Hyperventilation and hypophosphataemia.

We describe a case where extensive investigations were utilized to identify the aetiology of hypophosphataemia in a patient presenting with non-specific symptoms. The diagnosis of hyperventilation-induced hypophosphataemia was eventually established. Hyperventilation is a relatively common cause of isolated hypophosphataemia, but is easily overlooked as a cause.

Catecholamine-induced aggravation of aortic and coronary atherosclerosis in monkeys.

Advanced aortic and coronary atherosclerosis was produced in rhesus monkeys by means of two procedures' (a) high fat and cholesterol feeding for 7 months, and (b) this diet coupled with daily i.v. injection of adrenaline (50 micrograms/kg body weight). A total of 83% of the monkeys subjected to procedure (b) developed markedly advanced atherosclerosis in the form of fibrous plaques in the aorta and coronary artery, while these lesions were much less frequent in the other group. The ratio of total to free serum cholesterol, significantly increased and the aortic cholesterol content was very high in monkeys subjected to both the atherogenic diet and adrenaline injections. It is suggested that catecholamines cause vascular injury and, in the presence of hyperlipidaemia, cause accelerated and aggravated atherosclerosis.

Autopsy findings and clinical diagnoses: a review of 1,000 cases.

The protocols of 1,000 consecutive adult patients autopsied during the period June 1983 to December 1988 were retrospectively analyzed and the findings were compared with clinical diagnoses. The autopsy rates during this period ranged between 23% and 27% of hospital deaths. Eighty-seven percent of the autopsied patients were between 15 and 59 years of age. Major discrepancies between the autopsy reports and the clinical diagnoses were present in 31.7% of all autopsy reports reviewed. Infectious diseases were the most common cause of death (46.8%), followed by cardiovascular diseases (17.1%) and neoplastic diseases (14.3%). Infections were clinically recognized in 66.7% of cases and were missed or found to be incorrect in 33.3% of cases. Tuberculosis comprised 33.8% of the major bacterial infections and was clinically diagnosed in 82% of cases. Eighty-nine percent of the major fungal infections were not suspected clinically. Rheumatic heart disease (43.8%) was the most common cardiovascular disorder and was clinically diagnosed in 93.3% of cases. Pulmonary vascular episodes were the least common cause of death and were not suspected clinically in 62.9% of cases. Malignancies were incorrectly diagnosed in 25.8% of cases. We conclude from this study that routine autopsies revealed major unexpected findings that are of clinical importance, and that a continued emphasis on autopsy evaluation is necessary for the improvement of the quality of patient care.

Acute renal failure of obstetric origin.

Acute renal failure of obstetric origin is common among North Indian patients and comprised 72 (22.1%) of 325 patients undergoing dialysis over an 11-year period. Of these, 46 gravidas had developed renal failure following abortion, and 29 cases were due to complications of late pregnancy. The most striking feature of this study was a high incidence of irreversible renal lesions of bilateral diffuse cortical necrosis in early (18.6%) as well as late pregnancy (37.8%). Overall incidence of diffuse cortical necrosis was 25%. In the remainder, acute tubular necrosis was seen in 52 (72.2%), patchy cortical necrosis in 1 (1.4%), and tubular necrosis along with glomerular involvement in 1 patient (1.4%). Pathogenetic factors which contributed to the development of renal failure, either singly or in combination, were loss of blood failure, either singly or in combination, were loss of blood (79.1%), septicemia (31.9%), hypotension due th hemorrhagic and septicemic shock (51.4%), eclamptic toxemia (11.1%), and disseminated intravascular coagulation in 12.5% patients. Infrequent occurrence of disseminated intravascular coagulation in the septic anc eclamptic patients who developed diffuse cortical necrosis was an interesting finding, as was the fact that coagulopathy was more frequently observed in acute tubular necrosis. Late referral, frequent sepsis, and high incidence of bilateral diffuse cortical necrosis contributed significantly to a high mortality (55.3%).

Incomplete rupture of the heart with diverticulum formation.

Two diverticula of the heart that caused no perceptible bulge in the cardiac outline were found at necropsy amongst 197 hearts from patients who had had myocardial infarcts. They lay within the wall of the left ventricle communicating with the left ventricular lumen by a small orifice, had mural thrombus in their lumens, were lined by connective tissue and surrounded by a healing or healed infarct. The lesions resulted from an incomplete rupture of the heart caused by the arrest of a haemorrhagic dissection en route from endocardial to epicardial surfaces through the infarcted ventricular wall. Resorption and organization occurred and a diverticulum formed. The distinct morphology of the diverticulum permits its differentiation from both a left ventricular aneurysm and a pseudoaneurysm.

Spectrum of acute cortical necrosis in Indian patients.

