BCG vaccination confers poor protection against M. tuberculosis HN878-induced central nervous system disease

Using a rabbit model of tuberculous meningitis (TBM), we compared the protective efficacy of Mycobacterium bovis bacillus Calmette-Guérin (BCG) vaccination against central nervous system infection with the virulent M. tuberculosis clinical isolate HN878 and the laboratory strain H37Rv. Although BCG clearly provided protection against infection with either challenge strain, protection against disease manifestations was significantly poorer in rabbits infected with HN878. BCG was less efficient in protecting against HN878 dissemination to the liver and spleen and against HN878-induced inflammation, loss of body weight, lung and brain pathology, and signs of disease. We suggest that the efficacy of newly developed vaccines should be tested in animal models not only against challenge with M. tuberculosis H37Rv but also with different clinical isolates including the highly virulent strains of the W-Beijing family.

Evaluation of the Mtb72F polyprotein vaccine in a rabbit model of tuberculous meningitis

Using a rabbit model of tuberculous meningitis, we evaluated the protective efficacy of vaccination with the recombinant polyprotein Mtb72F, which is formulated in two alternative adjuvants, AS02A and AS01B, and compared this to vaccination with Mycobacterium bovis bacillus Calmette-Guérin (BCG) alone or as a BCG prime/Mtb72F-boost regimen. Vaccination with Mtb72F formulated in AS02A (Mtb72F+AS02A) or Mtb72F formulated in AS01B (Mtb72F+AS01B) was protective against central nervous system (CNS) challenge with Mycobacterium tuberculosis H37Rv to an extent comparable to that of vaccination with BCG. Similar accelerated clearances of bacilli from the cerebrospinal fluid, reduced leukocytosis, and less pathology of the brain and lungs were noted. Weight loss of infected rabbits was less extensive for Mtb72F+AS02A-vaccinated rabbits. In addition, protection against M. tuberculosis H37Rv CNS infection afforded by BCG/Mtb72F in a prime-boost strategy was similar to that by BCG alone. Interestingly, Mtb72F+AS01B induced better protection against leukocytosis and weight loss, suggesting that the polyprotein in this adjuvant may boost immunity without exacerbating inflammation in previously BCG-vaccinated individuals.

Virulence of SelectedMycobacterium tuberculosisClinical Isolates in the Rabbit Model of Meningitis Is Dependent on Phenolic Glycolipid Produced by the Bacilli

Infection with Mycobacterium tuberculosis in humans results in active disease in approximately 10% of immune-competent individuals, with the most-severe clinical manifestations observed when the bacilli infect the central nervous system (CNS). Here, we use a rabbit model of tuberculous meningitis to evaluate the severity of disease caused by the M. tuberculosis clinical isolates CDC1551, a highly immunogenic strain, and HN878 or W4, 2 members of the W/Beijing family of strains. Compared with infection with CDC1551, CNS infection with HN878 or W4 resulted in higher bacillary loads in the cerebrospinal fluid and brain, increased dissemination of bacilli to other organs, persistent levels of tumor necrosis factor-alpha , higher leukocytosis, and more-severe clinical manifestations. This pathogenic process is associated with the production by HN878 of a polyketide synthase-derived phenolic glycolipid (PGL), as demonstrated by reduced virulence in rabbits infected with an HN878 mutant disrupted in the pks1-15 gene, which is required for PGL synthesis.

Supraclavicular masses: results of a series of 309 cases biopsied by fine needle aspiration

BACKGROUND

The purpose of this study was to determine the current distribution of diseases resulting in supraclavicular swelling or lymphadenopathy as diagnosed by fine needle aspiration (FNA) biopsy.

METHODS

Supraclavicular aspirates in this retrospective 5-year study from a large public hospital were classified as neoplastic, infectious, inflammatory, reactive, and nondiagnostic.

