Clinical, epidemiologic, histopathologic and molecular features of an unexplained dermopathy.

BACKGROUND: Morgellons is a poorly characterized constellation of symptoms, with the primary manifestations involving the skin. We conducted an investigation of this unexplained dermopathy to characterize the clinical and epidemiologic features and explore potential etiologies. METHODS: A descriptive study was conducted among persons at least 13 years of age and enrolled in Kaiser Permanente Northern California (KPNC) during 2006-2008. A case was defined as the self-reported emergence of fibers or materials from the skin accompanied by skin lesions and/or disturbing skin sensations. We collected detailed epidemiologic data, performed clinical evaluations and geospatial analyses and analyzed materials collected from participants' skin. RESULTS: We identified 115 case-patients. The prevalence was 3.65 (95% CI = 2.98, 4.40) cases per 100,000 enrollees. There was no clustering of cases within the 13-county KPNC catchment area (p = .113). Case-patients had a median age of 52 years (range: 17-93) and were primarily female (77%) and Caucasian (77%). Multi-system complaints were common; 70% reported chronic fatigue and 54% rated their overall health as fair or poor with mean Physical Component Scores and Mental Component Scores of 36.63 (SD = 12.9) and 35.45 (SD = 12.89), respectively. Cognitive deficits were detected in 59% of case-patients and 63% had evidence of clinically significant somatic complaints; 50% had drugs detected in hair samples and 78% reported exposure to solvents. Solar elastosis was the most common histopathologic abnormality (51% of biopsies); skin lesions were most consistent with arthropod bites or chronic excoriations. No parasites or mycobacteria were detected. Most materials collected from participants' skin were composed of cellulose, likely of cotton origin. CONCLUSIONS: This unexplained dermopathy was rare among this population of Northern California residents, but associated with significantly reduced health-related quality of life. No common underlying medical condition or infectious source was identified, similar to more commonly recognized conditions such as delusional infestation.

Oxalosis in wild desert tortoises, Gopherus agassizii.

We necropsied a moribund, wild adult male desert tortoise (Gopherus agassizii) with clinical signs of respiratory disease and elevated plasma biochemical analytes indicative of renal disease (blood urea nitrogen [415 mg/dl], uric acid [11.8 mg/dl], sodium [>180 mmol/l] and chloride [139 mmol/l]). Moderate numbers of birefringent oxalate crystals, based on infrared and electron microscopy, were present within renal tubules; small numbers were seen in colloid within thyroid follicles. A retrospective analysis of 66 additional cases of wild desert tortoises was conducted to determine whether similar crystals were present in thyroid and kidney. The tortoises, from the Mojave and Sonoran deserts, were necropsied between 1992 and 2003 and included juveniles and adults. Tortoises were classified as healthy (those that died due to trauma and where no disease was identified after necropsy and evaluation by standard laboratory tests used for other tortoises) or not healthy (having one or more diseases or lesions). For all 67 necropsied tortoises, small numbers of crystals of similar appearance were present in thyroid glands from 44 of 54 cases (81%) and in kidneys from three of 65 cases (5%). Presence of oxalates did not differ significantly between healthy and unhealthy tortoises, between age classes, or between desert region, and their presence was considered an incidental finding. Small numbers of oxalate crystals seen within the kidney of two additional tortoises also were considered an incidental finding. Although the source of the calcium oxalate could not be determined, desert tortoises are herbivores, and a plant origin seems most likely. Studies are needed to evaluate the oxalate content of plants consumed by desert tortoises, and particularly those in the area where the tortoise in renal failure was found.

Deposition of calcium salts in a case of pulmonary zygomycosis: histopathologic and chemical findings.

We report a case of pulmonary zygomycosis associated with unusual deposition of calcium salt crystals. The patient was a 75-year-old female who had onset of cough and shortness of breath. She was treated for community-acquired pneumonia but died despite intensive therapy. Postmortem examination revealed diffuse alveolar damage and multifocal necrotizing pneumonia associated with herpes simplex infection and invasive zygomycosis. Birefringent particles were seen associated with fungal elements in the lung parenchyma, within bronchial cartilage, and in blood vessel walls. By infrared spectroscopy, the birefringent particles in the pulmonary parenchyma and within bronchial cartilage had spectral characteristics of calcium oxalate dihydrate and calcium oxalate monohydrate, respectively. The birefringent crystals within vascular walls were identified as calcium carbonate. This case documents the chemical composition and location of 3 different calcium salt crystals in pulmonary zygomycosis. It also shows that among pulmonary fungal infections, calcium oxalate deposition is not restricted to aspergillosis.

