The efficacy and safety of systemic corticosteroids as first line treatment for granulomatous lymphocytic interstitial lung disease

BACKGROUND

Granulomatous and lymphocytic interstitial lung disease (gl-ILD) is a major cause of morbidity and mortality among patients with common variable immunodeficiency. Corticosteroids are recommended as first-line treatment for gl-ILD, but evidence for their efficacy is lacking.

OBJECTIVES

This study analyzed the effect of high-dose corticosteroids (≥0.3 mg/kg prednisone equivalent) on gl-ILD, measured by high-resolution computed tomography (HRCT) scans, and pulmonary function test (PFT) results.

METHODS

Patients who had received high-dose corticosteroids but no other immunosuppressive therapy at the time (n = 56) and who underwent repeated HRCT scanning or PFT (n = 39) during the retrospective and/or prospective phase of the Study of Interstitial Lung Disease in Primary Antibody Deficiency (STILPAD) were included in the analysis. Patients without any immunosuppressive treatment were selected as controls (n = 23). HRCT scans were blinded, randomized, and scored using the Hartman score. Differences between the baseline and follow-up HRCT scans and PFT were analyzed.

RESULTS

Treatment with high-dose corticosteroids significantly improved HRCT scores and forced vital capacity. Carbon monoxide diffusion capacity significantly improved in both groups. Of 18 patients, for whom extended follow-up data was available, 13 achieved a long-term, maintenance therapy independent remission. All patients with relapse were retreated with corticosteroids, but only one-fifth of them responded. Two opportunistic infections were found in the corticosteroid treatment group, while overall infection rate was similar between cohorts.

CONCLUSIONS

Induction therapy with high-dose corticosteroids improved HRCT scans and PFT results of patients with gl-ILD and achieved long-term remission in 42% of patients. It was not associated with major side effects. Low-dose maintenance therapy provided no benefit and efficacy was poor in relapsing disease.

Determination of drugs of abuse in bovine dentin using liquid chromatography-electrospray ionization tandem mass spectrometry

Drugs deposited in human teeth are well preserved; the spectrum of toxicological investigations may therefore be supplemented by an analysis method for drugs in teeth. A liquid chromatography-electrospray ionization tandem mass spectrometry assay for the detection and quantification of basic drugs of abuse in bovine dentin samples was developed and validated. The drugs and metabolites amphetamine, methamphetamine, methylenedioxymethylamphetamine, methylenedioxyethylamphetamine, codeine, morphine, cocaine and benzoylecgonine were extracted from 50 mg ground dentin powder by ultrasonication for 60 min in methanol 3 times. The extracts were analyzed on a triple-quadrupole mass-spectrometer in multiple reaction monitoring mode. The method was validated and proved to be accurate, precise, selective, specific and stable with good linearity within the calibration range and a lower limit of quantification of 10 to 20 pg/mg. To artificially load bovine dentin samples with drugs, the natural process of de- and remineralization in the oral cavity was mimicked by a pH-cycling experiment. The artificially drug-loaded dentin samples showed drug concentrations of 20 to 80 pg/mg. The method can be applied in further in vitro experiments as well as in post-mortem cases, especially where limited sample tissue is available.

The German national registry for primary immunodeficiencies (PID)

In 2009, a federally funded clinical and research consortium (PID-NET, http://www.pid-net.org) established the first national registry for primary immunodeficiencies (PID) in Germany. The registry contains clinical and genetic information on PID patients and is set up within the framework of the existing European Database for Primary Immunodeficiencies, run by the European Society for Primary Immunodeficiencies. Following the example of other national registries, a central data entry clerk has been employed to support data entry at the participating centres. Regulations for ethics approvals have presented a major challenge for participation of individual centres and have led to a delay in data entry in some cases. Data on 630 patients, entered into the European registry between 2004 and 2009, were incorporated into the national registry. From April 2009 to March 2012, the number of contributing centres increased from seven to 21 and 738 additional patients were reported, leading to a total number of 1368 patients, of whom 1232 were alive. The age distribution of living patients differs significantly by gender, with twice as many males than females among children, but 15% more women than men in the age group 30 years and older. The diagnostic delay between onset of symptoms and diagnosis has decreased for some PID over the past 20 years, but remains particularly high at a median of 4 years in common variable immunodeficiency (CVID), the most prevalent PID.

