Clinical presentation of inhalational anthrax following bioterrorism exposure: report of 2 surviving patients.

The use of anthrax as a weapon of biological terrorism has moved from theory to reality in recent weeks. Following processing of a letter containing anthrax spores that had been mailed to a US senator, 5 cases of inhalational anthrax have occurred among postal workers employed at a major postal facility in Washington, DC. This report details the clinical presentation, diagnostic workup, and initial therapy of 2 of these patients. The clinical course is in some ways different from what has been described as the classic pattern for inhalational anthrax. One patient developed low-grade fever, chills, cough, and malaise 3 days prior to admission, and then progressive dyspnea and cough productive of blood-tinged sputum on the day of admission. The other patient developed progressively worsening headache of 3 days' duration, along with nausea, chills, and night sweats, but no respiratory symptoms, on the day of admission. Both patients had abnormal findings on chest radiographs. Non-contrast-enhanced computed tomography of the chest showing mediastinal adenopathy led to a presumptive diagnosis of inhalational anthrax in both cases. The diagnoses were confirmed by blood cultures and polymerase chain reaction testing. Treatment with antibiotics, including intravenous ciprofloxacin, rifampin, and clindamycin, and supportive therapy appears to have slowed the progression of inhalational anthrax and has resulted to date in survival.

Anisocoria associated with the medical treatment of irritable bowel syndrome.

A case of anisocoria associated with oral pharmacologic treatment of irritable bowel syndrome is reported. A 26-year-old woman developed sudden onset of anisocoria and compromised accommodation that lasted 2 days after the use of oral scopolamine methylbromide for treatment of irritable bowel syndrome. The anisocoria and compromised accommodation occurred after contamination of the ocular surface after administration of scopolamine methylbromide and resolved within 1 week without further contamination. Oral preparations used for the pharmacologic treatment of irritable bowel syndrome can cause anisocoria due to anticholinergic pharmacologic blockade of the iris sphincter muscle.

Acute myelogenous leukemia relapsing as granulocytic sarcoma of the cervix. A case report.

BACKGROUND: Granulocytic sarcoma of the uterine cervix is an unusual manifestation of acute myeloid leukemia, representing soft tissue masses of leukemic myeloblasts. An often misdiagnosed entity, it is often confused with other inflammatory or neoplastic conditions, including large cell lymphoma. CASE: A 67-year-old female presented with acute myelogenous leukemia and a normal karyotype. After eight years in complete remission, abdominal pain and an ulcerated mass in the uterine cervix developed, with a normal peripheral blood smear. Vaginal cytology examination revealed myeloid blasts, which, on subsequent cervical biopsy, stained positive for leukocyte common antigen, Kp-1 (CD68), antimyeloperoxidase, lysozyme and chloroacetate esterase, confirming the cytologic diagnosis. K-ras was not mutated at codon 12 or 13. Chemotherapy induced a complete remission, followed nine months later by central nervous system and then systemic relapse. The patient died 13 months after being diagnosed with granulocytic sarcoma of the cervix. CONCLUSION: This case illustrates the value of vaginal cytology and histologic biopsy evaluation in patients with acute myelogenous leukemia, including those without evidence of systemic disease. The characteristic cytologic features of granulocytic sarcoma led to the correct diagnosis. Histologic biopsy evaluation, including immunohistochemistry for myeloid markers, proved of value in confirming the diagnosis.

Ehlers-Danlos syndrome type IV with Charcot Marie tooth disease: an unusual combination of diseases.

Ehlers-Danlos Syndrome (EDS) type IV is a rare genetic disorder of connective tissue. Most patients with EDS type IV are frequently unaware of this disorder until the catastrophic rupture of an artery or bowel occurs. We are reporting an association between this and another uncommon autosomal dominant disorder, Charcot Marie Tooth disease. The neurologic problem led to painful foot deformities, requiring surgery, which was complicated by difficulty controlling bleeding in the friable tissues. Other reported associations of heritable disorders of connective tissue and neuropathies are described.

Enteropathy-associated T cell lymphoma with brain involvement.

