Beta-2 Microglobulin Amyloidosis in a Patient on LongTerm Continuous Ambulatory Peritoneal Dialysis (CAPD)

A 61-year-old female patient with ESRD due to analge sic nephropathy and treated solely with CAPD for 81 months is described. During this period she developed peritonitis 4 times. She eventually died of acute pulmonary edema due to coronary heart disease. The autopsy showed an analgesic nephropathy with contracted kidneys, diffuse peritoneal fibrosis, and articular and periarticular amyloidosis of AB2m-type. This form of amyloidosis is well known after hemodialysis; it was, however, not observed heretofore after sole long-term CAPD.

Intestinal ischemia after bushmaster (Lachesis muta) snakebite--a case report

After a snakebite by the Costa Rican bushmaster Lachesis stenophrys, a 64-year-old patient developed cardiovascular shock and coagulopathy. After intensive care and antivenom treatment, he was discharged after 4 days but had to be hospitalised again 3 days later because of abdominal pain and bowel obstruction. An emergency laparotomy revealed a necrotic ileum and caecum, and an obstruction of the superior mesenteric artery. Until now, this type of intestinal ischemic complication after a snakebite has not been reported in the literature. The effects of bushmaster venom are discussed.

[Sudden cardiac death during sports due to coronariitis]

A case of sudden and unexpected death of a 29-year-old man during a basketball game is reported. Six years before death a transient ischemic attack and a membranous glomerulonephritis were diagnosed. The autopsy revealed as cause of death to be a severe lymphoplasmocytic coronariitis and, in addition, a small single focus of a lymphoplasmocytic aortitis, indicating a systemic disease. A suspected syphilitic vasculitis could not be confirmed. In the literature there are few cases of similar coronary arteriitis are described, such as Takayasu's type of arteriitis in men of young and middle age.

Gastrointestinal pacemaker cell tumor: clinicopathological, immunohistochemical, and ultrastructural study with special reference to c-kit receptor antibody

Recent studies indicate that a subgroup of gastrointestinal stromal tumors, including gastrointestinal autonomic nerve tumors (GANTs), originate from stem cells that differentiate toward a pacemaker-cell phenotype. These pacemaker cells form a complex network intercalated between the autonomic nerves and the muscle walls of the gastrointestinal tract and are called interstitial cells of Cajal (ICC). The c-kit receptor (CD117) is a sensitive marker for ICC. The aim of our study was to support the hypothesis that GANTs show ICC differentiation. Seven GANTs without convincing smooth muscle or neural differentiation all showed homogeneous reactivity for the c-kit receptor. CD34 was positive in three cases. On electron microscopy, the typical features of GANT were present. Six tumors contained skeinoid fibers. Most tumors were related to the small bowel. They presented as single (two cases) or multiple (five cases) tumors. The presenting symptoms were abdominal bleeding (2), abdominal mass (2), anemia (1), and small-bowel perforation (1). In two cases, liver metastases developed. Because of the close immunohistochemical and electron microscopic similarities of these tumors to the interstitial cells of Cajal, the term gastrointestinal pacemaker cell tumor seems appropriate.

[Tenascin: a simple tool in the diagnosis of collagenous colitis]

BACKGROUND

Collagenous colitis is characterised clinically by chronic, voluminous, watery diarrhoea, and histopathologically by a thickened subepithelial collagen layer and infiltration of the lamina propria with inflammatory cells. In practice, the exact measurement of this subepithelial collagen layer is complicated by its blunt limit, a nonorthogradely affected cell layer and often only focal findings. Immunohistochemically, the subepithelial collagen layer stains positively with the glycoprotein tenascin, a marker for extracellular matrix remodeling.

AIM

To assess if immunohistochemical staining with tenascin could be used as a simple and practical tool in the diagnosis of collagenous colitis.

METHODS

86 of the routinely examined colon biopsy specimens with the following initial diagnosis: 33 collagenous colitis, 21 lymphocytic colitis, 15 inflammatory bowel disease (ulcerative colitis or Crohn's disease), 8 unspecific inflammation and 9 without histopathological findings, were incubated with tenascin. They were then evaluated blindly by 5 different investigators (2 senior pathologists, 2 assistant doctors and 1 chief assistant of the laboratory experienced in immunohistochemistry). Each specimen was evaluated semiquantitatively from 0 (for no tenascin-positive subepithelial collagen layer) to 3 (wide, clearly tenascin-positive collagen layer).

RESULTS

In specimens with the initial diagnosis "collagenous colitis" the semiquantitatively assessed subepithelial collagen layer was significantly wider than in specimens with other initial diagnosis. Experience and educational level of the investigators did not influence the results.

CONCLUSIONS

Immunohistochemical incubation with tenascin is a simple, economical and rapid tool in the diagnosis of collagenous colitis. With the aid of tenascin staining collagenous colitis can be differentiated histopathologically with sufficient accuracy from other colitis.

