Neutrophil recruitment in Clostridium difficile toxin A enteritis in the rabbit.

Neutrophil infiltration is a prominent feature of Clostridium difficile-associated enteritis and colitis. The aim of this study was to examine the importance of neutrophil recruitment and neutrophil-mediated tissue damage in C. difficile toxin A-induced enteritis. Competitive binding experiments using purified 3H-toxin A demonstrated the presence of a single class of medium affinity receptors on rabbit neutrophils (Kd 7 x 10(-8) M). Pertussis toxin and the nonhydrolyzable GTP analog GTPgamma S both inhibited 3H-toxin A binding (by 56 and 65%, respectively), indicating that the rabbit neutrophil toxin A receptor is G protein linked. Toxin A elicited a dose-dependent (25-200 micrograms/ml) stimulation of neutrophil migration in vitro, and this functional effect was also pertussis toxin sensitive (69% inhibition). Treatment of neutrophils with R15.7, a blocking monoclonal antibody to the leuocyte adhesion molecule CD18, inhibited toxin A-stimulated neutrophil migration by 85% in vitro. Pretreatment of rabbits with R15.7 also prevented neutrophil infiltration of toxin A-exposed ileal loops in vivo as determined by histologic examination and by ileal tissue myeloperoxidase levels. Furthermore, R15.7 effected a substantial inhibition of fluid secretion (by 65%), mannitol permeability (by 66%), and histologic damage in toxin A-exposed ileal loops. Anti-CD18 (R15.7) had no inhibitory effect on cholera toxin enterotoxicity. These data demonstrate that C. difficile toxin A is a proinflammatory toxin whose enterotoxic effects are substantially dependent upon neutrophil recruitment.

Synchronous diffuse large B cell lymphomas of the endometrium and breast: a staging dilemma.

BACKGROUND: A 66 years old presented with abnormal postmenopausal vaginal bleeding and was diagnosed with an endometrial lymphoma (diffuse large B cell type, DLBCL). A left breast lesion was found on PET CT which was subsequently biopsy-proven as a separate stage IE DLBCL, but she had no lymph node, bone marrow or spleen involvement. AIMS: This study aimed to review the available literature and discuss the management and staging of synchronous extra-nodal DLBCL's. RESULTS: Our patient was staged as having synchronous stage IE DLBCL's of the endometrium and breast. Subsequent molecular analysis (IgH gene rearrangement analysis) on both lesions, confirmed the two lesions to be clonally unrelated. CONCLUSIONS: Staging of synchronous extra-nodal lymphomas, particularly when they arise in rare sites such as the endometrium and breast, is difficult and previously unreported. We present our rationale for defining our patient's disease as synchronous stage IE DLBCL's.

The celtic coincidence--the frequency and clinical characterisation of hereditary haemochromatosis in patients with coeliac disease.

BACKGROUND: Hereditary Haemochromatosis (HH) and Coeliac disease (CD) are common disorders in Northern European populations, particularly the Irish population. AIMS: To investigate whether there was increased frequency of the two common HFE gene mutations, C282Y and H63D, associated with HH amongst a cohort of CD patients, and to determine the penetrance of the HH associated genotypes in this cohort. METHODS: HFE genotypes of a cohort of CD patients were determined using standard PCR techniques. HFE allele frequencies were compared to those of a previously reported, ethnically similar, cohort of 800 neonates, using Fishers exact test. Patients with HH-associated genotypes were subsequently evaluated. RESULTS: The C282Y and H63D allele frequencies, 24/222 (11%) and 28/222 (13%) respectively, in the CD patients were similar to those of the neonatal group, 171/1600 (11%) and 242/1600 (15%). Eight patients had HH-associated genotypes, of which two demonstrated biochemical evidence of iron overload. CONCLUSION: The HFE mutations associated with Hereditary Haemochromatosis are not more common in Irish CD patients.

Kaposi's sarcoma in women with AIDS.

