A contribution to the diagnosis of the small dentigerous cyst or the paradental cyst.

The aim of this study was to verify the relationship between the radiographically measured width of the pericoronal space (PS) and the microscopic features of the follicle in order to contribute to the diagnosis of small dentigerous cysts and paradental cysts. One hundred and thirty unerupted teeth (UT) and thirty-five partially erupted teeth (PET) were radiographed and extracted. The radiographic analysis consisted of measuring the width of the PS. The results of the radiographic analysis were compared with those of the histopathologic examination of the dental follicle. The width of the PS ranged from 0.1 to 5.6 mm. The most frequently observed lining of the follicles was a reduced enamel epithelium (REE) (68.4%) in UT and a hyperplastic stratified squamous epithelium (HSSE) (68.5%) in PET. Inflammation was present in 36.1% of the UT and in 82.8% of the PET. There was a statistically significant association between the presence of stratified squamous epithelium (SSE) and PS enlargement for UT (p < 0.05). There was a tendency of association between inflammation and PS enlargements in PET and, possibly, in UT, despite the absence of statistical significance. Surgically, we did not detect bone cavitation or luminal cystic contents in pericoronal spaces smaller than 5.6 mm. We suggest that the first radiographic diagnosis for a PS enlargement, in most of the routine clinical cases, should be of "inflammation of the follicle". The hypothesis of "dentigerous cyst" or "paradental cyst" is suggested as a second diagnosis. The final differential diagnosis between a small dentigerous or a paradental cyst and a pericoronal follicle depends on clinical and/or surgical findings, such as the presence of bone cavitation and cystic content.

Zoonotic sporotrichosis. Transmission to humans by infected domestic cat scratching: report of four cases in São Paulo, Brazil.

BACKGROUND: Sporotrichosis is a chronic, granulomatous, deep mycosis caused by the dimorphic fungus Sporothrix schenckii that usually results in indolent cutaneous lesions. OBJECTIVE: To describe four cases of human sporotrichosis transmitted by domestic cats in south-eastern Brazil. METHODS: Confirmation of the diagnosis was performed by histopathology, culture, and/or inoculation of hamsters. RESULTS: In all cases, the clinical findings in both cat and human groups were highly distinctive of the disease. In all human cases, there was a previous history of cat scratching before the development of lymphocutaneous lesions. Histopathology of the human lesions demonstrated the classical granulomatous and exudative pattern with scarce or absent fungal elements. Conversely, in cats, the cutaneous lesions were multiple, extensive, necrotic, exudative, and ulcerated. Histopathology revealed a widespread histiocytic reaction with a large number of fungal organisms. Disseminated lymphatic and visceral mycotic infection was observed in two necropsied cats. CONCLUSIONS: Domestic cats may be an important carrier of agents of sporotrichosis to humans.

Renal lesions in leprosy: a retrospective study of 199 autopsies.

In the present work, 199 patients with leprosy who underwent autopsy between 1970 and 1986 were retrospectively studied to determine the prevalence, types, clinical characteristics, and etiologic factors of renal lesions (RLs) in leprosy. Patients were divided into two groups: 144 patients with RLs (RL+) and 55 patients without RLs (RL-). RLs observed in 72% of the autopsied patients were amyloidosis (AMY) in 61 patients (31%), glomerulonephritis (GN) in 29 patients (14%), nephrosclerosis (NPS) in 22 patients (11%), tubulointerstitial nephritis (TIN) in 18 patients (9%), granuloma in 2 patients (1%), and other lesions in 12 patients (6%). AMY occurred most frequently in patients with lepromatous leprosy (36%; nonlepromatous leprosy, 5%; P < 0.01), recurrent erythema nodosum leprosum (33%; P < 0.02), and trophic ulcers (27%; 0.05 < P < 0.10). Ninety-seven percent of AMY was found in patients with lepromatous leprosy, 88% showed recurrent trophic ulcers, and 76% presented with erythema nodosum leprosum. NPS was found in older patients with arterial hypertension, neoplastic diseases, infectious diseases, and vasculitis associated with GN. Most patients with AMY presented with proteinuria (95%) and renal failure (88%). The most frequent causes of death were renal failure in patients with AMY (57%), infectious diseases in patients with GN (41%) and TIN (45%), and cardiovascular diseases in patients with NPS (41%). No difference in survival rates was observed among RL- patients and those with AMY, GN, NPS, or TIN.

Gastroesophageal reflux disease: New oral findings.

OBJECTIVE: The objective of this study was to investigate the effects of gastroesophageal reflux disease (GERD) on dentition, salivary function, and oral mucosa. STUDY DESIGN: Thirty-one patients with esophagitis underwent medical evaluation, which included taking their medical history, performing both an esophagogastroduodenoscopy and esophagus biopsy, and conducting a stomatologic examination. The latter consisted of an extraoral and intraoral physical examination, saliva tests (flow, buffer capacity, and pH), and biopsy and morphometry of the palatal mucosa, as well as taking a history of the patients' habits. Fourteen healthy volunteers from the same population were used as a control group. RESULTS: No relationship between GERD and changes in the oral cavity was shown by saliva tests, oral clinical examination, or histopathologic examination of the palatal mucosa. However, morphometric analysis of the palatal epithelium showed a statistically significant difference between the patients with GERD and the control group. CONCLUSIONS: GERD is associated with microscopic alterations in the palatal mucosa (epithelial atrophy and increased fibroblast number), which are only detected by morphometry.

