[Microvillus inclusion disease, a rare cause of severe congenital diarrhea]. / Microvillusinclusieziekte, een zeldzame oorzaak van ernstige aangeboren diarree.

To date, microvillus inclusion disease (MID) has been diagnosed in six Dutch patients. It is a rare autosomal recessive hereditary intestinal disorder mostly presenting with malabsorption and severe secretory diarrhoea from birth. The diagnosis is confirmed by electron microscopy of intestinal mucosal biopsies, which show characteristic intracytoplasmic vesicles containing clearly recognisable microvilli and irregularly distributed microvilli in the brush border. The two clinical forms of the disease that have been recognised internationally, a 'congenital' and a 'late-onset' form of MID, have also been observed in the Dutch patients. At the last follow-up five patients had died, the sixth was 17 years old and alive. The pathogenesis and genetics of MID are, as yet, unknown. Eventually, all patients die from complications of the disease, notably from the total parenteral nutrition. The only chance of survival is intestinal or combined liver-intestinal transplantation.

Delayed diagnosis of glucagonoma syndrome.

The classical presentations of necrolytic migratory erythema associated with alpha cell pancreatic tumour have been well documented. In addition, the occurrence of extracutaneous hallmarks of this disease such as weight loss, diabetes, anaemia, stomatitis and diarrhoea have been described in various reports. Here we report three cases with glucagonoma syndrome. Early detection is important in view of the malignant course of the disease. However, diagnosis is sometimes complicated by the fact that some patients may fail to show the characteristic feature of glucagonoma syndrome.

Immunohistochemical localization of glutathione S-transferase alpha and pi in human esophageal squamous epithelium, Barrett's epithelium and carcinoma.

High tissue levels of glutathione S-transferases (GSTs), a family of detoxification enzymes, are inversely correlated with cancer risk in the human gastrointestinal tract. Patients with Barrett's esophagus, wherein squamous epithelium is replaced by columnar epithelium, have an increased risk for developing esophageal adenocarcinoma. Biochemical analyses revealed that Barrett's epithelium contains lower levels of GST enzyme activity as well as some GST isoforms, as compared with squamous epithelium. So far, little information on the immunohistochemical distribution of the GST alpha and pi isoforms in normal squamous epithelium, in Barrett's metaplastic epithelium or in adeno- and squamous cell carcinomas of the esophagus is available. Tissues were fixed in formalin and embedded in paraffin. Three 4 microm thick sections were used for hematoxylin and eosin staining and for immunostaining with antibodies against GST alpha and pi. GST alpha and pi were seen in normal squamous epithelium (0% and 75%, respectively), Barrett's epithelium (75% and 100%), adenocarcinoma (25% and 100) and squamous cell carcinoma (27% and 91%). Staining was mainly cytoplasmic, though some nuclear staining with the GST pi antibody was apparent. The varying expression of GST alpha and pi in normal and (pre)neoplastic esophagus may have consequences for the treatment of these diseases and may contribute to an understanding of the development of these esophageal disorders.

[Hepatic steatosis during treatment with zidovudine and lamivudine in an HIV-positive patient]. / Steatosis hepatis tijdens behandeling met zidovudine en lamivudine bij een met HIV geïnfecteerde patiënt.

A 33-year-old HIV-infected man was given antiretroviral therapy with zidovudine and lamivudine. After ten months' treatment the patient had elevated hepatic transaminase levels. Severe hepatic steatosis was found in the biopsy. Clinical history, laboratory, microbiologic and X-ray examination revealed no other abnormalities. The transaminase levels remained high after withdrawal of zidovudine alone, but a decrease was observed when both zidovudine and lamivudine were stopped. Rechallenge of lamivudine therapy caused the levels to increase again. The hepatic steatosis was considered to be caused by the antiretroviral therapy, lamivudine having a synergistic influence on this side effect of zidovudine. Ten months after the therapy was changed to the protease inhibitor indinavir combined with zalcitabine and stavudine, two other nucleoside analogues, hepatic steatosis recurred.

Scintigraphic evaluation of experimental colitis in rabbits.

