Various morphologic features of Gnathostoma spinigerum in histologic sections: report of 3 cases with reference to topographic study of the reference worm.

Gnathostomiasis is common in Southeast Asian countries and can be found sporadically in other parts of the world mainly due to human migration. The definitive diagnosis can be given either by identification of the parasite isolated from the patient or through histologic section of the lesion. It is therefore important for pathologists to be familiar with the morphology of parasitic larvae which varies according to the levels of section-cutting so that the diagnosis will not be misled. We present three cases of gnathostomiasis with different features of parasitic morphology and compare these with the reference adult worm.

Bone mineral density and histology in distal renal tubular acidosis.

BACKGROUND: Chronic metabolic acidosis in distal renal tubular acidosis (RTA) has been implicated in the pathogenesis of enhanced bone resorption and osteopenia, resulting in a loss of bone mineral content. However, histomorphometric and bone densitometric studies of patients who suffered from long-standing distal RTA have rarely been done. METHODS: A cross-sectional study to determine the alterations of bone mineral density (BMD) and histology was done in 14 nonazotemic RTA patients (11 females and 3 males) who had never received alkaline therapy before enrolling into this study. The mean age was 32.7 +/- 11.9 years. BMD measurements and transiliac bone biopsy were done in all patients. Blood chemistries, intact parathyroid hormone level, and a 24-hour urine collection for the determination of urinary calcium, phosphate, sodium, and potassium were obtained from the RTA patients at the time of bone biopsy. Data from 28 age-, sex-, and body mass index-matched, normal controls who were residents in the same area were also obtained. RESULTS: Urinary excretion of calcium was 2.05 +/- 1.59 mmol/day. No patient had hypercalciuria. The serum intact parathyroid hormone level was 15.92 +/- 8.48 pg/mL. RTA patients had lower BMD in most areas when compared with normal controls. There were two patients who suffered from a pathologic fracture at the femur. Bone histomorphometry from RTA patients shows a significantly decreased bone formation rate (0.02 +/- 0.02 vs. 0.07 +/- 0.045 microm(3)/microm(2)/day, P < 0.05), not significantly decreased osteoblastic surface (0.78 +/- 1.03% vs. 2.6 +/- 1.1%) and osteoclastic surface (0.05 +/- 0.03 vs. 0.13 +/- 0.23%), but significantly increased osteoid surface (31.47 +/- 24.52 vs. 5.79 +/- 4.39%, P < 0.05) and osteoid volume (2.95 +/- 3.09 vs. 0.92 +/- 1.05%, P < 0.05) when compared with those of normal controls. There was no difference in osteoid thickness (10.65 +/- 6.10 vs. 8.69 +/- 2.14 microm). Only one distal RTA patient who had a marked increase in osteoid thickness justified the diagnosis of osteomalacia. CONCLUSIONS: This study demonstrates that low bone mass is common in distal RTA patients. Chronic metabolic acidosis results in suppression of bone formation and resorption, which in turn may contribute to the development of low bone mass in distal RTA patients. Although minor elevations in osteoid surface and osteoid volume are found among distal RTA patients, overt osteomalacia is not the predominant bone lesion.

Interspinous bursa and spinal instability.

STUDY DESIGN: This is a prospective study. Interspinous tissue was taken intraoperatively for pathological examination for the presence of bursa. The pathologist was unaware of the X-ray findings in each specimen. The presence of bursa was then correlated with X-ray evidence of hypermobility in each segment. OBJECTIVE: To verify the pathogenesis of interspinous bursal formation. SUMMARY OF BACKGROUND DATA: Interspinous bursa is common in the older population. It has been associated with degenerative lumbar diseases, aging and anatomical distance between the spinous process. However, no detailed exploration of the segmental instability as a cause of bursal formation has been done. METHOD: The insterspinous tissue was taken intraoperatively from patients diagnosed as multilevelled spinal stenosis who underwent extensive decompression, fusion and instrumentation. The specimens were examined by the same pathologist for the existence of bursa. The presence of bursa was correlated with X-ray motion study of each spinal segment by student t-test. RESULTS: The existence of bursal was significantly correlated with angular mobility of more than 10 degrees. CONCLUSION: Angular mobility is a possible cause of interspinous bursa. On the contrary, the presence of insterspinous bursa may be evidence of segmental hypermobility.

Aberrant cyclooxygenase isozyme expression in human intrahepatic cholangiocarcinoma.

