Granular cell tumor of the common bile duct: a case report.

Granular cell tumors (GCTs) are uncommon soft tissue tumors, usually presenting in the skin and subcutaneous tissue tongue and oral cavity. We present a case report of granular cell tumor of the common bile duct involving both extra- and intrapancreatic portions. The histogenesis appears to be related to Schwann cells, similar to granular cell tumors of other sites, as evidenced by histologic and immunohistochemical findings. Review of the English literature concerning biliary tract GCTs revealed a high occurrence in African-American females in their third decade. By-pass operation to correct the biliary tract obstruction may be appropriate, if the nature of the tumor can be obtained from intraoperative diagnosis by frozen section.

Combined Sarcocystis and gram-positive bacterial infections. A possible cause of segmental enterocolitis in Thailand.

Between 1981 and 1990, 22 intestinal specimens surgically resected due to segmental enterocolitis were collected and examined. Grossly, the specimens were classified into 3 groups 1) Acute inflammation with hemorrhage and necrosis 2) Constrictive lesion 3) False diverticulum with perforation. Mostly, there was unisegmental involvement, distributed in jejunum, ileum and ileocolon. Microscopically, small parasitic structures, interpreted to be unconventional excystation stage of Sarcocystis hominis, (Railliet and Lucet, 1891) Dubey 1976, were present on the luminal border and within the crypt-lining epithelial cells. At the ulcerated area, tissue invasion by Gram-positive bacteria were always seen and considered as second pathogen. Source of the parasite was likely from cyst-containing beef available in markets, (Bos indicus and Bubalus bubalis) along with consumption of undercooked beef. Antismooth muscle antibody, IgG class, with the titer ranging from 1:16-1:256 were detected in 45 per cent of the patients. This is considered as autoimmunity against intestinal smooth muscle damaged previously from subclinical inflammatory condition. Present information suggests a long-standing existence of Sarcocystis in the patients' intestine, associated with Gram-positive bacterial infection, as the mechanism producing segmental enterocolitis found in the Central region.

Sarcocystis infection and actinomycosis in tumorous eosinophilic enterocolitis.

Intramural masses were resected from jejunum and ileocecal portion of a 49-year-old, female patient with partial gut obstruction. Histopathological examination indicated the masses to be tumorous eosinophilic enterocolitis. Recent and late development phases of Sarcocystis in relation to bradyzoite infection have been observed and considered to be responsible for eosinophilic inflammation. Concomitant intestinal actinomycosis, known to produce tumorous lesion without eosinophilia, appears as an attractive natural model in producing tumorous eosinophilic enterocolitis. Pertaining to parasitic development, it is suggested that persisting sporulated oocyst may undergo spontaneous excystation in the host's intestinal wall, along with complex sporogony.

Fatal paraquat poisoning: a light microscopic study in eight autopsy cases.

Eight autopsy cases of paraquat poisoning from 1980 to 1990 were studied by light microscopy. An attempt was made to correlate the severity of poisoning, as assessed by the blood paraquat concentrations and the time between ingestion and treatment, with the survival periods and pathological changes. Six of the patients were male. The mean age was 21 years (range 12-33 years). The blood paraquat concentrations on admission ranged from 0.04 to 4.27 micrograms/ml. The survival periods were between 26 hours and 59 days. The main causes of death included circulatory collapse in one patient with 26 hours survival, and acute alveolar injury of the lungs and acute tubular necrosis or diffuse cortical necrosis of the kidneys in 4 patients who survived less than 7 days. Pulmonary proliferative changes leading to respiratory failure were detected in the remaining patients, who survived 11, 17, and 59 days. The liver revealed bile duct injury in the portal areas, centrolobular cholestasis, fatty metamorphosis, and inconspicuous centrolobular hepatic necrosis. The adrenal glands showed diffuse cortical necrosis in 3 severe cases. Mild acute pancreatitis was evident in one case. The brain was edematous with or without focal minimal hemorrhages. Toxic myocarditis, myositis, and aplasia of erythropoiesis, as previously described, were not present in this study. The severity of poisoning seems to correlate reversely with the survival periods and directly with degrees of pulmonary damage and adrenal cortical necrosis.

