Presumed Pseudomonas folliculitis outbreak in children following an outdoor games event.

In early summer 2001, an outbreak of atypical rash occurred among children from 24 junior schools who attended an outdoor games event. The event comprised a series of five water games including a water slide, and within 24 hours of attending the event 151/593 (26%) children developed a papulopustular rash. The rash had a characteristic distribution, predominantly over the lower trunk and buttocks, with some involvement of the arms and legs. Pseudomonas aeruginosa was isolated from a water butt used to draw water for the games, and from the tank of a fire engine that supplied the water. Similar outbreaks, due to Pseudomonas folliculitis, have been previously described and in immunocompromised people this can be associated with serious illness. We recommend that superchlorinated water be used for water play events and that care be taken to avoid abrasive surfaces.

Diagnosis of clinically unsuspected extrapulmonary tuberculosis by fine needle aspiration: a case report.

BACKGROUND: Mycobacterium tuberculosis (MTb) infection remains the cause of higher morbidity and mortality than any other infectious disease in the world. Intact cellular immunity is necessary to resist the disease, and therefore the AIDS epidemic has greatly contributed to the resurgence of MTb. Depending on the degree of immunosuppression, the presentation of MTb in patients with AIDS can be atypical and difficult to diagnose as compared to the classical presentation of MTb in the nonimmunocompromised population. CASE: A patient who was not known to be HIV positive had a clinical picture of extensive abdominal and pelvic lymphadenopathy without chest radiographic abnormalities. The diagnosis of MTb was made by fine needle aspiration (FNA) of a pelvic lymph node. CONCLUSION: Miliary tuberculosis associated with AIDS may have an unusual clinical presentation and unusual cytologic features on ENA.

Aggressive uterine sarcoma with rhabdoid features: diagnosis by peritoneal fluid cytology and absence of INI1 gene mutation.

We report a primary uterine sarcoma with classic histologic, immunohistochemical, and ultrastructural features of a malignant extrarenal rhabdoid tumor (MERT). It arose in a 71-year-old woman who presented with postmenopausal bleeding, ascites, and a right pelvic mass. Malignant cells with rhabdoid morphology were identified by cytologic examination of the peritoneal fluid. Exploratory laparotomy revealed a 10-cm right adnexal mass and disseminated peritoneal tumor. Pathologic study showed diffuse expansion of the endometrial stroma by rhabdoid-like cells with transmural infiltration of the myometrium and extensive involvement of uterine serosa and right ovary by tumor. Neoplastic cells were immunoreactive for vimentin, cytokeratin, and epithelial membrane antigen, and cytoplasmic whorls of intermediate filaments were observed by electron microscopy. Fluorescence in situ hybridization (FISH) studies with chromosome 22-specific probes showed no loss of the INI1 gene, and no coding sequence mutation was identified.

Benign cellular changes in Pap smears. Causes and significance.

OBJECTIVE: We reviewed consecutive cases classified as benign cellular changes (BCC) over a four-month period. STUDY DESIGN: Cases classified as BCC were retrieved from the cytology files. A search was carried out to identify the previous Pap smears and concomitant cervical biopsies. RESULTS: One thousand one hundred three cases (23% of our gynecologic smears) were classified as BCC. Ninety-two patients (8.3%) underwent concurrent cervical biopsies. Specific infections accounted for 8% of BCC cases; reactive changes accounted for 92%. Of the biopsy specimens, 8.3% had no significant pathologic change. The most common biopsy diagnoses were cervicitis (31.5%), immature squamous metaplasia (16.3%) and reserve cell hyperplasia (10.8%). Miscellaneous benign diagnoses accounted for 21.7%. Cervical intraepithelial neoplasia (CIN) 1/human papillomavirus (HPV) was present in 14% of cases. All patients with biopsy diagnoses of CIN 1 had at least two previous abnormal Pap smears. Previous biopsy reports were available for review in 127 (12%) of the 1,103 patients. Of these 127 cases, 53.5% had a previous diagnosis of CIN/HPV; 9.4% had invasive carcinoma. A benign diagnosis was reported in 36.5%. CONCLUSION: The majority of BCC cases are due to reactive and inflammatory processes. In patients with a previous history of CIN, BCC may be of some significance. In patients with no significant prior cervical abnormalities, a Pap smear classified as BCC represents a reactive process.

