Endorectal pull-through with posterior sagittal approach to the repair of postoperative rectourethral and rectovaginal fistula.

BACKGROUND/PURPOSE: Rectourethral (RUF) or rectovaginal fistula (RVF) is a troublesome complication after anorectal surgery because of dense adhesions around the fistula. The authors applied a new technique for the redo surgery. METHODS: Case 1 is Hirschsprung's disease in a 1-year-old boy who underwent modified Duhamel's procedure and had RUF. Case 2 is rectovestibular fistula in an 11-year-old girl who had anterior sagittal anorectoplasty complicated by RVF. Case 3 is multiple urogenital anomalies including rectovesical fistula in a 4-year-old boy in whom transvesical repair was unsuccessful. The colon was mobilized as far as possible at laparotomy. The rectum was opened via a posterior sagittal approach leaving 1 cm of the anal canal. Extended endorectal mucosectomy was performed to the dentate line, and the fistula was closed from inside of the rectum. The remaining mucosal cuff was everted out of the anus and the intact colon was pulled through the rectum and anastomosed to the cuff extraanally. RESULTS: The postoperative contrast enema showed no recurrent fistula, and defecation was not impaired. CONCLUSIONS: Endorectal pull-through of the intact colon can spare troublesome mobilization of the fistula and can prevent the recurrence of fistula. Rectal incision via a posterior sagittal approach provides a direct view of the fistula.

Cyclic thrombocytopenia and polycythemia vera.

A periodic fall of platelet number characterizes an acquired pathological condition named cyclic thrombocytopenia. We describe an unusual case of polycythemia vera in which the episodes of thrombocytopenia were followed regularly by thrombocytosis. The period of platelet count fluctuation was about 50 days, with the counts ranging from 34 to 820 x 10(9)/l. Bone marrow megakaryocytes were decreased in number during platelet nadir. Circulating thrombopoietin levels fluctuated out of phase with the platelet count. We suggest that at least some cases of polycythemia vera may have an unstable hematopoietic stem cell pool in nature, which could contribute to the development of unprovoked cyclic thrombocytopenia.

Hsp70 regulates the interaction between the peroxisome targeting signal type 1 (PTS1)-receptor Pex5p and PTS1.

The peroxisome targeting signal type 1 (PTS1) receptor, Pex5p, of the tetratricopeptide repeat (TPR) motif family is located mostly in the cytosol and mediates the translocation of PTS1 proteins to peroxisomes. As a step towards understanding the mechanisms of protein import into peroxisomes, we investigated the molecular mechanisms involved in PTS1 recognition by Pex5p with regard to requirement of energy and cytosolic factors, using cell-free synthesized acyl-CoA oxidase (AOx) as a PTS1 cargo protein, together with Pex5p and heat-shock protein (Hsp)70 from rat liver. Pex5p was partly associated with peroxisomes of rat liver, was resistant to washing with a high concentration of salt and to alkaline extraction and was inaccessible to protease added externally. Pex5p bound to AOx in an ATP-dependent manner. AOx synthesized in a cell-free translating system from rabbit reticulocyte lysate was imported into peroxisomes without being supplemented with Pex5p and Hsp70, implying that peroxisome-associated Pex5p was released from the membranes and functional in this in vitro import assay. Antibodies against Pex5p and Hsp70 inhibited AOx import. In contrast, AOx synthesized in a wheat-germ lysate required the external addition of Pex5p for import, in which Hsp70 augmented the AOx import. The TPR domain of Pex5p was revealed to bind to the N-terminal part in an Hsp70-independent manner, whereas mutual interaction of the TPR region was noted in the presence of Hsp70. Hsp70 interacted with the TPR domain of Pex5p. Moreover, Hsp70 and ATP synergistically enhanced the binding of Pex5p to the C-terminal PTS1-containing part of AOx, implying that Pex5p recognizes its cargo PTS1 protein by chaperone-assisted as well as energy-dependent mechanisms in vivo.