Histological, biochemical and clinical findings in hepatitis B carriers undergoing elective abdominal surgery.

Prospective surveillance for serum Hepatitis B surface Antigen (HBsAg) was performed in 255 patients undergoing elective abdominal surgery at Ramathibodi Hospital during 1984-1987. HBsAg was detected in 13 patients (5.0%), 11 of whom gave consent for serial evaluation of liver histology and laboratory findings. There were eight males and three females aged 20-75 years (mean = 43.4 years). Nine of the eleven patients had wedge liver biopsies taken at operation and two patients had percutaneous biopsies performed. All patients were followed up at 3-6 month intervals and after 20-36 months, follow-up liver biopsies by the percutaneous route were performed in the nine cases who gave consent. The histological findings of initial and follow-up biopsies from these patients were all abnormal, ranging from reactive hepatitis to chronic active hepatitis. During the follow-up study, none of the patients lost their HBs antigenemia and orcein staining of liver biopsies for HBsAg was positive in all ten cases tested. In the nine cases who underwent follow-up liver biopsy, progression of liver pathology was found in seven, although none of these patients showed clinical deterioration or had significant rise in HBsAg titre or SGOT/SGPT levels. The mean age of the five cases who progressed to CAH (51.2 years) was higher than that of the remaining four cases (32.5 years) who had no or minor changes in liver histology, although the difference was not significant. Of the five cases with progression to CAH, four cases were more than 40 years old. None of the conventional clinical or laboratory parameters correlated with the progression of liver disease.(ABSTRACT TRUNCATED AT 250 WORDS)

High urinary excretion of nitrate and N-nitrosoproline in opisthorchiasis subjects.

About 50% of the population in some provinces of north-east Thailand are infested with liver fluke (Opisthorchis viverrini), and many develop cholangiocarcinoma subsequently. This study was designed to demonstrate possible endogenous formation of N-nitrosoproline (NPRO) in this population. Diet samples, saliva and urine were taken from subjects with and without liver fluke and analysed for nitrate and nitrite; urine was also analysed for NPRO. Nitrate and nitrite levels in saliva were higher in subjects with liver fluke than in those without; total nitrate and NPRO excretion was also higher in this group. Subjects with liver fluke may therefore be more heavily exposed to N-nitroso compounds than others, and may be at higher risk for cholangiocarcinoma.

Spontaneous Vibrio vulnificus peritonitis and primary sepsis in two patients with alcoholic cirrhosis.

Two patients with alcoholic cirrhosis were seen on two separate occasions for fever, swollen legs, petechial hemorrhage, purpura, and cutaneous bullae. One patient ate oysters 2 days before the onset of illness. Vibrio vulnificus, a lactose-positive halophilic vibrio, was isolated from the ascitic and cutaneous fluid in both cases, and from the blood in one of the two cases. Both isolated strains were sensitive to the antibiotics given to the patients from the beginning; however, both patients died, one from septicemic shock and the other from massive esophageal variceal hemorrhage. Autopsies in both patients revealed alcoholic cirrhosis, hemorrhagic necrosis of the terminal ileum, intraalveolar hemorrhage, petechial hemorrhage in the peritoneum, and nonspecific acute inflammation of the dermis with vasculitis. Physicians should consider V. vulnificus in the differential diagnosis of cirrhotic patients with sepsis, primary skin lesions, and spontaneous bacterial peritonitis with or without history of recent oyster ingestion.

Opisthorchis viverrini infection and cholangiocarcinoma. A prospective, case-controlled study.

