Endometriosis-evidence of blood-borne spread

Theories that have been put forward concerning the histogenesis of endometriosis include retrograde menstruation, metaplasia of the coelomic epithelium, direct myometrial and utero-tubal extension, lymphatic spread, and blood-borne spread of the endometrium. Jeffcoate (1975), Blaustein (1977) and Novak and Woodruff (1979) state that blood-borne spread is the only plausible explanation of the rare cases occurring in the arm, leg and similar sites. There has been no documented proof of this. The case presented illustrates and supports the evidence of blood-borne spread in the pathogenesis of endometriosis (AU)

Yaws in Barbados

The first case of yaws diagnosed in Barbados is documented. The clinicopathological appearance is described, and the Caribbean experience is briefly reviewed. Although the disease is almost completely eradicated, there still has to be continuing vigilance on the part of medical personnel so that the condition is not overlooked. The surgical pathologist can aid in the diagnosis (AU)

Smooth muscle tumours of the gastrointestinal tract

Fifty smooth muscle tumours arising in the gastrointestimal tract and recorded in the surgical pathology files at the University Hospital of the West Indies were reviewed in an attempt to document their histopathological features. The mean age at occurrence was 59.8 years with a range of 34-80 years. Most tumours (64 percent) were symptomatic, while the remainder were incidental findings at laparotomy. The main symptoms were an abdominal mass, gastrointestinal bleeding, weight loss, vomiting, dysphagia and obstructive jaundice. The size of the tumours varied from less than 1 cm in diameter. Thirty-nine were from stomach, two from the duodenum, seven from the jejunum and ileum, one from the colon and one from the rectum. Tumours were classified as either benign, of indeterminate malignancy or frankly malignant. A rough correlation between malignance and the size of the tumours was found. The larger tumours were invariably malignant and the smaller tumours benign. There were three bizarre smooth muscle tumours one of which was frankly malignant.(AU)

Pulmonary teratoma

Intrapulmonary teratoma is reported in an 11-year-old-girl. The tumour is remarkable for its large size, since it occupied the entire right hemithorax. The presence of immature elements suggests that it is potentially malignant. However, complete surgical excision appears to have effected a cure at 5 years follow-up. This is the 14th such case to be recorded in the English literature (AU)

Autopsy experience in Barbados

Although there is world-wide concern about the decrease in autopsy rates, to the authors' knowledge, the rates in Barbados have never been documented. The calculation of the non-coroner's autopsy rates and accordance score, and the possible value of these autopies performed at the Queen Elizabeth Hospital constitute this paper (AU)

Human papilloma virus infection of the cervix uteri: observations in clinical private practice in Barbados - abstract

This study of female private patients was to determine the prevalence of Human Papilloma Virus (HPV) infection, diagnosed on the basis of changes in cervical smears. From January 1986 to July 1988, 14,891 cervical smears were classified by numerical and descriptive systems, and 505 (3.4 per cent) smears had cytological changes of condyloma. Six cases were excluded because their ages were not known. Of the remaining 499 cases, 385 (77 per cent) were diagnosed as class II, 105 (21 per cent) as class III, and 216 (43 per cent) had bunch biopsies and/or endocervical curettage, 34 per cent of class II and 79 per cent of class III. Of those biopsied, 106 (49 per cent) had histological evidence of condyloma (condyloma only, 31 per cent; condyloma and CIN, 18 per cent). Of the 110 (51 per cent) biopsied cases with no histological evidence of condyloma, 16 per cent had evidence of dysplasia and 0.5 per cent frankly invasive carcinoma. Eighty-five per cent of condylomata occurred in the 20-39-year age group. Condyloma with coexisting dysplasia and dysplasia only had a peak frequency in the 20-29-year age group. The frequency of dysplasia in patients with previous class II smears was 19 per cent and 42 per cent of class III smears had no dysplasia but condyloma. Because of the foregoing, patients with a smear diagnosis of class I and cytological changes associated with HPV infection require more intensive follow up (AU)