RESULTS

Malignancy was present in 55% of the 309 aspirates (47% metastatic, 8% lymphoma). Age was most predictive of malignancy (32% for age < or =41 years, 68% for age >40 years). Lymphoma occurred equally in both groups, but the lymphoma:metastasis ratio was much higher in younger patients (1:1.6 for age < or =41 years versus 1:11 for age >40 years). Ethnic origin was related to tumor type, metastatic uterine cervical carcinoma being most frequent in Hispanics, and lymphoma in Caucasians. Primary oropharyngeal sites were unusual; most malignancies originated in the lung, breast, or cervix. Left or right side did not discriminate for either the presence or type of tumor. The 43 aspirates from human immunodeficiency virus (HIV) positive (+) patients were predominantly inflammatory, infectious, or reactive; lymphoma was infrequent (7%). Overall, 39 patients had mycobacterial infection; aspirate smears or culture were positive in 19. Three other FNAs grew Staphylococcus aureus and one stained for Cryptococcus. Aspirates were not informative in 24 cases (8%). The sensitivity of FNA for malignancy was 97%, specificity was 98%, and positive predictive value 98%.

CONCLUSION

Aspiration biopsy is an excellent diagnostic tool for supraclavicular masses. Patients over 40 years old are likely to have metastatic malignancy, from breast, lung, or infradiaphragmatic sites. Aspirates with inflammation and those from HIV+ patients should undergo extensive culture.

Fine needle aspiration diagnosis of mycobacterial lymphadenitis. Sensitivity and predictive value in the United States

OBJECTIVE

Fine needle aspiration (FNA) has proven valuable in diagnosing tuberculous lymphadenitis in countries with endemic mycobacterial infection (MI). Its role in developed countries, where sensitivity and positive predictive value are likely to be lower, has not been adequately explored.

STUDY DESIGN

This retrospective, five-year study from a public hospital in the United States examined the predictiveness of 238 nodal FNAs in patients with MI; 59% of patients were also HIV+.

RESULTS

Diagnostic results (stainable acid-fast bacilli or positive culture) were present in nearly half the aspirates; sensitivity was 46%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 94%. If granulomatous inflammation (GI) was also considered a positive result, sensitivity increased to 53%; false positive cases of GI reduced PPV to 80%, while specificity (98%) and NPV (95%) changed little. Considered alone, GI had the lowest sensitivity (25%) and PPV (65%).

CONCLUSION

FNA was useful in this U.S. population with MI, identifying almost half the affected patients. However, nondiagnostic results, such as granulomatous inflammation, should be interpreted with caution.

Cytologic features of mycobacterial pleuritis: logistic regression and statistical analysis of a blinded, case-controlled study

Tuberculous pleural effusions are characterized by lymphocytosis; the significance of mesothelial cells is uncertain, as are the cytologic features in concurrent human immunodeficiency virus (HIV) infection. This blinded study compared 38 culture-positive pleural fluids (6 HIV+) with 38 controls from benign exudative processes. Logistic regression analysis selected mature lymphocytes as most predictive of positive culture, and mesothelial cells and eosinophils as negative predictors. Mesothelial cells were scant (< 10% of nucleated cells) in 36/38 cases with mycobacteria (sensitivity 95%); if these cell were > 10%, tuberculosis was virtually ruled out in HIV- patients. Specificity was maximized (82%) when mesothelial cells < 10% were combined with lymphocytes > 50%; positive predictive value with this combination was 76%, but was raised to 96% if moderate/marked cellularity was also identified. Among tuberculosis cases, reactive mesothelial cells differentiated HIV+ from HIV- patients; there was no other significant difference.

Fine needle aspiration (FNA) in HIV+ patients: results from a series of 655 aspirates

There are many selected small series or case reports of FNAs in patients with HIV infection, but large series are rare and epidemic's characteristics have evolved over time. The current study, from a large public hospital in the USA, included women as well as men, hetero- and homosexuals, in-patients and out-patients, and deep radiologically guided aspirates as well as superficial masses. Of 655 FNAs, reactive or benign changes were present in 37% confirmed or suspected malignancy in 13%, specific infection with stainable organisms in 14%, and inflammation in 16%. Twenty percent of cases were inadequate for diagnosis. Most of the identifiable infections were associated with Mycobacterium tuberculosis, with fewer atypical mycobacteria, fungi and other bacteria. Clinically significant diagnoses were correlated with deep aspirate location and lesion size > 2 cm, confirming other studies which also identified tenderness and recent enlargement as important indicators. The liberal use of FNA in our HIV+ population has greatly reduced the necessity for surgical nodal resection, reassured clinicians in continuing observation of reactive lymphadenopathy, and allowed immediate therapy for specific infection, cyst or malignancy.