CSF cytology of atypical teratoid/rhabdoid tumor of the brain in a two-year-old girl: a case report.

Atypical teratoma/rhabdoid tumor (AT/RT) of the central nervous system is a highly malignant neoplasm in infants and early childhood. Approximately one third of patients develop intracranial dissemination with involvement of cerebral spinal fluid (CSF). The clinical, radiological, and pathological features have been described, but cytology of the tumor cells in CSF has not. Multiple CSF samples were examined in a case of AT/RT in a 2-yr-old girl. The most consistent cytologic features of AT/RT are the large size of the tumor cells, eccentricity of the nuclei, and prominent nucleoli. The differential diagnosis includes medulloblastoma/primitive neuroectodermal tumor (PNET) of the brain. Because AT/RT often contains PNET-like regions, the differential diagnosis mainly relies on the presence or absence of large rhabdoid tumor cells. Cytological examination of CSF from a patient with AT/RT is important in the early diagnosis, disease progression analysis, and therapy modulation.

ASCCP Practice Guidelines Management Guidelines for the Follow-up of Atypical Squamous Cells of Undetermined Significance (ASCUS).

: Editor's Note: This guideline was first published in The Colposcopist in January 1996 and reflected the peer-reviewed literature available on the management of ASCUS at that time. The decision to republish this guideline in The Journal of Lower Genital Tract Disease, to accompany guidelines on the management of low-grade squamous intraepithelial lesion (LGSIL) and benign cellular changes (BCC) was made to complete the set of guidelines in the Journal pertaining to management of the cytology screening system. (See also previous guidelines on Management Issues Related to the Quality of the Smear, Management of Atypical Glandular Cells of Undetermined Significance (AGUS), and the Abnormal Pap Follow-up System.) Our original intention was to update the ASCUS guideline for this publication in the expectation that the data from the enrollment phase of the National Cancer Institute's ASCUS LGSIL Triage Study (ALTS) would be available to provide relevant evidence-based recommendations. The unavailability of this data at this time has ensured a later update of the ASCUS guideline. However, an accumulating body of new literature, particularly on the clinical utility of HPV testing with Hybrid Capture II (Digene Corp., Gaithersburg, MD), will be incorporated within the next year with the enrollment ALTS data in a new ASCUS guideline. Until that time, the guideline presented here remains the recommendation of the ASCCP, based on the review of the literature at that time, and on the collective experience and knowledge of the ASCCP Practice Committee and the Board of Directors.The cost analysis in this guideline is based upon a set of cost assumptions which will vary from setting to setting. This analysis is intended to serve as a reference for average costs in a fee-for-service setting. The individual practitioner will need to analyze cost differentials for his/her own setting.This guideline reflects emerging clinical and scientific advances as of February 1996, and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Do qualifiers of ASCUS distinguish between low- and high-risk patients?

OBJECTIVE: To evaluate the qualification of a Pap smear classified as atypical squamous cells of undetermined significance (ASCUS) favor reactive or neoplasia as recommended by the Bethesda System. STUDY DESIGN: The smears from 105 concurrent patients with a cytologic diagnosis of ASCUS not otherwise qualified were reviewed and subclassified as ASCUS favor reactive, low grade squamous intraepithelial lesion (LSIL) or high grade squamous intraepithelial lesion (HSIL) based on the Bethesda System criteria. The cervical biopsy diagnoses were correlated. RESULTS: Of the 105 cases classified as ASCUS, 37 were subclassified as favor reactive, 51 as favor LSIL and 17 as favor HSIL on cytologic review. In the ASCUS favor reactive group, 19 (51%) had reactive changes on biopsy, 17 (46%) had cervical intraepithelial neoplasia (CIN) 1, and 1 (2%) had CIN 3. A total of 48% patients had CIN. In the favor LSIL group, there was CIN 1 in 28 cases (55%), CIN 2 or 3 in 12 (23%) and benign changes in 11 (22%) on biopsy. Seventy-eight percent had CIN. In the 17 cases classified as ASCUS favor HSIL group, all had CIN. CONCLUSION: Of the total 105 cases of ASCUS, 71% had CIN, 29% had reactive changes on follow-up biopsies, and 48% of patients in the ASCUS favor reactive group had CIN. Qualifiers of ASCUS have questionable utility in patient management.