Autopsy in Barbados - abstract

Since 1977, the status of the autopsy has been the subject of much debate. The following questions have been posed: (i) Has the autopsy outlived its usefulness? (ii) Is the autopsy worth the expended effort and cost? (iii) How can the contributions of this physician service achieve their maximum usefulness and receive appropriate recognition? The College of American Pathologists' Foundation Conference has made an appeal to revitalize the autopsy. There was concern about the falling rate of autopsies in teaching hospitals. The Queen Elizabeth Hospital has been one of the hospitals involved in the Eastern Caribbean Medical Scheme since 1965. There is undergraduate and postgraduate teaching. Medical students have been doing their Pathology and Microbiology clerkships at this hospital since 1981. The morbid anatomy sub-department of Pathology also services the whole island. Is the autopsy rate at this institution, a teaching hospital, acceptable? Is maximum benefit being gained from the autopsies performed? In order to answer the above questions, the autopsy reports from the Pathology Department were reviewed for the four-year period (1979-1982). The autopsy rates were 17 percent, 14 percent, 13 percent and 16 percent respectively. The concordance score of 303 of the 400 autopsies performed during this period was calculated. Ninety-seven cases had to be excluded because of insufficient data. In 149 cases, the primary disease as diagnosed at autopsy had been recognized clinically, but in 154 cases it had not. The predominant diseases missed included sepsis, pulmonary thrombo-embolism, pulmonary oedema and gastrointestinal haemorrhage. Though the autopsy rate is low, there is a high discordant rate. The autopsy in Barbados is therefore potentially capable of improving medical care, not only through the teaching of medical students, but through the interest and involvement of the clinicians in autopsies requested (AU)

Leiomyosarcoma of the rectum

The only case of leimyosarcoma of the rectum seen at the University Hospital of the West Indies is reported. The natural history and pathology of this tumour are similar to those of smooth muscle tumours occurring elsewhere in the gut. When rectal leimyosarcoma invades adjacent organs such as the vagina and bladder, it may give rise to considerable morbidity. In addition, widespread metastases may occur. Aggressive surgical therapy is therefore warranted for early lesions if therapy is expected to be curative (AU)

Clinical and laboratory studies of bacterial vaginosis in Barbados - abstract

Bacterial vaginosis (BV) is a non-inflammatory infection of the vagina, characterized by the presence of a thin, homogenous, grayish-white discharge. The purpose of this study was to investigate (1) the prevalence of BV in Barbados and evaluate methods for its diagnosis, and (2) the relationship between clinically and microbiologically-confirmed BV and abnormal PAP smear results. Initially, 29 consecutive patients presented with vaginal discharge which was tested for pH and amines, and high vaginal swabs were cultured for Gardnerella vaginalis and obligate anaerobes. Of 21 patients without another demonstrable cause of their discharge, 16 had a vaginal pH o 5; 14 had a positive amine test, clue cells were observed in 8 and a heavy growth of either obligate anaerobes or G. vaginalis was recovered from 10 patients. BV was found in 16 of 29 patients (56 per cent). In a further 43 patients with a clinical diagnosis of BV, a vaginal pH o 5, and a positive amine test, vaginal swabs were obtained for culture and cervical smears stained with Papanicolaou stain. Thirty of these 43 patients (70 per cent) had class II Pap smears, 24 (56 per cent) had evidence of concurrent infection, including yeasts (12 per cent), Trichomonas vaginalis (24 per cent), and cytological evidence of infection with chlamydia (23 per cent) or human papilloma virus (32 per cent). It is concluded that BV is common in Barbados, is easily diagnosed in the physician's office, responds to treatment with metronidazole and is often associated with other genital tract infections which require additional investigations (AU)

