entity. The histologic findings in verified and probable cases of XLMTM are reviewed. In addition, the ultrastructural features of muscle in one case of XLMTM are compared with those of normal fetal muscle at various developmental ages. In XLMTM both muscle and nerve show evidence of immaturity. Proliferation of the sarcotubular organelles in XLMTM, not observed in normal fetal muscle, may be due to impaired innervation.

Chronic hyperinsulinemia in the fetal rhesus monkey. Effects of physiologic hyperinsulinemia on fetal growth and composition

One of the hallmarks of the hyperglycemic-hyperinsulinemic infant of the diabetic mother (IDM) is macrosomia and selective organomegaly. Primary hyperinsulinemia, with insulin levels similar to those observed in human IDMs at delivery, was produced in the fetal rhesus monkey during the last third of gestation. The effects of this physiologically relevant hyperinsulinemia, in the absence of hyperglycemia, on fetal growth were studied. Fetal macrosomia, with a 23% increase in total body weight, was observed in physiologically hyperinsulinemic fetuses. A similar 27% increase in weight was produced by fetal insulin levels that were 10 times higher. A logarithmic correlation was observed between fetal birth weight ratio and fetal plasma insulin concentration. In contrast to this increase in weight, skeletal growth, as measured by crown-heel length and head circumference, was not affected by hyperinsulinemia. Only cardiomegaly was found in the low-dose hyperinsulinemic fetuses, whereas cardiomegaly, hepatomegaly, and splenomegaly were produced by hyperinsulinemia in which insulin levels were in the highest range. Compositional analysis of heart and skeletal muscle indicated no differences in the protein, RNA and DNA concentration, or in the protein-to-DNA ratio in hyperinsulinemic fetuses. We interpret these data as indicating that fetal insulin plays the predominant role in controlling the normal, as well as the augmented, fetal weight characteristic of the human infant of the diabetic mother.

X-linked recessive myotubular myopathy: I. Clinical and pathologic findings in a family

Four neonatal deaths in one family were due to X-linked myotubular myopathy. The characteristic alterations in muscle, described in three cases, are marked fiber hypotrophy, size variability, and the presence of internal nuclei or pale areas. The diagnosis can be verified only by obtaining a careful genetic history. Previous occurrence of male neonatal death or stillbirth, or of hypotonia and respiratory insufficiency, is critical in the identification of suspected cases. There is morphologic justification for retaining the name "myotubular myopathy" to distinguish this X-linked disorder from other congenital conditions involving muscle weakness that have similar morphologic features.

Placentas in pregnancies complicated by maternal diabetes

PDMs tend to be large and the size is generally in proportion to fetal size. Infarcts are both more numerous and more common in PDMs than in normal placentas. These reflect the in utero hypoxia found in IDMs. Placental infarcts are increased not only in cases of severe DM (classes D, F-R) but also mild and early DM (class A). We infer from this that maternal vascular disease may be present functionally long before pathologic changes can be detected by direct examination of vessels. More subtle evidence of hypoxia in PDMs, such as an increased number of syncytial knots, has been suggested by qualitative data but has not been confirmed by morphometric analysis. Other qualitative observations in PDMs include thickened basement membranes, flattened microvilli on trophoblasts, ectasia of capillaries and villous stromal edema; changes in intracellular organelles and structures include enlarged mitochondria, increased pinocytotic vesicles, and dilated profiles of endoplasmic reticulum. Quantitative morphometric analysis shows no differences between normal placentas and PDMs with regard to these changes. The transport and secretory functions of the placenta, especially important in pregnancy complicated by DM, are not addressed here. As our understanding of placental physiology enlarges, it will be useful to relate each function with its structural counterpart. Perhaps this review will in part provide rational data from which to proceed with the task.

Two lethal chondrodysplasias with giant chondrocytes

Two infants, each with a different form of sporadic lethal chondrodysplasia, had multinucleated giant chondrocytes in resting cartilage. Both patients also had severe laryngeal stenosis and normal chromosomes. The radiographic abnormalities in one patient conformed to the recently delineated entity, atelosteogenesis (spondylohumerofemoral hypoplasia or giant cell chondrodysplasia); the other patient had an unclassified type of spondyloepiphyseal dysplasia. The findings in these two patients and the previously reported observations in spondylohumerofemoral dysplasia confirm that chondrocytic giant cells are a causally nonspecific phenomenon.

Symmetrical infantile thalamic degeneration in two sibs

This is the first observation of two cases of symmetrical infantile thalamic degeneration with cell mineralisation in a family. Although it cannot be established at present, autosomal recessive inheritance of a metabolic error causing or predisposing to damage to specific areas of the central nervous system is a possible aetiology for this condition.

Effects of acidosis on the activity of creatine phosphokinase and its isoenzymes in the serum of newborn infants

The total creatine phosphokinase (CPK) activity and the levels of activity of its MM, MB and BB isoenzymes were measured in sera obtained within four hours after birth from 32 newborn infants. The total CPK level and activity of its MM, MB, and BB isoenzymes increased significantly with increasing acidosis. In addition, statistically significant correlations were found between the total CPK level in infants' sera and their one-minute Apgar scores. The infants' birth weight, gestational age, and mode of delivery did not correlate significantly with the serum total CPK activity. Infants who died within ten days after birth from causes related to asphyxia had significantly higher total CPK activity levels in their sera in comparison with the survivors. The data suggest that perinatal asphyxia with acidosis may result in the leakage of CPK and its isoenzymes from the damaged cells into the circulation and that a marked elevation of their values may indicate a poor prognosis for survival.