Horner's syndrome: a rare presentation of cervical sympathetic chain schwannoma.

We describe a cervical sympathetic chain schwannoma in a 77-year-old woman who presented with a neck mass and Horner's syndrome. Such schwannomas are rare and this is the first documented case of a Horner's syndrome at presentation. The mass was excised via a cervical approach and her post-operative course was uneventful. The prognosis is excellent, with recurrence being rare. A brief discussion of the pathology, presentation, diagnosis, and treatment of this condition is made in this paper. The relevance of the uncertainty in diagnosis is discussed with the message that a pre-operative Horner's syndrome may guide the surgeon in the care of the patient but we suggest that in all cases proper counselling of the possible neurological consequences of this surgery be conducted.

The morphology of juxtaglomerular cell hyperplasia and hypertrophy in normotensive rats and monkeys given an angiotensin II receptor antagonist.

L-694,492 (DUP 532), an angiotensin II (AII) receptor antagonist, was given orally at 125 mg/kg/day to rats and monkeys for up to 6 mo to assess the effects of the compound on juxtaglomerular (JG) cells. In rats, mild JG cell hypertrophy/hyperplasia occurred and was associated with a 12-fold increase in the bromodeoxyuridine-labeling index of JG cells and a 10-fold increase in renal renin content. Ultrastructurally, intermediate cells with characteristics of both smooth muscle cells and granulated renin-producing cells as well as hypertrophied renin-synthesizing cells were seen in the afferent arterioles. In monkeys, marked hypertrophy and hyperplasia were seen with an 80% increase in JG cell numbers, mitotic activity, and a greatly increased renin content compared to controls. Three mo after drug withdrawal, an increased number of cells remained, which showed features of smooth muscle cells with essentially no renin. These results show that AII receptor antagonism stimulates increased renal renin production by hypertrophy of existing granulated cells, metaplasia of smooth muscle cells to renin-synthesizing cells, and cell proliferation. When treatment was discontinued, the renin-producing cells redeveloped the features of smooth muscle, but, as we have shown with enalapril (angiotensin-converting enzyme inhibitor), the increase in their number persists for at least 3 mo.

The morphology of juxtaglomerular cell hyperplasia and hypertrophy in normotensive rats and monkeys given an angiotensin II receptor antagonist.

L-694,492 (DUP 532), an angiotensin II (AII) receptor antagonist, was given orally at 125 mg/kh/day to rats and monkeys for up to 6 mo to assess the effects of the compound on juxtaglomerular (JG) cells. In rats, mild JG cell hypertrophy/hyperplasia occurred and was associated with a 12-fold increase in the bromodeoxyuridine-labeling index of JG cells and a 10-fold increase in renal renin content. Ultrastructurally, intermediate cells with characteristics of both smooth muscle cells and granulated renin-producing cells as well as hypertrophied renin-synthesizing cells were seen in the afferent arterioles. In monkeys, marked hypertrophy and hyperplasia were seen with an 80% increase in JG cell numbers, mitotic activity, and a greatly increased renin content compared to controls. Three mo after drug withdrawal, an increased number of cells remained, which showed features of smooth muscle cells with essentially no renin. These results show that AII receptor antagonism stimulates increased renal renin production by hypertrophy of existing granulated cells, metaplasia of smooth muscle cells to renin-synthesizing cells, and cell proliferation. When treatment was discontinued, the renin-producing cells redeveloped the features of smooth muscle cells, but, as we have shown with enalapril (augioteusin-converting enzyme inhibitor), the increase in their number persists for at least 3 mo.

Acid secretion from a Meckel's diverticulum: the unsuspected mimic of Crohn's disease?

The commonest causes of ulceration in the terminal ileum are Crohn's disease, infection, and neoplasia. Meckel's diverticulum is said to be found more commonly in patients with Crohn's disease than in the general population. We describe a patient who developed extensive terminal ileal ulceration caused by acid secretion from gastric mucosa within a Meckel's diverticulum, a condition that has not been recognized before. Our patient demonstrated a number of clinical features that would be consistent with Crohn's disease, and we wonder whether the rare condition of "Meckel's ileitis" is occasionally misdiagnosed as Crohn's disease in other patients.