Forty-nine out of 662 patients (7.4%) dialysed for acute renal failure were found to have bilateral renal cortical necrosis. Amongst 6061 autopsies carried out in our centre during the same period, the incidence of cortical necrosis was 0.7%. Obstetric causes were responsible for the renal lesion in 35 (71%) and non-obstetrical causes in 14 patients. In the obstetric group, cortical necrosis was observed in association with spontaneous or induced abortion in 39% and as a complication of late pregnancy in 33%. The non-obstetric causes included snake bite in 26 (12%), acute gastro-enteritis in 5 (10%), haemolytic uremic syndrome in 2 (4%) and G6PD deficiency with intravascular haemolysis in one patient (2%). Thirty-nine (80%) patients were anuric or severely oliguric throughout their illness but a steady rise in urinary output following a protracted phase of oligo-anuria was observed in ten patients. Forty-two (86%) patients died and seven survived. None of the survivors, however, achieved a normal renal function (Ccr 8 ml to 28 ml/min). The diagnosis of renal lesion was confirmed during life in 8 and after death in 41 patients. Morphological lesions were consistent with bilateral diffuse cortical necrosis in 39 (80%) and patchy lesions in 10 patients. Factors responsible for the high incidence of cortical necrosis amongst Indian patients have been high-lighted.

Acute renal failure due to intravascular hemolysis in the North Indian patients.

Acute renal failure due to intravascular hemolysis is a common clinical problem in North Indian patients. It constituted 21.5 percent of 325 patients dialyzed for acute renal failure over an 11-year period at Chandigarh. Thirty patients had developed acute intravascular hemolysis in association with erythrocyte glucose-6 phosphate dehydrogenase (G-6PD) deficiency, 17 due to copper sulphate intoxication and 8 due to envenomation by snakes. Less frequent causes were insect stings, incompatible blood transfusion, intake of anti-leprosy drug--dapsone in non-G-6PD-deficient patients, and mercuric chloride toxicity in two patients each; naphthalene poisoning in one; and uncertain causes in six patients. Renal histology was available in 55 patients. Acute tubular necrosis was seen in 54 and bilateral diffuse cortical necrosis in one patient. Fifty patients (71.43 percent) survived and 20(28.6 percent) diet. G-6PD erythrocyte deficiency, which is present in 4.5 percent of the North Indian population, was the most frequent cause of acute renal failure in this group.

Class specific antinuclear antibodies in systemic lupus erythematosus.

The incidence and significance of class specific antinuclear antibodies (ANA), specially with relevance to clinical manifestations of arthritis, renal disease and serositis was studied in 40 patients of systemic lupus erythematosus by the indirect immunofluorescent method. Clinical activity was scored by Morimoto's scoring system. A significant correlation was obtained between IgD ANA and clinical activity of the disease and IgG ANA exhibiting lupus pattern of immunofluorescence and serositis.

Kaposi's sarcoma of spleen with unusual clinical and histologic features.

We report a case of Kaposi's sarcoma in a young woman who presented with unusual clinical and histologic features. The unusual clinical features were the absence of cutaneous lesions; the presence of a splenic mass; and extensive involvement of the peritoneum, resulting in massive ascites and intestinal and ureteral obstruction. We postulate that the spleen was the primary site of the tumor. The unusual histologic features were the presence of both sclerotic and cavernous hemangioma variants in the same tumor and extensive areas of calcium deposits in the tumor. Such atypical clinical and histologic features can pose diagnostic difficulties for both clinicians and pathologists.

Morphologic changes in pulmonary vasculature with arteriographic correlation.

During fetal life the pulmonary circulation is one of high resistance. Soon after birth with the onset of breathing and thereafter, sequential structural changes in pulmonary vasculature take place. Several authors have reported differently on this structural remodeling. This study describes the changes in the pulmonary vasculature occurring following birth. Twenty-five cases submitted to autopsy with ages ranging from newborns up to fourteen years were studied. Postmortem arteriography was undertaken in most of the cases and arterial morphology was quantitated by histomorphometry. It was found that the thick-walled pulmonary arteries of the newborn show a reduction in medial thickness over a period of one month, the reduction being most rapid in the first three days. After one month there is no significant change in medial thickness until fourteen years of age.

Autopsy incidence of pulmonary vascular episodes. A study of 218 cases.