Observation of graphene bubbles and effective mass transport under graphene films

Mechanically exfoliated graphene mounted on a SiO2/Si substrate was subjected to HF/H(2)O etching or irradiation by energetic protons. In both cases gas was released from the SiO2 and accumulated at the graphene/SiO2 interface resulting in the formation of "bubbles" in the graphene sheet. Formation of these "bubbles" demonstrates the robust nature of single layer graphene membranes, which are capable of containing mesoscopic volumes of gas. In addition, effective mass transport at the graphene/SiO2 interface has been observed.

Embryology of dolphins. Staging and ageing of embryos and fetuses of some cetaceans

Comparative embryology has been neglected in the past decades. In our opinion the decreased interest has been caused by the fact that the time factor has not sufficiently been respected. Therefore we used the Staging and Ageing Method (Stĕrba 1999) to determine the ontogenetic age of embryos and to state the time tables and time relations of various ontogenetic events. We examined 167 embryos and fetuses of four dolphin species (collection Dr. Senckenbergische Anatomie, Frankfurt am Main). The study of intrauterine development and growth while consistently respecting the time factor enabled us to determine the time course of organogenesis of all organ systems. The resulting comparison with other mammals detected the time lag in ossification, retardation of odontogeny, the time of the origin and development of the fluke, dorsal fin and flipper, etc. We believe the Staging and Ageing Method serves for a much more efficient evaluation of existing embryological collections which very often contain embryos of unknown age.

Development of the cetacean nasal skull

The adaptation of cetaceans to aquatic life habits is reflected, in their nasal region, in three marked changes from the original relations found in land mammals. These changes include (1) the loss of the sense of smell, (2) translocation of the nostrils from the tip of the rostrum to the vertex of the head, and (3) elongation of the anterior head to form a rostrum protruding far towards anterior. The morphogenetic processes taking place during embryogenesis of the nasal skull play a decisive part in the development of all these changes. The lateral parts of the embryonic nasal capsule, encompassing the nasal passages, change their position from horizontal to vertical. At the same time, the structures of the original nasal floor (the solum nasi) are shifted in front of the nasal passages towards the rostrum. The structures of the original nasal roof (the tectum nasi) and of the nasal side wall (the paries nasi) are translocated behind the nasal passages towards the neurocranium. The medial nasal septum (the septum nasi) mostly loses its connection to the nasal passages and is produced into a point protruding far towards anterior. The transformed embryonic nasal skull of the Cetacea can be divided into three sections: 1. The median structures. These include the cartilaginous structures, viz., the rostrum nasi, the septum interorbitale and the spina mesethmoidalis, which are accompanied by the dermal bones, the vomer and the praemaxillare. In adult cetaceans the rostrum nasi is mostly preserved as a robust cartilage of the skull, which may possibly serve as a sound transmitting structure of the sonar system, or it may be responsible for the sensing of water streams and vibrations. 2. The posterior side wall structures. These include the following cartilaginous structures that are mostly heavily reduced or mutually fused: the cupula nasi anterior, the tectum nasi, the lamina cribrosa, the paries nasi, the commissura orbitonasalis, the cupula nasi posterior, the processus paraseptalis posterior, the crista semicircularis, the frontoturbinale, the ethmoturbinale I and the maxilloturbinale. The cartilaginous structures are largely accompanied by the dermal bone, the maxillare. Of these embryonic elements, very little is preserved in adult cetaceans. The cartilages of the cupula nasi anterior form the variable skeleton around the nostrils. In Physeter the tectum nasi forms a very long cartilaginous bar that passes through the whole giant anterior head of the sperm whale as a structure accompanying the left nasal passage. 3. The anterior side wall structures. These include the cartilaginous structures, viz., the cartilago ductus nasopalatini, the cartilago paraseptalis, the processus lateralis ventralis and the lamina transversalis anterior, accompanied by the dermal bones, the praemaxillare and the vomer. These structures participate in the formation of the robust rostrum of the cetacean skull, and they are partly preserved even in adults in the form of the isolated ossa pararostralia (the Meckelian ossicles). The comparison of morphogeny of the nasal skull has also made it possible to draw certain conclusions on the phylogeny and systematics of Cetacea. Already the earliest embryonic stages permit us to discern weighty transformations of the original nasal skull of land mammals. These transformations are common to all embryos examined. This fact indicates a common origin of all Cetacea, which thus form a single monophyletic order. However, later embryonic stages show some different modifications of the nasal capsule according to which at least three major groups can be distinguished within the order Cetacea, probably ranking as superfamilies: Balaenopteroidea, Physeteroidea and Delphinoidea. Our observations, being in full accordance with other morphological, and embryological, as well as molecular biological results, suggest that the division of the order Cetacea into two suborders, Mysticeti and Odontoceti, is no longer tenable.

