Sugammadex in the management of rocuronium-induced anaphylaxis.

Anaphylaxis during anaesthesia is a rare event that in ∼60-70% of cases is secondary to neuromuscular blocking agents. It has been suggested previously that the recent introduction of sugammadex may provide a novel therapeutic approach to the management of rocuronium-induced anaphylaxis. We describe the case of a 33-yr-old female who suffered a severe anaphylactic reaction to rocuronium, presenting with cardiovascular collapse on induction of anaesthesia. After 19 min of traditional management, she was given a bolus of sugammadex 500 mg. This was associated with an improvement in the adverse haemodynamic state. The underlying reasons for this are unclear, but sugammadex may potentially be a useful adjunct in the management of rocuronium-induced anaphylaxis.

A trinucleotide repeat-associated increase in the level of Alu RNA-binding protein occurred during the same period as the major Alu amplification that accompanied anthropoid evolution.

Nearly 1 million Alu elements in human DNA were inserted by an RNA-mediated retroposition-amplification process that clearly decelerated about 30 million years ago. Since then, Alu sequences have proliferated at a lower rate, including within the human genome, in which Alu mobility continues to generate genetic variability. Initially derived from 7SL RNA of the signal recognition particle (SRP), Alu became a dominant retroposon while retaining secondary structures found in 7SL RNA. We previously identified a human Alu RNA-binding protein as a homolog of the 14-kDa Alu-specific protein of SRP and have shown that its expression is associated with accumulation of 3'-processed Alu RNA. Here, we show that in early anthropoids, the gene encoding SRP14 Alu RNA-binding protein was duplicated and that SRP14-homologous sequences currently reside on different human chromosomes. In anthropoids, the active SRP14 gene acquired a GCA trinucleotide repeat in its 3'-coding region that produces SRP14 polypeptides with extended C-terminal tails. A C-->G substitution in this region converted the mouse sequence CCA GCA to GCA GCA in prosimians, which presumably predisposed this locus to GCA expansion in anthropoids and provides a model for other triplet expansions. Moreover, the presence of the trinucleotide repeat in SRP14 DNA and the corresponding C-terminal tail in SRP14 are associated with a significant increase in SRP14 polypeptide and Alu RNA-binding activity. These genetic events occurred during the period in which an acceleration in Alu retroposition was followed by a sharp deceleration, suggesting that Alu repeats coevolved with C-terminal variants of SRP14 in higher primates.

Phenotypic and functional activation of monocytes in HIV-1 infection: interactions with neural cells.

To investigate mechanisms that facilitate transendothelial migration of HIV-infected leukocytes and their interactions with neural tissues early in the disease, we studied peripheral blood from Centers for Disease Control class A patients. Patients' monocytes displayed increased quantities of the adhesion molecules CD11a, CD11b, and very late antigen 4 (VLA-4). Expression of these correlated directly with the numbers of monocytes that migrated through confluent endothelium. These ligands also mediated leukocyte interactions with cultured human neural cell lines. Although patients' cells bound in greater numbers, there was no evidence of target cell injury. To evaluate the direct effect of HIV-1 on monocyte neuroadhesion, we compared infected with uninfected monocytoid (U-937,THP-1) and T lymphoblastoid (MT-4) cell lines. HIV infection increased the neuroadhesiveness of monocytoid lines only. By using lines with more than 95% HIV-infected cells, we demonstrated that HIV-1 gp120 participates with lymphocyte function-associated antigen 1 and VLA-4 to mediate monocyte-neural cell interactions.

The use of immunohistochemistry in metastatic prostatic adenocarcinoma to the breast.

Since the introduction of hormonal therapy for the treatment of metastatic prostatic adenocarcinoma, there have been 33 reports of metastases of prostate carcinoma to the breast. We report two cases of diethylstilbestrol (DES)-treated patients with metastatic prostate adenocarcinoma who developed breast masses. The lesions had infiltrative patterns simulating primary breast carcinoma. Immunoperoxidase stains, prostate-specific antigen (PSA), and prostatic acid phosphatase (PAP) were positive, identifying these cases as metastatic prostatic carcinoma to the breast. Differentiating primary from secondary tumors in these patients is difficult since there have been 10 reports of primary breast carcinoma occurring in DES-treated patients with prostatic adenocarcinoma. Their differentiation is important to direct appropriate therapy, and PSA and PAP immunoperoxidase stains are important in their correct classification.

Relationship between Epstein-Barr virus and lymphoepithelioma-like carcinoma of the lung: a clinicopathologic study of 6 cases and review of the literature.