OBJECTIVE: To describe the presentation and incidence of Kaposi's sarcoma (KS) in a cohort of women infected with HIV and to compare their clinical characteristics with men at the same institution. DESIGN: Retrospective chart and database review. SETTING: Adult clinical AIDS program outpatient clinics at a municipal teaching hospital. RESULTS: One hundred and seven people with KS were found of whom twelve (11.2%) were women. The prevalence of KS in women was 3.6% compared with 9.9% among men (P < 0.001). Women born outside the United States were at increased risk of developing KS (P < 0.05). At initial KS presentation, no difference in HIV stage or CD4 count was found between men and women. Women presented with more advanced KS than men, with increased incidence of non-cutaneous disease (P < 0.001), lymphedema (P < 0.0001), lymph-node disease (P < 0.0001) and visceral disease (P = 0.03). Women had decreased survival after KS diagnosis compared to men, although the difference was not significant (P = 0.41). CONCLUSIONS: KS is not a rare diagnosis in HIV-infected women followed at our institution. Although the increased risk of KS in men is most likely to be related to differences in exposure, the sex-related differences in presentation and course may be due in part to delay in diagnosis. KS should be considered in the spectrum of HIV-related complications in women as well as in men.

Anti-estradiol immunoperoxidase labeling of nuclei, not cytoplasm, in paraffin sections, determines estrogen receptor status of breast cancer.

We evaluated a commercially available polyclonal antibody to 17 beta-estradiol as the basis for an estrogen receptor (ER) assay of breast carcinoma in formalin-fixed paraffin tissues and then compared it with both the ER-ICA antibody in serial paraffin sections and the biochemical assay of corresponding fresh tissue. Using the estradiol antibody, 49 of 50 cases showed some cytoplasmic staining; 38 cases had nuclear staining. Sensitivity and specificity for different proportions of positive nuclear and cytoplasmic staining were calculated using receiver-operator characteristic curves. The optimum correlation with the biochemical assay was obtained with nuclear staining alone. Greater than 30% nuclear positivity as a cut-off point yielded a sensitivity of 76% and a specificity of 82%. The corresponding ER-ICA values in 38 cases yielded a sensitivity of 93% and a specificity of 56%. The methodology for the ER-ICA assay was more technically demanding in paraffin sections than that of the estradiol antibody and considerably more expensive. This study is the first to show that with nuclear staining only, and not cytoplasmic staining, as the parameter of positivity, the immunocytochemical assay of ER with anti-17 beta-estradiol antibody in routinely processed, formalin-fixed, archival material is an accurate and specific method for the determination of the ER status of breast carcinoma.

Analysis of epithelial and lymphoid phenotypic markers in relation to growth pattern of colorectal adenomas.

The relationship of villous to tubular adenomas is poorly understood and often difficult to characterize morphologically. A villous growth pattern in colorectal adenomas has been associated with a higher frequency of high-grade dysplasia. We compared phenotypic markers using immunoperoxidase techniques in paired samples of villous (75% to 100% villous) and pure tubular adenomas matched for size and degree of dysplasia, which were selected by review of 1,000 polyps from our files. The following monoclonal antibodies were used: CAM 5.2 and AE1/AE3 to cytokeratins; B18, D14, B7.1, and B7.8 to four distinct carcinoembryonic antigen epitopes; Leu-M1 and LN3 to HLA-DR antigen; LN2 to invariant chain class II major histocompatibility complex; LN1 and MB2 to B-cell markers; UCHL1 and MT1 to T-cell markers; Leu-7 to natural killer cells; Mac 387 to macrophages; S-100 to Langerhans-type cells; and a polyclonal antibody to secretory component. LN3 reactivity correlated with villous morphology and secretory component correlated with tubular morphology. Combined HLA-DR and secretory component expression discriminated between tubular and villous growth patterns in 12 of 15 pairs of adenomas (P less than .001). LN2 was expressed more frequently than LN3, but did not correlate with growth pattern. Neuroendocrine cells (Leu-7) were more frequent in tubular adenomas. Carcinoembryonic antigen epitopes did not relate to growth pattern. We did not confirm previously reported differences in cytokeratin expression. We concluded that among the markers tested, HLA-DR expression, which may have an immunologic basis, is most characteristic of colorectal adenomas that exhibit a villous growth pattern.

Metastatic adenocarcinoma of an unknown primary site. A comparison of the relative contributions of morphology, minimal essential clinical data and CEA immunostaining status.