[Renal oncocytomatosis]

Multiple and bilateral oncocytomas are rare. There are only ten cases that have been previously described. Three of these displayed multiple and bilateral oncocytomas and microoncocytomas, a so-called oncocytomatosis. This report describes a case of renal oncocytomatosis found at autopsy. In addition, we found an adrenal adenoma, a pheochromocytoma and thoracic cicatrices 4 years after curatively resected large cell carcinoma of the lung. In the distal renal tubules we found oncocytic epithelial cells, with partial transition into microoncocytomas. Immunohistochemically, these and the main oncocytomas were CD 10 negative. These findings support the origin of oncocytoma from oncocytically transformed distal tubular epithelium. CGH analysis of the different tumors revealed no common cytogenetic changes. Coexistence of renal oncocytoma with other tumors is rare. Hitherto, coexistence of a renal oncocytomatosis with multiple tumors has not been described.

[Difficulties in differentiation between Crohn disease and ulcerative colitis]

We report on the medical history of a 44 year old woman, who has been diagnosed to suffer from ulcerative colitis, first diagnosed in 1991. Until 1994, when she had finally a colectomy, recurrent episodes occurred under full medical treatment. After colectomy the diagnosis had to be revised as histology revealed Crohn's disease. Only a few months after surgery a new episode of Crohns disease developed including the occurrence of an anal fistula.

[Duplication cyst of the stomach antrum as the cause of an acute gastric emptying disorder in an adult]

HISTORY AND CLINICAL FINDINGS

A 35-year old woman without previous history of gastrointestinal complaints developed increasing upper abdominal pain with nausea and postprandial vomiting over 2 days during which she had been unable to take any food. She had no fever; her general physical condition was slightly reduced. While her abdomen felt soft on palpation, she had epigastric pain on pressure but no resistance to palpation.

INVESTIGATIONS

Blood picture and routine laboratory tests were unremarkable. Plain film of the abdomen demonstrated marked gastric retention. Abdominal ultrasound showed an invagination in the gastric antrum suggesting a layering phenomenon. Gastroscopy revealed a submucosal tumour-like lesion with central ulceration which obstructed gastric exit.

TREATMENT AND COURSE

After conclusion of the diagnostic tests on the first hospital day partial gastric resection (Billroth I) was performed as, in the absence of any surrounding reaction, a leiomyoma had been suspected. The further course was without complication and she was discharged on the 13th hospital day. The surgical specimen revealed a duplication cyst of the gastric antrum.

CONCLUSION

(Endo)sonography, computed tomography and endoscopy make it possible to diagnose duplication cyst, as long as it is included in the differential diagnosis of acute abdomen in an adult. Emergency resection of the cyst is indicated because of the acute nature of the symptoms. But even in less urgent cases or as an incidental finding it is the treatment of choice.

[Coincidence of bone infarct and aggressive bone metastasis]

A 42-year-old male patient presented with a history of persistent pain in the right femur without trauma of 2 months, duration and an episode of bloody stools 3 months earlier with no clinical findings upon examination. X-rays and CT scan revealed a circumscribed lesion with sclerosis and periostal reaction in the right proximal femur. A three-phase bone scan showed a massive hot spot in this area. Primarily differential diagnoses included a Brodie's abscess and/or a tumor. An excisional biopsy of the area was performed and revealed the coexistence of a bone infraction and the metastasis of an adenocarcinoma of unknown origin. The lesion in the bone was resected, filled with autogenous cancellous bone and stabilized with a plate. Further intensive screening with CT of the abdomen, gastroscopy and colonoscopy led to the primary tumor, an adenocarcinoma at the rectosigmoidal junction. No other metastases were detected. This patient presented with severe pain an radiologically divergent findings: a presumably benign process on radiography, but a massive hot spot on scintigraphy. Further procedures such as a CT scan and/or MRI had to be undertaken. If the analysis includes the differential diagnosis of a malignant process, a biopsy must be obtained, and if this reveals a metastasis, the primary tumor must be sought.

[Symptomatic therapy of severe diarrhea in eosinophilic gastroenteritis with the somatostatin analog octreotide (Sandostatin)]

We describe a patient with eosinophilic gastroenteritis whose symptoms included severe watery diarrhea (1.5 l/d), abdominal cramps, and weight loss. Biopsies revealed massive eosinophilic inflammation of the entire gastrointestinal tract. The total plasma eosinophilic count was elevated by up to 30%. Infectious etiologies and chronic inflammatory bowel disease had been ruled out. By use of the somatostatin analogue octreotide the diarrhea decreased immediately in a dose-dependent fashion and the patient recovered within twelve days. In this case octreotide was helpful in controlling severe diarrhea and limiting the subsequent necessary i.v. fluid replacement.

[Liver cell carcinoma as a late complication of Alagille syndrome (arterio-hepatic dysplasia)]

The Alagille syndrome which is also known as arterio-hepatic dysplasia is an autosomal dominant inherited disorder. In several cases cytogenetic studies revealed an interstitial deletion of the short arm of chromosome 20. The hypoplasia or paucity of the interlobular bile ducts causes a chronic intrahepatic cholestasis. The association with facial dysmorphia, embryotoxon posterior, pulmonary stenosis and vertebral deformities are required for the diagnosis of the complete Alagille syndrome. The occurrence of hepatocellular carcinoma as a late complication of the Alagille syndrome was recognized only 11 years after the first publication by Alagille et al. So far 15 cases complicated by hepatocellular carcinoma have been reported. There is one family where all four siblings suffered from hepatocellular carcinoma. Our own case concerns a 31 year old man who died of hepatocellular carcinoma. The postmortem study of his medical history reaching back to childhood allowed the diagnosis of an unrecognized Alagille syndrome.

