Detection of Hantavirus during the COVID-19 Pandemic, Arizona, USA, 2020.

We identified 2 fatal cases of persons infected with hantavirus in Arizona, USA, 2020; 1 person was co-infected with SARS-CoV-2. Delayed identification of the cause of death led to a public health investigation that lasted ≈9 months after their deaths, which complicated the identification of a vector or exposure.

Intersecting Paths of Emerging and Reemerging Infectious Diseases.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) shares common clinicopathologic features with other severe pulmonary illnesses. Hantavirus pulmonary syndrome was diagnosed in 2 patients in Arizona, USA, suspected of dying from infection with SARS-CoV-2. Differential diagnoses and possible co-infections should be considered for cases of respiratory distress during the SARS-CoV-2 pandemic.

Schwannomatosis: the overlooked neurofibromatosis?

OBJECTIVE: Schwannomas are typically benign tumors that occur sporadically, in neurofibromatosis type 2 (NF2), or in an entity called "schwannomatosis." Schwannomatosis patients develop multiple schwannomas without involvement of the vestibular apparatus. Geneticists, neurologists, and pathologists have recognized that schwannomatosis is distinct from NF2, but schwannomatosis remains unfamiliar to many radiologists. This article reviews the current medical literature, highlighting the similarities and differences between the schwannomatosis and NF2 phenotypes, genotypes, clinical manifestations, management considerations, and imaging findings. CONCLUSION: Imaging plays a critical role in diagnosing schwannomatosis, and a basic understanding of this syndrome is of interest to diagnostic radiologists. Moreover, it is imperative that radiologists be able to differentiate schwannomatosis from NF2 on imaging because there are significant differences in the management of these two diseases and clinical outcomes for affected patients.

A case of natalizumab-associated progressive multifocal leukoencephalopathy with repeated negative CSF JCV testing.

The development of progressive multifocal leukoencephalopathy (PML) in patients treated with natalizumab is a well-known potential risk. Diagnosis of PML can be confounded in patients with multiple sclerosis (MS) if new demyelinating lesions develop, and the sensitivity of existing diagnostic tests is less than ideal. In the case presented here, four samples of cerebrospinal fluid tested negative for John Cunningham virus (JCV) DNA by polymerase chain reaction, yet brain biopsy eventually proved positive by immunohistochemistry. A review of the limitations of existing clinical diagnostic tests is addressed, and we review the most recent literature on the proper management of natalizumab-treated MS patients.

T-cell lymphoblastic lymphoma/leukemia presenting as a pituitary mass lesion: a case report and review of the literature.

We present a rare case of primary T-cell lymphoblastic lymphoma of the pituitary gland. A 58-year-old woman presented with headaches, right-sided ptosis and cranial nerve III palsy. She subsequently developed polyuria, polydipsia, and hyperglycemia and was found to have hypopituitarism. MRI revealed a large, heterogeneously enhancing intrasellar/suprasellar lesion displacing the optic chiasm and extending into the right cavernous sinus. Radiologically, these findings were thought to represent an invasive pituitary adenoma. Pterional craniotomy was performed with subtotal tumor resection. Histopathological examination revealed a T-cell lymphoblastic lymphoma/leukemia (T-LBL) admixed with pituitary corticotrophic cell hyperplasia. CT scans of the chest, abdomen and pelvis showed no evidence of systemic disease. Analysis of peripheral blood and bone marrow, including flow cytometry, demonstrated no involvement by T-LBL. Follow-up MRI of the spine revealed abnormalities in the distal thoracic spinal cord and conus medullaris, raising suspicions of leptomeningeal dissemination. Only five case reports of T-cell primary pituitary lymphoma (PPL) have been previously described, four of which were associated with hypopituitarism and/or concurrent pituitary adenoma. We present the first report of a T-cell PPL associated with adenohypophyseal hyperplasia and the third documented occurrence of a primary pituitary T-LBL.

Trends in Officer-involved Firearm Deaths in Oklahoma from 2000 to 2015.