Renal oxalosis in free-ranging green turtles Chelonia mydas.

Eighteen green turtles Chelonia mydas recovered from the Atlantic and Gulf coasts of Florida and Tortuguero National Park, Costa Rica, were diagnosed with renal oxalosis by histopathological examination. Affected sea turtles included 14 adults and 4 immature animals, which comprised 26% (18/69) of green turtle necropsy cases available for review. Calcium oxalate deposition ranged from small to moderate amounts and was associated with granuloma formation and destruction of renal tubules. All affected turtles died from traumatic events or health problems unrelated to renal oxalosis; however, 1 immature turtle had notable associated renal injury. Crystal composition was confirmed by infrared and scanning electron microscopy and energy dispersive X-ray analysis. The source of calcium oxalate is unknown and is presumed to be of dietary origin.

Wound fragments from cutaneous sites of U.S. Military personnel deployed in operation Iraqi Freedom: clinical aspects and pathologic characterizations.

BACKGROUND: A wide variety of materials present in current military conflict zones may be implanted and retained as "foreign bodies" or fragments in wounds. Analysis of removed fragments can be valuable to the patient, for research purposes, and for the protection of future potential victims. OBJECTIVES: The objectives were to evaluate the composition of retained fragments in wounds from combat injuries and correlate this information with the mechanism of injury. METHODS: Wound fragments from 10 U.S. military personnel wounded while deployed in Iraq for Operation Iraqi Freedom were removed from their skin and were subjected to gross examination, light microscopy, and scanning electron microscopy/energy-dispersive X-ray analysis (SEM-EDXA), with specimen radiography and infrared spectroscopy if indicated. RESULTS: A variety of exogenous substances, including iron, lead, antimony, copper, aluminum, and acrylonitrile-styrene plastic were detected. No (depleted) uranium was detected. There was a high degree of correlation between the composition of the fragment removed and the wounding event. CONCLUSIONS: Wound fragments may take months to years to manifest. Their gross appearance can be misleading. Establishing the composition of retained materials in wounds may assist in the clinical care of the wounded, provide forensic information, and have broader value in wound analysis and research.

Focal white matter changes in spasmodic dysphonia: a combined diffusion tensor imaging and neuropathological study.

Spasmodic dysphonia is a neurological disorder characterized by involuntary spasms in the laryngeal muscles during speech production. Although the clinical symptoms are well characterized, the pathophysiology of this voice disorder is unknown. We describe here, for the first time to our knowledge, disorder-specific brain abnormalities in these patients as determined by a combined approach of diffusion tensor imaging (DTI) and postmortem histopathology. We used DTI to identify brain changes and to target those brain regions for neuropathological examination. DTI showed right-sided decrease of fractional anisotropy in the genu of the internal capsule and bilateral increase of overall water diffusivity in the white matter along the corticobulbar/corticospinal tract in 20 spasmodic dysphonia patients compared to 20 healthy subjects. In addition, water diffusivity was bilaterally increased in the lentiform nucleus, ventral thalamus and cerebellar white and grey matter in the patients. These brain changes were substantiated with focal histopathological abnormalities presented as a loss of axonal density and myelin content in the right genu of the internal capsule and clusters of mineral depositions, containing calcium, phosphorus and iron, in the parenchyma and vessel walls of the posterior limb of the internal capsule, putamen, globus pallidus and cerebellum in the postmortem brain tissue from one patient compared to three controls. The specificity of these brain abnormalities is confirmed by their localization, limited only to the corticobulbar/corticospinal tract and its main input/output structures. We also found positive correlation between the diffusivity changes and clinical symptoms of spasmodic dysphonia (r = 0.509, P = 0.037). These brain abnormalities may alter the central control of voluntary voice production and, therefore, may underlie the pathophysiology of this disorder.