Cardiac involvement in severe leptospirosis

Eleven patients with severe leptospirosis and myocarditis are described. Widespread ST-T wave changes on the electrocardiogram were found in nine patients. Three had atrial arrhythmias, two had frequent premature ventricular contractions and two had conduction disturbances. In two patients, there were generalized low voltage. Pathological examination revealed interstitial myocarditis in five patients and perivascular infiltrates in two. It is important to recognize that myocarditis may occur in leptospirosis. Serial electrocardiograms should be performed in severe cases to detect this complication (AU)

Coexistence of porphyria cutanea tarda and systemic lupus erythematosus

The association of porphyria cutanea tarda with a well-documented case of systemic lupus erythematosus is reported. Renal histopathology is presented. Both conditions have been quiescent during the past year of follow-up (AU)

A clinicopathological study of granuloma inguinale in Barbados

The clinicopathological features of fifteen cases of granuloma inguinale diagnosed over a six-year period (1980-1985) are reported. The biopsy sites included cervix uteri, penis, vulva, perineum, anus, endometrium and vaginal wall, in decreasing order of frequency. The incidence was roughly equal in both sexes with an age range of 16-78 years. In females, the most frequent clinical diagnosis was carcinoma. The findings indicate that the clinical and histopathological diagnosis of granuloma inguinale entails a high degree of suspicion in a community where the disease is uncommon (AU)

Haemophagocytic syndrome

Two fatal cases of haemophagocytic syndrome diagnosed on the basis of autopsy findings at the Queen Elizabeth Hospital, Barbados, are presented. They were both young patients, a male 20 years of age and a female 28 years of age, with common clinical features of severe constitutional symptoms, pharyngeal haemorrhages, pancytopenia, and fever. The female patient had elevated titres to herpes simplex virus indicative of recent infection as well as postmortem evidence of overwhelming mixed bacteria sepsis. In both cases, histopathological studies showed lymphoid depletion and histiocytes displaying haemophagocytosis. (AU)

An analysis of cervico-vaginal (Papanicolaou) smears in girls 18 years and under

During the two year period, January 1995 to December 1996 124 cervico-vaginal smears from 109 girls 18 years old and younger were examined. The gynaecological history, cytology reports, histological and cytological follow-up reports were analyzed to determine the demographics, common infections, epithelial abnormalities and follow-up management in this age group. The mean age was 17.4 with a range of 15-18 years. Twenty-five percent were gravid and 4.5 percent multigravida. The teen delivery/termination ratio was 0.73:1. The most common specific infection was yeast and, suspected infection, HPV .39 percent had normal smears, 14.7 percent inflammatory epithelial changes, 36 percent atypical squamous cells of undetermined significance (ASCUS), 8.3 percent low grade squamous intra-epithelial lesions (LGSIL) and 1.0 percent high grade intra-epithelial lesions (HGSIL). The ASCUS/SIL ratio was 3.9. Only 40 percent of patients with cytologic diagnosis of SIL and 28 percent with ASCUS had follow-up by repeat smear and/or colposcopy, endocervical curettage and guided cervicals biopsy. Five (45 percent) of the followed up patients had LGSIL inclusive of CIN 1 and condyloma. These results indicate that sexually active girls are risk of developing SIL and those with a diagnosis of ASCUS should be adequately followed up.(AU)

Cervical cytology quality control cytological and histological correlation at a private laboratory in Barbados - abstract