Lymphoepithelioma-like carcinoma (LELC) is a rare form of lung cancer, usually encountered in Chinese patients. Similar to nasopharyngeal carcinoma, LELC of the lung is strongly associated with Epstein-Barr virus (EBV) infection in Asian patients, but there is controversy over whether an association exists in patients from Western countries. To determine whether such a relationship exists, we retrospectively studied 6 cases of primary LELC of the lung, all of which were in Western patients. There were 4 men and 2 women, ranging in age from 49 to 75 years. The tumors ranged from 1 to 4.5 cm in diameter. Four patients had stage I disease, 1 had stage IIb disease, and 1 had stage IIIa disease. All patients are alive without evidence of disease with a follow-up of 18 to 30 months. Formalin-fixed, paraffin-embedded tissue was stained with hematoxylin-eosin for routine evaluation and immunostained for keratin and leukocyte common antigen (LCA). LCA staining was performed to exclude large-cell lymphoma. Immunoperoxidase staining (1:500 clone CS1-4; Dako, Carpinteria, CA) and in situ hybridization were performed to detect EBV. Tumors consisted of solid nests of undifferentiated tumor cells in a syncytial arrangement surrounded by heavy lymphoplasmacytic infiltrate. Tumor cells stained positively for keratin but negative for LCA. All 6 cases were negative for EBV, suggesting no association between EBV and LELC in the Western population.

Hepatoblastoma in an adult with metastasis to the ovaries.

A 19-year-old female had ascites, an enlarged liver, pelvic masses, and an alpha-fetoprotein level of 397,000 micrograms/L with a normal beta-human chorionic gonadotropin serum level. Abdominal exploration revealed a large solitary liver mass with bilateral ovarian masses, and bilateral salpingo-oophorectomy and wedge liver biopsy were performed. The tumor was composed of cords, nests, and pseudorosettes of polyhedral cells with eosinophilic cytoplasm and nuclei with prominent nucleoli. The clinical, light microscopic, and immunocytochemical features indicate that the primary liver neoplasm and ovarian metastases were a purely epithelial hepatoblastoma. To the authors' knowledge, this is the first reported case of this type.

Uterine anomalies. Frequency of diagnosis and associated obstetric complications.

Uterine anomalies are associated with an increase in cases of breech presentation, premature labor, abnormal presentation with dystocia, and the necessity for cesarean section. The yearly frequency of diagnosis of an anomaly has varied from 0.06 to 0.48 at this medical center depending on the physician's clinical suspicion. Thus, if the true incidence and the decrease of obstetric complications are to be accomplished, an increased interest in diagnosing uterine anomalies is essential.

Cancer of the colon during pregnancy. A review of the literature and report of a case associated with ulcerative colitis.

The first case of adenocarcinoma of the transverse colon and splenic flexture during pregnancy associated with ulcerative colitis is reported. The patient presented with perforation and widespread metastatic disease. After 10 years' duration of symptoms of ulcerative colitis, the risk of coexisting cancer of the colon is 3 to 5% each year. As ulcerative colitis frequently coexists with pregnancy, the obstetrician needs to be alert to the potential for malignant changes in these patients. With the addition of this patient, there are now 18 reported cases of cancer of the colon during pregnancy. These 18 cases are reviewed especially as to management, outcome of the pregnancy, and prognosis.

Intracranial metastases as the first manifestation of prostate cancer.

We report on 2 patients with neurologic symptoms secondary to intracranial metastases from carcinoma of the prostate. In one of these patients, the intracranial lesion was the only clinically detectable metastasis. We have found only three other such cases reported in the English-language literature.

Role of nuclear grading in stage I renal cell carcinoma.

Through a retrospective histologic analysis of 55 cases of Stage I renal cell carcinoma, we evaluated the usefulness of the nuclear grading system (Fuhrman, Lasky, Limas) in identifying those tumors that will eventually metastasize and kill the patient. The difference in five-year survival rates between patients with combined nuclear grade 1-3 tumors (n = 50, 91%) and grade 4 tumors (n = 5, 9%) was significant (P less than 0.0046). Other predictors of death due to renal cell carcinoma included: tumor size greater than 8 cm (P less than 0.001) and mitoses greater than one per 10 high-power field (P less than 0.01). Within Stage I tumors, therefore, nuclear grade is an important morphologic variable for predicting long-term survival. Identification of nuclear grade 4 neoplasms may become prognostically indispensable to determine the metastatic potential of early-stage tumors and thereby to institute appropriate systemic therapy.

Pemphigus vulgaris. Combined treatment with intravenous corticosteroid pulse therapy, plasmapheresis, and azathioprine.

A 13-year-old child is described who presented with generalized pemphigus vulgaris associated with extraordinarily high titers of circulating autoantibodies against the pemphigus antigen. Because of the lack of response to treatment with reasonably high doses of oral corticosteroids, as well as the very high titer of circulating autoantibodies observed, this patient was treated with intravenous corticosteroid pulse therapy followed by plasmapheresis and then by combination immunosuppressive therapy (prednisone and azathioprine). A rapid clinical response was induced, correlating with reduction and subsequent elimination of the circulating pemphigus autoantibodies. Using such combination therapy, a remission of 12 months was achieved, and prednisone therapy was completely, albeit temporarily, tapered and then discontinued. Subsequent disease flare was then easily controlled with a short course of low-dose oral corticosteroid therapy.