In a patient with enteropathy-associated T cell lymphoma. there was dissemination to the brain manifesting as an inflammatory lesion. the intestinal and brain lesions were studied using routine histology, immunohistochemistry, and polymerase chain reaction. The jejunum was involved by a multifocal large cell lymphoma associated with multiple inflammatory ulcers and villous atrophy with crypt hyperplasia of the intervening mucosa. The lesion in the brain consisted of necrotic tissue associated with an infiltrate of histiocytes and a relatively scant infiltrate of primarily small lymphocytes. The appearance was that of an inflammatory rather than a neoplastic process. The intestinal lymphoma cells were positive for T cell markers and contained cytotoxic granules detected with the TIA-1 monoclonal antibody. The small lymphocytes and occasional large cells in the cerebral lesion showed the same immunophenotype. DNA extracted from the intestinal lymphoma and the cerebral lesion showed identical monoclonal rearrangement of the TCR-gamma gene. Dissemination from enteropathy-associated T cell lymphoma may masquerade as an inflammatory lesion. Molecular analysis is useful in confirming the diagnosis.

Expression of human herpesvirus-8 oncogene and cytokine homologues in an HIV-seronegative patient with multicentric Castleman's disease and primary effusion lymphoma.

Human herpesvirus-8 (HHV-8) has been described in association with two lymphoproliferative disorders: one benign, multicentric Castleman's disease (MCD), and one malignant, primary effusion lymphoma (PEL). The factors that lead to malignant transformation of lymphoid cells are unknown, although most cases of PEL also are positive for EBV, suggesting a role for EBV as a cofactor in malignant transformation. We encountered a rare case of an HHV-8-associated MCD, followed by the development of an HHV-8-positive pleural PEL and a gastric large cell lymphoma in an HIV-seronegative male patient. The lesions were negative for Epstein-Barr virus (EBV). The combination of these diverse HHV-8-associated lymphoproliferative disorders in a single patient afforded us the ability to study potential differences in gene expression in these conditions. HHV-8 DNA was demonstrated by PCR in lymphoid tissues involved by MCD and PEL. By reverse transcriptase-PCR, HHV-8-related transcripts, including vG-coupled protein receptor, vbcl2, vcyclin D, vIL-6, vMIPI, and vMIPII, were detected in the PEL from the pleural cavity and the gastric lymphoma, whereas these transcripts, except for vIL-6, were not detected in a lymph node biopsy with MCD. Expression of hIL-10 was weak in the PEL from the pleural cavity, and expression of hIL-6 was undetectable in all three lesions. These data suggest that vIL-6 may be integral to the pathogenesis of MCD, whereas other viral transcripts that encode oncogene and chemokine homologues are important for HHV-8 tumorigenicity.

Correlation between selected environmental exposures and karyotype in acute myelocytic leukemia.

Many bone marrow cytogenetic abnormalities in acute myelogenous leukemia (AML) are tumor specific, clonal, nonrandom, and related to prognosis; it has been hypothesized that they may be markers of exposure to etiological agents. A previous report from our institution revealed several such associations; the purpose of the current study was to determine whether previous findings were present in a new group of patients. Subjects included 84 newly diagnosed AML patients (French-American-British M1 and M2); exposure data were gathered using self-report questionnaires at the time of registration. Two sets of comparisons were made: (a) patients with all (AA) or some (AN) cytogenetically abnormal cells versus those with normal karyotypes (NN) and (b) patients with specific abnormalities [-5/5q-, -7/7q-, +8, t(8;21)] versus all others. Odds ratios (ORs) were 4.64 for the association between prior cytotoxic therapy and -5/5q- and 6.38 for the association with -7/7q-, but were <1.00 for +8 and t(8;21). There were no ORs > 2.0 for specific abnormalities in any of the other exposures evaluated (cigarette smoking, alcohol use, occupational exposure to organic chemicals, paints, or pesticides/herbicides), with the exception of exposure to paints and -7/7q- (OR, 7.50). The ORs for AA/AN versus NN patients were 1.43 and 3.81 for smoking and alcohol use, and weak dose-response trends were present. The most consistent positive associations between the two series were for prior cytotoxic therapy (-5/5q-; -7/7q-), cigarette smoking (AA/AN versus NN) and alcohol use (AA/AN versus NN). Reasoning from the known association between prior cytotoxic therapy and -7/7q-, we would have predicted relatively high ORs (> 4.0) if specific abnormalities acted as markers for the exposures assessed, but none were present. However, in both series, AA/AN patients were more likely to smoke and use alcohol than were NN patients, and weak dose-response patterns were present for both. This finding suggests that both smoking and alcohol use may play a role in the pathogenesis of cytogenetic abnormalities in AML-M1/M2; however, the mechanism by which they work and whether they are involved in the etiology of these diseases remain unclear.