In this study, the cytological and histological diagnoses made during a six and a half-year period were compared with the aim of assessing the diagnostic accuracy of cervical cytology in a small private laboratory. There were 3486 cases biopsied, 40 (1.2 percent) cases with previous inadequate cervical smears, 195 (5.6 percent) cases with normal cytology and the remaining 3251 (93.2 percent) with abnormal cytological diagnoses. The overall concordance between the cytological and histological diagnoses was 63.9 percent. The greatest concordance was in cases with cytodiagnosis of CIN grade 3 (CIS) and invasive carcinoma combined 100/112 (89.3 percent), and the lowest with normal cytodiagnosis 75/195 (38.5 percent) cases. The significant histological diagnoses of the discordant cases were CIN 22.6 percent, condyloma 15.3 percent and carcinoma 1.1 percent. Fifty percent of the carcinomas diagnosed by cytology were of endometrial origin. Significant discordance occurred in cases with cytodiagnosis of HPV infection and CIN, in that 113 cases with cytodiagnosis of HPV infection/codyloma had histological diagnosis of CIN, and 156 cases with the cytodiagnosis of CIN had histological diagnosis of condyloma. The sensitivity rate for the diagnosis of HPV infection or condyloma by cytology was 632/1214 (52 percent). Most of the cases with inadequate smears had histodiagnosis of cervicitis with inflammatory atypia. This study has shown that the cytological evaluation of the severity of significant cervical abnormalities was a reliable guide for the clinician to the proper management of the patient (AU)

What is the significance of the class II Papanicolaou-stained cervical smear in Barbados? - abstract

At the Barbados Reference Laboratory (BRL), Papanicolaou-stained cervical smears are reported by a modified Papanicolaou system of Classes I to V, accompanied by a description of the significant findings. Concerns and criticisms of too many Class II reports, quality assurance rate and management of such patients were addressed in this study. From 1986 to 1989, of 27,327 smears screened at the BRL, 8,581 (31.4 percent) were given a Class II report and 984 (11.5 percent) of these patients were biopsied; 60.1 percent (591) of the biopsies showed evidence of cervicitis with and without inflammatory epithelial atypia, 24.2 percent (238) had no diagnostic abnormality, 15.2 percent (150) had evidence of cervical intraepithelial neoplasia (CIN) and 0.4 percent (4) had frank malignancy. There were 3 cases of endometrial adenocarcinoma and one of invasive squamous cell carcinoma. The false negative rate for CIN was 15 percent. On reviewing 74 (48 percent) of the smears with corresponding histologic diagnosis of CIN/carcinoma, 22 (29.7 percent), including the case of invasive carcinoma, were missed. All these smears had a marked acute inflammatory exudate making assessment difficult. In conclusion, this study showed that a Class II smear indicated a reasonable chance (75.7 percent) of an abnormality in the cervix, ranging from cervicitis (high risk) to invasive cancer (low risk), and that the quality assurance for cytologic diagnosis of CIN was low (AU)

Cervical chlamydia trachomatis infection detection by papanicolaou-stained smears and enzyme immuno-assay - abstract

Ceervicitis is a very common finding. Approximately 40 percent of Papanicolaou (Pap) smears of Barbadian women indicate cervical infection. While some of the infective agents have been identified, viz., abnormal bacterial flora, trichomonads, yeast and to a lesser extent herpes and human papilloma virus infection, a large proportion show no identifiable organism on light microscopy. It is now thought that chlamydial infection is one of the major sexually transmitted diseases. However, inexpensive and rapid diagnostic tests are lacking. Though cytological changes of chlamydial infection have been described in Pap smears, their sensitivity has been questioned. The abnormal cytological changes associated with chlamydial infection may stimulate early changes of epithelial neoplasia so that the organism is a possible procarinogen or a potentiator. Is this infection a risk factor for carcinoma of the uterine cervix in Barbadian women ? Its association with dysplasia, pelvic inflammatory disease and neonatal infections has been described. Since the Pap smear is a relatively cheap procedure, this study was undertaken to determine whether it could be used to detect unsuspected chlamydial infection. A total of 5,029 cervical smears from women visiting doctors in private practice were screened during a 15-month period, October 1985 - December, 1986. Enzyme immuno-assay for chlamydia was performed on 382 patients who among them had a total of 454 smears; 42 patients (with 51 smears, 11.2 percent) had a positive test. The smears from these patients and from an equal number who had negative tests were reviewed. Infection was not diagnosed cytologically in 19 patients (45 percent). Infection was diagnosed cytologically in 23 patients (55 percent), 16 (38 percent) of whom were not suspected clinically, and in 7 there was clinico-cytological correlation. Failure of cytological diagnosis of 45 percent of patients with proven chlamydia confirms the non-specificity of cervical Pap smears in the detection of chlamydial infection. Lack of clinical suspicion in 38 percent of patients emphasises that the disease may be asymptomatic. Judicious screening, looking for characteristic changes, may select some patients on whom the conformity test can be done (AU)