Measurement of the relative contributions of morphology alone; minimal essential clinical data; immunohistologic reactivity of a prototypic tumor marker, carcinoembryonic antigen (CEA); and the process by which a pathologist can identify the origin of a metastatic adenocarcinoma of unknown primary site is the subject of this report. To standardize the case material, we used an image digitizing and archival system to present 100 metastatic adenocarcinomas of known primary site as unknowns to two pathologists. The images were selected to show only gland-forming areas of the carcinomas and excluded all normal tissue elements. They were viewed, initially without, and then with, identification of gender and metastatic site. Subsequently, the results of immunoperoxidase staining for CEA, assessed independently by a third pathologist, were provided. Our analysis showed that, overall, the correct primary site was chosen as choice 1, 2, or 3 in 72% and 76%, and as choice 1 in 49% and 47% of cases, respectively. Accuracy was highest for prostatic, ovarian, and breast carcinomas, and lowest for upper-gastrointestinal tract, biliary tract, and pancreatic adenocarcinoma. Statistical analysis showed the largest increments in accuracy in the choice 1 prediction in each tumor category were achieved by provision of minimal essential clinical data. Knowledge of CEA status did not affect overall accuracy; however, it increased the odds of making the correct diagnosis for ovarian, colorectal, and endometrial (both pathologists) carcinomas, and for prostatic, pulmonary and esophago-gastric adenocarcinomas (one pathologist). The study exemplifies a model for the objective measurement of the contribution of ancillary studies, such as immunoperoxidase markers, to the accuracy of pathologic diagnosis.

Differential reactivities of carcinoembryonic antigen (CEA) and CEA-related monoclonal and polyclonal antibodies in common epithelial malignancies.

To evaluate the role of carcinoembryonic antigen (CEA) in solving problems of tumor histogenesis in surgical pathology, monoclonal antibodies to four distinct epitopes of CEA (E-Z-EM) were applied to paraffin sections of 303 epithelial neoplasms from multiple sites. Two epitopes were CEA specific (D14 and B7.1), one was shared with nonspecific cross-reacting antigen (NCA) (B7.8), and the fourth (B18) was common to CEA, NCA, and biliary glycoprotein antigen (BGP). A sample of the tumors (n = 110) was also stained with a polyclonal anti-CEA (DAKO). Gastrointestinal adenocarcinomas, including esophageal and gastric (n = 19), small intestinal (n = 8), colorectal (n = 56), biliary tract (n = 8), and pancreatic adenocarcinomas (n = 14), were consistently positive with all five antibodies. Other predominantly gland-forming carcinomas tested, comprising lung (n = 22), ovary (n = 18), and endometrium (n = 12), were either invariably negative with all five antibodies (endometrial adenocarcinoma, non-mucinous ovarian adenocarcinoma) or demonstrated selective and variable positivity (lung: D14, 50%; ovarian mucinous: D14, 50%). Among large polygonal cell carcinomas (hepatocellular carcinoma, renal cell carcinoma, melanoma, and adrenal carcinoma), only hepatomas stained positively, showing a distinctive canalicular staining pattern with the B18 (BGP epitope) (55%) and polyclonal antibody (50%). In the small polygonal cell carcinoma category, true CEA positivity was rare in breast (D14, 10% and B7.1, 14%) and never seen in prostatic carcinomas and carcinoid tumors. A subset of these breast (8 of 42), prostate (4 of 22), and carcinoids (4 of 7) showed exclusive positivity for the B18 antibody (NCA/BGP epitope). Ovarian serous papillary carcinomas (n = 14), papillary carcinomas of thyroid (n = 12), transitional cell carcinomas of the bladder (n = 11), and mesotheliomas (n = 3) were negative with all monoclonal antibodies. Metastatic carcinomas (n = 74) showed a similar pattern of reactivity to primary tumors. The authors conclude that CEA immunostaining may assist in identifying the histogenesis of epithelial tumors in several morphologic categories; that differential reactivities of the CEA monoclonal antibody panel exceed those of the polyclonal antibody; and that the discriminating power of the monoclonal panel is related to whether (1) CEA is or is not produced or (2) NCA or BGP is produced without concomitant CEA production. There is little evidence to support a concept of site-specific CEA species.

Liver viability after ischemia-reperfusion.