Plaque-like structures and arteriosclerotic changes in "diffuse neurofibrillary tangles with calcification" (DNTC).

"Diffuse neurofibrillary tangles with calcification" (DNTC) is a rare form of slowly progressive dementia characterized by temporal or fronto-temporal atrophy with neuronal loss and astrocytosis, neurofibrillary tangles and Fahr-type calcification, but no senile plaques in the cerebral cortex. In patients with DNTC, we detected a novel histopathological abnormality that we termed "plaque-like structures" (PLS). PLS appeared as oval, slightly eosinophilic masses of up to 100 microns in diameter. With methenamine silver stain, the PLS were argyrophilic, and thread-like structures were observed in and around them. Most PLS were observed in deep layers of the cortex and subcortical white matter, and were accompanied by small vessels. They were intimately associated with the small-vessel walls and astrocytes. They were composed of two types of fibers. The first type comprised straight and loosely interwoven fibers about 25-30 nm in diameter, while the other type evoked tangles. These structures have not been found in other neurodegenerative diseases, including Alzheimer's disease. In addition, to evaluate hyaline arteriosclerosis in DNTC, we examined sclerotic changes of the medullary arteries and assessed white matter lesions in affected patients. In three of four patients with DNTC, sclerosis of the medullary arteries was significantly more extensive than in age-matched controls. In all four patients, the severity of white matter lesions was graded as moderate or severe in the temporal lobe and as mild or moderate in the frontal lobe. Arteriosclerotic changes and white matter lesions can occur without hypertension and beta amyloid deposits in DNTC.

Two cases of histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto's disease) following diffuse large B-cell lymphoma.

Histiocytic necrotizing lymphadenitis (HNL) is often mistaken for malignant lymphoma clinically and is also sometimes difficult to differentiate from lymphoma even histopathologically. In this report, we describe the first 2 reported cases of HNL following non-Hodgkin's lymphomas. The patients were 27- and 30-year-old women who developed cervical and axillary lymph node swellings, respectively, in the course of remission of diffuse large B-cell lymphoma. The affected lymph nodes showed the typical histology of HNL: irregular-shaped "necrotic" foci with histiocytes engulfing apoptotic bodies intermingled with large-sized blastic lymphocytes. These findings mimicked the partial involvement of large-cell lymphoma. However, the blastic cells were almost exclusively T cells, and numerous apoptotic bodies were present, which excluded the possibility of recurrence of diffuse large B-cell lymphoma.

Occurrence of ganglioside GD3 in neoplastic astrocytes. An immunocytochemical study in humans.

GD3 immunocytochemical analysis was performed in 25 human specimens obtained by autopsy and biopsy from patients with astrocytomas, anaplastic astrocytomas, cerebellar astrocytomas and glioblastoma multiforme (GM), using the ABC method. Extraction of the ganglioside fraction from GM was used for thin-layer chromatography (TLC) analysis to confirm the specificity of anti-GD3 monoclonal antibody (DSG-1). Normal astrocytes were not immunoreactive for GD3. Neoplastic astrocytes of low- to high-grade tumours were GD3 immunoreactive. In GM, the multinucleated giant cells were also immunoreactive. All immunoreactivity present was within the cytoplasm. In TLC analysis, enzyme immunostaining of gangliosides from GM with DSG-1 showed only one positive band, which had the same TLC migration rate as GD3, indicating that GD3 of the ganglioside fraction from GM is the antigen detected by DSG-1. The presence of GD3 within the cytoplasm of neoplastic astrocytes showing invasive and proliferative properties, is of considerable interest. The implications and possible significance of the presence of GD3 in the cytoplasm in glioma cells are discussed.

Deletion of Epstein-Barr virus latent membrane protein 1 gene in Japanese and Brazilian gastric carcinomas, metastatic lesions, and reactive lymphocytes.