Association between Meckel's diverticulum and Crohn's disease: a retrospective review.

The operation notes and pathology records of 294 consecutive patients who had right hemicolectomy for Crohn's disease were reviewed. A Meckel's diverticulum was found in 17 (5.8%) of these patients, 2-3 times the expected rate in the general population. At least 50% of diverticula in the normal population contain heterotopic mucosa, but none was found in those diverticula that were examined from this group. The increased prevalence of Meckel's diverticulum in patients with Crohn's disease confirms previous anecdotal reports, but the cause for the increased frequency remains unexplained. The significance of this finding is discussed.

Primary lymphoma of the small intestine. A clinicopathological study of 119 cases.

Small bowel lymphomas account for 20 to 40% of primary gut lymphomas in Western populations and are among the most common malignant tumours of the small bowel. We studied 119 cases of primary small bowel lymphoma presenting over 4 decades. Two thirds of the patients were men with a peak age incidence in the 7th decade. Common presenting features included abdominal pain, weight loss, small bowel obstruction, and acute abdomen. Tumours were classified using the Kiel European Association for Haematopathology Geneva Workshop scheme and phenotyped on paraffin sections; 66% were B cells, and 34% were T cell. In all cases, the antibodies L26 and polyclonal CD3 reliably distinguished between B- and T-cell tumours. Of the B-cell lymphomas, 62% were diffuse high grade, 20% were low-grade lymphomas of mucosa-associated lymphoid tissue, 11% had both low- and high-grade components, and 7% were other low-grade types. Of the T-cell lymphomas, 83% were high grade, and 49% were enteropathy associated. Most T-cell lymphomas were ulcerated plaques or strictures in the proximal small bowel; B-cell lymphomas tended to be annular or polypoid masses in the distal and terminal ileum. Survival data showed that low-grade B-cell lymphomas had the best outcome and T-cell lymphomas the worst. Adverse prognostic features included perforation, high-grade histology, multiple tumours and advanced stage.

High frequency of K-ras mutations in sporadic colorectal adenomas.

The frequency of activating mutations at codons 12 and 13 of the K-ras gene was investigated in 57 sporadic adenomas from 47 patients using the polymerase chain reaction and oligonucleotide hybridisation assay. Sixty eight per cent of the adenomas tested were positive for K-ras mutations. This high frequency, combined with the lack of a correlation between mutations and adenoma size, suggest that K-ras mutations occur earlier in the adenoma-carcinoma sequence than has previously been suggested. The high frequency observed in sporadic adenomas contrasts with the reported low frequency (18%) in adenomas from patients with familial adenomatous polyposis (FAP), suggesting a possible difference in the molecular genesis of FAP and non-FAP adenomas. Finally, it was found that adenomas from patients with a personal history of colorectal cancer were more likely to contain a K-ras mutation than those from patients with no such history. This is a new finding and worthy of further study.

Successful treatment of a primary endodermal sinus tumor of the liver.

A 27-year-old woman had a large hepatic tumor and a markedly increased serum alpha-fetoprotein (AFP) level. A diagnosis of endodermal sinus tumor was made after a needle biopsy was performed on the liver. Clinical and radiologic examinations did not show an alternative primary site. Treatment with cisplatin, etoposide, and bleomycin was started, but, after three cycles, was changed to cisplatin, vincristine, methotrexate, bleomycin, dactinomycin, cyclophosphamide, and etoposide because the serum AFP level was decreasing too slowly. After additional chemotherapy was given, the patient was well but had an increased AFP level and a large residual mass in the liver. A right hemihepatectomy was performed, but no viable tumor was present. The patient is alive and disease-free 5 years later. Thus, AFP levels may be misleading in the presence of large necrotic tumors. The authors stress the need to make a diagnosis of these rare tumors early because aggressive treatment with combination chemotherapy may result in cure.

