Carbon monoxide poisoning without cherry-red livor.

Carbon monoxide (CO) poisoning typically causes so-called cherry-red livor of the skin and viscera. The authors report a case of CO poisoning in which cherry-red livor did not develop. The decedent was a 75-year-old white man who was found dead in his car during a cold winter. Blood CO saturation was 86%. The death was attributed to CO poisoning, and the manner of death was designated suicide. The curious absence of cherry-red livor was studied. The decedent's tissue and blood specimens were tested at different temperatures. There was no tendency for either type of specimen to develop cherry-red color at cold or warm temperatures. The antemortem response of the skin to cold possibly sequestered CO-saturated blood in the cadaver. As regards the viscera, there are other proteins to which CO can bond, and possibly these proteins contribute to the development of visceral cherry-red livor. In this case, the absence of cherry-red livor could have led to misclassification of the cause and manner of death. The medicolegal and social consequences of such misclassification can be significant, and psychiatric history, which may be useful to surviving family members, could be lost.

Death from asthma associated with sertraline overdose.

The authors report a case of a young woman for whom autopsy confirmed the cause of death to be due to an acute asthma attack. In addition, she had high serum levels of sertraline hydrochloride (Zoloft). The decedent had a recent prescription for sertraline filled, from which most of the pills were missing, suggesting a large consumption of medication. She was found dead at home, immersed in a bath. Autopsy revealed anatomic evidence of a severe recent asthma attack. Quantitative blood assay for sertraline was very high (620 ng/ml). Fatalities from sertraline alone are virtually nonexistent. The effects of sertraline on asthma, however, are not well-studied. Why the patient ingested so much sertraline is unclear. However, it is possible that, in a variant of the serotonin syndrome, a large dose of a selective serotonin reuptake inhibitor participated in precipitating an asthma attack or prevented her from being aware of the evolution of such an exacerbation. Additional observations in the future will be useful in assessing the role of this class of drugs in patients with asthma.

Coronary arteritis diagnosed at autopsy: three case reports and review of the literature.

Coronary arteritis is rare but can be fatal either by itself or in conjunction with other diseases. The authors report cases of three men in whom coronary arteritis was an interesting finding that may have caused or contributed to death. One 45-year-old man collapsed at work, another 56-year-old man was found dead in his parked car, and one 80-year-old man had a recent cerebrovascular accident. All three men had coronary arteritis, arteriosclerotic cardiovascular disease, some form of myocardial disease, and fatty liver change. Two had different lung diseases. The findings suggest that coronary arteritis may be an independent cause of death, part of a systemic disease, or, as these three cases illustrate, part of a constellation of cardiac and cardiovascular pathologies with a possible relation to other medical conditions. Coronary arteritis is an important finding in forensic pathology and merits consideration in a case of unexplained death.

Declining immunoglobulin A production in prostates of men with AIDS.

We studied immunoglobulin A production (IgA) in prostates of men with AIDS. Prostate sections from AIDS patients and human immunodeficiency virus-negative men were stained for IgA with immunoperoxidase. Prostate sections from nondiseased men were positive for IgA, while prostate sections from AIDS patients were essentially negative for IgA. Diminishing secretory IgA production may represent a characteristic of AIDS.

Four deaths due to carbon monoxide poisoning in car washes.

In a period of 13 months, three separate incidents of lethal carbon monoxide (CO) poisoning in closed car wash bays resulted in the deaths of 4 white men aged 20 to 36 years. Each man appears to have been intoxicated with mind-altering substances, which may impair judgment, perception of outside conditions, and self-awareness. All four died in winter months. For three men, the deaths were ruled accidental, and for the remaining man, the previous deaths appear to have provided a model for suicide. Warning signs may not be effective to prevent future CO deaths in car washes because of the possible role of intoxication. Mechanical or electronic methods to prevent a bay door from closing completely may be preferable.

The clinical context and utility of tongue biopsies.

Lesions of patients' tongue biopsies are described to determine whether certain patients had predilections to develop various lesions based on gender or age, and to determine whether there were significant correlations between the diagnoses, which could be clinically useful, and the various patients. Surgical pathology specimens of the tongue were reviewed. Patients' gender, age and diagnoses were recorded. Most of the 399 patients surveyed were elderly. Patients with epidermal inclusion cysts or granular cell tumors were significantly younger than others. Men were younger than women with squamous cell dysplasia and carcinoma. Benign diagnoses were nearly equally distributed between men and women. Premalignant and malignant conditions were significantly more common among men than women. Follow-up revealed a moderate degree of risk that a premalignant lesion may later develop frank malignancy.

Female genital tract bacterial coisolates with Candida albicans in patients without clinical vaginitis.