A 30-bp deletion in the Epstein-Barr virus (EBV) latent membrane protein 1 (LMP1) gene has been reported in nasopharyngeal carcinoma and EBV-associated malignant lymphomas. Information on this deletion in EBV-associated gastric carcinoma (EBVaGC) is limited. The association of gastric carcinoma (GC) with EBV was examined by EBV-encoded RNA (EBER) in situ hybridization in 510 patients from Japan and 80 patients from Brazil. We studied the prevalence of 30-bp LMP1 gene deletion in EBVaGC in Japan (29 cases) and Brazil (four cases) in comparison with the corresponding EBER1-positive metastatic lesions in lymph nodes (10 cases) and EBV-infected reactive lymphocytes from dissected nonmetastatic lymph nodes (22 cases), microdissected non-neoplastic gastric mucosa of EBVaGC (five cases), and EBV-nonassociated GC (25 cases). We studied the status of the LMP1 gene by Southern blot hybridization of polymerase chain reaction products obtained after amplification with primers flanking the site of the deletion. We also performed EBV typing and LMP1 protein immunohistochemistry. EBV DNA was amplified by polymerase chain reaction in 30 of 33 EBVaGC cases, 8 of 10 metastatic carcinomas, 14 non-neoplastic tissues from 27 EBVaGC cases, and 12 of 25 non-EBV-associated GC cases with EBER1-positive lymphocytes. The 30-bp LMP1 gene deletion was observed in 23 of 26 (88.5%) cases of EBVaGC from Japan and two of four (50%) cases of Brazilian EBVaGC as compared with EBER1-positive reactive lymphocytes from 11 of 14 (78.6%) EBVaGC cases and 9 of 12 (75%) cases of non-EBV-associated GC. The variant type (the 30-bp deletion variant or nondeleted wild type) of LMP1 gene was the same among reactive lymphocytes, primary and secondary lesions of EBVaGC in all cases for which all three tissue types were studied (six of six). There was no correlation between the presence of the 30-bp deletion with depth of cancer invasion or presence of metastasis. Type A was detected in all available EBV-positive cases. The similar high incidence of 30-bp deletion in LMP1 gene in both carcinoma cells and reactive lymphocytes in EBVaGC cases suggests that this deletion may not be relevant to the pathogenesis of EBVaGC.

Epithelial hyperplasia of the larynx a clinical follow-up study.

In this retrospective study, the records of 40 patients with epithelial hyperplasia of the larynx, seen between 1980-1991, were reviewed to determine the incidence of malignant transformation during long term follow-up. The mean follow-up time was 58.6 months. The initial pathological diagnoses were hyperkeratosis in one case, parakeratosis in one, dyskeratosis in 12 and dysplasia in 26. During follow up, nine patients developed carcinoma in situ and/or invasive carcinoma. Of these, two patients had been diagnosed with dyskeratosis without dysplastic cells at the initial biopsy. It is therefore important to follow up patients with epithelial hyperplasia of the larynx even when no dysplastic cells are found at the time of diagnosis.

[Granulomatous angiitis of the central nervous system complicated by the syndrome of inappropriate antidiuretic hormone].

We report an autopsy case of granulomatous angiitis of the central nervous system (GANS) complicated by the syndrome of inappropriate antidiuretic hormone (SIADH). A 88-year old female was admitted because of progressive mental deterioration, fever, and vomiting. A computed tomogram disclosed bilateral periventricular lucency, and a low-density area in the right occipital lobe. Laboratory studies during her hospital stay, revealed hyponatremia, hypoalbuminemia, and increased antidiuretic hormone. Treatment with antibiotics, hypertonic saline solution, and steroids, and water restriction was ineffective, and the patient died six weeks after admission. Autopsy examination of the brain revealed slightly turbid meninges with multiple small infarctions in the corona raiata of both cerebral hemispheres. Microscopic study disclosed granulomatous inflammation with many giant cells in the walls of small and medium sized vessels, and the adventitia and media were more involved than the intima. Their lumens were narrowed, and many thrombi were observed. Extensive non-granulomatous inflammatory change was found mainly in the subarachnoid space. All of these findings were similar to the GANS firstly reported by Cravioto et al, in 1959. Since the blood vessels in the central nervous system play an important part in any inflammatory conditions and the blood vessels may be involved by bacterial, fungal, parasitic or viral meningitis, various microorganisms have been suspected as the cause of GANS, including mycoplasma, herpes zoster, herpes simplex viruses, cytomegalovirus, and human T-lymphotropic virus type III (HTLV-III). Some reported cases have been associated with Hodgkin's disease and cerebral amyloid angiopathy. We could not identify any cause in our case.(ABSTRACT TRUNCATED AT 250 WORDS)