Psammoma bodies in fine-needle aspirates of the thyroid: predictive value for papillary carcinoma

BACKGROUND

Although characteristic of thyroid papillary carcinoma, psammoma bodies occasionally arise in benign or nonpapillary lesions. Their predictive value in fine-needle aspirates (FNA), without other features suggestive of papillary carcinoma, is uncertain.

METHODS

This retrospective study determined the frequency of psammoma bodies and other calcifications in 313 FNAs and 69 resected thyroids; positive predictive value, sensitivity, and specificity were calculated and compared with a triad of characteristic cytologic features (papillary fronds, nuclear ridges/grooves, and intranuclear inclusions). Psammoma bodies from benign and malignant conditions were assessed for differentiating architectural or staining characteristics.

RESULTS

Psammoma bodies were found in only 8 of 313 FNAs. Their positive predictive value for papillary carcinoma was 50%, the rest arising from multinodular goiters. By contrast, the positive predictive value of combined cytologic features was 100%. These features were also much more sensitive, present in 80% of papillary carcinomas compared with 14% with psammoma bodies. The psammoma bodies of papillary carcinoma could not be differentiated from those of other lesions either by staining characteristics or by architecture. Other types of calcifications also were present in diverse conditions, and did not discriminate among them.

CONCLUSIONS

Isolated psammoma bodies are an unreliable predictor of papillary carcinoma in the absence of cytologic features. In view of the relatively low aggressiveness of papillary carcinoma in most age groups, repeat fine-needle aspiration and clinical correlation are recommended prior to consideration of surgery.

Mucin histochemistry of the developing gastroesophageal junction

Mucin histochemistry was performed on the squamocolumnar junction (Z-line) of the gastroesophageal region of 49 autopsied previable fetuses, stillbirths, infants, and young children, using alcian blue pH 2.5/periodic acid-Schiff (PAS) and alcian blue pH 1.0/PAS stains. Sialylated and neutral mucins were present in most and sulfated mucin in many cases. In only one fetus was a heterotopic focus of goblet cells found in the distal esophagus. This study confirms that the presence of acidic mucins in columnar epithelium, without goblet cells, at the Z-line and adjacent cardia is common in this age group. Undue reliance on mucin stains to identify metaplastic columnar epithelium, in the absence of goblet cells, may result in overdiagnosis of Barrett's esophagus in children.

Fine-needle aspiration of peripheral lymph nodes in patients with tuberculosis and HIV

Previous studies of fine-needle aspiration (FNA) specimens from lymph nodes of patients with tuberculosis (TB) and infection with the human immunodeficiency virus (HIV) have often involved small numbers of specimens and have produced conflicting results. We reviewed 93 FNA specimens from peripheral lymph nodes in a consecutive series of 79 patients with TB to compare results for patients with and without HIV infection. The 45 patients with HIV infection in the series were more frequently male, more likely to have negative results on a purified protein derivative tuberculin skin test, and they had more disseminated disease. Granulomatous inflammation, a positive result on a culture, acid-fast bacilli, or necrosis was found in 71% of the studies. Identification of granulomatous inflammation occurred at a similar rate in FNA specimens from patients with HIV infection (16%) and without HIV infection (21%; P = .56). Necrosis was the sole reported finding in a significant subset of cases (16%), occurring in patients with and patients without HIV infection. FNA of peripheral lymph nodes of patients with TB was an effective diagnostic test. Granulomatous inflammation and other FNA findings in peripheral lymph nodes of patients with TB were similar in those with and those without HIV infection.