[Lung metastasis of a benign giant cell tumor of the skeleton 27 years after resection of a recurrent tumor]

Benign giant cell bone tumors sometimes develop benign pulmonary metastases. Most of these appear 3 to 4 years after the treatment of the primary tumor. Metastases have been diagnosed up to 11 years after the first diagnosis. The following is a case report of a 58-year-old man who developed lung metastases 27 years after the treatment of an aggressive local recurrence.

[Tumor of the gastrointestinal autonomic nervous system (GAN-tumor or plexus sarcoma)]

GAN-tumors or plexosarcomas, first described by Herrera et al. in 1984, are uncommon neurogenic stromal spindle cell tumors of the intestinal tract mainly located in the stomach and the small intestine. The distinctive immunohistochemical pattern is the positive staining for vimentin and neuron-specific-enolase. Ultrastructural features are neuron-like cells with interdigitating cytoplasmic processes, dense-core neurosecretory granules, the lack of basement membranes and the presence of interstitial skeinoid fibers. Pain, chronic and acute bleeding are the most frequent but not specific symptoms and the diagnostic delay is reflected by a large average diameter of these tumors. For even smaller tumors and those with a low mitotic rate may metastasize, GAN-tumors must be considered malignant and need a radical surgical resection.

Long-term outcome of idiopathic hypereosinophilic syndrome--transition to eosinophilic gastroenteritis and clonal expansion of T-cells

We describe a patient with idiopathic hypereosinophilic syndrome, without initial gastrointestinal symptoms, and their transition to eosinophilic gastroenteritis. This patient, a 65-year-old man, presented with fever, constitutional symptoms, peripheral and bone marrow eosinophilia 20 years ago. During the course of the disease, diarrhoea and malabsorption became prominent, whereas bone marrow eosinophilia regressed completely and blood eosinophilia regressed partially. Biopsies showed a severe eosinophilic gastroenteritis of the mucosal type involving the stomach, small bowel and colon. During the final years of the patient's disease, mucosal eosinophilia became less intense and a mucosal infiltration with T-cells dominated. At autopsy, immunopathological studies of small intestines and colon specimens showed a clonal expansion of morphologically normal T-cells in the intestinal mucosa, which expressed the abnormal phenotype CD2+CD3+CD4-CD5-CD8-. Flow cytometry examination of peripheral blood revealed a corresponding abnormal population of CD3+CD4-CD8- T-cells, indicating a systemic spread of the process. The patient eventually died of non-obstructive small bowel infarction with peritonitis 20 years after the onset of the first symptoms. We postulate that the destructive eosinophilic/lymphocytic inflammation is caused by a clonal proliferation of T-lymphocytes with probable secretion of Type 2 T(helper) cell cytokines and consecutive stimulation of eosinophils.

p53 protein expression in colorectal adenomas: an immunohistochemical study using an antigen retrieval system

The immunohistochemical expression of the p53 gene product was examined in 91 colorectal adenomas from patients without (group 1, 50 cases) or with (group 2, 41 cases) concurrent sporadic colorectal carcinoma, and in 15 additional cases of randomly selected carcinomas from group 2 patients. Immunohistochemical reactions were performed with the DO-7 monoclonal and the CM1 polyclonal antibodies, following microwave irradiation of the tissues in an antigen retrieval solution, and the proportion of the immunoreactive cells was semiquantitatively assessed. p53 protein immunoreactivity was present in 46.1% (42, of 91, i.e., 20 out of 50 of group 1 and 22 out of 41 of group 2) and 33% (30 of 91, i.e. 14 out of 50 of group 1 and 16 out of 41 of group 2) of the adenomas using DO-7 and CM1 antibody, respectively. High p53 expression (i.e. immunolabelling of more than 30% of the tumour cell nuclei) was found in 13.2% of the adenomas (12 of 91, i.e. three out of 50 of group 1 and nine out of 41 of group 2; P = 0.025 using the chi 2 test) using the DO-7 antibody, and in 6.6% of the cases (six of 91, i.e. two out of 50 of group 1 and four out of 41 of group 2) using the CM1 antibody. In carcinomas, 80% of the cases (i.e. 12 of 15) were found to express p53 protein with both antibodies. p53 immunoreactivity in colorectal adenomas increased with the degree of dysplasia: only five (17.8%) of the 28 adenomas with mild dysplasia were found to be DO-7 positive, while all of them remained CM1 negative. From the 50 adenomas exhibiting moderate dysplasia, 28 (56%) were DO-7 positive, and 22 (44%) were CM1 positive. Finally, from the 13 adenomas with severe dysplasia, nine (69.2%) and eight (61.5%) were found to be positive with the DO-7 and the CM1 antibody, respectively. Our results indicate that an increased number of group 2 adenomas express p53 protein, when compared with group 1 adenomas, and suggest that a strong correlation exists between p53 protein expression and the degree of dysplasia in colorectal neoplasms.