Clues in the eye: ocular signs of metabolic and nutritional disorders.

Ocular signs and symptoms provide clinical clues to many of the more common metabolic and nutritional disorders seen in older adults. Diabetes mellitus can affect all parts of the eye and orbit. Complications include refractive visual loss, macular edema, retinopathy, increased risk of fungal infection, and diplopia. In patients with gout, urate crystals may precipitate in the eye and cause conjunctivitis, uveitis, or scleritis. Other problems are seen with Wilson's disease, hyperlipidemia, and albinism. Nutritional disorders usually arise from malabsorption, gastrointestinal surgery, and alcohol abuse. Deficiencies in vitamins A, B1 (thiamine), B12, and C may be manifest in the eye.

S-100-positive T-cell lymphoproliferative disorder. A case report and review of the literature.

The authors describe a patient with a S-100-positive T-cell lymphoproliferative disorder, characterized by clinically aggressive behavior, with leukemic dissemination and death within 1 year of the onset of symptoms. The neoplastic cells had abundant amphophilic cytoplasm, suggestive of plasmacytoid differentiation, but demonstrated a mature T-cell immunophenotype characteristic of the suppressor-cytotoxic subset. In addition, the cells expressed the S-100 protein within the cytoplasm. Genotypic studies were performed by Southern blot analysis, which demonstrated beta-chain T-cell receptor gene rearrangement, further confirming the T-cell nature of this disorder. This case had features very similar to those of the seven cases previously reported. It has been proposed that the S-100-positive T-cell lymphoproliferative disorder is a distinctive clinicopathologic entity.

Germline p53 gene mutations in subsets of glioma patients.

BACKGROUND: Heritable germline mutations of the p53 gene have been described in patients with Li-Fraumeni syndrome, occasionally in nonfamilial malignancies such as multifocal osteosarcoma, in a small subgroup of young patients with two or more primary malignancies, and in patients with sporadic breast carcinoma. We recently reported that multifocal gliomas are frequently associated with other primary malignancies, and we hypothesized that genetic alterations may account for this phenomenon. PURPOSE: We examined the frequency of germline p53 gene mutations in patients with glioma and either multifocality of lesions, history of an additional primary (different) malignancy, or a family history of cancer. METHODS: Lymphocytes from 51 glioma patients were analyzed for germline p53 gene mutations using RNA-polymerase chain reaction analysis, single-strand conformation polymorphism, and gene sequencing techniques. RESULTS: Germline p53 gene mutations were detected in six of 19 patients with multifocal glioma, including two with family history of cancer, one with another primary malignancy, and two with all three risk factors; one of four patients with unifocal glioma, another primary malignancy, and a family history of cancer; and two of 15 patients with unifocal glioma and a family history of cancer but no second malignancies. No mutations were detected in the patient with unifocal glioma and another malignancy or in the 12 control patients with unifocal glioma and no second malignancies or family history of cancer. Patients having mutations were younger than other patients in the same group. CONCLUSIONS: Germline p53 mutations are frequent in patients with multifocal glioma, glioma and another primary malignancy, and glioma associated with a family history of cancer, particularly if these factors are combined. IMPLICATIONS: Relatives at high risk can be identified for genetic counseling, early cancer detection, and possible enrollment in chemoprevention trials.

Esthesioneuroblastoma presenting as sudden unilateral blindness. Histopathologic confirmation of optic nerve demyelination.

We report here a case of esthesioneuroblastoma an 11-year-old girl presenting as acute loss of vision with minimal evidence of orbital, nasal, or paranasal sinus disease, a rare presenting symptom for this tumor. The initial diagnosis was postviral optic neuritis, a pattern of presentation not previously reported. When vision failed to improve, magnetic resonance imaging revealed a lesion in the posterior ethmoid and sphenoid sinuses. After a biopsy, the tumor was excised through the cranium and paranasal sinuses. A mass completely surrounding the optic nerve without invasion was found. Histochemical staining suggested demyelination secondary to compression, confirming the clinical impression of optic neuritis. Anti-Leu 7 monoclonal antibody is useful in characterizing of this tumor, since other immunochemical stains can be misleading. Radiation and chemotherapy were given after the tumor was removed. Two years later, the patient has had neither recurrence nor complications.