On the development of Cetacean extremities: II. Morphogenesis and histogenesis of the flippers in the spotted dolphin (Stenella attenuata)

Externally, the flippers of Cetacea resemble fish fins, but their internal structure is entirely mammalian. They show, however, some adaptative deviations from the typical pattern of the mammalian extremities, the most striking of which is an increased number of phalanges. The aim of this study is to describe the course of the development of flippers in the spotted dolphin (Stenella attenuata) and compare its features with other similar species from an evolutionary perspective. Early stages of flipper development were studied histologically. Differentiation of cartilaginous anlagens of the skeleton progresses proximodistally, condensation in digital rays being evident sooner than chondrogenesis in the carpal region. In one specimen, the temporary presence of cartilaginous rudiments of two carpal elements, which are not found in adults, was observed. At all examined stages, phalangeal number progressively increases up to (radial to ulnar) 3, 7, 7, 5, 3 in the most advanced stage. The reason for this condition is the specialised function of these limb-like structures. It is a classical example of convergence, in which mammalian extremities change their form to emulate the fin function. A similar condition is found in another group of originally terrestrial animals secondarily fully adapted to the aquatic mode of life-Ichyosauria (Reptilia).

On the development of Cetacean extremities: I. Hind limb rudimentation in the Spotted dolphin (Stenella attenuata)

The Cetacea are group of animals which have completely lost their hind limbs during the course of evolution as a result of their entirely aquatic mode of life. It is known, however, that during their embryonal period, the hind limb buds are temporarily present. The control mechanisms of this regression are not yet understood, and vestigial limbs can sometimes be found in adults. The aim of the present study is to describe the course of hind limb rudimentation during prenatal development of Stenella attenuata (Spotted dolphin) at tissue and cell levels and compare the results with other natural or experimentally induced amelias. Hind limb buds of dolphin embryos, CRL 10-30 mm, were examined histologically. Before total disappearance, they show histodifferentiation comparable with other mammals. Initially, they form the apical ectodermal ridge, which soon regresses. The mesenchyme undergoes the process of condensation to form anlagens of prospective skeletal elements. These condensations are surrounded by vascular plexuses. During the course of rudimentation, some mesenchymal cells die, while the others are incorporated into the body wall. Nerve ingrowth into rudimentary limb buds was also detected. The temporary presence of hind limb rudiments in cetacean embryos can be regarded as a good example of recapitulation of phylogenesis in ontogenesis.

Role of Staphylococcus aureus surface adhesins in orthopaedic device infections: are results model-dependent?

Bacterial colonisation of prosthetic material can lead to clinical infection or implant failure, or both, often requiring removal of the device. Adherence of Staphylococcus aureus to bioprosthetic materials is mediated by adhesins belonging to the MSCRAMM (microbial surface components recognising adhesive matrix molecules) family of microbial cell surface proteins. The objective of this study was to compare the virulence of a mutant strain of S. aureus Newman that possesses all three fibrinogen-, fibronectin- and collagen-binding MSCRAMMs (MSCRAMM-positive strain) with that of a mutant strain that lacks all three types of MSCRAMMs (MSCRAMM-negative strain) in a rabbit model of orthopaedic device-related infection. After a hole was drilled into the knee joint of each animal, a group of 10 rabbits was inoculated with the MSCRAMM-positive strain and another group of 10 rabbits received the MSCRAMM-negative strain. A stainless steel screw was then placed into the drilled hole. Two weeks later, the rabbits were killed and serum samples, bone tissue and implants were harvested for bacteriological and histopathological evaluation. No significant difference in infection rates was demonstrated between the two groups. The ability to delineate the role of S. aureus surface adhesins in causing orthopaedic device-related infection could be model-dependent.