Recurrent and metastatic cutaneous neuroendocrine (Merkel cell) carcinoma mimicking angiosarcoma.

An elderly man presented with bright red-to-purple confluent nodules and plaques of the scalp that appeared clinically consistent with angiosarcoma. He had undergone surgical removal of a similar lesion from his left temple seven months before this presentation. Although routine histologic examination was not sufficient for diagnosis, Merkel cell carcinoma was diagnosed by immunohistochemical studies and electron microscopy. In addition, oat cell carcinoma of the lung was excluded with a computed tomographic scan of his chest. With chemotherapy, the recurrent and metastatic lesions of Merkel cell carcinoma completely resolved, rapidly recurred, and resolved a second time with chemotherapy. Eight months following the fourth course of chemotherapy, the patient again developed widespread cutaneous lesions. He committed suicide within one month of this last recurrence. An autopsy revealed no primary tumor other than of the skin.

Needle biopsy for suspicious lesions of the head of the pancreas: pitfalls and implications for therapy.

Controversy continues to exist concerning the optimal diagnostic approach to a pancreatic head lesion suspected of being a neoplasm. The objective of this study was to evaluate the impact of needle biopsy in suspicious pancreatic head neoplasia and its effect on therapy and outcome. Seventy-three patients with symptoms or signs of periampullary neoplasia and a pancreatic head lesion identified on CT scan were reviewed retrospectively. Forty patients with potentially resectable lesions underwent intraoperative transduodenal core needle biopsy of the head of the pancreas. Thirty-three patients underwent CT-guided percutaneous fine-needle aspiration. The sensitivity and specificity of core needle biopsy were 76% and 100%, respectively. One death was directly related to the procedure and therapy was adversely affected in one patient with a false negative result. The sensitivity and specificity of percutaneous fine-needle aspiration were 85% and 92%, respectively, and were not significantly different from the core needle biopsy results (P >0.3). Three false negative fine-needle aspiration biopsies occurred in patients with potentially resectable lesions and a low clinical suspicion for malignancy. In patients with a mass in the head of the pancreas on CT scan, fine-needle aspiration biopsy offers results similar to those of intraoperative transduodenal core needle biopsy. In patients estimated to have resectable disease, a pancreaticoduodenectomy should be performed without a biopsy. For patients with unresectable disease, cytologic examination of fine-needle aspirate should be performed. If this examination is positive, it offers the advantage of facilitating the construction of a rational plan for palliation.

Neuroendocrine neoplasms of the larynx.

Neuroendocrine neoplasms of the larynx are a rare group of tumors that include carcinoid tumor, atypical carcinoid tumor, and small cell carcinoma. These neoplasms pose interesting diagnostic, prognostic, and therapeutic dilemmas, and they are, as a whole, aggressive tumors with a tendency for local and distant spread. The authors of this study examined six new cases of laryngeal neuroendocrine neoplasms. One case manifested itself as a primary atypical carcinoid tumor and caused a "carcinoid syndrome." The remaining five cases were small cell carcinomas of the larynx. Histologic, immunocytochemical, DNA flow cytometric, and p53 studies were performed on all cases. The expression of neuron-specific enolase and chromogranin were the most useful markers in this group of tumors. Overexpression of p53 protein was present in the majority of cases, including the atypical carcinoid tumor. The implications of these studies for diagnosis, classification, and treatment are discussed.

Case report: vitamin D-mediated hypercalcemia in fungal infections.

Hypercalcemia has been well described in a variety of neoplastic and granulomatous diseases. One mechanism for this hypercalcemia is via the excess production of 1,25-dihydroxyvitamin D from extra-renal sources. The authors describe an AIDS patient infected with Cryptococcus neoformans who had suggestive evidence of vitamin D-mediated hypercalcemia. He had an elevated serum 1,25-dihydroxyvitamin D value, a normal 25-hydroxyvitamin D value, and low values for parathyroid hormone and parathyroid hormone-related peptide. Most previously reported cases of hypercalcemia associated with fungal infections did not include sufficient evidence to implicate a role for excess 1,25-dihydroxyvitamin D production, except for two case reports involving patients with hypercalcemia with infections due to Pneumocystis carinii and Candida albicans. The authors' patient's hypercalcemia resolved during treatment of his underlying infection. Patients with hypercalcemia or in whom hypercalcemia develops during a disseminated fungal infection should have vitamin D metabolites measured as part of their work-up.