The purpose of this study was to collect data and disseminate trends in officer-involved firearm deaths in Oklahoma from 2000 to 2015. The Oklahoma Office of the Chief Medical Examiner (OCME) database was searched for civilian decedents with gunshot wounds inflicted by law enforcement officers and officer decedents with gunshot wounds inflicted by civilians. Five decedents were law enforcement officers, while 274 decedents were civilians. The number of civilian decedents throughout the study followed a quadratic trend. Civilian decedents were most commonly males (95%) between the ages of 20 and 39 (64%), had one or two gunshot wounds (46%), and had an increasing number of gunshot wounds over time. Postmortem toxicology testing most commonly detected ethanol, methamphetamine, cocaine, and PCP. Efforts toward increased tracking by various agencies and more scientific studies like this are needed to facilitate future analysis of trends in officer-involved firearm deaths.

Synthetic cannabinoid drug use as a cause or contributory cause of death.

Adverse effects associated with synthetic cannabinoid use include agitation, psychosis, seizures and cardiovascular effects, all which may result in a lethal outcome. We report the collection of data from 25 medical examiner and coroner cases where the presence of synthetic cannabinoids was analytically determined. Participating offices provided case history, investigative and relevant autopsy findings and toxicology results along with the cause and manner of death determination. This information, with the agency and cause and manner of death determinations blinded, was sent to participants. Participants offered their opinions regarding the likely contribution of the toxicology findings to cause and manner of death. The results show that some deaths are being attributed to synthetic cannabinoids, with the highest risk areas being behavioral toxicity resulting in excited delirium, trauma or accidents and as contributing factors in subjects with pre-existing cardiopulmonary disease. While insufficient information exists to correlate blood synthetic cannabinoid concentrations to effect, in the absence of other reasonable causes, the drugs should be considered as a cause or contributory cause of death based on history and circumstances with supporting toxicological data.

Dissecting Thoracic Aortic Hematoma Masquerading as Blunt Force Injury of the Neck.

Discoloration of the skin of the anterior and lateral neck may raise suspicion for blunt force injury, particularly cervical compression, in an unwitnessed death. We present a case of an elderly woman with an unwitnessed death at home which highlights an external examination finding of blue/purple discoloration of the skin of the neck and links this finding with those from internal examination at autopsy. Pertinent negatives include absence of conjunctival and mucosal petechiae, absence of cutaneous abrasions of the neck, and absence of contusions of the anterior neck musculature. This case illustrates a natural disease entity, spontaneous dissection of a thoracic aortic hematoma, masquerading as blunt force injury externally and highlights the importance of having an appropriate index of suspicion when triaging jurisdictional cases for postmortem examination to accurately determine cause and manner of death.

A rare fatality attributed solely to metaxalone.

Metaxalone (Skelaxin) is a prescription medication used primarily as a centrally acting skeletal muscle relaxer and is rarely implicated in drug fatalities. We present a case study involving a relatively young decedent where metaxalone is implicated as the sole agent causing death with little in the way of confounding factors. The concentration of metaxalone in hospital admission blood was determined to be 37.4 mcg/mL. In postmortem specimens the concentrations were shown to be 13.5 mcg/mL (heart blood), 4.9 mcg/mL (vitreous humor), 69.4 mcg/g (liver) and 74.0 mcg/g (brain). Additionally a blood-to-plasma (b/p) ratio was estimated using antemortem blood and serum specimens taken at the same time on the second day following admission. The b/p ratio was calculated to be 1.4 implying a higher proportion of the drug to be found in whole blood versus plasma/serum samples, an important factor which should be taken into account when comparing blood concentrations to published therapeutic ranges determined in serum/plasma.

The pathological spectrum of solid CNS metastases in the pediatric population.

OBJECT: Collectively, metastatic tumors are the most common malignancy encountered in the adult central nervous system (CNS), arising most often from lung, breast, skin, and gastrointestinal tract carcinomas. Limited information is available in the literature regarding solid nonhematopoietic CNS metastases in children. The authors carried out a retrospective study of pediatric metastatic neoplasms to the CNS treated in a 30-year period to characterize their frequency, common histological subtypes, and sites of origin. METHODS: The archival pathology files were searched (1981-2011) for metastatic tumors to the CNS in patients 21 years of age and younger. Pathology material was reviewed, tumors were classified by site of origin and histological subtype, and survival was evaluated. RESULTS: The authors identified 26 patients with solid nonhematopoietic CNS metastases out of 1135 pediatric CNS tumors diagnosed from 1981 to 2011. Patients ranged in age from 1.5 to 20.3 years and were equally divided between sexes. Most CNS metastases were supratentorial (85%) and solitary (65%). The mean interval from primary malignant diagnosis to CNS metastasis was 27 months. Sites of origin included kidney/adrenal, bone/soft tissue, gonads, head and neck, lung, and liver. Mean survival after CNS involvement was 36.6 months. Overall 1-year and 5-year survival rates were 52% and 16%, respectively. CONCLUSIONS: In neuropathology practice, nonhematopoietic pediatric CNS metastases are far less common than are nonhematopoietic adult CNS metastases, accounting for approximately 2% of all pediatric CNS tumors. The most common tumors to exhibit CNS metastasis are of kidney/adrenal origin, followed by those from bone/soft tissue. As expected, prognosis is dismal, despite aggressive therapy.