METHODS: Cellular localisation of the cyclooxygenase (COX) isozymes COX-1 and COX-2 was analysed in 24 cholangiocarcinomas, including 17 matched tissues originating from non-tumorous liver tissue adjacent to tumours and seven biopsies of normal human liver, by immunohistochemistry using isozyme selective antibodies. RESULTS: In normal liver, constitutive expression of COX-2 protein was a characteristic feature of hepatocytes whereas no COX-2 immunosignal was detectable in normal bile duct epithelium, Kupffer, and endothelial cells. In cholangiocarcinoma cells, COX-2 protein was strongly expressed at high frequency. The intensity, percentage of positive cells, and pattern of COX-2 expression were found to be independent of the stage of tumour differentiation. In hepatocytes of matched non-tumorous tissue, COX-2 expression was unaltered. In contrast, strong COX-1 expression was frequently localised to Kupffer cells, endothelial cells, and occasionally to hepatocytes, but not to bile duct epithelial cells. In approximately half of moderately and poorly differentiated but not well differentiated cholangiocarcinomas, weak to moderate COX-1 staining was found in tumour cells while COX-1 expression in Kupffer cells was much more pronounced. CONCLUSION: Aberrant COX-2 expression occurs during the early stage while COX-1 over expression seems to be related to later stages of cholangiocarcinogenesis.

Fibromuscular dysplasia: a rare cause of cilioretinal artery occlusion in childhood.

OBJECTIVE: To report a case of cilioretinal artery occlusion with angiographic findings characteristic of the "string of beads" associated with renovascular hypertension secondary to fibromuscular dysplasia of the renal artery in a child. DESIGN: Case report. INTERVENTION: The patient underwent ex vivo renal artery reconstruction with saphenous vein graft and reimplantation. MAIN OUTCOME MEASURES: The main clinical outcomes were control of severe hypertension, reversible hypertensive retinopathy, and improvement of vision. RESULTS: Revascularization of the kidney improved renal function, and renovascular hypertension was clearly improved. Visual acuity improved to 20/200. CONCLUSIONS: A child with hypertensive retinopathy and arterial occlusion in the retina should undergo investigation to rule out a surgically curable hypertension. Magnetic resonance angiography of extrarenal vessels may reveal other sites of involvement of fibromuscular dysplasia. Evaluation and early diagnosis of renovascular hypertension will prevent severe end-organ damage.

Renal osteodystrophy in Ramathibodi Hospital: histomorphometry and clinical correlation.

UNLABELLED: The spectrum and clinical relevance of renal osteodystrophy in Thai dialysis patients are unknown. A study was conducted on the prevalence and clinico-pathological correlation of renal osteodystrophy in chronic dialysis patients who attended Ramathibodi Renal Transplant Clinic between September 1996 and March 1998. All possible volunteers were enrolled irrespective of musculoskeletal symptoms. Fifty six dialysis patients, including 17 (30.4%) CAPD and 39 (69.6%) hemodialysis patients, participated in this study. Serum calcium, phosphate, iPTH, and bone specific alkaline phosphatase were determined. Transiliac crest bone specimens were measured with an average of 30 fields/specimen by a specific computer program for bone histomorphometry (Osteomeasure), and were also studied for dynamic by double tetracycline label. Bone mineral density (BMD) was also determined by DEXA scan. The type of bone pathology was based on Fournier's criteria for renal osteodystrophy. The mean +/- SEM for age was 45.52 +/- 1.74 years, dialysis duration 42.26 +/- 5.54 (range 1-156) months, calcium phosphate product 52.31 +/- 2.77, and iPTH 307.73 +/- 62.04 pg/ml. The following types of renal osteodystrophy were found: adynamic bone 23 (41.1%), hyperparathyroid 16 (28.6%), mixed type 11 (19.6%), mild lesion 3 (5.4%), osteomalacia 2 (3.6%), and osteosclerosis 1 (1.8%) cases. Two cases of aluminum related bone disease were found. The distribution of different bone diseases was not affected by mode of dialysis or vitamin D supplement, but it was affected by dialysis duration. High turnover bone diseases were associated with longer dialysis duration (63.19 +/- 8.9 vs 23 +/- 4.73 months), higher iPTH (541.53 +/- 109.32 vs 87.77 +/- 15.76 pg/ml), and higher bone specific alkaline phosphatase (25.43 +/- 5.04 vs 9.62 +/- 1.34 mg/ml) when compared to low turnover bone diseases, p < 0.05. Intact PTH of greater than 200 pg/ml was a good predictor for high turnover bone diseases (74% sensitivity and 96% specificity). BMD at torch and wards areas varied inversely with dialysis duration (r = -0.3 and r = -0.4, respectively; p < 0.05). Chronic dialysis patients had a greater tendency of bone loss compared to the general Thai population. There was no difference in BMD between CAPD and hemodialysis patients or different types of bone lesions. CONCLUSION: Significant bone diseases are common among Thai chronic dialysis patients. Adynamic bone disease is the most common bone lesion followed by hyperparathyroid and mixed type. The spectrum of bone diseases is affected mainly by dialysis duration. Intact PTH is a good predictor of high turnover bone disease. Greater bone loss than in the general population is common in our patients and is also accentuated by longer dialysis duration.