OBJECTIVE: In vitro, Candida albicans has demonstrated the ability to inhibit replication of selected bacteria. Little information exists on the impact of C. albicans on the vaginal bacterial flora in vivo. The purpose of this study is to identify the coexisting bacterial flora when C. albicans is isolated from vaginal cultures submitted to a hospital-based testing facility for reasons other than vulvovaginitis. METHODOLOGY: All specimens (240) received from ambulatory care clinics over a six-month period were cultured for aerobic and anaerobic bacteria and Candida species. Those specimens submitted for cervicitis, vaginitis, or vaginal discharge and those from which yeasts other than C. albicans were isolated were eliminated. To control for sample biases, a subgroup composed of all pregnant women for whom cultures were done as screening procedures was similarly studied. Chi-square analyses, comparing the prevalence of individual bacteria isolated with and without the presence of C. albicans, were done for all study populations using SPSS for Windows software (1994). RESULTS: Two hundred and forty consecutive specimens were bacteriologically analyzed. Of the 220 vaginal samples used in the study, C. albicans was isolated in 44 instances (20%). Neither the presence of the lactobacilli nor the presence of Gardnerella vaginalis markedly influenced the isolation rate of C. albicans. The group B streptococci had a greater probability of coisolation when C. albicans was present (27.3% verses 16%), but this was not statistically significant (P < 0.8). Dissociation between the presence of C. albicans and the coisolation of Peptostreptococcus species and anaerobic gram-positive cocci and/or bacilli was noted (P < 0.0819), while the incidence of gram-positive aerobic bacilli was reduced in the presence of C. albicans (30/176 [17.1%] versus 6/44 [13.6%]), this reduced incidence was not statistically significant. Isolation data of the subgroup of pregnant women supported these observations. CONCLUSION: Within the limitations of the study, statistically, the data suggests that an inverse relationship exists between the presence of C. albicans and recovery of Peptostreptococcus and anaerobic gram-positive cocci and bacilli.

Proliferation markers and prognosis in Merkel cell carcinoma.

Merkel cell carcinoma (MCC) is a frequently aggressive primary cutaneous neuroendocrine malignancy. We investigated 3 cell proliferation markers which may be useful in predicting the aggressiveness of MCC: 1) p53, a tumor suppressor protein, 2) Ki-67, a marker of cell cycling, and 3) proliferating cell nuclear antigen (PCNA). Twenty patients with MCC were studied. The 3 cell proliferation markers were studied by immunoperoxidase. Clinical and immunoperoxidase results were tabulated according to recurrence or death from disease. Of the 20 patients, 10 experienced recurrence, and 10 did not. Seven tumors were positive for p53. We found correlations between recurrence and death in MCC patients, between p53 positivity and recurrence/death, and between p53 positivity and head/neck primary sites. We found no correlation with recurrence by gender or primary site. PCNA was positive in only 1 patient, while Ki-67 was positive in all patients, making these 2 markers unsuitable for predicting recurrence. Further clinical studies will be helpful to confirm and refine the application of this test. Prognostic information from such studies may be useful in planning observation and treatment for patients in the future.

Haemophilus segnis cholecystitis: a case report and literature review.

Haemophilus segnis is a normal commensal of the human oropharynx which is occasionally associated with appendicitis, endocarditis or pancreatic abscess. Haemophilus segnis in the gall-bladder from a 58-year-old white female was recently encountered. The patient recovered from surgery without incident. This case is reported because the gall-bladder is now another site which has become infected with this organism. In order to provide guidance to physicians when H. segnis organism is identified, microbiologists should be aware of its behaviour in different sites.

Interrelationships within the bacterial flora of the female genital tract.

Analysis of 240 consecutive vaginal swabs using the compatibility profile technique revealed that only 2 bacteria have the ability to be a sole isolate and as such a candidate to be a major aerobic regulator of the bacterial flora of the female genital tract (BFFGT). Compatibility profiles of Lactobacillus and Gardnerella vaginalis have shown that these organisms shared compatibility profiling for the majority of the normal bacterial constituents of the female genital tract. Dominance disruption appears to come from the addition of compatible co-isolates and presumed loss of numerical superiority. These phenomena appear to be the keys to reregulation of BFFGT. Lactobacillus appears to be the major regulator of both G. vaginalis and anaerobic bacteria. When additional organisms are added to the bacterial flora, they may add to or partially negate the inhibitory influence of Lactobacillus on the BFFGT. Inhibitor interrelationships appear to exist between coagulase-negative staphylococci and Staphylococcus aureus and the group B streptococci (GBS) and other beta hemolytic streptococci. Facilitating interrelationships appear to exist between S. aureus and the GBS and selected Enterobacteriaceae.

Unexpected synchronous non-Hodgkin's lymphoma encountered during the treatment of a previously-diagnosed carcinoma: report of three cases.

We report three patients in whom non-Hodgkin's lymphomas (NHL) were unexpectedly found during treatment of previously-diagnosed carcinoma. The first patient was a 72 year old woman with an endometrioid carcinoma in whom NHL was found in the pelvic lymph nodes. The second patient was a 76 year-old man with adenocarcinoma of the stomach and NHL of the small intestine. The third patient was a 66 year old man with adenocarcinoma of the prostate and NHL of the iliac lymph nodes. In these patients, it was necessary to exclude metastasis of the known carcinoma and to establish the diagnosis of unexpected NHL. The adjuvant treatment plans of the patients were ultimately not significantly altered, but increased surveillance for recurrence of two neoplasms is now warranted. These patients altered us to beware of indolent NHL in specimens removed for the treatment of carcinoma.