Pyoderma gangrenosum complicating Felty's syndrome.

The case of a 54-year-old woman with Felty's syndrome whose course was complicated by mucocutaneous lesions clinically typical of pyoderma gangrenosum is described. Necrotizing sinusitis and saddle nose deformity were distinctive clinical features. Lymphocytic vasculitis and rheumatoid nodule formation observed within panniculus at the base of a cutaneous lesion and in a nasal mucosal lesion were unexpected histopathologic findings.

Studies of eosinophil medusa cells by electron imaging modes.

Medusa cells, amoeboid variants of the eosinophil with pseudopod-like processes, were examined by light microscopy (LM), transmission electron microscopy (TEM), the secondary electron imaging (SEI) and the backscattered electron imaging (BEI) modes of the scanning electron microscope. TEM was performed on rare medusa cells found in leukocyte concentrate preparations where the ion contents of the collection and fixation media were balanced so that divalent cations such as calcium and magnesium were not sequestered. LM, SEI and BEI studies were performed principally on cytochemically-stained films of leukocyte concentrate preparations on microscope slides or coverslips. These films of patients with eosinophilia contained many medusa cells and much higher ratios of medusa cells to eosinophils than critical point-dried specimens, if they were prepared as for routine hematologic examination, and precautions were taken to insure that calcium and magnesium ions in collection and fixation media were not sequestered. After brief glutaraldehyde fixation, the smears were stained with either osmium tetramethylethylenediamine (Os-TMEDA) for acid mucopolysaccharides, or 3,3'-diaminobenzidine (DAB)/hydrogen peroxide medium for peroxidases. The Os-TMEDA was sufficiently conductive for SEM. Chelation of the oxidatively-polymerized DAB dye with copper nitrate rendered it conductive. These conductive and electron-opaque stains permitted the correlation of SEI with BEI on individual cells, their unambiguous identification as eosinophils or medusa cells and their differentiation from other leukocytes by virtue of content and/or size of their granules and their degree of nuclear segmentation.

Comparison of selective staining of fungi in paraffin sections by light microscopy, SEM and BEI.

Paraffin-embedded sections from human tissues with fungi or organisms classified with fungi were studied by light microscopy (LM), scanning electron microscopy (SEM), and the backscatter electron imaging (BEI) mode of the SEM. The fungal organisms selected for study were those familiar to the pathologist on the basis of their appearance in paraffin-embedded material stained with the Gomori-Grocott Chromic Acid Methenamine Silver Stain (GMS). The organisms were Actinomyces, Rhizopus, Cryptococcus, Histoplasma capsulatum, and Coccidia imitis. Sections were stained with the GMS Stain and/or the Becker modification of the GMS Stain (BGMS) and examined in the secondary electron imaging mode (SEI) and BEI mode with an annular backscatter electron detector. This silver staining technique accentuated the wall of fungal organisms, in the backscatter mode. Depending on the fungal organism and type of silver stain employed, the GMS seemed the preferable stain. The advantages of SEM over LM were greater depth of focus and potential range of magnifications. BEI may also be used in conjunction with LM stain for microorganisms to establish their presence.

Idiopathic neonatal iron storage involving the liver, pancreas, heart, and endocrine and exocrine glands.

Autopsy studies of two infants, one a newborn, the other 4 months old, revealed massive amounts of iron in lysosomes of hepatocytes and pancreatic acinar cells. Iron, which had been transported across the placenta, accumulated in the same cell types as in adults with primary and secondary hemochromatosis. Hemosiderin was found in cardiac muscle cells, gastric and intestinal glands, and endocrine and exocrine organs including pituitary, thyroid, adrenals, islets of Langerhans, and sublingual and sweat glands. The liver was the most affected organ and the normal hepatic architecture was replaced by hepatocytes which were arranged in cluster, pseudoacinar structures, and multinucleated giant cells embedded in a collagen matrix. The islets of Langerhans were hyperplastic and hypertrophic. Ten similar cases, in five families, have been described; no patients liver longer than 4 months. Neonatal iron storage disease is clinically and pathologically distinct from Zellweger's cerebrohepatorenal syndrome and hypermethioninemia (tyrosinemia) neonatal diseases in which large stores of iron are present in hepatocytes. No abnormalities in serum iron, ferritin, or transferrin concentrations were detected in five parents of the affected children.