Q-Switched ruby laser therapy of acquired bilateral nevus of Ota-like macules.

BACKGROUND: Acquired bilateral nevus of Ota-like macules (ABNLM), also called nevus fuscoceruleus zygomaticus or nevus of Hori, is a relatively common disease in Asia. It is refractory to all medical treatment. OBJECTIVE: To present the first report on the use of Q-switched ruby laser to treat ABNLM. METHODS: One hundred and forty female patients, ages 19-62 years (mean 39 years), were included in the study. The laser fluence employed was 7-10 J/cm2, at a repetition rate of 1 Hz, and with a spot size of 2-4 mm. The number of treatment sessions ranged from 1 to 6 (mean 2.3). RESULTS: Nine patients were lost to follow-up before complete clearance of the lesions, while in the remaining 131 patients complete clearance was obtained. The only complication was a long-term hypopigmentation, observed in three patients. There was no recurrence at 6 months- 4.3 years (mean 2.5 years) of follow-up. CONCLUSION: Q-switched ruby laser is an effective and less invasive tool to eradicate ABNLM.

Delayed sequelae of hydrochloric acid ingestion.

Hydrochloric acid is the active ingredient in common toilet bowl cleaner agents used in Thailand but it is occasionally abused for suicidal attempts by ingestion. Clinicopathological description caused by this agent has rarely been mentioned in the literature. We reported three cases of gastric outlet obstruction. Two of these cases were initially treated in provincial hospitals by gastric lavages. No clinical symptoms relating to ingestion and swallowing were present in the early period after ingestion but patients developed vomitting and cachexia a few months later. Among these three cases, pylorus and antrum were the most common sites of injury. All cases were gastrectomized and pathological findings of the resected specimens showed mucosal ulceration, submucosal fibrosis, thickening of muscularis mucosae, and eosinophilic infiltrations. Most cases in the literature had preoperative jejunostomy preformed but our cases did not have such a preoperative procedure. The outcomes of all cases were considered good and no postoperative complication was found. This presentation is aimed to stimulate physicians to be aware of delayed complications of hydrochloric acid ingestion and long term follow-up is required even though the initial symptoms of the patients were minimal.

Coinfections with hepatitis g and/or c virus in hepatitis B-related chronic liver disease.

Concurrent infections with HGV and/or HCV (HGV/HCV) were investigated in 196 patients with HBV-related chronic liver disease (115 chronic hepatitis, 31 liver cirrhosis, 50 hepatocellular carcinoma), and in 100 HBsAg carriers. Coinfections were detected in 18 (9.2%) patients with HGV (10) or HCV (5) or both agents (3), but in none of the HBsAg carriers. Patients with coinfection were more frequently exposed to blood transfusions (55.6% vs 5.6%) and also were more commonly anti-HBe positive. Serum levels of HBV-DNA were lower in patients with HCV coinfection than in those coinfected with HGV. Interferon was administered to 39 patients with chronic active hepatitis including 7 patients with HGV/HCV coinfection. Sustained clearance of HBV-DNA was observed in 10 (25.6%) patients who were solely infected with HBV. These patients were significantly younger and had much lower histological scores than non-responders. Patients with HCV coinfection had significantly higher pre-treatment histological scores than those without HCV. After interferon treatment, a significant reduction in histological scores was observed in all patients except those coinfected with HGV/HCV. None of the 7 patients with coinfection had sustained clearance of HBV-DNA or HCV-RNA, and only one had cleared HGV-RNA. These results suggest that parenteral exposure is a risk factor for HGV/HCV coinfection in chronic HBV infection. HGV infection shows no significant impact on chronic HBV infection. HCV coinfection appears to inhibit HBV replication, but causes more severe chronic hepatitis and increases resistance to interferon therapy.