Lack of a reproducible model to quantitatively assess hepatocellular injury following ischemia has made it difficult to assess new strategies for minimizing hepatic injury. We studied the progression of hepatocellular injury after ischemia and ischemia with reperfusion in rats. Irreversible injury was quantitated using a triphenyltetrazolium chloride assay that was shown to correlate with ultrastructural changes. Adenosine triphosphate decreased to 36% of basal values after 30 minutes, but returned to normal with reperfusion with no decrease in viability. In contrast, viability fell by 30% after 60 minutes of ischemia, and by 64% when 60 minutes of ischemia was followed by reperfusion. We conclude that reperfusion of ischemic liver increases the degree of irreversible damage. The model employed here seems to be useful for studying ischemic and reperfusion injury in the liver.

Vascular malformations presenting as spinal cord neoplasms: case report.

Three cases of adult patients with subacute courses of progressive caudal spinal cord disease are presented. Computed tomography, magnetic resonance imaging, and myelographic studies were interpreted preoperatively as representing a spinal cord neoplasm in each case. No evidence of enlarged or abnormal surface vessels was observed by neuroimaging or intraoperatively. Biopsy specimens from each spinal cord lesion showed the typical histopathological features of a spinal vascular malformation. We conclude that vascular malformations of the caudal spinal cord can appear as isolated intramedullary lesions with apparently normal surface vessels and that these lesions may be difficult to distinguish from spinal cord neoplasms.

Primary hepatic lymphoma in a man with chronic hepatitis C.

We report the case of a middle-aged man who presented de novo with abdominal pain and hepatomegaly and was found to have positive serology for hepatitis C and subsequently a primary hepatic lymphoma. An increased incidence of primary hepatocellular cancer is well characterized in both cirrhotic and non-cirrhotic cases of chronic hepatitis C. The relationship between chronic hepatitis C and primary hepatic lymphoma remains obscure. It has been established that hepatitis C can sustain the clonal B-cell expansion that occurs in associated cryoglobulinaemia, and hepatitis C RNA has been detected within extrahepatic lymphoma tissue. Viral aetiologies for lymphoma are well characterized, such as Epstein-Barr virus (EBV) and human T-cell leukaemia virus (HTLV) I and II. Existing models of chronic infection causing lymphoma within the gastrointestinal tract include that of Helicobacter pylori and mucosa-associated lymphoid tumour of the stomach. Given the relatively low frequency of occurrence it may be prudent to perform a retrospective analysis on past cases of primary hepatic lymphoma in order to determine whether or not hepatitis C was present.

The detection of cytokeratins in lymph nodes of Duke's B colorectal cancer subjects predicts a poor outcome.

OBJECTIVES: The objectives of this study were to examine the frequency of lymph node micrometastases detected by keratin immunohistochemistry and their relationship with survival behaviour. METHODS: A total of 133 consecutive patients staged as Duke's B, who had curative resection for colorectal cancer (CRC), comprised the study population. Patients who had died of a non-CRC-related cause or who became lost to follow-up were excluded, resulting in an amended population of 100. Study end-points were defined as disease-free survival of 5 years or CRC-related death. Paraffin-embedded lymph node sections were stained with a commercial cytokeratin antibody using a standard avidin-biotin technique. RESULTS: One quarter of subjects had micrometastases. Fifty-six per cent of subjects with positive lymph nodes had an adverse outcome, compared with 11% of subjects with negative nodes. A highly significant association was found between lymph node cytokeratin expression and mortality in both the univariate (log rank P = 0.0001) and multivariate (Cox proportional hazards P = 0.0123) analysis. CONCLUSIONS: Lymph node micrometastases detected by this inexpensive and simple technique are significantly associated with mortality in Duke's B CRC. This technique may be used to select patients for adjuvant chemotherapy.

Fatigue does not correlate with the degree of hepatitis or the presence of autoimmune disorders in chronic hepatitis C infection.

