αB-crystallin negative astrocytic inclusions.

We report on an unusual pathological finding of astrocytes, observed in the brain of a 16-year-old African-American male with severe intellectual disability and spastic quadriplegia. The brain showed bilateral pericentral, perisylvian polymicrogyria and pachygyria, in conjunction with a large number of hypertrophic astrocytes with eosinophilic granular cytoplasmic inclusions. The astrocytic abnormality was more severe in the dysgenetic area but present throughout the cerebral cortex. Astrocytic inclusions stained with acid fuchsin, azocarmine and Holzer's stain, and were immunoreactive for GFAP, S-100, and ubiquitin, but not for αB-crystallin, filamin, vimentin, nestin, tau or α-synuclein. Based on the case and a review of the literature, the authors postulate that these astrocytic inclusions in the cerebral cortex reflect abnormalities in radial glial developmental processes, such as migration, differentiation, or glial-neuronal interaction function during neuronal migration.

Characterization of human mesenchymal stem cell-engineered cartilage: analysis of its ultrastructure, cell density and chondrocyte phenotype compared to native adult and fetal cartilage.

The production of engineered cartilage from mesenchymal stem cells is a rapidly developing field. Potential applications include the treatment of degenerative joint disease as well as the treatment of traumatic and surgical bone injury. Prior to clinical application, however, further characterization of the morphology, ultrastructure, biocompatibility, and performance of the engineered tissue is warranted. To achieve this, human mesenchymal stem cells (hMSCs) were grown in vitro in pellet culture for 3 weeks in chondrogenic medium conditions. The resultant engineered cartilage was compared to native adult and fetal tissue. Routine histology, special stains, and ultrastructural and quantitative histomorphometric analyses were performed. The engineered tissue demonstrated a similar chondrocyte phenotype, collagen fibril appearance, and matrix distribution when compared to native cartilage. By histomorphometric analysis, the cell density of the engineered cartilage was between that of native fetal and adult cartilage. The cell-to-matrix ratio and cellular area fraction of engineered cartilage samples was significantly greater than in adult samples, but indistinguishable from fetal cartilage samples, supporting the hypothesis that hMSC-engineered cartilage regeneration may mimic fetal cartilage development.

Henrietta Lacks, HeLa cells, and cell culture contamination.

Henrietta Lacks died in 1951 of an aggressive adenocarcinoma of the cervix. A tissue biopsy obtained for diagnostic evaluation yielded additional tissue for Dr George O. Gey's tissue culture laboratory at Johns Hopkins (Baltimore, Maryland). The cancer cells, now called HeLa cells, grew rapidly in cell culture and became the first human cell line. HeLa cells were used by researchers around the world. However, 20 years after Henrietta Lacks' death, mounting evidence suggested that HeLa cells contaminated and overgrew other cell lines. Cultures, supposedly of tissues such as breast cancer or mouse, proved to be HeLa cells. We describe the history behind the development of HeLa cells, including the first published description of Ms Lacks' autopsy, and the cell culture contamination that resulted. The debate over cell culture contamination began in the 1970s and was not harmonious. Ultimately, the problem was not resolved and it continues today. Finally, we discuss the philosophical implications of the immortal HeLa cell line.

Vascular and apoptotic changes in the placode of myelomeningocele mice during the final stages of in utero development.