Bauhinia purpurea (BPA) binding to normal and neoplastic thyroid glands.

Biotinylated bauhinia purpurea agglutinin (BPA) was studied, using the ABC method, in different thyroid gland conditions (26 follicular adenomas, 39 papillary carcinomas, 15 follicular carcinomas, and 10 normal thyroids), to determine whether specific lectin binding patterns were developed during malignant transformation that could enable the distinction of carcinoma from adenoma. In normal thyroids, BPA was very rarely and faintly reactive with follicular cells. In neoplastic conditions, BPA binding profiles for follicular adenoma were essentially identical to those of normal follicles, whereas BPA unequivocally reacted with follicular carcinoma and papillary carcinoma. BPA reacted more strongly with cells of papillary structures than with those forming solid nests and follicles. In papillary carcinoma, BPA binding was observed mostly in the apical surface and cytoplasm of carcinoma cells, whereas a diffuse cytoplasmic binding pattern was predominant in follicular carcinoma. Neuraminidase treatment had little or no effect on either normal or adenomatous follicular epithelium, whereas in follicular carcinoma, the number of positive cells and the staining intensity was increased. These findings suggest that BPA would be useful for the differential diagnosis of papillary and follicular carcinomas, and less consistently so, for differentiating follicular carcinoma from follicular adenoma. Peanut agglutinin with similar sugar specificity was not reactive with follicular cells either in normal or neoplastic glands.

Malignant melanoma of the nasal cavity.

We report a case of amelanotic melanoma arising in the nasal cavity and paranasal sinuses, that could not be positively diagnosed as malignant melanoma before the patient's death in spite of repeated biopsies both from primary and metastatic lesions, including ultrastructural examination and immunohistochemical staining for S-100 protein with usual polyclonal antibody. The patient died of rapid wide-spread dissemination of the tumor. In autopsy specimens, melanin pigment was detected, for the first time, by the Fontana's silver stain. The posthumous diagnosis of malignant melanoma was immunohistochemically confirmed for the specific antibodies, anti alpha-subunit of S-100 protein antibody and SK-46 (original antibody for melanoma made at the Department of Pathology, University of Gunma School of Medicine) from specimens obtained while alive. The application of a specific antibody for S-100 protein is recommended as useful for the diagnosis of malignant melanoma even when routine immunohistochemical procedures fail to demonstrate S-100 protein.

Tumor marker studies of cervical smears: an immunohistochemical approach.

Immunoreactivity with monoclonal antibodies against epithelial membrane antigen (EMA), vimentin, squamous epithelium-specific keratin, nonsquamous epithelium-specific keratin, and polyclonal antibodies epithelial cells of 55 cervical smears using the avidin-biotin-peroxidase complex and indirect immunoperoxidase methods to detect antigens. Most of the abnormal squamous cells with few normal cells were reactive for EMA but the intensity of the reaction was variable in both cases. There was no correlation in the reactivity between normal and abnormal cells with different cytokeratins varying in their molecular weight. Vimentin was also reactive with both cells. The results of this experiment suggest that antibodies used, appear to be of limited usefulness in the diagnosis of cervical smears.

Role of immunoperoxidase staining in serous effusions.