Clinically-occult mixed cellularity Hodgkin's disease with Charcot-Leyden crystals.

Charcot-Leyden crystals (CLC) are rarely described in tissue. Because of the derivation of CLC from eosinophils, and the antineoplastic functions that eosinophils effect, it is plausible that CLC in neoplastic tissue specimens may be significant. We recently encountered a case in which Hodgkin's disease and CLC were unexpectedly found. We reviewed 31 cases of Hodgkin's disease for CLC and sought relationships between CLC incidence and morbidity or mortality. While various grades of eosinophilia were represented, CLC were encountered only in the case reported. The role of eosinophils and CLC in Hodgkin's disease is enigmatic. With clinicopathologic correlations from additional patients, it may be determined that CLC play a role in the natural history or prognosis of Hodgkin's disease.

Fine-needle aspiration of supraclavicular lymph nodes.

Malignancies from many primary sites may metastasize to supraclavicular lymph nodes (SCLN). We reviewed 100 fine-needle aspirations (FNAs) of SCLNs. There were three major types of malignancy detected by this method: adenocarcinoma (n = 40), squamous cell carcinoma (n = 14), and other malignancies (n = 29). Adenocarcinomas and other malignancies from all sites tended to metastasize to the left SCLN. Squamous cell carcinomas from all sites, however, tended to appear on the right side. For 61 patients, a previous diagnosis of malignancy had been made within 1 yr of the clinical appearance of the abnormal SCLN. For 20 patients, the primary diagnosis antedated SCLN metastasis by more than 1 yr, particularly patients with adenocarcinoma of the breast, prostate, or thyroid papillary carcinoma.

Incidence of neoplasia in Hashimoto's thyroiditis: a fine-needle aspiration study.

There is a recognized association between Hashimoto's thyroiditis (HT) and thyroid neoplasms. We reviewed fine-needle aspirations (FNAs) from 90 patients with HT to assess the contribution of this procedure. For seven patients, FNA showed HT and follicular neoplasm (n = 6) or HT and papillary carcinoma (n = 1). Eighteen patients underwent thyroid resection. Three patients had follicular adenomas which were not detected by FNA, one patient had papillary carcinoma confirmed, and six patients with follicular neoplasm by FNA were negative for tumor. Thus, 4% of our patients had confirmed neoplasms, an incidence lower than usually reported. One reason for the lower rate of neoplasia in our series was misinterpretation of follicular neoplasia in the background of HT. The cytologic changes in the hyperplastic follicular and metaplastic oncocytic epithelium are similar to those seen in follicular neoplasm. Our study suggests that these processes may be indistinguishable, and thus, in the presence of HT, the diagnosis of follicular neoplasm probably should not be rendered.

Mucinous carcinoma of the eyelid. An immunohistochemical study.

Mucinous carcinoma is a rare primary eyelid malignancy. It is, however, more common in other sites and may metastasize to the eye. Thus, it is important to consider a distant primary when diagnosing mucinous carcinoma of the eyelid. We studied various immunohistochemical markers that may be useful. Two cases of mucinous carcinoma from the eyelid were reacted with antibodies to cytokeratins (35-beta-H11), carcinoembryonic antigen, S-100 protein, gross cystic disease fluid protein-15, alpha-lactalbumin, estrogen receptor, and progesterone receptor. All antigens were positive in both cases. This study shows that immunohistochemistry may help exclude metastatic mucinous carcinoma to the eyelid from many sites, except the breast, which the eyelid primary closely resembles. Thus, a breast primary should be specifically sought and excluded clinically.

Peritoneal implantation of meningeal melanosis via ventriculoperitoneal shunt: a case report and review of the literature.

Systemic spread of primary intracranial neoplasms is rare and may be due to ventriculoperitoneal shunt (VPS). The most common tumors to metastasize via VPS are germinoma of the pineal gland and medulloblastoma. We report a case of 16-yr-old girl with central nervous system malignant melanosis who developed subsequent peritoneal implants via VPS. To the best of our knowledge, this patient represents the third reported case of meningeal melanosis or melanoma which metastasized to the peritoneal cavity via VPS. The VPS should be considered as possible mode of systemic spread in patients with primary cranial malignancy.

Cell proliferation markers in predicting metastases in malignant melanoma.

It is often difficult to predict the outcome of melanoma in patients with Clark level III-IV disease. We sought to identify markers of cell proliferation which may be useful in predicting prognosis. Patients with Clark's level III-IV malignant melanoma who had no local recurrences or metastases were matched with patients of comparable level and thickness who did experience recurrences of metastases. Cell proliferation markers p53, proliferating cell nuclear antigen (PCNA), and Ki-67 were assessed by immunohistochemistry. DNA ploidy was determined by flow cytometry. There was no difference in the expression of p53, PCNA, and Ki-67 between patients with metastases and patients without metastases. However, patients with metastases were more likely to have an aneuploid tumor cell population than were patients without metastases (p < 0.03). Expression of cell proliferation markers do not appear to help predict prognosis in advanced level melanoma; however, aneuploidy may be associated with a greater probability of metastasis.