Raman chemical imaging spectroscopy reagentless detection and identification of pathogens: signature development and evaluation.

An optical detection method, Raman chemical imaging spectroscopy (RCIS), is reported, which combines Raman spectroscopy, fluorescence spectroscopy, and digital imaging. Using this method, trace levels of biothreat organisms are detected in the presence of complex environmental backgrounds without the use of amplification or enhancement techniques. RCIS is reliant upon the use of Raman signatures and automated recognition algorithms to perform species-level identification. The rationale and steps for constructing a pathogen Raman signature library are described, as well as the first reported Raman spectra from live, priority pathogens, including Bacillus anthracis, Yersinia pestis, Burkholderia mallei, Francisella tularensis, Brucella abortus, and ricin. Results from a government-managed blind trial evaluation of the signature library demonstrated excellent specificity under controlled laboratory conditions.

Forensic visualization of foreign matter in human tissue by near-infrared spectral imaging: methodology and data mining strategies.

BACKGROUND: Rapidity of data acquisition, high image fidelity and large field of view are of tremendous value when looking for chemical contaminants or for the proverbial "needle in the haystack" - in this case foreign inclusions in histologic sections of biopsy or autopsy tissues. Near infrared chemical imaging is one of three chemical imaging techniques (NIR, MIR and Raman) based on vibrational spectroscopy, and provides distinct technical advantages for this application. METHODS: We have chosen to utilize and evaluate near infrared (NIR) imaging for studies of foreign materials in tissue because the experimental configuration is relatively simple, data collection is rapid, and large sample areas can be screened with high image fidelity and spatial resolution. RESULTS: We have shown that NIR imaging can readily find and identify silicone gel inclusions in biological tissue samples. Additionally, preliminary results indicate that spectral signatures in the data set are also potentially sensitive to structural changes in the surrounding tissue that may be induced by the foreign body. CONCLUSIONS: NIR chemical imaging is a powerful, non-destructive tool for localization and identifying foreign contaminants in biological tissue. Preliminary results indicate that NIR imaging is also sensitive enough to differentiate tissue types (perhaps based on collagen structural differences), and provide data on the spatial localization of these components.

Characterization of acrylic polyamide plastic embolization particles in vitro and in human tissue sections by light microscopy, infrared microspectroscopy and scanning electron microscopy with energy dispersive X-ray analysis.

Vascular embolization is a well-established practice for the treatment of tumors and vascular lesions. Rounded beads (microspheres) of various materials (collagen, dextran and trisacryl-polymer-gelatin) were developed to solve problems encountered with earlier versions of embolic material. We performed histochemistry, Fourier transform infrared microspectroscopy and scanning electron microscopy with energy dispersive X-ray analysis on two uterine and one hepatic specimen with unidentified intravascular foreign material, and examined a reference embolization product for comparison. The hematoxylin and eosin stained tissue sections showed multiple foci with unidentified intravascular foreign material and fibrous obliteration of vessel lumens. Only one case had a clinical history of previous embolization but without specifying the material used. One case was submitted for identification of a 'parasite'. The material stained positively with Sirius red and mucicarmine, variably with Masson's trichrome stain and Movat pentachrome, and did not stain centrally with periodic acid Schiff with diastase. Infrared spectrophotometric analysis of the material from all three cases demonstrated the spectrum of acrylic polyamide plastic. A control sample of EmboGold exhibited infrared microspectroscopic spectra similar to the three tissue specimens. Analysis by scanning electron microscopy with energy dispersive X-ray analysis demonstrated some differences in elemental composition between the tissue sections and the selected reference material. To our knowledge, this is the first report of infrared spectrophotometric analysis with scanning electron microscopy with energy dispersive X-ray analysis of an acrylic polyamide plastic embolization product both in vitro and in human histologic tissue sections. In cases lacking appropriate clinical information, identification by these methods and/or a panel of special stains may assist pathologists unfamiliar with this material's light microscopic appearance.

Self-treatment of a basal cell carcinoma with "black and yellow salve".