Immunoreactivity with monoclonal antibodies against epithelial membrane antigen, vimentin, keratin-squamous epithelium, keratin-nonsquamous epithelium and with polyclonal antibodies against keratin, involucrin, S-100 protein, desmin and varies; is directly proportional to-1 antitrypsin was done in 30 pleural and peritoneal effusion fluids; 15 each of benign and malignant origin using the avidin-biotin-peroxidase complex (ABC) technique to differentiate between the mesothelial cells and the adenocarcinoma cells. In the present study we have demonstrated that desmin and S-100 protein are distributed in the cancer cells and the mesothelial cells of the effusion fluids. Neither EMA nor keratin has the specific reactive pattern which could lead to the differentiation of the mesothelial cells from the cancer cells, but vimentin and keratin could be used for the diagnosis of the mesothelial cells since they had maximum reactivities compared to the cancer cells.

Distribution of lectin receptors in the human hyperplastic tonsil: histochemical and flow cytometric analyses.

The distribution of lectin receptors in the human tonsil was studied using 16 biotinylated lectins. The avidin-biotin-peroxidase complex (ABC) method was used on frozen and paraffin-embedded tissue sections. Cell suspensions were also analysed by dual flow cytometry using respective fluorescein isothiocyanate-conjugated lectins and phycoerythrin-labeled anti-CD3 and anti-human immunoglobulin. Frozen sections fixed with acetone and paraffin-embedded materials fixed in three solutions were compared for lectin affinity; ethanol-fixed sections gave best results followed by frozen and buffered formalin-fixed ones, then nonbuffered formalin. Con-A, RCA-1, LcH, WGA, MPA, PHA, PSA, PNA, SJA and GSA-1 reacted with all tissue components of the tonsil in immunohistochemical studies, but binding intensity was fixative dependent. Binding of Lotus and BPA to lymphocytes was limited to germinal center lymphocytes. Other tissue components were also reactive but staining intensity was weaker in Lotus compared with BPA. SBA and DBA did not react with lymphocytes, but reacted with macrophages/histiocytes, vascular endothelia, and epithelial cells. LBA and LPA were constantly negative with all tissue components irrespective of fixatives. Flow cytometric analyses showed that all but three (DBA, LBA and LPA) partially or totally stained lymphocyte surfaces. Lotus receptors were expressed exclusively on B-lymphocytes.

[Aspergillosis involving the thoracic spinal cord--an autopsy case].

A 63 year old male complained of persistent backache and productive cough. The chest X-ray revealed the fungus ball at the left apical-posterior segment and Aspergillus fumigatus was cultured from the sputum. He was treated on fulconazole and miconazole. Six months later, motor and sensory paralysis below the mamillary level and urinary and stool incontinence developed. A magnetic resonance image disclosed the destruction of the second thoracic spinal vertebra involved by the cavitated fungus ball of the left lung. Continuous peroral administration of antifungal drugs was not successful, and he expired with severe dyspnea. The autopsy revealed an extensive granulomatous and purulent change of the epidural and subdural spaces of the second to fifth thoracic spinal cord. Subdural inflammation extended to the lower thoracic and lower cervical level. Thoracic spinal cord revealed an extensive myelomalacia predominantly involving the left lateral white column, and also anterior and posterior columns. Small areas of the white matter were cystic. The left anterior horn cells revealed severe central chromatolysis. Moderate lymphocytic and plasma cell infiltration was found around the vessels within the cord. A few thrombi were found in the vein near the anterior nerve root. Central nervous system involvement of pulmonary aspergillosis is quite uncommon. However, there are a few reports of patients with paraplegia secondary to the spinal extension by aspergillus infection. Sheth et al. described that epidural and subdural granulomatous change with aspergillus abscesses and spinal cord myelomalacia is comparable to metastatic carcinoma. However, the aspergillus infection in the spinal cord is more extensive and destructive.(ABSTRACT TRUNCATED AT 250 WORDS)

Bauhinia purpurea--a new paraffin section marker for Reed-Sternberg cells of Hodgkin's disease. A comparison with Leu-M1 (CD15), LN2 (CD74), peanut agglutinin, and Ber-H2 (CD30).