OBJECT: Myelomeningocele (MMC) is a primary neurulation defect that is associated with devastating neurological disabilities in affected newborns. To better characterize the in utero neurodegenerative process of MMC, the authors investigated the changes in vascular organization, apoptosis, and the presence of inflammatory cells during gestation by using a mutant mouse model of MMC. METHODS: The curly tail/loop tail (ct/lp) mutant mouse model of MMC was chosen to obtain fetuses at different stages of gestation. Mouse fetuses harboring MMC were harvested by caesarean section at embryonic Days 14.5, 16.5, and 18.5 (complete mouse gestation at 19 days, 6 mice/group); littermate fetuses with the same gestational age but without an MMC were used as controls. Samples of the MMC placode or normal spinal cord were stained for immunocytochemical labeling with caveolin antibody (endothelium marker) and activated caspase-3 antibody (apoptosis marker). Samples were morphometrically analyzed with a computer-assisted image analyzer. RESULTS: The MMC mice presented with an increase in vascular density from embryonic Days 16.5-18.5 and an enhanced number of apoptotic cells at embryonic Day 18.5, compared with controls. There were scarce signals of an inflammatory reaction in the MMC placode, as a few infiltrating neutrophils were seen only at embryonic Day 18.5. CONCLUSIONS: Fetal placodes in MMC mice showed evidence of increased vascular density since embryonic Day 16.5 and increased apoptosis at embryonic Day 18.5. These new data support the view that in utero changes of the MMC placode, occurring during the last stages of gestation, contribute to the neuropathological manifestations in full-term newborns with MMC.

Immunocytochemical characterization of astrocytosis along the spinal cord of loop-tail/curly-tail mice with myelomeningocele.

BACKGROUND: The neurological deficits of myelomeningocele (MMC) have been attributed both to a primary neurulation defect and to a secondary injury of the placode in the intrauterine environment. Since astrocytes are involved in glial scar formation after spinal cord injury, the characterization of astrocyte density along the spinal cord upstream of the MMC can be used as a surrogate marker of the extension of the injury beyond the MMC. METHODS: The curly-tail/loop-tail murine model was applied to obtain newborn mice with MMC. The astrocyte density and topography both at the MMC placode level and at the upper segments of the spinal cord was characterized by immunolabeling using the anti-glial fibrillary acidic protein antibody. This was followed by a qualitative evaluation of immunolabeled cells and morphometric analysis of the samples. RESULTS: The topography of astrocytes in the spinal cord of MMC newborn mice was compared with that of newborn control mice (without spina bifida aperta) (n = 8/group). The anti-glial fibrillary acidic protein immunoreactivity was significantly increased in the MMC samples in comparison with the normal spinal cord, indicating the presence of an astrocytic response. Increased astrocytosis was also observed in the transitional area located above the MMC. The astrocytosis decreased progressively along the MMC spinal cord until matching the pattern of the control spinal cords. This transitional area involved a segment of the spinal cord with a length of 240 microm in the newborn mouse. CONCLUSIONS: MMC newborn mice show spinal cord injury that is located upstream of the exposed placode and is characterized by proliferation of astrocytes. This finding offers further support for the hypothesis of a tethering mechanism as part of the spinal cord injury observed in MMC newborns.

Did Sir William Osler perform an autopsy at the Johns Hopkins Hospital?

Sir William Osler was the preeminent internist of his time, who also worked as a pathologist for a considerable period during his career. Between 1876 and 1889, he performed nearly 1000 autopsies in Montreal, Quebec, and Philadelphia, Pa. Many authors concluded that Osler stopped performing autopsies once he moved to Baltimore, Md, because the autopsy service was organized under William Welch, the professor of pathology. However, this assertion has been contradicted by a recent biography of Dr Osler. To reexamine this issue, the autopsy records of The Johns Hopkins Hospital and relevant publications were examined. The evidence suggests that Dr Osler was an enthusiastic, and sometimes engaged, observer of Hopkins autopsies but that he did not function as an autopsy prosector.

Multifocal ischemic necroses of varying age (MINOVA): A distinctive form of atherosclerotic heart disease.

While reviewing the cardiac histopathology and the postmortem arteriography of patients studied at autopsy, a collection of findings was identified in a small proportion of those with ischemic heart disease. These included varying degrees of hypertrophy and left ventricular dilation and severe multifocal atherosclerotic obstruction of the coronary arteries by gross examination. Histology showed multiple small foci of coagulation or contraction-band necrosis in a circumferential, subendocardial pattern; focal replacement fibrosis of varying ages and size; focal atrophy or vacuolization (a marker of chronic ischemia) of surviving myocytes; and marked dilation of the subendocardial vasculature. This collection of findings described here is termed multifocal ischemic necroses of varying age (MINOVA). Review of patient histories showed that the clinical suspicion for the degree of ischemic heart disease did not correlate well with the severity of the pathological findings.