BACKGROUND: Fatigue is probably the most commonly reported symptom in chronic hepatitis C virus (HCV) infection. It is unclear whether fatigue is related to the severity of underlying liver disease or other autoimmune disorders often described with chronic HCV infection. OBJECTIVE: To quantify fatigue in terms of its impact on quality of life in a homogeneous cohort and examine its relationship to the status of liver disease or associated autoimmunity. METHODS: The Fatigue Impact Scale (FIS) questionnaire (Fisk et al. Clin Infect Dis 1994; 18:S79-S83), a recently validated psychometric tool for assessing patients' perceptions of the functional limitations attributable to fatigue (40 statements; three subscales: physical, cognitive and psychological; maximum score = 160), was applied to a cohort of Irish women who were PCR-positive for HCV genotype 1b via inoculation with contaminated anti-D products in 1977. RIBA-positive, PCR-negative patients (n = 20) and healthy age-matched women (n = 50) served as controls. The degree of hepatitis was assessed using the Knodell histological activity index (HAI) score on previous liver biopsies. Clinical and laboratory evidence of cryoglobulinaemia, Sjogren's syndrome, connective tissue diseases, autoimmune thyroid disease and glomerulonephritis was sought. RESULTS: The mean FIS score of the 66 PCR-positive women (mean 78+/-36; range 7-153) was significantly higher than in age-matched controls (mean 31+/-24, range 0-78, P<0.001) but not statistically different from that of the RIBA-positive, PCR-negative group. The FIS score did not correlate with the HAI score (median HAI = 4; range 2-9; Pearson's correlation coefficient r=0.01, P=0.9). Significant levels of cryoglobulins were detected in 10 (15.2%). The sicca complex was diagnosed in six patients, three of whom had associated cryoglobulinaemia. Thyroid antibodies, anti-nuclear antibody, rheumatoid factor, antimitochondrial antibody and anti-smooth muscle antibody were detected in 15.2%, 6%, 4.5%, 4.5% and 1.5%, respectively. There was no significant difference in the FIS score between the groups with autoimmune diseases and those without. The FIS score of the nine patients previously treated with interferon was not statistically different from the untreated group (P=0.39). CONCLUSION: The perceived functional impact of fatigue on quality of life is significantly higher in patients with chronic HCV genotype 1b infection compared to healthy controls. However, it is unrelated to the degree of hepatitis and cannot be accounted for by the co-existence of autoimmune disorders alone.

Hepatocellular carcinoma arising in the absence of cirrhosis in genetic haemochromatosis: three case reports and review of literature.

Genetic haemochromatosis constitutes a high risk factor for the development of hepatocellular carcinoma. It is widely accepted that venesection prevents the evolution of cirrhosis in haemochromatosis and indirectly protects against the development of hepatocellular carcinoma. Clinical, pathological and radiological data are presented on three patients who did not conform to the 'siderosis-cirrhosis-carcinoma' sequence and in whom prompt and adequate iron depletion did not prevent the development of cancer. This is the first report of hepatocellular carcinoma intervening in non-cirrhotic liver in two siblings with genetic haemochromatosis. The current literature on the subject is reviewed. The direct oncogenic role of iron remains to be elucidated. Hepatocellular carcinoma should be considered as a differential diagnosis in patients with non-cirrhotic genetic haemochromatosis who present with clinical deterioration during the course of an otherwise uneventful venesection programme.

Changes in liver histopathology in women infected with hepatitis C through contaminated anti-D immunoglobulin injections in Ireland.

OBJECTIVE: To evaluate histological findings in untreated chronic hepatitis C patients at diagnosis 17 years after infection and to assess histological progression on repeat liver biopsy 2 years later. PATIENTS: Thirty patients infected with hepatitis C virus (HCV), genotype 1b, by contaminated anti-D immunoglobulin in Ireland in 1977 were studied. These patients were diagnosed in 1994 for the first time. All patients were positive for HCV-RNA by polymerase chain reaction (PCR). METHODS: Each patient underwent two liver biopsies approximately 2 years apart 17 and 19 years after initial infection. The liver biopsies were scored by two pathologists by the modified histological activity index using a numerical score. At first liver biopsy at time of presentation, eight patients had normal alanine aminotransferase (ALT), four had an ALT of more than 100 IU/I and 18 had an ALT level between 40 and 100 IU/I. RESULTS: In the initial (1994) biopsies, the median grade (inflammation) was 5/18, range 1-9 and the median stage (fibrosis) was 2/6, range 0-6. One patient showed cirrhosis (stage 6/6) and six patients (20%) had developed moderate fibrosis (stage 3-4/6). On the repeat biopsy, 2 years later, median grade (inflammation) was 5/18, range 2-9 and stage (fibrosis) was 1/6, range 0-6. CONCLUSION: This group of patients, infected with HCV genotype 1b and untreated for 19 years, allows evaluation of the natural history of this virus. The majority of patients showed mild chronic hepatitis. Only one patient had developed cirrhosis. There was no significant histological disease progression between the two biopsy specimens over a 2 year period. The results suggest that the prognosis in such cases could at least be guardedly optimistic and that sequential liver biopsy may be performed less frequently.