Prenatal development of the integument in Delphinidae (Cetacea: Odontoceti)

The prenatal development of epidermis, dermis, and hypodermis was studied in embryos of different age of two delphinid species (Stenella attenuata, Delphinus delphis), using light and transmission electron microscopical methods. The delphinid embryo is covered by a multilayered tissue formed by four different epidermal generations (periderm, stratum intermedium-I, str. intermedium-II, str. spinosum) produced by the str. basale. The first layer appears at about 40-50 mm of body length, the second type (s.i.-I) about 60-160 mm, and the third type (s.i.-II) is present at 160-500 mm. The first spinosal cells are produced at 225-260 mm body length; thenceforth, the epidermis increases continuously in thickness. Epidermal ridge formation begins about 400-mm body length. The development of the dermis is characterized by the early production of thin connective tissue fibers (40-70-mm body length) and simultaneously the cutaneous muscle matures in structure. Vascular development intensifies between embryos of 150-225 mm, and collagen production increases markedly in fetuses of 225-260-mm length. These events are paralleled by an increase in dermal thickness. The first elastic fibers can be recognized in the skin from the abdomen at about 600-mm body length. The development of the hypodermis is marked by very rapid and constantly progressing growth, beginning about 60-mm body length. The first typical fat cells appear in animals of 360-400 mm. Regional differences are obvious for all skin layers with regard to the flippers, where structural maturation proceeds more rapidly than in dorsal or abdominal regions.

Osteomyelitis associated with pressure sores

BACKGROUND

Pressure sores may be associated with underlying osteomyelitis that is difficult to differentiate clinically from infection or colonization of adjacent soft tissue. Cultures of bone specimens are frequently contaminated with organisms residing in adjacent soft tissue. The three objectives of this cohort study were to (1) determine the accuracy of clinical evaluation for osteomyelitis; (2) evaluate the potential role of quantitative cultures of bone in differentiating osteomyelitis from soft-tissue infection or colonization; and (3) assess the impact of treating osteomyelitis on the outcome of pressure sores.

METHODS

Thirty-six patients with pressure sores related to spinal cord injury or cerebrovascular accident underwent clinical evaluation for osteomyelitis, followed by percutaneous needle biopsy of bone. Routine semiquantitative and quantitative, aerobic and anaerobic cultures of bone specimens were performed. Pathologic examination of bone tissue was used as the standard criterion for diagnosing osteomyelitis.

RESULTS

Six (17%) of 36 patients were diagnosed by pathologic examination as having osteomyelitis. The sensitivity and specificity of clinical evaluation were 33% and 60%, respectively. When positive, quantitative bone cultures yielded a similar number of bacterial isolates and a comparable range of bacterial concentration in patients with osteomyelitis vs those without osteomyelitis. Pressure sores healed in all six patients with osteomyelitis after appropriate therapy.

CONCLUSIONS

Clinical evaluation for osteomyelitis is often inaccurate. Pathologic examination of bone tissue is required for definitive diagnosis of osteomyelitis. Quantitative bone cultures do not help differentiate osteomyelitis from infection or colonization of adjacent soft tissue. It is possible that treatment of osteomyelitis may improve the outcome of associated pressure sores.

Temporal changes in myocardial uptake on serial bone scans in two cases of presumed senile cardiac amyloidosis

Two unusual examples of cardiac uptake in elderly patients who had received serial bone scans, one with a "waxing" and the other with a "waning" pattern of myocardial tracer uptake, are presented. An apparent temporal discordance between echocardiographic and scintigraphic findings is noted. Neither of the two patients had clinical, electrocardiographic, or other laboratory evidence of old or new myocardial infarction. Possible causes for the temporal changes are described. Presumptive diagnoses of senile cardiac amyloidosis were made based on clinical findings, noninvasive imaging, and comparison with a historic cohort at the Veterans Administration Medical Center in Houston.