Serial Mitsuda tests for identification of reactional tuberculoid and reactional borderline leprosy forms.

The authors studied the Mitsuda reaction in 37 leprosy patients (18 reactional tuberculoid, 19 reactional borderline cases) and compared the results with clinical findings, histopathology and bacilloscopy. Evaluation of the Mitsuda reaction was carried out on days 30, 60, 90 and 120. Most of the reactional tuberculoid patients showed a Mitsuda reaction of +3 in opposition to the reactional borderline patients who showed only +. Bacilloscopic analysis revealed that in 75% of the reactional tuberculoid cases there were rare or no bacilli; bacilli were present in 95% of the reactional borderline cases. The authors conclude that reactional tuberculoid cases have a greater ability to clear bacilli than reactional borderline cases, and that the Mitsuda reaction is a useful tool for the differentiation between these two types of leprosy.

Reduction of epidermal cell proliferation in skin lesions in lepromatous leprosy is greater than in indeterminate and tuberculoid leprosy lesions.

We have compared epidermal cell proliferation in skin biopsies from areas with lesions to contralateral areas without lesions in patients with indeterminate, tuberculoid and lepromatous leprosy. Cell proliferation was determined as the percentage of labeled cells in the basal and suprabasal epidermal layers, using autoradiographic preparations of skin biopsies taken 1 hr after a 3H-thymidine intradermal injection. We have found a significant reduction in epidermal cell proliferation in areas with lesions in the three groups of patients. The greatest reduction occurred in lepromatous patients. In lesions of patients with indeterminate or tuberculoid leprosy, the reduction was the same, and in both groups it was smaller than in lepromatous patients. In the areas without lesions, the index of labeled cells was similar to that of "normal" skin of nonleprosy patients. In the contralateral unaffected areas from leprosy patients and in "normal" skin from nonleprosy patients, as well as in affected areas from patients with indeterminate leprosy, epidermal cell labeling was greater in the suprabasal layer than in the basal layer. In lesions of lepromatous patients, cell labeling was greater in the basal layer than in the suprabasal layer. Our findings suggest that the reduction of epidermal cell proliferation in leprosy patients is restricted to the cell-mediated immune response, more intense in lepromatous leprosy. It does not seem to be related to denervation, which is greater in tuberculoid leprosy.

[Assessment of the Mitsuda reaction in lepromatous patients inactive before and after immunotherapy]. / Avaliação da reação de Mitsuda em pacientes virchovianos inativos antes eapós imunoterapia.

In this study the immunopotentiator levamisole as well as a mixture of BCG/Mycobacterium leprae were investigated in inactive lepromatous leprosy patients by using the Mitsuda reaction as a parameter. Twenty lepromatous patients ten years ago classified as histologically negative for Mitsuda's test were divided into three groups: five patients that were only retested with Mitsuda antigen; eight patients that received oral levamisol and seven patients that received a mixture of alive BCG plus autoclaved M. leprae. The results indicated that: 1) the levamisole did not alter the reactivity to lepromin in any of the patients studied; 2) neither the changes in the reactivity to lepromin by using the mixture (3 cases) nor those that occurred spontaneously (3 cases) were clear. They properly reflected the natural variation of patients with some degree of resistance to Mycobacterium leprae.

Correlaçöes histopatológicas entre pele e linfonodos nas fases evolutivas da hanseníase virchoviana / Histopathologic correlations between skin and lymphonodes in evolutive fases of lepromatous leprosy

É realizada uma análise das correlaçöes evolutivas em pele e linfonodos de 30 pacientes protadores de hanseníase virchoviana, sendo 10 virchovianos ativos e em progressäo, 10 virchovianos ativos e em regressäo. 10 virchovianos residuais (inativos). A análise das biópsias de pele e linfonodos nos dois primeiros grupos mostrou marcada heterogeneidade na cosntituiçäo dos granulomas específicos presentes nos linfonodos em contraste com a constituiçäo mais homogênea dos granulomas cutâneos. No terceiro grupo os infiltrados cutâneos eram focais e discretos, enquanto os linfonodos, em numerosos casos, mantinham extensos granulomas macrofágicos residuais em localizaçäo paracortical. Os granulomas macrofágicos mostraram estratificaçäo muito característica nos linfonodos, observando-se tendência dos macrófagos mais jovens e com maior contingente de bacilos típicos a se localizarem em situaçäo cortical e paracortical, enquanto os macrófagos com características regressivas contendo bacilos granulosos tendiam a se situar nas áreas paracorticais profundas e medular. Nos virchovianos ativos há intensa reduçäo da populaçäo linfocitária paracortical, hiperplasia folicular, e plasmacitose medular. Nos virchovianos inativos näo se observa hiperplasia folicular mantem-se a plasmocitose medular e em alguns casos mantem-se a deplecçäo linfocitária paracortical. Três virchovianos regressivos e um residual apresentaram alteraçöes próprias do eritema nodoso hansênico nos linfonodos e em dois virchovianos inativos notou-se deposiçäo amilóide vascular

[Difficulties in the use of the Ridley and Jopling classification--a morphological analysis]. / Dificuldades no emprego da classificação de Ridley e Jopling--uma análise morfologica.