Pulmonary hyalinizing granuloma: a rare cause of a solitary pulmonary nodule.

Pulmonary hyalinizing granulomata are unusual, noninfectious lesions of the lung of uncertain etiology that probably represent an exaggerated immune response. They present radiographically as noncalcified solitary or multiple pulmonary nodules, thereby mimicking primary or metastatic malignancy. The article discusses a case of this rare entity that presented as a solitary pulmonary nodule.

Immunohistochemical detection of mutant p53 protein in regional lymph nodes is associated with adverse outcome in stage II colorectal cancer.

Epidemiologic data identifies a cohort of Duke's B (CRC) patients whose survival more closely matches that of Duke's C. Lymph node micrometastases may account for this discrepancy. Lymph node expression of mutant p53 protein (Mp53P) has been linked to a reduction in survival in Japanese Duke's B patients. We aimed to determine the significance of nodal p53 expression in European Duke's B patients using immunohistochemistry. The study comprised 134 consecutive patients who had resections for CRC between 1984 and 1991. End points were 5 year disease free survival or CRC related death. Thirty-four subjects did not achieve end points and were excluded. We examined tumour and nodal sections for Mp53P by immunohistochemistry and correlated this with survival using a Kaplan-Meier (KM) and a Cox Proportional hazards model (CPHT). Five year survival was 73%. Fifty-eight percent of primary tumours expressed Mp53P. Tumour p53 expression did modulate survival behavior. Twenty-six percent of subjects' lymph nodes expressed Mp53P. Fifty-three per cent of those with positive and 17% of those with negative lymph nodes died of recurrence. The relative risk for nodal Mp53P expression was 3.1. There was a significant univariate relationship between lymph node p53 expression and mortality. (Log Rank p = 0.028). Multivariate analysis also showed a significant relationship with mortality. (CPHT p = .03). We conclude that lymph node expression of Mp53P is associated with increased mortality in Duke's B CRC.

Subcutaneous Kaposi's sarcoma. Thallium scan demonstration.

A case of AIDS-related Kaposi's sarcoma involving subcutaneous tissues beyond the visible skin lesions is reported. In this case, the tumor was thallium avid. Thallium scintigraphy was able to demonstrate the true extent of the tumor and may be used to document the presence and extent of cutaneous and extracutaneous AIDS-related Kaposi's sarcoma.

Bizarre parosteal osteochondromatous proliferation (Nora's lesion) of the sesamoid: a case report.

We report the a case of Nora's lesion (Bizarre Parosteal Osteochondromatous Proliferation) of the sesamoid. A 32-year-old woman presented with a painless, enlarging mass of two years duration on the plantar aspect of the first metatarsophalangeal joint of the left foot. Radiographs, Computerized Tomographs and Magnetic Resonance images, initially suggested a parosteal osteosarcoma arising from the tibial sesamoid. The mass was excised, and a histological diagnosis of Bizarre Parosteal Osteochondromatous Proliferation of bone (Nora's lesion) was made. The aggressive growth of this lesion may suggest a neoplasm clinically. Histological features, however, are those of a reactive lesion.

Minor salivary glands: causing major problems.

Tumours arising in the parapharyngeal space (PPS) are rare and account for approximately 0.5% of all head and neck neoplasms. These neoplastic processes represent a wide variety of both benign (80%) and malignant lesions arising from the diverse range of structures within and surrounding the PPS. The PPS is typically conceptualized as a potential neck space in the shape of an inverted cone with its base at the skull base and apex at the greater cornu of the hyoid. Because of this unique structure, lesions must often grow to a considerable size before symptoms become apparent and clinical detection is possible. A rare case of mucoepidermoid tumour of the minor salivary glands arising in the prestyloid parapharyngeal space is described. The complex anatomical and pathological considerations within this region present a substantial challenge to the head and neck surgeon in the evaluation and management of these lesions.