4-MAPC, a 5 alpha-reductase inhibitor, reduces rat ventral prostate weight, DNA, and prostatein concentrations

Several compounds, such as 4-MAPC (4-methyl-3-oxo-4-aza-5 alpha-pregnane-20- carboxylate), that inhibit conversion of testosterone (T) to dihydrotestosterone (DHT) by 5 alpha-reductase have been demonstrated to reduce prostate size in rats and dogs. The current studies were undertaken to determine if this effect is due to a reduction in cell number, in epithelial cell synthetic activity, or both. Eight-week-old intact rats were treated daily for 14 days with sesame seed oil, 4-MAPC (10 mg/kg), 4-MAPC + testosterone propionate (TP, 1 mg/kg), or 4-MAPC + TP (3 mg/kg). Rats were killed 24 hours after the last injection. In the animals treated only with 4-MAPC, ventral prostate weight was reduced 37%, but the 14% reduction in total DNA was not significant. The mean intraprostatic concentration of prostatein, a major secretory protein, was reduced 45% (P less than 0.05). The 3 mg/kg dose of TP increased ventral prostate weight, prostatein concentrations, and acid phosphatase activity, even though DNA/ventral prostate was similar to that in control animals. These observations indicate that the reduction in ventral prostate weight in adult rats is due in part to a reduction in cell number, but the primary effect was due to a reduction in synthetic activity, and possibly atrophy of the epithelial cells. Furthermore, TP in pharmacologic doses increased ventral prostate weight and synthetic activity without increasing DNA.

The use of immunohistochemistry in metastatic prostatic adenocarcinoma to the breast

Since the introduction of hormonal therapy for the treatment of metastatic prostatic adenocarcinoma, there have been 33 reports of metastases of prostate carcinoma to the breast. We report two cases of diethylstilbestrol (DES)-treated patients with metastatic prostate adenocarcinoma who developed breast masses. The lesions had infiltrative patterns simulating primary breast carcinoma. Immunoperoxidase stains, prostate-specific antigen (PSA), and prostatic acid phosphatase (PAP) were positive, identifying these cases as metastatic prostatic carcinoma to the breast. Differentiating primary from secondary tumors in these patients is difficult since there have been 10 reports of primary breast carcinoma occurring in DES-treated patients with prostatic adenocarcinoma. Their differentiation is important to direct appropriate therapy, and PSA and PAP immunoperoxidase stains are important in their correct classification.

Subcutaneous fat necrosis associated with pancreatic islet cell carcinoma

A 75-year-old man with generalized subcutaneous fat necrosis was found to have an islet cell carcinoma of the pancreas. The histologic diagnosis of islet cell carcinoma was confirmed by electron microscopy, which showed characteristic intracytoplasmic granules. This is the second report of the association of islet cell carcinoma of the pancreas with generalized subcutaneous fat necrosis.

Pathologic findings in the hearts of patients with acquired immunodeficiency syndrome

To determine the extent of myocardial involvement in acquired immunodeficiency syndrome, we reviewed specimens of cardiac tissue obtained during autopsies of 54 patients with this disease. Forty-nine of the specimens showed subtle microscopic changes, the most common being lymphocytic infiltration (49 cases), unevenness of myocardial fibers (34 cases), interstitial fibrosis (28 cases), and myocardial atrophy (22 cases). Twenty-one of the specimens showed a morphologic abnormality that may be classified as a mild cardiomyopathy. Four had microscopic evidence of lymphocytic myocarditis; clinically, however, such myocarditis was diagnosed in only 1 patient, who died of cardiac failure. In a retrospective review, 7 additional hearts (among the 54) showed mild, nonspecific cardiac changes. The causative mechanism and significance of AIDS-related cardiac involvement remain uncertain; nevertheless, physicians should be aware of such involvement, to avoid overburdening the heart with medications that would further impair the myocardium.