Ganglioglioma of the brain stem: neurological dysfunction of 16-year duration

An autopsy case of a brain stem ganglioglioma in a 38-year-old male patient with neurological dysfunction of 16-year duration is reported. Immunohistochemical investigation of the tumor was performed using a panel of antibodies against neurofilament protein (NFP), synaptophysin (SY 38), beta-tubulin (TUJ1), neuron specific enolase (NSE), and glial fibrillary acidic protein (GFAP). The value of these markers in the establishment of the diagnosis, as well as the general features, the prognosis and the therapeutic approach of the gangliogliomas are discussed.

A deletion mutant of the LMP1 oncogene of Epstein-Barr virus is associated with evolution of angioimmunoblastic lymphadenopathy into B immunoblastic lymphoma

The latent membrane protein 1 (LMP1) oncogene is one of the major proteins synthesized by the Epstein-Barr virus (EBV). It is expressed in Reed-Sternberg cells of Hodgkin's disease (HD), tumor cells of nasopharyngeal carcinoma (NPC), and immunoblasts of angioimmunoblastic lymphadenopathy (AILD). A particular LMP1 deletion mutant was recently identified in NPC and clinically and histologically aggressive HD. We studied two patients with AILD that subsequently progressed into immunoblastic lymphoma (IBL) in order to investigate whether the LMP1 deletion mutant was implicated in progression of AILD into IBL. Immunohistology and in situ hybridization were performed on diagnostic biopsies. DNA extracted from fresh frozen material was used for rearrangement studies and polymerase chain reaction (PCR) based amplification and sequencing of portions of the LMP1 gene. Immunohistochemistry revealed B cell origin of both cases of IBL. In the first patient clonal rearrangement of the immunoglobulin heavy-chain gene was present in IBL but not in AILD. In this patient, scattered immunoblasts of AILD and numerous tumor cells of B-IBL were shown to contain EBV transcripts (EBER1) and to express LMP1. Sequence analysis of the LMP1 gene from AILD and IBL in the first, and from IBL in the second patient, revealed identical deletions and point mutations. This LMP1 deletion mutant is identical to those which have been reported in HD and NPC. Its association with evolution of AILD into B-IBL, aggressive HD and NPC, suggests that this particular mutant is more widespread than originally thought and is clinically relevant.

Karyomegalic interstitial nephritis: further support for a distinct entity and evidence for a genetic defect

Karyomegalic interstitial nephritis was first described in 1979 by Mihatsch, who was reporting three such cases. We report here four additional cases as well as two family investigations. Our findings support the association of karyomegaly and interstitial nephritis as a distinct entity. Typical clinical features are asymptomatic progressive renal failure in the third decade of life and recurrent infections, mostly of the upper respiratory tract. Histologic alterations consist of markedly enlarged and hyperchromic nuclei in many tubular epithelial cells throughout the nephron accompanied by interstitial fibrosis in the surrounding atrophic tubules. Karyomegaly is not limited to the kidneys. In one case, autopsy revealed karyomegaly in epithelial and mesenchymal cells of many other organs. However, no association of karyomegaly with further histologic damage is evident except in the kidneys. Because of the familial clustering, karyomegalic interstitial nephritis seems to be an inherited disease. Examination of the nuclear proliferation-associated structures proliferating cell nuclear antigen/cyclin, Ki 67, and p53 suggests an inhibition of mitosis in karyomegalic cells. The finding of the same HLA haplotype, A9/B35, in four of six HLA-typed cases suggests the possibility of a genetic defect on chromosome 6, which is inherited and linked to the HLA locus.

[Signet ring cell carcinoma of Vater's papilla: a very rare malignancy]

We describe a rare variant of carcinoma of the ampulla of Vater. A 70-year-old man with several illnesses and a newly appeared jaundice was investigated and a signet-ring cell carcinoma of the ampulla of Vater diagnosed. We performed a local transduodenal excision. One year after operation the patient is asymptomatic. This is the second case report in the literature.

[Prolonged course of an idiopathic hypereosinophilic syndrome with transition to eosinophilic gastroenteritis]

Idiopathic hypereosinophilic syndrome (IHES) is a multi-system disorder of unknown origin with eosinophilic infiltration of bone marrow and various organs, including the gastrointestinal tract. Involvement of the heart has a poor prognosis. The etiology of eosinophilic gastroenteritis (EGE) also is unclear. In this disease there is exclusive involvement of the gastrointestinal tract (including liver/bile ducts) and prognosis usually is good. Transition from one disease to the other has not yet been described. We report the 20 years' history of a male patient with an initial IHES without gastrointestinal symptoms and transition to a clinically pure EGE with resolution of any other involvement. At the age of 45 years the patient developed IHES with fever and constitutional symptoms. Fluctuating eosinophilia and symptoms necessitated continuous steroid therapy. After a 10 years' disease course watery diarrhea and malabsorption syndrome became more and more prominent. On the other hand, bone marrow eosinophilia regressed completely and blood eosinophilia partially. Biopsies showed a severe EGE of the mucosal type with involvement of the whole gastrointestinal tract. Besides the prominent eosinophilia there was a dense infiltration of the intestinal mucosa with T-lymphocytes invading the epithelium. We postulate that the destructive eosinophilic/lymphocytic inflammation is caused by a pathologic proliferation of T-lymphocytes with liberation of type 2 helper cell cytokines and consecutive stimulation of eosinophils.