There are many difficulties in the use of the Ridley & Jopling classification in daily practice. The author identified the morphologic parameters whose variations permit to distinguish the polar types and borderline groups according to Ridley. If we avoid the inconstant histologic alterations we believe that this distinction depends basically on the following parameters: epithelioid cell, granuloma of epithelioid cells, numbers of lymphocytes and number of bacilli. A critical analysis is performed of each of these parameters and the author concludes that they are scarce, and that there are great difficulties for the identification and interpretation of their variations for classification purposes. These difficulties are even more important during the reactional episodes.

[Myocardial disease, heart failure and reactional tuberculoid leprosy]. / Seção anátomo-clínica.

A 60-year-old woman was admitted with congestive heart failure, essential hypertension and abdominal distension. Her son reported that she appeared with red spots in the body and that she was under dapsone therapy. Seven months ago there was sudden increase of the skin lesions. In the 11th day after admission she underwent a stroke that progressed to decerebration and she expired on the fourth day. Autopsy confirmed CHF due to chronic myocarditis related to Chagas' disease. Aneurysm of the apical region of the left ventricular chamber was also observed leading to thrombosis and systemic embolism with brain and spleen hemorrhagic infarct. In the encephalous there was edema, uncus herniation and hemorrhagic infarct of the brain stem. The skin lesions were due to reactional tuberculoid hanseniasis (RHT) with focal lesions in axillary lymphnodes, nasopharyngeal mucosa and in the posterior tibial nerve. The pathogenesis of RHT is discussed as well as its differentiation with the BT group of Ridley and Jopling and its probably relationship with the secondary tuberculoid hanseniasis reported by Ridley. The focal lesions are also discussed with END to the involvement of a peripheral nerve trunk what is said to be uncommon in this form of Hansen's disease.

[Lymphomatoid granulomatosis vs. leprosy]. / Seção anátomo-clínica.

Lymphomatoid granulomatosis (LYG) was first described by LIEBOW, A.A. et al. Histologically is characterized by an lymphohistiocytic infiltrate with granulomatous features, polymorphous and pleiomorphic, angiocentric and angiodestructive and mainly involves lungs, skin, kidneys and CNS. LYG does not involves spleen, bone marrow and lymph nodes. Presently there is a concept that LYG is an angiocentric variant of T-cell peripheral lymphoma and histologically indistinguishable from polymorphic reticulosis of the upper airways (midline lethal granuloma). The prognosis for patients with LYG is guarded. Treatment with cyclophosphamide and prednisone may lead to remission in early cases. The skin is the most commonly involved extrapulmonary organ and in 13 to 34% of patients the skin lesions precede the pulmonary involvement. The clinical features of the skin lesions may vary, but frequently they are erythematous and violaceous plaque lesions or annular infiltrated lesions with central clearing. The differential diagnosis of these lesions includes granuloma annular, sarcoidosis and Hansen's disease. Since Hansen's disease is common among us and that LYG includes involvement of cutaneous branches and nerve trunks, with hypo or hyperesthesia in skin lesions and paresthesia of limbs, it is of utmost importance to make differential diagnosis. This report deals with a 42 years old male with cutaneous lesions of LYG and concomitant pulmonary and systemic manifestations. A first skin biopsy roughly suggested tuberculoid leprosy due to a granulomatous and perineural localization of cellular infiltrate. The patient died on respiratory insufficiency and the necropsy findings of the skin revealed important histological modifications. The infiltrate was more polymorphous, pleiomorphic and angiocentric. The same histological features were found in CNS, heart, digestive tract, liver, prostate, testes, lungs and kidneys. In these two last organs there were large nodules made of the characteristic cellular infiltrate and also large necrotic areas.

Histologic responses in sixty multibacillary leprosy patients inoculated with autoclaved Mycobacterium leprae and live BCG.

Sixty lepromatous or borderline lepromatous patients were submitted to immunotherapy with a mixture of autoclaved Mycobacterium leprae and BCG. The histopathologic findings in skin biopsy specimens taken before and after immunotherapy were evaluated independently by six histopathologists in a workshop setting. Their pooled observations on diagnosis and classification were analyzed to assess the histopathologic changes following various periods of immunotherapy. Expressing the results as the average value of five to six independent observations, there were changes in classification of reversal or upgrading toward the tuberculoid end of the leprosy spectrum in 90.5% of the patients initially classified as lepromatous (LL), and in 83.3% of those initially classified as borderline lepromatous (BL). The histopathologic findings amply support the clinical, bacteriologic and immunological changes following immunotherapy from LL or BL, to BL, mid-borderline (BB) or even borderline tuberculoid (BT) leprosy.