Myocardial fibrosis in the elderly

The increasing interest in geriatric medicine demands an understanding of aging in human tissues. The changes in the human heart are an important aspect of this understanding because cardiovascular diseases are a leading medical problem in the elderly. The published data about age-related changes in the human myocardium remain incomplete and occasionally are controversial. An ongoing study of the hearts of people aged 80 years and older is being conducted at our institution. Various aspects of morphologic changes in these hearts were studied. In this report, we discuss the presence and extent of myocardial fibrosis, namely, the interstitial type. Two types of fibrosis are recognized: (1) scarring, the fibrotic replacement of lost myocardium, usually of vascular origin; and (2) interstitial, in which a delicate fibrotic net encircles single myocardial fibers. The morphologic findings were correlated with the following clinical findings: hypertension, congestive heart failure, emphysema, cor pulmonale, and coronary artery disease. The results support the hypothesis that interstitial fibrosis develops independently of the above-mentioned clinical conditions and may be considered as a true aging process.

Morphometry of the aging heart

Myocardial structure was studied in seven geriatric patients (cases), aged 79 to 91, and ten younger adult patients (controls), aged 22 to 52. Myocardial sections of posterior left ventricle (PLV), anterior left ventricle (ALV), and ventricular septum (VS) were studied using computerized morphometry. Each section of heart (PLV, ALV, or VS region) was divided into three zones: subepicardial (epi), midmyocardial (myo), and subendocardial (endo). Interstitial collagen content and nuclear and cell diameters of myocytes were obtained. Large scars were excluded. Student's t-test was used to evaluate differences, which were considered significant at a level of P less than 0.001. No significant zonal or regional variation in collagen content was found in control hearts, where interstitial trichrome-positive tissue comprised 6.61% of the myocardium. By contrast, elderly hearts showed a distinct increase in interstitium in the PLV region (18.3%), as compared with ALV and VS, and as compared with control hearts (P less than 0.001). Relative myocyte hypertrophy with aging was most prominent in a zonal midmyocardial distribution (P less than 0.001). Myocyte nuclei showed shrinking with age in the subepicardial zone (P less than 0.001). These findings indicate there are specific age-related alterations in myocardium, which may relate to functional abnormalities seen in the elderly.

Differences in lectin binding of malignant pleural mesothelioma and adenocarcinoma of the lung

In order to differentiate between malignant pleural mesothelioma and adenocarcinoma of the lung, the glycoconjugate profiles of 6 reactive mesothelial lesions, 23 mesotheliomas (17 epithelial, 1 desmoplastic, 2 biphasic, and 3 fibrous types), and 28 well-differentiated pulmonary adenocarcinomas were evaluated with the use of 8 lectins in addition to anti-carcinoembryonic, anti-keratin and anti-epithelial membrane antigen. Formalin-fixed, paraffin-embedded tissues were stained with the avidin-biotin peroxidase complex method. Reactions of wheat germ (WGA) and peanut (PNA) agglutinin with neuraminidase treatment lectins were positive in 5 of 6 (83%) and 3 of 6 (50%) cases, respectively, in reactive mesothelial lesions. Thirteen of 23 (57%) malignant mesotheliomas of the pleura showed a positive reaction for WGA and PNA with neuraminidase treatment; other lectins were low-positive, below 9%. In contrast, pulmonary adenocarcinomas showed positive reactions in 27 of 28 cases (96%) for PNA, 26 of 28 (93%) for Ricinus communis (RCA-I), 25 of 28 (89%) for WGA, and 22 of 28 (79%) for succinylated WGA (SucWGA). The findings suggest that malignant pleural mesothelioma and pulmonary adenocarcinoma have consistent and distinct glycoconjugate profiles, and that stains for RCA-I and SucWGA may be useful for differential diagnosis.

Malignant granular cell tumor

A case of a granular cell tumor with a malignant behavior is described. Several repeated biopsy specimens, a resection specimen, and the metastatic lesions were compared with one another. Consecutive specimens showed increasing atypia. Electron microscopy of the metastatic lesions confirmed the granular cell nature of the tumor. The historic aspects of histogenesis are briefly discussed. The findings agree with a presently accepted origin from a primitive mesenchymal cell.