Pulmonary thromboembolism is a rarity in India. This common clinical impression has so far not been tested. Among 7000 autopsies between 1964 and 1980, a total of 218 cases (126 males and 92 females) were recorded to have thrombosis and/or embolism and/or infarction in the lungs. This incidence of 3.1% is far lower than that reported in the West and similar to the low incidence in Africa. Of the 218 cases, 42.6% had a cardiac disease, 18.3% had systemic septicemia, 13% had a malignancy, 12.8% had pulmonary disease, and the remaining suffered from diseases of liver, kidney, CNS, etc. Of the 218 cases, 141 (64.6%) showed only infarcts, 40 (18.3%) had only thromboemboli, and 37 (16.9%) showed both events. In view of the overlap among these three conditions and their essential pathophysiologic identity (thrombus/embolism/infarction), it is suggested that these be grouped under the name "pulmonary vascular episode."

FNA cytodiagnosis of non-Hodgkin's lymphoma and its subtyping under working formulation of 175 cases.

One hundred thirty-two cases diagnosed as non-Hodgkin's lymphoma (NHL) by fine-needle aspiration cytology (FNAC) and histology, and 43 cases in which there were minor or major discrepancies between cytology and histology for diagnosis of NHL, were reviewed. The diagnostic accuracy of FNAC for NHL was 86.3% at the initial diagnosis. Following review, all the 132 cases initially diagnosed as NHL by cytology and histology remained so with minor changes in subtypes in a few cases. Of the 43 discrepant cases, 28 turned out to be NHL and 6 as Hodgkin's disease (HD); 3 were anaplastic carcinoma; and in 6 cases the discrepancy still persisted. Diagnostic accuracy of FNA for NHL improved to 98.0% following review. Categorization of histologically diagnosed NHL cases under working formulation showed that 10.4%, 21.5%, and 57.7%, respectively, were low, intermediate, and high-grade lymphomas. The corresponding figures were 16.6%, 18.4%, and 60.1%, respectively, in cytology. The diagnostic accuracy of cytology for subtyping was found to be 67.5%.

Working formulation of the non-Hodgkin's lymphomas: a study of cell size and mitotic indices in cytologic subtypes.

Cell size and mitotic indices were studied in 243 non-Hodgkin's lymphomas (NHL) diagnosed cytologically and classified according to the Working Formulation. Low-, intermediate-, and high-grade lymphomas constituted 14.8%, 18.9%, and 61.7% of the cases, respectively. Measurement of the diameter of 100 lymphoid cells in each case showed that in most of the low-grade malignant lymphomas, 50-80% of the cells were small (less than 10 microns). A majority of the cells (an average of 45-60%) in intermediate- and high-grade lymphomas were in the range of 11-15 microns. Only the intermediate-grade large noncleaved and high-grade immunoblastic lymphomas had a majority of their cells (greater than 50%) larger than 15 microns. The mitotic indices (number of mitotic figures per 500 lymphoid cells) showed a highly significant difference between low- (0.7 +/- 1.14), intermediate- (3.0 +/- 2.67), and high-grade (5.4 +/- 3.40) lymphomas using the Wilcoxon's signed rank test (P less than 0.0001). Nearly two-thirds of the cases in each grade were within specific ranges of mitotic indices, i.e., less than 1 for low-, 1-3 for intermediate-, and greater than 3 for high-grade lymphomas.

Malignant lymphoma of convoluted lymphocytes: diagnosis by fine-needle aspiration cytology and cytochemistry.

The technique of fine-needle aspiration cytology (FNAC) was utilized in the diagnosis of 31 cases of malignant lymphoma of convoluted lymphocytes. The age of the patients ranged from 5 to 70 yr (median, 24 yr). Clinical history was available in 29 cases. All patients had peripheral lymphadenopathy. There was radiological evidence of mediastinal adenopathy in 62% of the cases, and 41% had pleural effusion; 52% of the patients presented with mediastinal compression syndrome. The diagnostically crucial convoluted cells comprised 47.3 +/- 23.73% of all lymphoid cells. Nuclear convolutions were appreciated in a significant number of cells in paraffin sections of 17 of 21 cases (85.7%) having subsequent histopathology. Cytochemical and E-rosette tests performed in 17 cases confirmed the T cell nature of the neoplasms. On an average, 72.3% of cells showed focal positive reaction for acid phosphatase, and 73.8% of cells formed E-rosettes.

Fine-needle aspiration cytology in azoospermic males.

Bilateral testicular fine-needle aspiration cytology (FNAC) was performed in 100 males, including 10 controls with normal fertility and 90 infertile azoospermic males. The various seminiferous tubular cells were easily identified in smears. It was possible to give a cytological diagnosis in histologic terms by analysis of the combinations of various cell types. The cytohistologic correlation in 25 cases was nearly 100%. FNAC is particularly useful in cases of obstructive azoospermia, where mature spermatozoa are seen in smears.

Pleural effusions in non-Hodgkin's lymphoma. A cytomorphologic, cytochemical and immunologic study.