Idiopathic infantile arterial calcification: the spectrum of clinical presentations.

Idiopathic infantile arterial calcification (IIAC) is a rare disorder characterized by extensive calcification of medium and large arteries. We report the case of a 32-week-old infant with hydrops fetalis and heart failure who died at 4 days of age. At autopsy the infant was found to have cardiomegaly, myocardial infarctions and multifocal calcifications of the aorta and arteries in the lungs, heart, thyroid, spleen, and testis. Calcification extended from the internal elastic lamina into the intima and media and was associated with a giant-cell reaction and smooth muscle proliferation. A search of the English language medical literature identified 161 IIAC case reports. Of these, 48% of cases presented in utero or at birth with hydrops fetalis, maternal hydramnios, heart failure, or respiratory distress and 52% present later, at a median age of 3 months, with sudden onset of fever, vomiting, irritability, or respiratory distress in a previously healthy infant. Significantly, 19 of 22 IIAC survivors presented at less than 2 weeks of age, and 15 survivors were treated with diphosphonates.

In utero topographic analysis of astrocytes and neuronal cells in the spinal cord of mutant mice with myelomeningocele.

OBJECT: Myelomeningocele (MMC) is the most severe form of spina bifida causing severe neurological deficits. Injury to the placode has been attributed to in utero aggression. In this study, glial and neuronal cell changes in both number and topography in mice with MMC were investigated during gestation. METHODS: The curly tail/loop-tail mice model of MMC was used, and fetuses were harvested using caesarean surgery at Days 14.5, 16.5, and 18.5 (full gestation at 19 days). Immunohistochemical analyses of the MMC placodes and the normal spinal cords from the control group were performed using anti-glial fibrillary acidic protein (astrocytes) and mouse anti-neuronal nuclear (neurons) antibodies. Light microscopy was used along with computer-assisted morphometric evaluation. Progressive increases in astrocytes in the spinal cord of all mouse fetuses were found between Days 14.5 and 18.5 of gestation. This increase was significantly higher in the placodes of mice with MMC than in those of normal mice, particularly in the posterior region. Neuronal labeling at Day 14.5 of gestation was similar between mice with MMC and control mice. At Day 16.5 of gestation there was a deterioration of neural tissue in MMC fetuses, mainly in the posterior region, progressing until the end of gestation with a marked loss of neurons in the entire MMC placode. CONCLUSIONS: This study delineated the quantitative changes in astrocytes and neurons associated with MMC development during the late stages of gestation. The detailed topographic analysis of the MMC defines the timing of the intrauterine insult and how the placode lesions progress. This study supports the current concept of placode protection through in utero surgery for fetuses with MMC.

Haemophilus influenzae serotype f purulent pericarditis: a cause of death in a child with Down syndrome.

Purulent pericarditis is a cardiac emergency that can be difficult to diagnose and can be rapidly fatal. We report the case of a child with Down syndrome and recent atrial and ventricular septal defect repair who died from Haemophilus influenzae serotype f pericarditis.

Max brödel: illustrating healed valve ring abscesses.

A 14-year-old adolescent girl presented with severe congestive heart failure, progressive throughout 3 months. A precordial thrill, machinery-like murmur, and right bundle branch block were noted. Death occurred despite digitalis and diuretic therapy and removal of pleural and ascitic fluid. The autopsy revealed 2 multilocular cystic structures in the interventricular septum consistent with being spontaneously drained valve ring abscesses. One of these lesions formed a fistulous communication that penetrated through the interventricular septum between the right aortic sinus of Valsalva and the crista supraventricularis that connected to the right ventricle. Another lesion, an adjacent separate but similar cystlike structure, communicated only with the left ventricular cavity. Although the cause of these lesions is uncertain, it seems probable that they are the residue of spontaneously drained and healed valve ring abscesses. Max Brödel, a medical illustrator and the first director of the Department of Art as Applied to Medicine at The Johns Hopkins University, drew previously unpublished figures of this patient's cardiac lesions. These illustrations exhibit Brödel's superb command of both art and medicine essential to his ability to make complex anatomic relationships demonstrable. We discuss Brödel's career and his influence on both the art and science of medicine.