During a prospective, 24-mo case-controlled study, 551 patients from northeastern Thailand were independently evaluated for Opisthorchis viverrini infection, hepatobiliary tract disease, and hepatic carcinoma to determine whether there was any association between hepatic carcinoma and O. viverrini infection. Stool examination by the formalin-ether concentration method revealed O. viverrini ova in 389 (70.6%) patients. Of the 551 patients, 72 (13.1%) had both clinical and laboratory evidence of hepatobiliary tract disease, chronic liver disease, or hepatic carcinoma, alone or in combination. Of these 72 patients, 28 (38.9%) had a liver biopsy that revealed cholangiocarcinoma in 7 patients with O. viverrini ova in their stools, and in 4 patients without. In another patient with ova in the stool combined hepatocellular carcinoma and cholangiocarcinoma was found. In the 4 patients with cholangiocarcinoma who had no O. viverrini ova in their stools, ova were detected in the bile fluid aspirated from the intrahepatic biliary tree during exploratory laparotomy. An additional patient with clinically suspected cholangiocarcinoma and O. viverrini ova in stool had a left supraclavicular lymph node biopsy specimen taken that revealed metastatic adenocarcinoma; this adenocarcinoma was interpreted as compatible with cholangiocarcinoma. Cholangiocarcinoma, therefore, was found only in patients with O. viverrini ova in stool or in the intrahepatic biliary tree. Statistical analysis revealed that patients with known O. viverrini infection had a higher incidence of cholangiocarcinoma than did patients without such infection (X2 test, p less than 0.05).

Nitrate and nitrite in saliva and urine of inhabitants of areas of low and high incidence of cholangiocarcinoma in Thailand.

Cholangiocarcinoma is one of the main liver diseases in northeast Thailand. Associations with exposure to liver fluke and N-nitrosodimethylamine in formation of the tumour have been demonstrated in animals. This study was carried out to compare possible endogenous formation of N-nitroso compounds in inhabitants of areas with low and high incidences of cholangiocarcinoma by examining the levels of nitrate and nitrite in their saliva and urine. Thirty-two subjects (16 males and 16 females) living in the north-east (high incidence) and 12 volunteers (6 males and 6 females) in Bangkok (low incidence) were allowed to take regular meals, and their saliva and urine were collected before, and 30, 60 and 120 min after each meal. Nitrate and nitrite concentrations in saliva of the group in the high-incidence area were significantly higher than those of the group in Bangkok: salivary nitrate was 2-2.8 times higher and nitrite 2-5.6 times higher in the north-eastern group when compared with levels at each corresponding time interval in the low-incidence group. Nitrate levels in urine were also significantly higher in the north-eastern group at some time intervals, but urinary nitrite levels were similar and very low in both groups throughout the day. This finding may indicate a greater possibility of in-vivo formation of N-nitroso compounds in the north-east area than in Bangkok and might be associated with the occurrence of cholangiocarcinoma in north-east Thailand.

Human intestinal sarcosporidiosis: report of six cases.

Specimens of resected small intestine from six patients aged 3 to 70 years with acute enteritis contained sexual forms of sarcosporidia. Histopathologically, the diagnoses were either segmental eosinophilic enteritis or segmental necrotizing enteritis. The presence of sarcosporidia in market beef (Bos indicus), and the patients' habit of eating the beef uncooked in the form of chili-hot dishes, suggest that the species is an ox-man parasite similar to Sarcocystis hominis (Railliet and Lucet, 1891) Dubey, 1976. Presence of numerous Gram-positive bacilli in segmental necrotizing enteritis suggests an interplay between two etiological agents in producing the hosts' inflammatory responses. Five patients recovered after resection, but one died due to extensive necrosis of the intestinal wall and leakage at the site of anastomosis. Only conventional antibiotics were given after the operations. None of the five surviving patients has had recurrent enteritis for at least 1 year.

Haemorrhage in neonatal hepatic necrosis due to herpes infection.

A case of early neonatal severe bleeding and persistent hypoglycemia with a fatal outcome is reported. The autopsy examination revealed the features of neonatal hepatic necrosis. Further study by the electron microscopy indicated the presence of herpes type particles in the nucleus and cytoplasm of the remaining liver cells. Serological study of the maternal blood, post partum, revelaed positive reaction to Herpes simplex virus type 2 at low titer. It is believed that intrauterine herpes infection was responsible for the severe hepatic damage manifesting in complex clinical findings.