An intragenic region downstream from the dihydrofolate reductase promoter is required for replication-dependent expression.

The gene encoding dihydrofolate reductase (DHFR) is down-regulated as myoblasts withdraw from the cell cycle and commit to terminal differentiation. To localize cis-acting elements involved in regulating DHFR gene expression, the DHFR promoter and upstream region, together with differing amounts of contiguous intragenic sequence, were fused to the bacterial chloramphenicol acetyltransferase (CAT) gene. The resulting fusion genes were stably transformed into muscle cells, and CAT mRNA levels were measured in proliferative myoblasts and committed myocytes. A gene consisting of the -850/+465 region of DHFR (numbers refer to distance in base pairs from transcription initiation site) fused to CAT was efficiently expressed in proliferating myoblasts and was appropriately down-regulated during commitment. A gene consisting of the -850/+60 region of DHFR fused to CAT was poorly expressed in proliferating myoblasts and was not down-regulated during commitment. When inserted between the Rous sarcoma virus promoter and CAT sequence of RSVpCAT, the +61/+465 region of the DHFR gene augmented CAT mRNA expression in muscle cell transformants but did not confer a regulated pattern of expression. Our data indicate that DHFR sequences between +60 and +465 are required but are not sufficient for replication-dependent expression. The DHFR sequences may be operating at either a transcriptional or posttranscriptional level.

The varied appearances of starch particles in smears and paraffin sections.

Evidence is presented to show that maize starch particles, usually recognized in histological sections by their Maltese cross birefringence under cross-polarized light, lose this characteristic appearance when transected by the microtome blade. Such particles are, therefore, likely to be overlooked. Though maize starch usually enters the abdomen during surgery, the female genital tract is another possible route from sources such as contraceptive devices. Other types of starch particle have different shapes, sizes and surface markings and these may be distinguished from maize starch by light and electron optical methods.

Clinical observations on the use of BCG cell wall fraction for treatment of periocular and other equine sarcoids.

Clinical observations on the use of BCG cell wall fraction in oil for treating seven horses with periocular sarcoids and five horses with sarcoids in other regions are described. Therapy was successful when used for periocular or solitary and smaller sarcoids. For sarcoids previously treated with cryosurgery, therapy appeared to be less efficient. A horse with a sarcoid on the stifle developed a septic gonitis due to necrosis of the sarcoid tissue adjacent to the joint. Sarcoids of the axilla appeared to be more aggressive than sarcoids at other locations and did not respond favourably to this form of therapy.

Leiomyoma of the iris in a Sprague-Dawley rat.

A leiomyoma of the iris was composed of bundles of spindle-shaped cells with abundant myoglial fibres and represents the first observation of this rare tumour in a rat.

Clinical course of renal adenocarcinoma associated with hypercupraemia in a horse.

A four-year-old shire mare with haematuria, colic, terminal weight loss and an abdominal mass had a large unilateral renal adenocarcinoma. Clinical signs were monitored for 11 months. Increased serum copper concentrations were measured on two occasions. Hypercupraemia is discussed as a possible paraneoplastic change.

Asymptomatic microhematuria and urologic disease. A population-based study.

Asymptomatic microhematuria is a common finding, occurring in 13% of adult men and postmenopausal women in Rochester, Minn. Previous recommendations to perform cystoscopic and excretory urographic examinations on all patients with this finding were based on findings in referred patients. In the present population-based study, the frequency of serious urologic disease in patients with asymptomatic microhematuria was 2.3%; only 0.5% had bladder or renal cell carcinoma. Urologic malignant lesions occurred more frequently in the elderly. There was a trend toward more serious diseases in those with higher grades of hematuria. Complete urologic investigation of all patients with any degree of asymptomatic microhematuria cannot be recommended. The presence of other risk factors should be considered in opting for further evaluation.