Progression of liver pathology in patients undergoing the Fontan procedure: Chronic passive congestion, cardiac cirrhosis, hepatic adenoma, and hepatocellular carcinoma.

BACKGROUND: Staged palliative surgical procedures have been an effective treatment of complex congenital heart defects. The Fontan procedure has been of particular benefit to infants with functional single-ventricle complexes but with the consequence of a sustained increase of right-sided venous pressure. METHODS: We reviewed the clinical and pathologic features of 9 autopsied patients having undergone the Fontan procedure, with special attention given to their liver pathology. RESULTS: The 9 patients died from a few hours to 18 years after the Fontan operation. Chronic passive congestion was seen in 7 patients, and 4 patients surviving 4 to 18 years also had cardiac cirrhosis. Hepatic adenoma in the setting of cardiac cirrhosis was found in a patient surviving for 9 years. One patient surviving for 18 years had hepatocellular carcinoma superimposed on cardiac cirrhosis. Rupture of the hepatoma in this case led to fatal hemorrhage. CONCLUSION: The study shows that chronically increased hepatic venous pressure from the Fontan procedure might lead to chronic passive congestion, cardiac cirrhosis, hepatic adenoma, and hepatocellular carcinoma.

Postoperative gastric rupture in children with cerebral palsy.

Children with cerebral palsy (CP) develop difficulties with swallowing and bowel motility, although the underlying etiology of these disorders is unclear. The authors identified three children treated at their institution in the past 6 years who developed severe gastrointestinal dysfunction leading to gastric rupture after orthopaedic surgery; all three had a history that included CP (subtype spastic quadriparesis), low cognitive function, and gastrointestinal motility disorders. All three cases were fatal; in two patients the diagnosis was made at autopsy. No case of postoperative gastric rupture has been identified in children undergoing orthopaedic surgery without concomitant CP at the authors' institution. In this case series, they describe the preoperative and postoperative course of these three children. Since the only cure for gastric rupture is prompt surgical attention, orthopaedists should consider gastric rupture in the differential diagnosis of a postsurgical CP patient who becomes acutely unstable.

Autopsy findings of a 37-year-old man with a complex mosaic karyotype involving del(18p), monosomy 13, and trisomy 20.

We report on the autopsy findings of a 37-year-old man with a complex karyotype (mos46,XY,del(18)(p11.1)[14]/46,XY, -13, del (18)(p11.1), +20[8]/47,XY,del(18)(p11.1), +20[8]). He was known to be blind, non-ambulatory, have severe mental retardation, and a seizure disorder. External physical findings at the time of autopsy included micrognathia, short stubby fingers, and rocker bottom feet. Left lobe dominance of the liver and mislocation of the ileocecal junction and appendix were noted on internal examination. The brain was small (700 g) and poorly developed. Microscopically it showed an absence of neurons in the olivary and dentate nuclei, absence of Purkinje cells in the cerebellum, severe depletion of internal granular cells in the cerebellum, and cerebellar dysplasia. Fat infiltration was noted in an unusual distribution in several organs including a pattern in the heart consistent with arrythmogenic right ventricular dysplasia (ARVD). Findings of this mosaic chromosomal karyotype have not been previously described. This report will discuss this individuals physical findings and their relation to similar monochromosomal aberrations.

William H. Welch, MD, and the discovery of Bacillus welchii.