[Nephroblastoma-like kidney adenoma: case report of an extremely rare kidney tumor]

The nephroblastoma-like adenoma of the kidney is an extremely rare tumor with similarities to the nephroblastoma (Wilm's tumor) of the adult. In the literature, different terms are applied to these lesions. We present the case of a 64-year-old woman who underwent a nephrectomy for suspicion of renal cell carcinoma. Histologically the tumor consisted of tubular and papillary formations of monomorphic tumor cells without mitoses or cell-atypias and showed no fibrous capsule. The differential diagnosis to the nephroblastoma of the adult was difficult. Immunohistochemically the tumor expressed the embryonic form of the neural cell adhesion molecule (N-CAM) interstitially and not in the epithelial tumor cell as seen in Wilm's tumor. For the biologic tumor-definition it is important to collect and follow these very rare cases.

[Recurrent and metastasizing hemangiopericytoma of the meninges with paraneoplastic hypoglycemia]

Primary meningeal hemangiopericytomas (formerly referred to as angioblastic meningiomas) are by most authors no longer considered to be actual meningiomas but rather thought to be intracranial hemangiopericytomas. Their biological behavior is usually malignant, with recurrences and metastases, often at intervals of years. Both intracranial and extracranial hemangiopericytomas may, however rarely, be accompanied by paraneoplastic hypoglycemias. Our own characteristic observations are based on a female patient aged 67 at the time of her death, in whom a meningeal tumor was resected first at the age of 41. Later recurrencies were removed at the age of 52 and 58 respectively. Three years prior to her death liver metastases had developed followed by increasingly frequent attacks of early morning hypoglycemia with blood sugar levels ranging between 1.4-2.3 mmol/l. Specific examinations revealed low endocrine production of insulin and a distinctly decreased insulin-like growth factor (IGF) I of 25 ng/mb (normal 120-130) and a normal value of total IGF II of 724 ng/ml (normal 400-900), though with a big macromolecular share. The observed paraneoplastic hypoglycemia is probably brought about by coincidence of blocked hepatic glucose production, suppressed lipolysis and increased peripheral glucose uptake. Autopsy revealed a third intracranial recurrence of meningeal hemangiopericytoma and a large metastatic liver. No other sites of metastases were found. Histologic, immunohistologic and electron microscopic findings showed the characteristics features of a hemangiopericytoma. Light microscopic pictures of the primary tumor, recurrences and metastases were identical. Additional autopsy findings were a papillary carcinoma of the right kidney, an angiomyolipoma of the left kidney and a thecoma of the left ovary.

Diagnostic tools for differentiating pleural mesothelioma from lung adenocarcinoma in paraffin embedded tissue. II. Design of an expert system and its application to the diagnosis of mesothelioma

A panel of 14 antibodies (panepithelial antibody Lu-5, anti-keratin-18, anti-keratin-7, Ber-EP4, anti-Leu-M1, HEA-125, anti-carcinoembryonic antigen, anti-blood group-related antigens A, B, H, B72.3, anti-placental alkaline phosphatase, anti-vimentin and BMA-120), which have been evaluated for use in differentiating mesothelioma from lung adenocarcinoma, was applied to a group of 24 suspected mesotheliomas. Using the established qualitative, descriptive criteria derived from monovariate statistical analysis of the tumour control groups (definite mesotheliomas, adenocarcinomas), a definitive allocation was possible in only 25% of suspected cases. We therefore constructed two "expert systems", based on multivariate discriminant analysis with either the ALLOC 80 program for ordinal data or a newly developed analysis program for binomial data. With these two systems diagnostic allocation of suspected mesotheliomas was improved to 75% and 79%. The use of binomial data ("positive" versus "negative") in conjunction with the probability-based test system is of particular interest because the primary data are easy to record and the test results have a higher statistical probability.

[Perforated small intestine diverticulum as a cause of acute abdomen in Ehlers-Danlos syndrome]

Based on a rare case of perforated small-bowel diverticulum combined with Ehlers-Danlos syndrome (EDS) we investigated in a retrospective study several swiss hospitals for symptomatic small-bowel diverticulosis aiming at any clue on EDS. We came up with 15 more cases, 5 of them with perforation, yet none showed any sign of EDS. A review of the literature on either small-bowel diverticulosis or the intestinal complications of EDS amounted to 131 cases of perforation and 11 cases of symptomatic small-bowel diverticulosis in combination with EDS, 2 of them suffering from perforation. Regarding the rarity of these diseases the number of patients presenting both is surprising. Although the EDS-specific histopathological changes of the skin could not be shown in the specimen of the intestinum, it seems quite reasonable to suggest an increased incidence of diverticulosis in patients with EDS, since the weakness of the connective tissue allows an easy protrusion of the mucosa through the intestinal wall.