Mucin histochemistry of the developing gastroesophageal junction

Mucin histochemistry was performed on the squamocolumnar junction (Z-line) of the gastroesophageal region of 49 autopsied previable fetuses, stillbirths, infants, and young children, using alcian blue pH 2.5/periodic acid-Schiff (PAS) and alcian blue pH 1.0/PAS stains. Sialylated and neutral mucins were present in most and sulfated mucin in many cases. In only one fetus was a heterotopic focus of goblet cells found in the distal esophagus. This study confirms that the presence of acidic mucins in columnar epithelium, without goblet cells, at the Z-line and adjacent cardia is common in this age group. Undue reliance on mucin stains to identify metaplastic columnar epithelium, in the absence of goblet cells, may result in overdiagnosis of Barrett's esophagus in children.

Spontaneous rupture of a pancreatic pseudocyst into the portal vein

An unusual complication of pancreatic pseudocyst is reported. A 47-year-old woman with chronic liver disease and a history of recurrent pancreatitis died of fulminant, gram-negative septic shock. Acute, bilateral thigh cellulitis with tissue culture positive for Escherichia coli was the only potential infectious source identified. Autopsy revealed a pseudocyst in the head of the pancreas that had eroded into the portal vein, with embolization of mucoid cyst material into intrahepatic portal vein branches. Fibrous organization and recanalization of some of the occluded portal vein branches indicated that this process had been present for weeks to months and was therefore not the direct cause of death. The literature on this unusual complication of pancreatic pseudocyst is also reviewed.

Fine-needle aspiration diagnosis of extrapulmonary Pneumocystis carinii lymphadenitis in a human immunodeficiency virus positive patient

Extrapulmonary Pneumocystitis carinii is an uncommon and probably underdiagnosed complication of pulmonary P. carinii infections. We report the cytologic diagnosis of a case of P. carinii lymphadenitis which presented, without concurrent or historical pneumonitis, in a human immunodeficiency virus (HIV) positive patient who was taking aerosolized pentamidine. The diagnosis was suggested by abundant granular exudate on the cell block. Only scant, fragmented, irregular-shaped granular exudate was present on the direct smears and the Millipore filter preparation. The diagnosis was confirmed by special stains on the cell block.

Decrease of prostatic intraepithelial neoplasia following androgen deprivation therapy in patients with stage T3 carcinoma treated by radical prostatectomy

OBJECTIVES

Prostatic intraepithelial neoplasia (PIN) is considered the most likely precursor of prostatic adenocarcinoma. The effect of androgen deprivation therapy on the prevalence of PIN is unknown.

METHODS

We undertook a case-control study of radical retropubic prostatectomies from 24 treated patients and a control group of 24 untreated patients matched for age and clinical stage (all T3). Androgen deprivation therapy included LHRH agonist leuprolide and flutamide (18 patients), diethylstilbestrol (DES) (2 patients), DES with leuprolide and flutamide (1 patients), and orchiectomy (3 patients). Prostatectomy specimens were evaluated for the presence and extent of high-grade PIN according to the number of high-power microscopic fields, and nuclear tumor grade (1 to 4 scale) and Gleason score were also determined.

RESULTS

The prevalence of high-grade PIN in pretreatment transrectal needle biopsies was similar in the treated and untreated groups. The prevalence and extent of high-grade PIN were lower in cases treated with androgen deprivation therapy than controls. Nuclear tumor grade was also lower in treated patients, but there was a paradoxical increase in the Gleason score. The prevalence of aneuploidy in the cancers was similar in both groups.

CONCLUSIONS

These findings suggest that androgen deprivation therapy decreases the prevalence and extent of high-grade PIN.

Accuracy of a removable die-dowel pin tchnique

Stone working casts with removable dies with metal dowel pins were constructed from impressions of a master die to sim. ulate a quadrant cast of a three unit fixed partial denture. Measurements indicated that a small horizontal and a greater vertical shift occurred with the repositioned die.