Reproducibility of the histopathological classification of vulvar squamous carcinoma and intraepithelial neoplasia.

Invasive vulvar carcinoma has been shown to be etiologically heterogeneous on the basis of pathological, virological, and epidemiological criteria. Human papillomavirus-related invasive vulvar carcinoma has basaloid or warty morphology and has adjacent basaloid or warty intraepithelial neoplasia. Invasive carcinoma unrelated to human papillomavirus is a keratinizing squamous carcinoma that may have adjacent squamous hyperplasia. We provided to 3 pathologists for their review and pathological diagnoses stained tissue sections from 95 patients with vulvar carcinoma. The reproducibility for grading individual categories of intraepithelial lesions was only fair (kappa values of 0.31-0.43). The reproducibility was better (moderate to good; kappa values of 0.58-0.59) for grading individual categories of invasive carcinomas. The agreements improved when the basaloid and warty categories were combined. Good agreement was achieved (kappa values of 0.55-0.79) in distinguishing human papillomavirus-related lesions from those unrelated to human papillomavirus; all three reviewers agreed on this classification for 67% of the cases. The intrareviewer agreement was of the same order as interreviewer agreement. Difficulties in differentiating between some lesions (e.g., a warty carcinoma with little atypia from a well- to moderately differentiated keratinizing squamous carcinoma) and concurrent occurrence of human papillomavirus-related lesions and those lesions unrelated to human papillomavirus in a patient may account for some of the discrepancies in the histopathological diagnoses of vulvar carcinoma.

Primary ovarian sarcoma: analysis of prognostic variables and the role of surgical cytoreduction.

BACKGROUND: Data regarding the value of cytoreduction and cell histology in ovarian sarcomas are limited. The goal of this study was to assess the value of surgical cytoreduction, preoperative CA 125 levels, stage, histology, and platinum-based chemotherapy in the primary treatment of ovarian sarcomas. METHODS: A retrospective analysis of 47 women with primary ovarian sarcomas was performed. RESULTS: Forty-one patients (87%) presented with advanced stage disease (International Federation of Gynecology and Obstetrics Stage III or IV). Optimal surgical cytoreduction (< 1 cm residual tumor burden) was achieved in 25 patients (53%). Forty patients (85%) had a malignant mixed müllerian tumor whereas 7 patients had a pure sarcoma. Eighteen women with mixed müllerian tumors had homologous tumors and 22 had heterologous elements. Patients treated with platinum-based chemotherapy were significantly more likely to have a response (P = 0.008) compared with those treated with other regimens. Treatment with platinum-based chemotherapy also showed a survival advantage (P = 0.03). Preoperative CA 125 levels were elevated (> 35 U/mL) in 93% of patients with ovarian sarcomas. A preoperative CA 125 level < 75 U/mL was significantly associated with better survival (P = 0.01). In univariate analysis, other significant predictors of improved survival were early stage (P = 0.04), homologous tumors (P < 0.05), and optimal surgical cytoreduction (P < 0.001). In multivariate analysis of various prognostic variables, optimal surgical cytoreduction (P < 0.001) was the most significant factor, followed by histologic subtype (P < 0.02). CONCLUSIONS: Ovarian sarcomas are rare malignancies with a poor prognosis. All women with suspected ovarian carcinoma or sarcoma should have a preoperative CA 125 level taken. Surgical cytoreduction to a residual tumor burden of < or = 1 cm improves outcome and should be the goal of surgery. Although the optimal consolidation chemotherapy regimen remains unknown, platinum should be included as part of the regimen.

Atypical glandular cells of undetermined significance and other glandular cell abnormalities in a high-risk population.