UNLABELLED: Scintigraphic techniques are frequently used for evaluation of inflammatory bowel disease. The radiopharmaceutical of choice is labeled leukocytes. In this study, two new agents, 111In-labeled polyethylene glycol-coated liposomes and 111In-labeled human nonspecific gamma globulin (immunoglobulin G; IgG), were compared with 111In-leukocytes in a rabbit model of colitis. METHODS: In rabbits, acute colitis was induced by colonic instillation of trinitrobenzene sulfonic acid at 25 cm from the anal sphincter. After 24 hr, 15 MBq of the radiopharmaceuticals was injected intravenously in groups of four rabbits. Twenty-four hours after injection, the animals were killed and macroscopic abnormalities were scored in seven consecutive affected colonic segments of 5 cm each (0 = normal, 1 = inflammation, 2 = ulcers). The ex vivo uptake was measured in the normal ascending colon and the affected colonic segments. The colitis index (CI, affected-to-normal colon-uptake ratio) was calculated. RESULTS: Histologically, an acute, patchy, transmural colitis was observed at the site of instillation and the distal colon. The CI of all agents in colitis lesions correlated with the severity of the abnormalities. With increasing severity, the CI for liposomes was 1.86 +/- 0.24, 4.88 +/- 0.42 and 7.42 +/- 0.54 (r2 = 0.68, p < 0.001); for leukocytes 1.77 +/- 0.32, 3.10 +/- 0.58 and 5.54 +/- 0.83 (r2 = 0.31, p < 0.01); for IgG 1.60 +/- 0.29, 2.81 +/- 0.21 and 2.65 +/- 0.21 (r2 = 0.29, p < 0.02). CONCLUSION: Indium-111-labeled-leukocytes, -IgG and -liposomes all show increased uptake in inflamed colonic tissue. Indium-111-liposomes showed the highest CI, which correlates best with the morphological abnormalities. Indium-111-leukocytes and 111In-liposomes are superior to 111In-IgG for this indication.

Species specificity for HBsAg binding protein endonexin II.

BACKGROUND/AIMS: Hepatitis B virus displays a distinct species and tissue tropism. Previously we have demonstrated that a human liver plasma membrane protein with a molecular weight of approximately 34 kiloDalton specifically binds to HBsAg. This protein was identified as endonexin II, a Ca2+ dependent phospholipid binding protein. METHODS: Using a mouse monoclonal antibody, directed against the HBsAg binding epitope on human endonexin II, liver tissue from various non-human species, human liver tissue and some extra-hepatic human tissues were screened for the presence of endonexin II. RESULTS: Endonexin II was detectable in human, chimpanzee and rhesus monkey liver and in all tested extra-hepatic human tissues, using western blot and immunohistochemical techniques. In rat, mouse, cow and pig liver tissues endonexin II could not be detected with the antibody. CONCLUSIONS: The species specific distribution of the HBsAg binding protein endonexin II apparently correlates with the species tropism of hepatitis B virus. Furthermore, the detection of HBV-DNA, RNA transcripts and antigens in a variety of tissues in chronic infected patients, is in agreement with the wide distribution of the HBsAg binding endonexin II in various tissues.

Undefined malabsorption syndrome with villous atrophy successfully reversed by treatment with cyclosporine.

A 47-year-old man with a flat jejunal mucosa complicated by malabsorption, diarrhoea and lymphocytic colitis is presented. There was no response to gluten withdrawal alone, combination of a gluten-free diet and prednisone therapy, or total parenteral nutrition. Complete clinical remission was only achieved after simultaneous treatment with cyclosporine and a gluten-free diet. Rechallenge with a gluten-containing diet while cyclosporine treatment continued resulted in a relapse of diarrhoea and malabsorption. We conclude that cyclosporine may be an effective agent for the treatment of undefined, refractory forms of malabsorption.

Unusual intracytoplasmic inclusions in metastatic carcinoma. Discussion of their possible significance.

Unusual filamentous inclusion bodies in the cytoplasm of metastatic tumor cells are described. Their presence (intermingled with zymogen granules) seems rather restricted to cells of primary or metastatic acinar cell carcinoma of the pancreas, acinic carcinoma of salivary gland (parotid gland) and Paneth cells (neoplastic or in zinc deficiency state). For the time being, the real nature of these inclusions (deranged zymogen granules?) is unclear. This case also emphasizes the value of electron microscopy in solving the problem of the occult primary tumor and avoiding the misdiagnosis of an endocrine tumor (e.g. islet cell tumor or carcinoid), or a duct cell tumor with eosinophilic granular cytoplasm or in recognizing the foci of acinar cells in a mixed variant of carcinoma of the pancreas.

Demonstration of skin-derived antileukoproteinase (SKALP) and its target enzyme human leukocyte elastase in squamous cell carcinoma.