Culture-negative endocarditis with purpura and arterial emboli

We have presented a case of culture-negative endocarditis in which purpura and arterial emboli were the major findings, and in which echocardiograms were normal, but angiograms revealed vegetations and unsuspected severe aortic valve insufficiency.

Pacemaker associated infection due to a corynebacterium species

Pacemaker associated infection (PAI) is a rare but often serious complication of permanent or temporary transvenous cardiac pacemakers. The major risk factor is recent or multiple pacemaker manipulations or surgical procedures. A PAI can occur at the time of insertion, from contiguous spread to the access site, or from transient bacteremia. We report a case of PAI of a retained pacemaker electrode from which a Corynebacterium species was isolated. Multiple preoperative cultures were sterile, but bacteria were isolated from tissue removed at surgery, and were seen around the wire deep inside a thrombus. The importance of cultures and special stains (including electron microscopy) of surgical materials is stressed, especially when dealing with microorganisms of ordinarily low virulence, or those that are commonly considered laboratory contaminants.

Hairy cell leukemia associated with focal vascular damage

In a patient with hairy cell leukemia, segmental vascular alterations developed in many of the larger visceral arteries. In previously reported instances of this association, the vasculitis resembled polyarteritis nodosa. In contrast, in the present case the vessels did not show the typical necroses, polymorphonuclear infiltrates, and aneurysmal changes. Instead, vascular alterations consisted of edema, fibrosis, and infiltration by tumor cells. A possible pathogenetic mechanism for these findings may be a local immunologic interaction of tumor cells and vessels, suggesting a direct relation between hairy cell leukemia and vascular damage.

Sarcomatous type of malignant mesothelioma

Thirteen malignant mesotheliomas of a sarcomatous type were studied by light microscopy and ten were studied by electron microscopy. The histologic patterns varied from tumor to tumor, often resembling other soft tissue sarcomas. Electron microscopic observation showed most of the tumors to be composed of primitive cells. Despite their mesenchymal character, many tumors contained foci of rudimentary epithelial differentiation. It is concluded that both histologic types of malignant mesothelioma, the epithelial as well as the sarcomatous, originate from the same precursor cell at various points of its differentiation and reflect the range of maturation from the mesenchymal reserve cell to the epithelial mesothelial cell.

Osteomyelitis beneath pressure sores

Twenty-eight pressure sores were evaluated prospectively. Osteomyelitis was reported histologically in nine of 28 bones and pressure-related changes were reported in 14 bones. Roentgenograms suggested the presence of osteomyelitis in four instances of histologically proved osteomyelitis. Technetium Tc 99m medronate bone scans were highly sensitive, showing increased uptake in all cases of osteomyelitis; however, increased uptake also occurred commonly in uninfected bones due to pressure-related changes or other noninfectious causes. Cultures of bone biopsy samples usually disclosed anaerobic bacteria, gram-negative bacilli, or both. The diagnosis of osteomyelitis must be considered if a pressure sore does not respond to local therapy. If the technetium Tc 99m medronate uptake is increased in the involved area, or roentgenographic findings are abnormal, the diagnosis can only be made with certainty by histologic examination of bone. Antibacterial treatment should be selected based on the results of bone culture.

Transepithelial elimination in cutaneous sarcoidosis

A patient known to have sarcoidosis exhibited cutaneous lesions. Microscopic examination of serial sections showed histologic evidence of transepithelial elimination of the sarcoidal granuloma. The concept and possible mechanisms of transepithelial elimination are discussed.

Sweat gland tumors of the head and neck

Surgeons performing soft-tissue surgery in the head and neck area occasionally will encounter other varieties of neoplasms, such as skin-appendage tumors, in addition to basal cell carcinoma and squamous cell carcinoma. Sweat gland tumors are the most common variety of the skin-appendage tumors and the most easily confused with basal cell carcinoma and squamous cell carcinoma. We report this case to illustrate this fact. The classification of sweat gland tumors and their suggested management are reviewed.