[Simultaneous occurrence of lymphocytic gastritis and lymphocytic colitis with transition to collagenous colitis]

Lymphocytic gastritis and lymphocytic colitis are two rare disorders of unknown etiology, only diagnosable by histology. Simultaneous occurrence of lymphocytic colitis and lymphocytic gastritis has not been described up to now. A 69-year-old female patient was examined because of crampy abdominal pain and watery diarrhea. Laboratory tests did not reveal an etiology and in colonoscopy the colon and terminal ileum were normal. Histology disclosed lymphocytic colitis. Esophagogastroduodenoscopy showed erosive bulbitis. Biopsies of the stomach revealed lymphocytic gastritis. A second colonoscopy one year later showed the development of collagenous colitis.

Immune-mediated type A gastritis and glomerulonephritis

The first two cases reported in the literature of patients with immune-mediated type A gastritis with microcarcinoids (as part of a polyglandular syndrome type II in one) in combination with chronic glomerulonephritis are presented. Immune-mediated type A gastritis appears to be another immunologic disorder that can be associated with chronic glomerulonephritis.

Diagnostic tools for differentiating between pleural mesothelioma and lung adenocarcinoma in paraffin embedded tissue. Part I: Immunohistochemical findings

Specimens of 27 histologically definite mesotheliomas and 34 proven adenocarcinomas were examined with a panel of 14 antibodies: pan-epithelial antibody Lu-5, anti-keratin-18, anti-keratin-7, Ber-EP4, anti-Leu-M1, HEA-125, anti-carcino-embryonic antigen (CEA), anti-blood group-related antigens (anti-BGR A, B, H), B72.3, anti-placental alkaline phosphatase (PLAP), anti-vimentin and BMA-120 used to determine their value in the differentiation between pleural mesothelioma and lung adenocarcinoma. Lu-5, anti-cytokeratin-7 and -18, B 72.3 and PLAP reacted in a high percentage of cases with both mesothelioma and adenocarcinoma. Anti-CEA and anti-Leu-M1 did not react with any of the 27 mesotheliomas tested but showed a reaction in 75% (anti-CEA) and 66% (anti-Leu-M1) of the lung adenocarcinomas. Seventeen percent of the adenocarcinomas and 96% of the mesotheliomas showed a positive reaction with anti-vimentin. Ber-EP4 was demonstrated in all lung adenocarcinomas, but only in 2 mesotheliomas in a focal manner (7%). HEA-125 and anti-BGR A, B, H reacted with 83% (HEA-125) and 75% (anti-BGR A, B, H) of the lung adenocarcinomas. The statistical parameters, sensitivity and efficiency were estimated and a normogram for judging the diagnostic power of a single antibody for the differential diagnosis of mesothelioma versus adenocarcinoma was developed. According to this, Ber-EP4, HEA-125, anti-BGR A, B, H and anti-CEA were, in descending order, the most powerful discriminatory antibodies.

[Secondary oxalosis following small bowel resection with kidney insufficiency and oxalate vasculopathy]

A 58-year-old female patient admitted to hospital for advanced renal failure had a 40 years' history of Crohn's disease and had undergone ileocecal resection. Nevertheless, chronic diarrhea persisted. Subsequently calcium oxalate stones in the urine were repeatedly observed. Progressive renal failure developed. The investigation of the patient showed severe steatorrhea and pronounced hyperoxaluria, and renal biopsy showed severe chronic interstitial nephritis with calcium oxalate crystals. The skin biopsy revealed severe calcium oxalate vasculitis. The pathophysiology and therapy of secondary hyperoxaluria due to small bowel resection are discussed.

[Combined oral and endoscopic mepacrine therapy in therapy-resistant symptomatic giardiasis]

A case of extremely refractory infection with Giardia lamblia is described. A 28-year-old male patient with a 7-year history of mushy diarrhea and epigastric pain was repeatedly treated orally and intravenously, without success, with metronidazole, tinidazole, ornidazole, and mepacrine. The rate of success for these drugs is generally more than 90%. Only therapy with mepacrine orally in combination with intraduodenal administration, was successful. Therapeutic failure of 5-nitroimidazole derivatives is described in relation to immune deficiency syndromes and IgA deficit. None of these defects were found in this case.

[Gastritis associated with Gastrospirillum hominis--a zoonosis?]