The significance of atypical squamous cells of undetermined significance in Barbados - Poster abstract

OBJECTIVE: To evaluate the significance of a Papanicolaou (Pap) cervico-vaginal smear diagnosis of atypical squamous cells of undertermined significance (ASCUS) using cytohistologic correlation and to determine the ASCUS squamous intraepithelial lesions (SIL) ratios of five cytopathology laboratories. DESIGN AND METHODS: A combined retrospective and prospective study was undertaken to evalute the histologic diagnoses of the biopsies from patients who attended the colposcopy clinic at the Queen Elizabeth Hospital with the Pap smear cytologic diagnosis of ASCUS during the period, January 1 - April 15, 1998. The laboratory from which the Pap reports were issued was recorded. RESULTS: During this three and a half month period three hundred and sixty-four (364) patients with abnormal smears diagnosed at five different cytology laboratories were investigated. One hundred and fifty (42.1 percent) patients has a Pap smear diagnosis of ASCUS, followed by 161 (46.5 percent) SIL, 130 (35.8 percent) wit low grade intraepithelial lesions (LSIL) and 31 (10.7 percent) high grade intraepithelial lesions (HSIL). Three cases with ASCUS were subsequently excluded from the study because of insufficient data. The histologic diagnosis of the remaining 147 biopsies from patients with the Pap smear diagnosis of ASCUS were LSIL 49 (33.6 percent), HSIL 9 (6.2 percent), atypia/metaplasia 66 (45.2 percent) and inflammation/normal 23 (15.1 percent). The overall ASCUS/SIL ratio was 0.90 and the individual laboratory ratios ranged from 0.25 to 1.70 with a mean of 0.84 ñ 0.63. CONCLUSION: The histologic diagnosis of a cervical cytologic smear assessed as ASCUS may vary from normal to HSIL. Just under 40 percent are likely to be SIL with LSIL predominant. The ASCUS/SIL ratios of Barbadian cytopathology laboratories are less than the ASCUS/SIL ratio (2.0-3.0) suggested by the 1992 NCI Workshop at Bethesda. Hence a diagnosis of ASCUS in Barbados requires careful follow-up.(AU)

Cotyledonous leiomyoma, a rare variant of uterine leiomyoma: case report

A postmenopausal woman admitted to Bayview Hospital for total abdominal hysterectomy for uterine leiomyoma had unusual frond-like vascular excrescences on the anterior wall. These were biopsied, a subtotal hysterectomy was subsequently performed and cotyledonous leiomyoma, a rare and unusual form of uterine leiomyoma, was diagnosed. The macroscopic and microscopic features were presented.(AU)

Detection of oncogenic HPV DNA by a consensus polymerase chain reaction method in genital carcinomas in twenty women in Barbados

Paraffinized tissue from Barbadian women with histologically proven gential carcinoma was subjected to a consensus polymerase chain reaction method. Nineteen patients had cervical and one, vaginal carcinoma. The histological types were 17 squamous cell carcinoma, 2 adenocarcinoma and 1 adenosquamous carcinoma. HPVDNA was detected in 18/20 (90 percent). HPVDNA type 16 in 13 (65 percent), type 33 and type 45 in 1 (5 percent) each and 3 (15 percent) could not be typed. HPVDNA, type 16, was detected in one (50 percent) of the two cases of adenocarcinoma and 12/17 (71 percent) cases of squamous cell carcinoma. DNAHPV, type 33, and type 45 were each detected in 1/17 (6 percent) cases of squamous cell carcinoma. No HPVDNA, type 18, was detected (AU)