Patients may seek "alternative" or "non-traditional" therapies for dermatologic problems, frequently in search of a miraculous cure. However, many of these medicaments contain unknown compounds with questionable benefit and a potential for significant harm. We describe a patient who developed a large ulceration on her nose after applying "black and yellow salves" obtained from Mexico in an attempt to self-treat a basal cell carcinoma.

Infrared and Raman microspectroscopy of foreign materials in tissue specimens.

Infrared and Raman spectra of materials found in tissue specimens submitted for histopathologic diagnosis have been recorded. These foreign materials range in size from approximately 5 to 50 microm, and the vibrational spectra have been used to identify them. Examples include cholesterol and polytetrafluoroethylene (PTFE) in an implant case, polyethylene terephthalate (PET) and polyacrylonitrile (PAN) in a pilonidal cyst, and carbenicillin in a skin biopsy. In some instances, either the infrared or Raman spectra were sufficient to make a definitive identification, while in other cases both were necessary. Because some of the samples fluoresced with visible excitation at 532 nm, FT-Raman spectra with 1064-nm excitation were also recorded. The flexibility of sampling for vibrational microspectroscopy and the value of the recorded data in assisting pathologists render medical diagnoses in the examples cited and other cases are discussed.

Embolized crospovidone (poly[N-vinyl-2-pyrrolidone]) in the lungs of intravenous drug users.

Crospovidone is an insoluble polymer of N-vinyl-2-pyrrolidone that is used as a disintegrant in pharmaceutical tablets. It can potentially embolize to the lung when aqueous tablet suspensions are injected intravenously. In this report, we identified embolized crospovidone in autopsy-derived lung tissue from three adult IV drug users, 1 man and 2 women, whose ages respectively were 27, 38, and 40 years. Suspected crospovidone was compared with pharmaceutical-grade crospovidone by means of histochemical stains, transmission electron microscopy, and infrared spectroscopy. Similar particles were also observed by light microscopy in a 4-mg tablet of hydromorphone, a preparation prescribed to two of the patients. Two patients had sickle cell disease and were taking methadone and/or hydromorphone for pain management; the third was receiving parenteral hyperalimentation after small bowel resection. Crospovidone appeared as deeply basophilic, coral-like particles within pulmonary arteries and in extravascular foreign-body granulomas. Intrapulmonary crospovidone stained similarly to the pure substance, including intense staining with mucicarmine, Congo red, and Masson trichrome. With Movat pentachrome stain, both intravascular and purified crospovidone appeared orange-yellow, whereas most interstitial particles associated with giant cells stained blue-green. Alcian blue failed to stain intravascular or purified crospovidone but strongly decorated some phagocytized particles. Ultrastructurally, both purified powder and tissue deposits of crospovidone appeared as irregular, electron dense, laminated, and finely granular material. Intrapulmonary crospovidone was associated with inflammatory cells and exhibited degenerative changes. By infrared spectroscopy, crospovidone in tissue had the same spectral characteristics as pharmaceutical grade crospovidone and the library reference, polyvinylpyrrolidone (PVP). We conclude that crospovidone contributes to pulmonary vascular injury in some persons who illicitly inject pharmaceutical tablets. It is readily identifiable histologically and distinguishable from other tablet constituents, such as cornstarch, talc, and microcrystalline cellulose. The variable staining with Alcian blue and Movat suggests that crospovidone is altered in vivo by the inflammatory response.

A histopathological study of head and neck specimens from a cohort of Persian Gulf War military veterans.

Approximately 700,000 U.S. military personnel were deployed to the Persian Gulf region during the Gulf War. Since their return, many Persian Gulf War veterans (GWVs) have presented with various medical symptoms, including those related to the head and neck. A study devoted to the histopathology of head and neck specimens from GWVs has not been previously reported. Surgical, autopsy, and cytological specimens from GWVs were evaluated by light microscopy at the Armed Forces Institute of Pathology with additional studies as required and were entered into the Kuwait Registry. The Kuwait Registry contained 361 head and neck specimens from 264 GWVs. Neoplasms were relatively infrequent, including six malignant neoplasms and 14 benign neoplasms. The most frequent diagnoses were chronic sinusitis, allergic rhinitis, and lymphoid hyperplasia of the tonsils. These conditions are frequently encountered in routine anatomic pathology practice in the general U.S. population.