Human granulocytic ehrlichiosis in pancreas transplant recipients.

Human ehrlichioses are tick-borne infections caused by bacteria in the genus Ehrlichia of the family Rickettsiaceae. To date there have been three cases of ehrlichiosis reported in the transplant population, a human monocytic ehrlichiosis (HME) infection in a liver transplant recipient and two cases of human granulocytic ehrlichiosis (HGE) in kidney transplant recipients. We report three pancreas transplant patients who developed HGE in the last two years at a single southeastern center in the United States. All three patients had clinical, laboratory, and pathophysiologic findings on bone marrow biopsy and peripheral blood smears consistent with HGE, and responded to doxycycline therapy. In the setting of potent immunosuppression, ehrlichiosis should be considered in the differential diagnosis of transplant patients presenting with persistent fever, pancytopenia, and abnormal liver function. Patients with ehrlichiosis infection may be at risk for developing other opportunistic infections or lymphoproliferative disease.

Correlation between Banff classification, acute renal rejection scores and reversal of rejection.

The Banff classification of acute rejection is based on histologic grades and scores for borderline changes, glomerular, vascular, interstitial and tubular lesions. We reviewed 56 episodes of acute rejection occurring in 44 kidney allograft recipients (30 cadaveric and 14 living donor transplants), comparing Banff classification to degree of reversibility of rejection. Rejection reversal was defined as complete if serum creatinine returned < or = 25% of baseline, partial if creatinine was > 25% to < 75% of baseline, and irreversible if creatinine was > or = 75% of baseline or graft loss occurred. Eight biopsies were classified as borderline (SUM score 1.6 +/- 0.5), 14 grade I (SUM score 3.3 +/- 0.4), 19 grade II (SUM score 4.2 +/- 0.3), and 15 grade III (SUM score 8.5 +/- 0.4). SUM distinguished borderline and grade III rejections, but not grades I and II. Clinically, grade and SUM score correlated with rejection reversal. Complete reversal of rejection occurred in 93% of patients with grade I rejection, while 47% of patients with grade III had irreversible rejection. The mean SUM for complete reversal was 3.9 +/- 0.34 and was different from SUM of partial (6.0 +/- 0.86) and irreversible (8.5 +/- 0.93), P < 0.006. Meanwhile, vascular scores were similar for rejections with complete (0.9 +/- 0.2) or partial (1.0 +/- 0.4) reversal, but significantly higher in those with irreversible rejection (3.0 +/- 0.4, P < 0.000). Likewise, mean scores for tubulitis and interstitial inflammation were significantly higher for irreversible rejection. Resolution of rejection by steroids was correlated to low vascular score (steroid sensitive 0.65 +/- 0.25 vs. steroid resistant 1.42 +/- 0.18, P < 0.01), and low SUM score (steroid sensitive 3.7 +/- 0.5 vs. steroid resistant 5.22 +/- 0.43, P < 0.04). Neither scores for tubulitis nor interstitial cellular inflammation were predictive of steroid sensitivity. These data demonstrate that Banff scoring has clinical relevance in predicting rejection reversal and has implications to first-line therapy of rejection episodes.

Nephrogenic adenoma in a urethral diverticulum. A case report.

A nephrogenic adenoma was identified histologically in the excised specimen of a urethral diverticulum. Urethral diverticulum is a relatively common disorder of the female lower urinary tract, and nephrogenic adenoma is an extremely rare finding: this is the 13th reported case of this association. Of clinical importance is the close histopathologic resemblance of nephrogenic adenoma to clear cell adenocarcinoma. Nephrogenic adenoma is a benign metaplastic change of the urothelium in response to repair.

The presentation of adenocarcinoma of the uterine cervix.

BACKGROUND: Among malignancies of the uterine cervix, the percentage of adenocarcinomas seems to have increased in recent reports. METHODS: The clinical presentation of adenocarcinoma of the uterine cervix during the past 25 years was examined by review of charts and pathologic specimens. The data of a total of 124 patients with cervical adenocarcinoma treated between 1964 and 1988 were evaluated. RESULTS: During the 25-year period, the percentage of adenocarcinoma among all cervical malignancies increased from 9% to 25%. In addition, the average number of new cases per year increased from 3.7 to 10.8. The percentage of women young than 35 years with adenocarcinoma increased from 16% in 1964 to 24% in 1989. Of these younger women, 74% had disease discovered by cytopathology, in comparison with 27% of the patients who were older than 35 years. The overall percentage of patients with disease diagnosed by cytology increased from 24% in the first half to 39% in the second half of the study period. Vaginal bleeding was the most common symptom. In the entire period, 57% of patients had International Federation of Gynecology and Obstetrics (FIGO) Stage I disease, with a median tumor diameter of 1 cm in patients with no symptoms and 3 cm in patients with symptoms. Outcome was inversely related to stage, tumor volume, and the presence of lymph node metastasis but not to histologic tumor type. CONCLUSION: The frequency of adenocarcinoma of uterine cervix is increasing in patients 35 years or younger. Cytopathology is a good screening tool for these patients, leading to earlier diagnosis and improved outcome.