Luminal subtypes predict improved survival following central nervous system metastasis in patients with surgically managed metastatic breast carcinoma.

CONTEXT: Metastatic breast cancer to the central nervous system (CNS) is second only to lung cancer metastasis to the CNS in frequency. Patients with triple-negative primary breast cancer and those with human epidermal growth factor receptor 2 (HER2)-positive primary breast cancer are at an increased risk for metastasis. Very little is known about predictive or prognostic variables once patients develop CNS metastases. Currently, therapeutic options are limited, with surgery generally offered primarily to those with solitary lesions. OBJECTIVES: To determine the influence of molecular subtypes of metastatic breast cancer on survival from the time of CNS metastasis and to aid in the prognostic stratification of these patients. DESIGN: We identified 59 cases of metastatic breast cancer to the CNS and analyzed them for various demographic and clinicopathologic parameters. Tumors were categorized into molecular subtypes using immunohistochemical methods: luminal A [estrogen receptor (ER⁺)/Ki67low], luminal B (ER⁺/Ki67 high), intrinsic HER2 (ER⁻/HER2⁺), and triple-negative. Survival after CNS metastasis for each group was plotted using a Kaplan-Meier curve, and multivariate analysis was performed. RESULTS: Patients with metastases from luminal tumors had a statistically significant survival advantage when compared with those of the triple-negative phenotype. Importantly, survival among patients with luminal A and luminal B tumors was not significantly different. Similarly, patient's age, histologic grade, and number of lesions did not contribute to determining outcomes. CONCLUSIONS: Estrogen receptor positivity (ie, luminal phenotype) of tumors appears to determine outcomes after development of metastases. In contrast, proliferation rate had little or no effect on the long-term survival. Understanding the biology of metastases can help stratify patients into prognostically meaningful categories and tailor treatment regimens for individual patients.

Polysomy of chromosomes 1 and/or 19 is common and associated with less favorable clinical outcome in oligodendrogliomas: fluorescent in situ hybridization analysis of 84 consecutive cases.

It is well established that the combined del(1)(p36) and del(19)(q13) is a positive prognostic molecular event in oligodendroglial tumors. However, very little is known about the frequency or impact of polysomy status for chromosomes 1/19. We examined 84consecutive pure oligodendrogliomas (68 World Health Organization [WHO] grade II and 16 WHO grade III) and analyzed them for del(1)(p36) and del(19)(q13) by fluorescent in situ hybridization. Polysomy status was recorded with accompanying deletion status, WHO grade, recurrence-free survival, and overall survival. Codeletion of 1p/19q was detected in 48% of cases and correlated with superior patient survival (p < 0.01), as expected. Of 84 cases, 36 (43%) showed polysomy of chromosome 1, 30 (36%) demonstrated polysomy of chromosome 19, and 28 (33%) had copolysomies of chromosomes 1/19. The presence of polysomy of either/or both chromosomes, regardless of deletion status, correlated with younger patient age at initial diagnosis (p < 0.01). Combined polysomy was associated with higher histologic tumor grade (p = 0.04) and conferred poor survival likelihood (p = 0.03). We conclude that polysomy of 1 and/or 19 is a relatively frequent occurrence in oligodendrogliomas and usually confers an unfavorable outcome.

Lateral posterior fossa encephalocele with associated migrational disorder of the cerebellum in an infant.

Encephaloceles are acquired or congenital defects in which intracranial contents protrude through a defect in the calvaria. The embryogenesis of these lesions is incompletely understood. The vast majority of lesions occur at or near the anatomical midline. The authors present an extremely rare case of a laterally oriented, pathologically proven encephalocele associated with a posterior fossa cyst and cerebellar migrational defect in an infant. The authors review past and current theories of encephalocele formation as it relates to this case.