Thirty-three cases of Hodgkin's disease (thirteen nodular sclerosis, four diffuse, lymphocyte predominance, and sixteen mixed cellularity) were studied with Bauhinia purpurea (BPA), peanut agglutinin (PNA), anti-Leu-M1, LN2, and Ber-H2 by the avidinbiotin-peroxidase complex (ABC) method in paraffin sections. Reed-Sternberg (RS) cells and variants were stained positively with one or more of the reagents in all cases. BPA staining was positive in 32 of 33 cases (97.0%), PNA staining was positive in 23 of 33 cases (69.7%), Leu-M1 was positive in 13 of 33 cases (39.4%), LN2 was positive in 14 of 33 cases (42.4%), and Ber-H2 was positive in 24 of 33 cases (72.7%). Many RS cells were stained moderately to strongly and were readily recognized in 31 cases (96.9%) of BPA+, 10 (43.5%) of PNA+, 8 (61.5%) of Leu-M1+, 6 (42.9%) of LN2+, and 22 (91.7%) of Ber-H2+ cases; in the remaining positive cases, the RS cells were found only after careful searching. Three staining patterns were recognized: paranuclear, diffuse cytoplasmic, and membranous. These three patterns were obtained with all markers except for LN2. LN2 showed diffuse cytoplasmic staining in most of the positive cells, and a few cells showed paranuclear deposits. BPA reactivity was not affected by formalin fixation or paraffin embedding. Except for RS cells, BPA also showed dense cytoplasmic staining reaction with macrophage-histiocytes. Sixty cases of non-Hodgkin's diffuse lymphomas (30 T- and 30 B-cell origin) were also studied. Tumor cells were not stained with BPA, PNA, and Leu-M1, but stained positively with LN2 in six T-cell lymphomas and thirteen B-cell lymphomas, and with Ber-H2 in six T-cell lymphomas and one B-cell lymphoma. In conclusion, to facilitate the detection of RS cells and related variants in paraffin sections, BPA can be accepted as a useful marker due to its high-detection rate, reproducible staining pattern, and resistance to fixatives.

Expansion of the population of double negative CD4-8- T alpha beta-cells in the liver is a common feature of autoimmune mice.

There have been several reports that double negative (DN) CD4-8- T alpha beta-cells might be responsible for the onset of autoimmune diseases in humans and mice. We previously revealed that such DN T alpha beta-cells are generated in the liver of autoimmune MRL-lpr/lpr mice. In the present study, we further characterize the histology of the liver in these mice by light and electron microscopic studies. An intensive accumulation of mononuclear cells in the liver was demonstrated and a significant proportion of these mononuclear lymphocytes was found to intimately interact with Kupffer cells or endothelial cells of the hepatic sinusoids. The majority of such lymphocytes were TcR+CD4-8-Pgp-1+ alpha beta-cells. Identification of DN T alpha beta-cells was then performed in various autoimmune model mice. Interestingly, all autoimmune mice tested (i.e., MRL-lpr/lpr, C3H/HeJ-gld/gld, BXSB, NOD, MRL(-)+/+ and NZB/W F1 mice), showed an increased proportion of DN T alpha beta-cells (greater than 11% among all MNC) in the liver when they became old and diseased. On the other hand, young and old normal mice and young autoimmune mice before the onset of disease did not have such a high proportion of DN T alpha beta-cells (less than 10%) in the liver. Among autoimmune mice, MRL-lpr/lpr and C3H/HeJ-gld/gld mice had lymphadenopathy, which consisted of DN T alpha beta-cells (greater than 25%), after the onset of disease. Autoimmune mice of the other strains had neither lymphadenopathy nor DN T alpha beta-cells in the periphery, even when they were diseased. These results suggest that the expansion of the DN T alpha beta-cell population in the liver is a common feature of autoimmune mice, irrespective of the information of lymphadenopathy.