Review of the records of 243 cases of cytologically diagnosed non-Hodgkin's lymphomas (NHL) revealed pleural effusions in 21 (8.6%). Cytologic examination of pleural fluid was done in 17 cases, of which 16 were reported as positive. Cytologic examination was supplemented with cytochemical staining (acid phosphatase, alpha naphthyl acetate esterase and periodic-acid-Schiff reactions) and E-rosetting studies in 12 cases. Of the 16 positive cases, 11 were malignant lymphomas consisting of convoluted lymphocytes. Acute lymphatic leukemia of the prothymocytic type (T-ALL) and chronic lymphocytic leukemia of the T-cell type (T-CLL) comprised one case each, and there were three cases of follicular center cell lymphomas, two of the cleaved-cell type and one of the Burkitt-type. Comparison of the cytomorphology of the tumor cells in the pleural effusion with those in fine needle aspiration smears from the solid tumors in 14 cases showed an identical appearance in 13 cases; in one, the Burkitt-type lymphoma, the cells were larger and more pleomorphic in the pleural effusion. This study indicates that the cytologic diagnosis and categorization of NHL of the convoluted-cell type is greatly enhanced by the study of neoplastic lymphocytes in a pleural effusion.

Burkitt-type lymphoma. Diagnosis by fine needle aspiration cytology.

Forty cases of lymphoma were categorized as Burkitt-type lymphoma in a study of fine needle aspiration (FNA) smears. These constituted 14.3% of all cases of non-Hodgkin's lymphoma diagnosed between 1974 and 1982. The median age was 22 years in these cases, 81.8% of which had extranodal tumors. The majority of the cells in the smears (59.8% +/- 8.32%) were in the 11 micron to 15 micron size range and 60.3% +/- 10.3% had noncleaved nuclei. An average 71% of the cells contained cytoplasmic and/or nuclear vacuolizations. Nonneoplastic macrophages were present in the smears in 87.5% of the cases. A study of paraffin-embedded sections in 17 cases revealed the characteristic "starry-sky" appearance in 11; in 5 it was not clearly appreciated and in 1 the nonneoplastic macrophages were absent. FNA cytology was found to be quite reliable for arriving at a diagnosis of Burkitt-type lymphoma. More than 50% of the cases were managed without resort to subsequent surgical biopsy. Exploratory laparotomy was avoided in 69% of the cases having abdominal tumors.

Fine needle aspiration cytodiagnosis of Hodgkin's disease and its subtypes. I. Scope and limitations.

The fine needle aspiration (FNA) smears and paraffin-embedded sections from 89 cases with a cytologic and histologic diagnosis of Hodgkin's disease (HD) and 27 cases with minor or major cytohistologic discrepancies were reviewed. The accuracy of the initial cytologic study was found to be 91.8% for diagnosing HD and 58.1% for classifying its subtypes. Following review, 87 of the 89 agreement cases remained classified as HD. Of the 27 cases with initial cytohistologic discrepancies, 12 were classified as HD and 10 were categorized as lymphocytic or non-Hodgkin's lymphoma by both cytology and histology upon review. Following review, the accuracy of FNA cytology for the diagnosis of HD improved to 98.0%, with 71.4% correct subtyping. The greatest limitation of cytologic subtyping was in cases of nodular sclerotic HD: only 3 of 17 cases could be subtyped even after review. The cytomorphologic features of the HD subtypes are described, and the difficulties encountered in the cytodiagnosis of HD are discussed at length. The results of this study indicate that FNA cytology is a useful tool not only for the diagnosis of HD, but also for its subtyping.

Pattern of hypertrophy of left ventricle--a histometric analysis of eighteen cases.

The pattern of myocardial hypertrophy in different sites of the left ventricular wall was morphometrically analysed in aortic stenosis (6 cases), hypertensive hypertrophy (5 cases), mitral incompetence (4 cases), and dilated cardiomyopathy (3 cases). The diameter of individual circumferentially oriented mid wall (or middle) fibre was significantly greater than those of subepicardial and subendocardial zones. Thus, hypertrophy does not affect the entire left ventricular myocardium uniformly. It seems to vary according to the spatial configuration of the fibrosis in relation to the cavity.

Morphologic and arteriographic changes in the pulmonary vasculature in children with congenital heart disease.

This study was undertaken to determine the morphologic changes occurring in the pulmonary vasculature in congenital heart disease. Autopsy was performed in twenty cases of congenital heart disease ranging in age from newborn (full term) to 14 years. Postmortem arteriography was performed in most of them followed by histomorphometry. It was found that medial hypertrophy of the muscular pulmonary arteries was the most consistent change and the smallest muscular arteries were the most severely affected. The lesions were focal and randomly distributed. Hence, morphologic observations on open lung biopsies may not be accurate.