Osteosarcoma: a study of 130 cases.

Multidisciplinary treatment of osteosarcoma in the Faculty of Medicine Ramathibodi Hospital, Mahidol University, using preoperative intraarterial and postoperative chemotherapy, with or without local irradiation, combined with surgery and prophylactic lung irradiation provided an excellent 5 years' survival of 55 per cent, the same rate as the 9 years' survival. The survival was stable after 4.4 years. The patients with local irradiation had more tumor destruction apparent on the surgical specimen. The administration of prophylactic whole lung irradiation provided an outcome without any undesirable complication. Sixteen per cent of the cases with PLI developed lung metastasis compared to 48 per cent without PLI. The most important prognostic factor was low level of serum lactic acid dehydrogenase. The unanswered question is what is the optimal treatment for osteosarcoma?

Miliary tuberculosis with unusual matted giant mesenteric lymph nodes.

We report a case of miliary tuberculosis in a 10-month old female with unusual matted giant mesenteric lymph nodes. She presented with prolonged fever and poor feeding for two months. With the evidence of miliary pattern in chest X-ray and the positive acid-fast bacilli from the sputum, she was treated with antituberculous chemotherapy. She died from pneumomediastinum and pneumopericardium. Post-mortem findings disclosed miliary tuberculosis involving major organs. Acid-fast bacilli were numerous. Large matted mesenteric lymph nodes measuring 10 x 6 x 5 cm3 were noted. A strikingly large palpable matted mesenteric lymph nodes in suspected miliary tuberculosis should not be confused with tumors in the children.

Dermabrasion is an effective treatment for acquired bilateral nevus of Ota-like macules.

BACKGROUND: Dermal pigmented lesion, or acquired bilateral nevus of Ota-like macules, is a common entity in Asian skin. There are no established data supporting the safety, effectiveness, and cosmesis of its treatment. The lesions do not respond to bleaching or peeling agents. OBJECTIVE: To search for a means of treatment that is cost effective, safe, and yields a good cosmetic result. If possible, these requirement should be accomplished within one session. METHODS: Three hundred and twenty patients who presented themselves with acquired bilateral nevus of Ota-like macules were included in the study. Area dermabrasion using a hand engine with a coarse diamond fraise was performed in every case. RESULTS: Three hundred and twenty patients (97%) achieved 100% clearance of the pigment. In the remaining 10 patients (3%) there was 5% residual pigment. The wound healed with excellent cosmesis, and without changing skin texture. CONCLUSION: Dermabrasion is an excellent modality for the treatment of acquired nevus of Ota-like macules.

Treatment of giant-cell tumor of the spine: report of four cases.

Four patients who had a giant-cell tumor of the spine were managed in Ramathibodi Hospital from 1986 to 1993. All of the patients are female and the age onset was between 14-36 years. The location of the lesions was distributed in the sacrum (2 cases), lumbar spine (1 case) and cervical spine (1 case). Surgical approach was determined by the location, extent of involvement and feasibility of marginal resection. Anterior approach was performed in cases of tumor mass confined to the vertebral body and posterior approach was done in cases of posterior neural arch involvement. Adjuvant therapy and preoperative internal iliac artery ligation contributed to successful treatment in cases of sacral involvement. After follow-up of fifteen to fifty months (average, 30 months), the pain subsided and neural symptoms improved. Roentgenograms showed no evidence of local recurrence.

Melioidosis. Another etiology of granulomatous osteomyelitis. Report of 2 cases.

Two cases of granulomatous osteomyelitis caused by melioidosis are reported. Histologically, the granulomatous lesions were indistinguishable from tuberculosis and required confirmation with microbiological culture. It is important that melioidosis be considered in the differential diagnosis of granulomatous osteomyelitis since the treatment is quite different from tuberculosis.

Cushing's syndrome caused by Ewing's sarcoma secreting corticotropin releasing factor-like peptide.