Age-related variations in renal structure and function in Sprague-Dawley rats.

Data from 500 male and 500 female Sprague-Dawley rats used as controls in studies performed at Huntingdon Research Centre to assess the safety of drugs were sampled at 17, 30, 56, 82, or 108 weeks of age. Plasma urea nitrogen levels remained constant, except in aged males. Aging caused increased proteinuria and decreased urinary concentrating ability, in addition to increased size, weight, and degree of cortical scarring of kidneys. Chronic progressive nephropathy, first seen histopathologically at 30 weeks of age, accounted for these changes and ultimately affected 81% of male and 44% of female rats. One-fifth of two-year-old male rats had diffuse parenchymal damage and a small number also had secondary hyperparathyroidism. Other notable changes included basophilic (often colloid-filled) cortical tubules, mononuclear cell infiltrations, parenchymal and pelvic mineralization, urothelial hyperplasia, and pyelonephritis. Miscellaneous low incidence findings included one lipomatous tumour and generalized lymphosarcoma.

Fecal blood levels in health and disease. A study using HemoQuant.

We tested HemoQuant, a quantitative assay of fecal blood based on the fluorescence of heme-derived porphyrin, in 106 healthy volunteers, 170 patients with gastrointestinal symptoms but with normal diagnostic studies, 44 patients with gastrointestinal cancer, 75 patients with benign polyps, and 374 patients with a variety of other benign gastrointestinal lesions, including ulcers and erosions. In 98 per cent of the healthy volunteers, fecal hemoglobin concentrations were less than 2 mg per gram of stool. Levels were similarly low in stools from patients with symptoms and normal studies and in patients with relatively minor benign lesions. Within these groups, levels were slightly higher in those who had ingested red meat or aspirin. The fecal hemoglobin concentration was higher in patients with gastrointestinal cancer than in any other group, and 97 per cent of those with colorectal cancer had levels above 2 mg per gram. The sensitivity of HemoQuant was significantly greater than that of the guaiac test Hemoccult, particularly when heme was degraded or stools were dry. Intestinal degradation of heme to porphyrin can be measured separately by HemoQuant, and was greater when bleeding was from proximal lesions rather than distal ones. We conclude that HemoQuant is a more sensitive measure of gastrointestinal bleeding than Hemoccult, and that its capacity to measure degraded heme may be useful in indicating the anatomic site of bleeding.

Effects of transportation, surgery, and antibiotic therapy in ponies infected with Salmonella.

Seventeen ponies were infected with Salmonella typhimurium and then 15 were variously stressed by transportation and/or surgery and 9 were given oxytetracycline. Indications of Salmonella reactivation occurred in all the stressed ponies. Diarrhea due to a reactivation of the Salmonella infection did not develop until greater than 3 days after stress, although maximal shedding of organisms occurred within 24 hours. A neutropenia generally occurred within 24 hours after stress and lasted about 5 days. A rectal temperature greater than 39 C usually did not occur. An increase in serologic titer was noticed in about half of the ponies. Transportation had a major role in reactivating the Salmonella infection, and 1 pony died of peracute colitis. The use of oxytetracycline prolonged the excretion of Salmonella; therefore, this drug should not be used after stress, particularly transportation, in ponies that have diarrhea or are known to be Salmonella carriers.

An equine cryptorchid with testicular and ovarian tissues.

Cytogenetic and histological studies were carried out on an intersex horse which was diagnosed clinically as a cryptorchid. Surgery confirmed the horse to be a bilateral abdominal cryptorchid and histological examination revealed ovarian tissue associated with the left epididymis. Chromosome analysis of cultured cells from testicular tissue, ovarian tissue and skin revealed 64-XX and 64-XY make-up, the left gonad containing a greater preponderance of XX cells over XY cells. The external characteristics and behaviour of the horse were indistinguishable from that of a "routine" cryptorchid. Other cases of equine intersexes are reviewed and theories for the discrepancies between genetic, gonadal and phenotypic sex are discussed.