Skin-derived antileukoproteinase (SKALP), also known as elafin, is a strong and specific inhibitor of elastase and proteinase 3. SKALP is not present in normal epidermis, but is expressed by epidermal keratinocytes under hyperproliferative conditions such as psoriasis, wound healing, and in cell culture. In human epidermal tumours, SKALP is differentially expressed and restricted to tumours with distinct squamous differentiation. We have studied the presence of both SKALP and one of its known target enzymes, leukocyte elastase, in 41 squamous cell carcinomas of the skin. SKALP expression correlated with the degree of differentiation: strong expression was seen in well-differentiated cells and expression was absent in poorly differentiated tumour cells. Most of the squamous cell carcinomas showed elastase-positive cells in the tumour stroma and also within the tumour cell nests. SKALP may interfere with the proteolytic activity of infiltrating inflammatory cells or with hitherto unknown proteinases from the tumour cells. We hypothesize that in squamous cell carcinoma progressive loss of SKALP expression could facilitate tumour spread.

A solitary metastasis in the heart from Ewing's sarcoma.

We present a patient with a solitary metastasis in the heart 8 years after treatment for Ewing's sarcoma. Exploratory thoracotomy was performed and biopsies were taken. Despite high dose ifosfamide, the patient died a few weeks after surgery.

Differential expression of SKALP/Elafin in human epidermal tumors.

Recently we described a new epidermal serine proteinase inhibitor, skin-derived antileukoproteinase (SKALP), also known as elafin. SKALP/elafin was found to be absent in normal human epidermis, but can be induced in vitro and in vivo under hyperproliferative conditions. Here we studied the expression of SKALP/elafin in several types of epidermal tumors (basal cell carcinoma, squamous cell carcinoma, Bowen's disease, actinic keratosis, and keratoacanthoma). Using immunohistochemical staining SKALP/elafin appeared to be differentially expressed in these tumors. Functional measurements of anti-proteinase activity, and Western blotting of tumor extracts confirmed our findings at the histological level. In well differentiated squamous cell carcinoma, SKALP/elafin messenger RNA was demonstrated by non-radioactive in situ hybridization. We conclude that SKALP/elafin is a marker for abnormal or disturbed squamous differentiation. A possible role of SKALP/elafin in the control of tumor cell invasion is discussed.

Primary carcinoid tumors of the middle ear. Report on four cases and a review of the literature.

Carcinoid tumors are rare in the middle ear. To our knowledge, only 17 cases could be found in the literature, the first of which was described in 1980. In addition to enlarging on a previous observation we present three new cases. The neoplasms showed a striking, heterogeneous aspect ranging from solid trabecular to tubuloglandular growth patterns resembling the classic carcinoid tumor and adenomatous middle ear tumor, respectively. Based on immunohistochemistry and electron microscopy, three cell types were found. A review was made of our four patients and the cases described in the literature. The medical histories ranged from 1 month to 9 years. Presenting symptoms and signs were not characteristics, but hearing loss predominated. In two patients, the eardrums were perforated, in all the others it was intact and often bulging. Surgery, usually radical mastoidectomy, was performed in all cases. Often the tumor encased the ossicular chain, without infiltration. In two patients, local recurrence occurred that was treated successfully with surgery. All the cases showed an indolent biological course and the tumors were clinically nonfunctional, despite the recognition of biogenically active products by immunohistochemistry. To our knowledge, regional or distant metastases have never been reported. Conservative surgery with radical removal of the primary or recurrent tumor is the treatment of choice.

Adeno-carcinoid or amphicrine tumors of the middle ear a new entity?

The clinicopathological, ultrastructural and immunohistochemical characteristics of four primary tumors of the middle ear are reported. These neoplasms showed a striking, heterogeneous aspect ranging from solid-trabecular (Type I) to tubulo-glandular (Type II) growth patterns. Secretory activity of the tumor cells was evaluated by immunohistochemistry and electron microscopy. Based on these procedures, three cell types were found, mainly limited to tumors with a tubulo-glandular (Type II) growth pattern. Most frequent were B-cells with an abundant pale cytoplasm containing neuroendocrine granules, both cytokeratin and vimentin as well as several endocrine marker substances. Less frequent were A-cells, which are slender, darkly staining and line the glandular lumina. They showed exocrine activity only and stained strongly with a polyclonal cytokeratin antibody. Finally, least frequent were amphicrine cells, which were characterized by both lumina and neuroendocrine granules in their cytoplasm and were interpreted as the link between A and B cells. Although this morphological description closely resembles that of carcinoids and adenocarcinoids of the respiratory tract and gut, the clinical behaviour of these middle ear tumors nevertheless seems different, with no recurrence or metastasis after a follow-up of 1 to 14 years (median 78 months). Therefore, some authors suggest that these tumors should be classified as middle ear adenomas or adenomatous tumors. However, we strongly feel that these tumours represent a distinct entity and can be classified as adenocarcinoids or amphicrine tumors, i.e. demonstrating both exocrine and endocrine activities. Further work is required to evaluate the exact proportion of neuroendocrine and amphicrine tumors in the heterogeneous group of adenomas and in the rarely described group of adenocarcinomas.