William H. Welch, MD, and his colleagues performed an autopsy at The Johns Hopkins Hospital in October 1891 on a 38-year-old man and discovered a new bacterium, Bacillus aerogenes capsulatus. During the postmortem examination, gas bubbles were noted within many of the patient's blood vessels. Welch's laboratory personnel determined that a previously unknown bacterium was the source of the gas. Through a series of experiments, the organism's characteristics were described and its pathophysiology was detailed, findings that proved accurate in explaining gas gangrene during World War I. Welch never followed up these initial investigations with more experimentation. His subsequent writings regarding the bacterium that came to be known, appropriately, as Bacillus welchii consisted mostly of case reports from other medical institutions and summaries of previous data.

Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are distinct pathologic entities. A review of 56 autopsy cases.

CONTEXT: Thrombotic thrombocytopenic purpura (TTP) and the hemolytic uremic syndrome (HUS) share many clinical features and have been difficult to separate into distinct entities. Histologic examination of organs from autopsied patients suggested that TTP and HUS have dissimilar lesions of different severity and distribution. OBJECTIVE: To perform a retrospective observational review of autopsied patients with TTP or HUS to compare the nature and severity of the lesions found. DESIGN: To examine the pathologic features of these conditions, we reviewed all cases among 51 350 indexed autopsies at The Johns Hopkins Hospital (Baltimore, Md) diagnosed with TTP or HUS, and included those showing multiple arteriolar thrombi or their sequela. RESULTS: The 56 cases that met the inclusion criteria fell into 2 distinct groups, based on distribution and severity of arteriolar lesions. In 25 patients classified as having TTP, platelet-rich thrombi were present-in decreasing severity-in heart, pancreas, kidney, adrenal gland, and brain. In 31 patients with HUS, fibrin/red cell-rich thrombi were present, largely confined to the kidney and often severe, and only 6 cases showed pancreas involvement, 4 adrenal gland involvement, 2 brain involvement, and 1 heart involvement. CONCLUSION: Despite similar clinical features and therapeutic approaches, TTP and HUS each have a characteristic constellation of histopathologic findings. This observation suggests that TTP and HUS are 2 distinct disease entities with different pathophysiologies, and that they do not represent a spectrum of the same disease process.

Pulmonary embolization of bovine collagen.

A bovine collagen matrix is sometimes used as a delivery medium during direct intratumoral injection of a chemotherapeutic agent. The bovine collagen enhances the dose and duration of local drug delivery and limits systemic toxicity. Although this strategy is advocated as a means of easy and effective delivery of chemotherapeutic drugs, the associated risks are not well defined. We report the case of a 71-year-old man with hepatocellular carcinoma who underwent weekly intratumoral injections of cisplatin in a bovine collagen matrix. During the third injection, he suddenly and unexpectedly underwent cardiac arrest and died. An autopsy disclosed diffuse occlusion of the pulmonary microcirculation by bovine collagen. The collagen emboli were associated with an inflammatory infiltrate typical of bovine collagen-induced hypersensitivity. This case identifies a fatal complication of intratumoral chemotherapy injections using a bovine collagen matrix, which does not appear to have been previously reported. This case underscores the valuable role of the traditional autopsy examination as a means of identifying possible complications of novel oncologic strategies, which are being rapidly developed and implemented.

Phimosis as a cause of the prune belly syndrome: comparison to a more common pattern of proximal penile urethra obstruction.

The pathogenesis of the prune belly syndrome (PBS) remains controversial, but two theories predominate. The first theory supports an obstructive phenomenon early in gestation leading to irreversible damage to the genitourinary tract and abdominal wall. The second theory suggests mesodermal injury between the 6th and 10th weeks of gestation as the primary abnormality. This paper reports of two fetuses with the PBS phenotype that were examined postmortem at our institution. Thorough examination of the lower urinary tract allowed demonstration of anatomic obstruction of the urethra in both cases. One case illustrated a relatively common pattern of proximal penile urethral obstruction, a flap-like obstruction between the prostatic and penile urethra. The other case provided what we believe to be the first description of PBS caused by severe phimosis.