OBJECTIVES: We set out to determine our rate of atypical glandular cells of undetermined significance (AGUS) classification, to compare our AGUS rate to rates reported by others, and to determine the correlation between AGUS and histological abnormalities in our population. MATERIALS AND METHODS: Reports from all Papanicolaou (Pap) smears and associated histological specimens interpreted by the University of Florida Department of Pathology between 1992 and 1996 were reviewed. RESULTS: A total of 462 (1.2%) of 39,484 Pap smears were classified as epithelial cell abnormality-glandular cell, with 328 (0.83%) AGUS, 102 (0.26%) endometrial cells out of phase or in a postmenopausal woman, and 32 (0.08%) adenocarcinoma. A total of 146 (45%) of the AGUS cases had timely biopsies: 95 (65.1%) had benign findings, 27 (18.5%) had cervical intraepithelial neoplasia, 14 (9.6%) had adenocarcinoma (10 endometrial, 2 endocervical, 2 extrauterine), 9 (6%) had endometrial hyperplasia, and 1 (0.7%) showed endocervical glandular cell dysplasia. CONCLUSIONS: AGUS on Pap is associated with a clinically significant histological abnormality in a moderate percentage of patients. Both squamous and glandular lesions are seen, supporting the need for aggressive evaluation of the cervix, endocervix, and endometrium when AGUS is reported.

Squamous intraepithelial lesions of the cervix in a high-risk population.

OBJECTIVES: We set out to examine our use of the squamous intraepithelial lesion (SIL) category, compare our SIL rate to rates reported by others, and determine the corre-lation between SIL and histologically proven cervical intraepithelial neoplasia (CIN) in our population. MATERIALS AND METHODS: Reports from all Papanicolaou smears and associated histological specimens interpreted by the University of Florida Department of Pathology between 1992 and 1996 were reviewed. RESULTS: Of 39,484 Papanicolaou smears, 2,101 (5.3%) were classified as low-grade squamous intraepithelial lesion (LGSIL) and 1,366 (3.5%) were classified as high-grade (HGSIL). Of the LGSIL cases, 972 (46.3%) underwent timely biopsy: Findings were benign in 29.9%; 41.7% had CIN1,20.9% had CIN2, and 7.5% had CIN3. Of the HGSIL cases, 932 (68.2%) underwent timely biopsy: Findings were benign in 12.3%; 17.1% had CIN1, 26.7% had CIN2, 42.2% had CIN3, and 1.6% showed squamous cell carcinoma. Condusions. Our LGSIL rate is similar to reported rates, but our HGSIL rate of 3.5% is higher. We found good correlation between SIL on Papanicolaou smear and CIN on biopsy (70.1% for LGSIL and 86% for HGSIL).

Correlation between cervical cytologic results and Gram stain as diagnostic tests for bacterial vaginosis.

OBJECTIVE: Our purpose was to determine the reliability of the Papanicolaou smear in making the diagnosis of bacterial vaginosis with the vaginal Gram stain used as the diagnostic standard. STUDY DESIGN: We conducted a prospective, blinded, cross-sectional study of 210 consecutive patients referred to the Colposcopy Clinic for evaluation of abnormal cervical cytologic results. Each patient had a standard Papanicolaou smear and Gram stain of vaginal discharge. The sensitivity, specificity, positive predictive value, and negative predictive value of the Papanicolaou smear were determined with the Gram stain used as the standard for diagnosis of bacterial vaginosis. RESULTS: Of the 210 patients, 80 (38.1%) had Gram stains that were positive for bacterial vaginosis and 118 (56.2%) had negative Gram stains. Twelve (5.7%) had intermediate Gram stains that were also considered negative. Of the 80 patients with positive Gram stains, 44 had cervical smears consistent with bacterial vaginosis and 36 had negative smears. Of the 130 patients with negative Gram stains, two had a positive cervical smear. Therefore, compared to the Gram stain, cervical cytologic test results had a sensitivity of 55% and a specificity of 98%. The respective positive predictive and negative predictive values were 96% and 78%. CONCLUSION: Compared to Gram stain of vaginal secretions, the cervical Papanicolaou smear has fair sensitivity (55%) and excellent positive predictive value (96%) in diagnosing bacterial vaginosis.