Procedures were carried out in a 12-year-old girl to relate Ewing's sarcoma of the left tibia with Cushing's syndrome. Computed tomography revealed a normal pituitary and hypothalamus but bilateral adrenal hyperplasia without focal enlargement, thus readily excluding hypothalamic-pituitary-adrenal tumor. Negative results from a high-dose dexamethasone suppression test do not support pituitary-dependent Cushing's disease. Ewing's sarcoma was diagnosed on tibial biopsy. The regression of the physical and biochemical findings of Cushing's syndrome subsequent to amputation of the left lower leg strongly suggests ectopic Cushing's syndrome caused by Ewing's sarcoma. Immunohistochemical studies of the resected bone were negative for corticotropin but positive for corticotropin releasing factor-like peptide. We conclude that this is the first reported case of ectopic Cushing's syndrome in a child that is caused by Ewing's sarcoma secreting corticotropin releasing factor-like peptide.

Malignant pericardial tumor in childhood: a case report diagnosed by cross-sectional echocardiogram and magnetic resonance imaging.

Since primary malignant pericardial tumors are seldomly found in children, we reported a case with massive pericardial effusion. Pericardial tumor was diagnosed by cross-sectional echocardiogram. The extent of the tumor was well demonstrated by magnetic resonance imaging. The tumor was removed successfully and proved to be low grade fibrosarcoma. Modern technics can be very helpful in the diagnosis of pericardial tumor.

Limb salvage for extremity sarcoma in Ramathibodi Hospital.

From May 1986 to July 1991, a retrospective review of 27 patients treated with limb salvage surgery for extremity sarcomas, was evaluated by our team. There were 12 males and 15 females with a mean age of 22.7 years (ranging from, 9 to 53 years). The mean of the follow-up period was 27.6 months. (ranging from 6 to 62 months). Twenty-four patients had bone sarcomas which included 20 osteosarcomas, 3 chondrosarcomas and one adamantinoma. The locations of bone sarcomas were the proximal tibia (6 cases), distal femur (5 cases), proximal humerus (4 cases), proximal fibula (3 cases), scapula (3 cases), proximal femur (1 case), tibial shaft (1 case) and pelvis (1 case). The remaining three patients had malignant fibrous histiocytomas located in scapular, tibialis anterior muscle, and knee regions. In total there were 1 stage IA, 2 stage Ib, 1 stage IIA and 23 stage IIB. Twenty-four cases had wide excisions; two had marginal excisions and one radical excision. There were 17 bone reconstructions consisting of 11 allografts and 6 autografts. At the most recent follow-up examination, 74 per cent of the patients are alive and the overall disease free survival was 63 per cent. Local recurrences occurred in 11 per cent. The major complication rate was 3 per cent and the minor complication rate was 33 per cent. With respect to a functional outcome, 84 per cent of the patients achieved excellent or good results.(ABSTRACT TRUNCATED AT 250 WORDS)

Malignant osteoblastoma versus osteosarcoma: a case report.

A 33-year-old male developed a slow-growing mass at the anterior aspect of the left tibia for 8 months. The radiologic finding revealed a well-circumscribed osteolytic mass and appeared benign to most radiologists. The lesion was then excised locally. The histology revealed bizarre osteoblasts and osteoclast-like giant cells interspersing in the vascularized stroma and trabeculated osteoids; the periphery of the lesion showed sclerotic mature bones. Malignant osteoblastoma was, therefore, entertained and the patient was treated as such without aggressive surgery and chemotherapy. He has survived for 11 years. However, the diagnosis of malignant osteoblastoma was still a contradiction because of the presence of cartilage foci.

Metastatic bone tumors in Ramathibodi Hospital, Thailand during 1985-90.

The study was aimed to analyse the histologic typings of metastatic bone tumors, age of patients and skeletal distributions in Ramathibodi Hospital. There were 122 cases of metastatic bone tumors out of 217 cases of all malignant bone tumors as retrieved from the files of surgical records in the Department of Pathology, Ramathibodi Hospital from 1985 to 1990. Approximately 80 per cent of metastatic bone tumors were carcinomas of which adenocarcinoma was the most common and accounted for 44.3 per cent of all metastatic bone tumors. The most common site of biopsy which possibly reflects the skeletal distribution of metastases was the vertebra which accounted for 35 per cent. The average age of patients presenting with metastatic carcinomas was about 50 years which was comparable to those of other series. It was obvious that biopsy of metastatic lesions was helpful in narrowing the scope of investigation but could hardly define the primary sites without further investigations.