Verrucous carcinoma of skin

Five different cases of verrucous proliferative lesions of skin are described and discussed. One of each developed in a chronic ulcer on a heel, in a scar on a lower leg, and on the penis, and two appeared in the region of the buttock in relation to chronic inflammatory sinuses. All these lesions showed morphological and clinical features of verrucous carcinoma which are described. It has been concluded that the variously named verrucous lesions in the literature (epithelioma cuniculatum, florid papillomatosis, giant cutaneous papilloma and papillomatosis cutis carcinoides), as well as our five cases represent a verrucous carcinoma which is a particular type of squamous cell carcinoma. This tumor develops typically in moist areas which are frequently sites of chronic inflammation. Despite the favorable prognosis, it is a potentially invasive tumor.

Basal cell tumors of the parotid gland

We present two patients with parotid tumors; one had a basal cell adenoma, and the other had a malignant tumor of uncommon morphologic features that was diagnosed as basal cell carcinoma. Both tumors showed morphologic similarities: peripheral, palisading, nests-like arrangements and organelle-poor cytoplasm. This suggests the same cell of origin.

Benign pleural lesion and malignant mesothelioma

In a series of eighteen diffuse malignant mesotheliomas, five cases were encountered in which thoracic surgery with benign nontumorous diagnosis preceded the development of a malignant mesothelioma by several years. The morphological findings in three of these five cases are compared with the morphology of the tumor specimens and an attempt is made to recognize the earliest possible malignant features. Crowding of mesothelial cells, their variability in size and nuclear hyperchromatism are pointed out as warning signs. In relation to these findings, the histogenetic significance of predominantly fibroproliferative versus epithelial-like pleural lesions is discussed. A histogenetic classification, based on the studies of eighteen diffuse malignant mesotheliomas, two benign fibrous mesotheliomas, one pleural fibrosarcoma, and numerous pleural plaques as well as reactive mesothelial lesions, is offered. The therapeutic aspects are mentioned.

Electron microscopy in the diagnosis of giardiasis

Biopsy specimens of intestinal mucosa from two patients with malabsorption syndrome were examined with routine light and electron microscopy. Both showed intact intestinal mucosa, but by electron microscopy, the presence of Giardia lamblia in the intervillar spaces was identified. Electron microscopy is useful for the identification of this parasite, since the stool examinations in up to 50% may be negative. The parasites appear in light microscopy as cellular debris and can be easily overlooked, while by electron microscopy the typical morphologic features of the parasite are diagnostic.

Incidence of intermembrane alterations in human heart mitochondria: a preliminary ultrastructural study

An alteration consisting of widening of the inner membrane space (approximately 240 A) of the human heart mitochondria was studied and compared in surgical and autopsy material. The presence of these changes in well-preserved surgical material suggests that it may be a morphologic manifestation of an unknown biochemical alteration.

Diffuse malignant mesothelioma

Thirteen cases of diffuse malignant mesothelioma, 12 pleural and one peritoneal, were examined and reviewed from the clinical and morphologic points of view. The most frequent symptom and sign were pain and effusion. Periods of survival varied, with one patient surviving 11 years despite morphologic features of the pleural tumor. The diagnosis can be made only on the basis of excised tumor tissue. The best control of the tumor is attained by repeated surgical removal. Neither radiation nor chemotherapy altered significantly the growth of the tumors.

Malignant mesenchymoma. Case report with electron microscopic study

A malignant tumor from the thigh of a 65-year-old man was examined by light and electron microscopy. The tumor was diagnosed by light microscopy as malignant mesenchymoma with prevalence of leiomyosarcomatous or liposarcomatous components, but electron microscopic study revealed that the basic cell was similar to chondroblastic or osteoblastic cells. However, a precise ultrastructural classification of the tumor cells was not possible, since the majority of the cells had mixed features. The histogenesis, differentiation, and relation to prognosis are discussed.

[Suprasternal ossicles in primates and the special adaptation of the manubrium sterni in howling monkeys (Alouatta)]

The suprasternal ossicles were found in 21 specimens and 15 species of primates in a relative high frequency of 9,6 % of the material examined. They occur both in prosimians and in simians. A description is given of their shape, dimensions and position. The special bilateral processes in the manubrium sterni of howling monkeys are not homologous with the ossa suprasternalia. They are equivalent with a partial fissura sterni.