We found spiral bacteria (non-Helicobacter pylori, SB) in gastric biopsies of 5 patients corresponding to an incidence of 0.3%. The bacteria were found on the surface of the gastric mucosa and in part tightly packed within the crypts. Contrary to Helicobacter pylori, most of them had no direct contact to the surface and crypt epithelium. They are distinctly coiled, 3.6-5.5 microns in length and on average 0.5 microns thick. Ultrastructural studies revealed sheathed flagella at each pole. In one case the bacteria displayed periplasmic fibrils in pairs as also described in cultures of SB from cats' stomachs. In all 5 cases there was histological evidence of inflammation of the gastric mucosa, i.e. one acute diffuse gastritis, one case of granulomatous and three of slight to medium grade chronic gastritis. Biopsies of 2 patients showed a positive urease reaction in the CLO test. Morphologically very similar SB occur as commensals in the stomachs of various animals, in particular dogs and cats. We investigated the stomachs of four dogs and four cats and found all to be infested with SB. The bacteria were found not only on the surface of the mucosa and in crypts, but within the glands of the corpus and antrum and often also within parietal (oxyntic) cells. Yet despite bacterial colonization there was no evidence of gastritis in dogs. However, all of the cats' stomachs showed slight to medium grade chronic gastritis. Cultivation of SB has not been successful so far, with the exception of cats' stomachs. Since the germs have been defined only morphologically, the question as to how close the relationship is among SB of various origins must for the time being remain unanswered. Furthermore, species-specific pathogenicity and the possibility of contagion from animal to man has not yet been clarified.

[Prostate cancer with an unusual course]

The case of a 60 years old patient with peritoneal carcinomatosis of a tumor with small cell histology is reviewed. At presentation, biopsy of a rectal palpatory finding revealed a small cell carcinoma, infiltrating the mucosa. A laparotomy was done, which showed a grotesque peritoneal carcinomatosis of the same histology with masses retro- and infraperitoneally and in the pelvis. Clinically and histologically a probable epithelial peritoneal mesothelioma was diagnosed. The patient survived half a year only. Autopsy and post-mortem work-up demonstrated the presence of a small cell prostatic cancer, positive for both prostate specific antigen and acid phosphatase. A discussion of diagnostic procedures and differential diagnoses is given.

[Chronic gastritis. Pathogenesis, clinical aspects and therapy]

Based on clinical and histopathological features, three different types of chronic gastritis can be distinguished: gastritis A is confined to the proximal stomach and is the result of an autoimmunological process with antibodies against parietal cells and intrinsic factor. It is a rare disorder and may lead to pernicious anaemia. Distal, antral gastritis B is caused by an infection of the gastric mucosa with Helicobacter pylori (HP). Its incidence increases with age (greater than 50% above age 50). Gastritis C may be caused by drugs and alcohol but is mainly found in gastric remnants after partial resection as a consequence of biliary reflux. Gastritis A rarely causes symptoms. A relationship between gastritis B and C and non-ulcer dyspepsia (NUD) is highly controversial. Gastritis B is very closely associated with peptic ulcer disease. HP-positive antral gastritis seems to be the prerequisite for ulcer formation. All 3 types of gastritis carry an increased risk of malignancy, which seems to be positively correlated with hypoacidity, the chronicity of the inflammation and the histopathological feature of intestinal metaplasia. Noninvasive diagnostic tests (serology, breath tests, scintigraphy) are available, but the diagnosis of gastritis is still mainly based on endoscopy and biopsy. Treatment of gastritis A is not possible. Gastritis B can be healed by eradication of HP using bismuth salts and antibiotics but only combinations of 2-3 compounds seem to afford long-term positive results. Further clinical trials are needed to determine whether such treatment is justified in patients with gastritis and NUD. In patients with chronic recurrent peptic ulcers eradication of HP prevents relapses and heals ulcer disease. Gastritis C complicated by severe symptoms or ulcer can only be successfully treated by a biliary diversion, i.e. Roux-Y-gastrojejunostomy. The discovery that gastritis B is caused by HP improves our understanding of peptic ulcer disease and will change therapeutic concepts.

[Dissecting aneurysm of the common iliac artery in Marfan syndrome: rupture following sports activities]

In a 40-year-old man who collapsed after sporting activity and died shortly after in spite of surgery, autopsy revealed a small ruptured dissecting aneurysm of the left common iliac artery. At the site of rupture, in the aorta and in multiple visceral arteries extensive mucoid degeneration of the media was found. Additional findings (bone deformities, bullous emphysema of the apices of both lungs, and familial affliction) made it possible to establish the diagnosis of an oligosymptomatic form of Marfan syndrome.

[ERCP in bile duct dilatation with jaundice due to spontaneous hydatid cyst rupture. Diagnosis, differential diagnosis, therapy and result]

We report the case of a 17 years old Turkish patient hospitalized for colics and jaundice. Ultrasound, computer tomography and ERC showed enlarged intra- and extrahepatic bile ducts. The further investigations documented the rupture of a hepatic hydatid cyst into the biliary tract with obstructive jaundice. Other causes of jaundice as cystic duct malformation, calculi, tumours could be ruled out by surgery and histology. Etiology, diagnosis and treatment of hydatid jaundice are discussed.

[Long-term suppression of acid secretion with omeprazole use in metastatic gastrinoma]

We report on the clinical signs, diagnosis and 8-year course in a 54-year-old female patient with myeloma and gastrinoma with liver metastasis and associated Cushing syndrome treated for the last 3 years with the new H+/K+-ATPase inhibitor omeprazole which has successfully suppressed the massive gastric acid hypersecretion.