The use of gastric salvage cytology in the diagnosis of malignancy: a review of 731 cases.

Over an 8-yr period at the Houston Veterans Hospital, 731 endoscopic gastric salvage cytologies were performed in 671 patients, with surgical biopsy also done in 660. Seventy-six patients subsequently had tissue biopsy-proven or resection-proven malignancies. Salvage cytology had a sensitivity of 91% and a specificity of 100% for the detection of primary adenocarcinoma. Biopsy alone had a sensitivity of 92%; endoscopic gastric salvage cytology and surgical biopsy combined had a sensitivity of 100% in both primary and metastatic neoplasms. This study shows that the combination of endoscopic biopsy and salvage cytology increases the diagnostic accuracy for gastric carcinoma. Gastric salvage cytology requires minimal disruption of the routine endoscopic procedure and is therefore an easier and more rapid cytologic technique than gastric brushing cytology.

Primary angiosarcoma of the cuboidal bone: a case report.

Primary angiosarcoma of bone is a rare neoplasm. The unique cytomorphologic and ultrastructural aspects of a primary angiosarcoma of the cuboid bone diagnosed by fine-needle aspiration are presented. Smears and cell block preparations revealed single and clustered large, pleomorphic, and spindle-shaped cells with a markedly hemorrhagic background. Electron microscopy revealed characteristic features of endothelial cells including rare Weibel-Palade bodies. The clinical, cytologic, histologic, and ultrastructural aspects of the case are discussed.

Leu-7 immunoreactivity in cytologic specimens of thyroid lesions, with emphasis on follicular neoplasms.

Anti-Leu-7 (HNK-1, CD 57) antibody, a marker for natural killer lymphocytes, was employed by Ghali et al. (Hum Pathol 1992;23: 21-25) to study surgically resected formalin-fixed, paraffin-embedded thyroid lesions. They demonstrated strong immunoreactivity of this antibody with thyroid carcinomas, both follicular and papillary, and only occasional weak immunoreactivity with colloid goiters and follicular adenomas. We studied cytologic specimens (primarily fine-needle aspiration biopsy specimens) from 44 thyroid lesions, including 10 follicular carcinomas, 14 follicular adenomas, seven adenomatous nodules, six papillary carcinomas, and seven cases of Hashimoto's thyroiditis. All follicular carcinomas exhibited immunoreactivity to anti-Leu-7 antibody, usually of a moderate to strong degree (9/10); however, six of 14 follicular adenomas yielded similar results. The patterns of immunoreactivity in the other lesions were similar to those previously described (Ghali et al., Hum Pathol 1992;23:21-25). It does not appear that anti-Leu-7 antibody can be used as a specific marker of malignancy in the cytologic assessment of follicular neoplasms of the thyroid.

Utilization of fine-needle aspiration biopsy in the diagnosis of metastatic tumors to the pancreas.

There is relatively little information concerning the use of fine-needle aspiration biopsy (FNAB) to diagnose a mass in the pancreas that is secondary to metastatic tumor. This study reviews the incidence and types of neoplasms which metastasize to the pancreas and assesses the contribution FNAB can make in their diagnosis. Of 117 radiologically guided FNABs of the pancreas, 11% (n = 13) showed metastatic malignancy. Nine patients had a previous history of malignancy while four patients presented with a pancreatic mass and were subsequently found to have wide-spread malignant disease. The majority of metastatic lesions were epithelial (77%, n = 10). Patient outcomes were generally poor (mean survival 2.8 mo). Metastases to the pancreas occur from a variety of primary sites and should be considered in patients with a pancreatic mass and a history of prior malignancy. FNAB is useful in diagnosing these metastases and this is clinically important because of their poor prognosis.

Increased natural killer cells in fluids. A new, sensitive means of detecting carcinoma.

OBJECTIVE: Natural killer (NK) cells are cells of undefined lineage that are capable of lysing certain tumor cell lines in vitro. Determination of NK cell percent (NK%) in effusions by flow cytometry could aid in the detection of malignancies. STUDY DESIGN: Over a six-month period at the Houston Veterans Affairs Medical Center, fresh effusions were routinely processed for cytology, and a portion was submitted for lymphocyte immunophenotyping using the FACScan and a panel including CD16/CD56 for NK cells. Seventy fluids (42 pleural, 28 peritoneal) from 62 men were examined. RESULTS: NK cell percents were markedly increased in 15 cases (29-68%, mean 45.5) and low in 55 (2-20%, mean 8). Fourteen of the 15 cases with increased NK% were positive for carcinoma (93%), while 54/55 cases with low ones were negative for carcinoma (98%). Mesotheliomas, lymphomas and leukemias had low NK%. CONCLUSION: Using the Mann-Whitney U test, an increase in NK% predicts metastatic carcinoma with a P level of < .00001.