Inflammatory pseudotumor of the subglottis.

A rare case of an idiopathic inflammatory pseudotumor of the larynx is described. Management consisted of midline vertical thyrotomy with anterior cricoid splitting, excision of the subglottic tumor and temporary stenting of the lumen with a siliconized tube. While these lesions are benign, the therapeutic consequences of misdiagnosis can be serious. Effective treatment consists of surgical excision, which results in a permanent cure.

Basal cell-specific and hyperproliferation-related keratins in human breast cancer.

In normal breast tissue and in noninvasive breast carcinomas, various keratin-14 antibodies were reactive predominantly with the basal/myoepithelial cell layer, although mainly in terminal and larger ducts luminal cells sometimes also were stained. A similar reaction pattern was found with an antibody directed against keratin 17, although this antibody was more often found negative than keratin 14 in the pre-existing myoepithelial cells in intraductal carcinomas. Furthermore antibodies reactive with hyperproliferation-related keratins 6 and 16 were used. One of these (LL025) was completely negative in normal breast tissue and noninvasive breast carcinomas. However 10% of the invasive carcinomas were diffusely or focally positive with this latter antibody, while in 18 of 115 cases of invasive breast carcinomas studied, a basal cell phenotype was detected. A relatively high concordance was found between the carcinomas immunostaining with the basal cell and the hyperproliferation-related keratins, but not between these markers and the proliferation marker Ki-67. This supports the conclusion that basal cells in breast cancer may show extensive proliferation, and that absence of Ki-67 staining does not mean that (tumor) cells are not proliferating.

Canavan disease: neuromorphological and biochemical analysis of a brain biopsy specimen.

In this study we present a patient with Canavan disease or Van Bogaert and Bertrand type of spongiform leukodystrophy, proven by brain biopsy. We performed morphological studies and biochemical assays on fresh homogenates of the grey and white matter. Quantitative neuromorphological analysis of the cortex showed normal values except for poor dendritic arborization of the inner layers. No signs of neuronal damage were observed. The Na-K-ATPase activity was increased. Pyruvate and ketone bodies oxidation rates and the activity of cytochrome-c oxidase were normal. We conclude that there is neither a primary neuronal damage nor a primary mitochondrial dysfunction in the oxidative processes despite the abnormal morphology of mitochondria in this disease.

Severe hepatotoxic reaction with progression to cirrhosis after use of a novel retinoid (acitretin).

We report the case of a 50-year-old female who suffered from severe palmar and plantar pustulosis. During treatment with acitretin, a novel oral retinoid, which is the main derivative of etretinate, the patient developed a severe hepatotoxic reaction. Subsequent histological studies strongly suggested the development of liver cirrhosis. Reversible elevation of serum aminotransferase values during treatment with acitretin has been reported. However, the present observation indicates that severe hepatotoxic injury may also follow treatment with this agent.

Pancreatic carcinoma with polyarthritis, fat necrosis, and high serum lipase and trypsin activity.

A 46 year old white man presented with subcutaneous and intramedullary fat necrosis, destructive polyarthritis, and osteolytic bone lesions, complicating a poorly differentiated adenocarcinoma of the tail of the pancreas with metastases in the liver and omentum. There was a 100-fold increase in serum lipase and trypsin activity. His condition deteriorated rapidly, was characterised by rapid tumour growth, formation of ascites, a 20 kg weight loss, extensive subcutaneous fat necrosis, and fistula formation in the left calf. Treatment with 5-fluorouracil 300 mg/m2 on days 1-5 and doxorubicin 50 mg/m2 and cisplatin 100 mg/m2 on day 1, every three weeks, was well tolerated and resulted in rapid clinical improvement. After three courses of treatment a partial remission was seen and after seven courses further improvement occurred with a return to normal of serum lipase and trypsin activity. One year after starting chemotherapy the tumour relapsed but responded again to chemotherapy (epirubicin 40 mg/m2 and carboplatin 300 mg/m2 on day 1, every three weeks).

Ultrastructural and immunohistochemical study of epithelioid hemangioendothelioma of bone: coexpression of epithelial and endothelial markers.

Four cases of epithelioid hemangioendothelioma of bone--a borderline malignant tumor of vascular origin--were studied ultrastructurally and immunohistochemically. The epithelioid tumor cells were positive for vimentin, polyclonal and monoclonal cytokeratins, and the endothelial markers factor VIII-related antigen (FVIII:RAg) and Ulex europaeus agglutinin I. The coexpression of polyclonal cytokeratin and FVIII:RAg was demonstrated by means of step sections in the same tumor cells. The endothelial origin of epithelioid tumor cells was supported ultrastructurally by identification of Weibel-Palade bodies.