[Campylobacter pylori, gastritis and ulcer disease. Microbiological, histological and serological studies]

In a prospective study of 70 patients with epigastric pain, gastroduodenoscopy revealed gastric and/or duodenal ulcers in a total of 41 and no ulceration in the remainder. Biopsies were taken to assess the severity of gastritis and the presence of Campylobacter pylori (CP) by histology and culture. Gastritis was found in 54 patients. CP was detected in 78% of the ulcer patients and 52% of the patients without ulcer (p less than 0.05). CP was demonstrated in 83% of the histologically diagnosed cases of gastritis (all grades) but no CP was detectable in patients with normal gastric mucosa. Among the ulcer patients, CP was more frequent in those with no history of medication with nonsteroidal antiinflammatory drugs (p less than 0.01). Sera from CP-positive ulcer and gastritis patients have significantly higher levels of IgG antibodies to CP than sera from those found to be free of ulcer or gastritis. In 200 blood donors an increasing percentage of elevated CP-antibody titres were found with advancing age (50% over 60 years of age). Quantification of circulating CP antibodies, would thus seem a valuable adjunct in the diagnosis of gastritis and probably also of peptic ulcer. The data presented furnish further evidence of the high rate of association of CP and the gastritis-peptic ulcer complex.

[Histoplasma duboisii osteitis as an imported disease]

A case of imported Histoplasma duboisii osteitis in a visitor from Africa to Switzerland is described. The diagnosis was by histology confirmed by culture. Infection of other organs was ruled out. Amphotericin B therapy and its side effects are discussed.

[Glomerular erythrocytes in urine. Identification and significance]

The glomerular origin of microhematuria can often be identified by typical changes in erythrocyte morphology when the urinary sediment is examined with a phase contrast microscope. The so-called "glomerular erythrocytes" appear in uneven annular shape (ring forms) or as fragmented, crushed and ruptured cells (destroyed forms). Non-glomerular erythrocytes originating from the urinary tract have different morphological characteristics. The occurrence of only a few glomerular erythrocytes (0-2 per high power field) is a normal finding. The morphological characteristics of the erythrocytes should be analyzed as the first step in the work up of microhematuria. In the case of clearcut glomerular microhematuria, unnecessary urological or radiographical investigation can thus be avoided.

Persistent pulmonary granulomas after recovery from varicella pneumonia

A 41-year-old man was found to have a miliary infiltrate on chest roentgenogram two months after recovery from varicella pneumonia. The patient remained in good health and there was no objective sign of pulmonary disease. The infiltrate showed no change in subsequent serial chest films, and after one year, open lung biopsy was performed. Histology revealed isolated necrotizing granulomas with a mononuclear infiltration and a fibrous capsule. We discuss the differential diagnosis of pulmonary granulomas and conclude that the roentgenographic and biopsy findings probably represent a persistent lesion after varicella pneumonia.

[Granulomatous hepatitis caused by nomifensine]

Four patients are described who developed granulomatous hepatitis 4-6 weeks after treatment with nomifensin. The granulomas were located both in the portal tract and the liver parenchyma, and contained eosinophils and a few polynuclear giant cells. Serum alkaline phosphatase, alanine aminotransferase and bilirubin were raised in three, two and one patient respectively. After medication was discontinued all abnormalities disappeared within 6-10 weeks. After oral intake of 25-50 mg nomifensin all patients experienced paroxysms of high body temperature for several hours. Reexposure in one patient resulted in another fever spike 6 hours after ingestion. No other cause of the fever or the granulomatous hepatitis was identifiable. The clinical data, especially the simultanous occurrence of drug fever and the histologic pattern, are compatible with an allergic mechanism of the liver granulomas. In the presence of high fever and abnormal liver tests in relation to nomifensin treatment, an allergic drug reaction should be considered.

Angiomatoid malignant fibrous histiocytoma. Evidence for the histiocytic origin of tumor cells

The results of an histological, immunocytochemical and electron microscopic study of an angiomatoid malignant fibrous histiocytoma are reported. Our results support an histiocytic, rather than an endothelial origin for the tumor cells.

[Intestinal pseudo-obstruction in primary amyloidosis of the intestinal tract]

In an 80-year-old patient who had recurrent attacks of subileus over three years, a complete large bowel ileus finally developed. At laparotomy, massive dilatation and extreme fragility of the large bowel was found. Subtotal colectomy was performed, within 24 h of which the patient died. The surgical specimen and autopsy revealed primary amyloidosis (A light chain type) confined nearly exclusively to the intestinal tract. Pseudoobstructive ileus in amyloidosis can be chiefly accounted for by the heavy amyloid infiltration of the tunica muscularis of the bowel wall. Amyloidosis of the arteries and nerve plexus may be contributory factors.

[Cystic testis dysplasia with ipsilateral kidney agenesis]

A 6-year-old boy was seen for a left side scrotal mass which developed within a few months. Orchidectomy revealed an enlarged testis with multiple cysts in the head of epididymis and cystic transformation of the rete. At the same time, ipsilateral renal agenesis was found. This is a very rare combined malformation of the urogenital system which is of unknown etiology. Its pathogenesis may be related to developmental defects at the proximal and distal portion of the wolffian duct.