Characterizing "blue blobs". Immunohistochemical staining and ultrastructural study.

OBJECTIVE: To investigate the nature and origin of "blue blobs" (Bbs) in atrophic Pap smears in postmenopausal women and to study their clinical significance. STUDY DESIGN: A retrospective study of 412 atrophic Pap smears from postmenopausal women was done to detect the presence of Bbs. The smears from 24 cases showing Bbs were further studied to evaluate the nature of the Bbs with special stains, immunohistochemistry and electron microscopy. RESULTS: Bbs showed a heterogeneous morphology, with variable numbers and staining intensity. The diameter of Bbs was approximately equivalent to that of a parabasal/intermediate squamous cell. Special stains showed Bbs to be positive for periodic acid-Schiff and methyl green pyronin and negative for mucicarmine and calcium. Immunohistochemistry revealed Bbs to be positive for cytokeratin, epithelial membrane antigen and carcinoembryonic antigen and negative for vimentin and muscle-specific actin. Some Bbs had residual ghost nuclear shadows. Electron microscopy revealed cellular skeletons with residual tonofilaments enmeshed within a loose cytoskeleton matrix and nuclei with variable degrees of degeneration. CONCLUSION: Special stains, immunohistochemistry and electron microscopy indicated that Bbs represent parabasal/intermediate squamous cells exhibiting various degree of degeneration. In general, Bbs appear to be of no clinical significance except as a source of potential diagnostic error.

Cellularity of lobular carcinoma and its relationship to false negative fine needle aspiration results.

OBJECTIVE: To evaluate the cytocellularity and histocellularity of lobular carcinoma (LC) and the relationship to high false negative results of fine needle aspiration cytology (FNAC). STUDY DESIGN: In this retrospective study, cellularity was studied in 60 cases of classic LC, LC variants and lobular carcinoma in situ, comparing cytologic smears to their corresponding histologic sections. The cytologic smears were grouped into acellular, low, moderate and high categories, and the histologic sections were grouped into low, moderate and high categories. RESULTS: Malignancy or suspicion of malignancy was diagnosed in 78% of cases. Overall cytocellularity showed acellularity or low cellularity in 60% of cases, while overall histocellularity showed moderate or high cellularity in 95% of cases. When the cytocellularity was moderate or high, the corresponding histocellularity always showed moderate or high histocellularity. When the cytocellularity was low, the corresponding histology showed low histocellularity in 6.3% of cases. Thus, in acellular and low cellular aspirations, corresponding histocellularity may not be the contributing factor toward low cellular yield. In this study, 22% of cases were diagnosed as false negative, 40% were diagnosed as suspicious, and 38% were called positive. Only 17% of positive cases were diagnosed as LC. A large number of LC were misdiagnosed by FNAC as duct cell carcinoma, and most cases of low histocellularity were of the classic type. CONCLUSION: The results of this study suggest that in the majority of cases of LC, cellular yield of FNAC is disproportionately lower than expected when compared to the corresponding histocellularity. Awareness of modest cellularity and subtle cytologic features will aid in the correct preoperative diagnosis of LC, and false negative diagnoses can be minimized.

Cytomorphologic features of classic and variant lobular carcinoma: A comparative study.

There are several subtypes of lobular carcinoma (LC), and their cytomorphologic features differ from classic lobular carcinoma (CLC). The finer details of the differences between CLC and variant lobular carcinoma (VLC) have not been adequately studied. A comparative study of 54 cases of CLC and VLC was done in order to verify any statistically significant differences between them. All cases had histologic confirmation of the diagnosis. Six parameters, which included cellularity, signet-ring cells, intracytoplasmic lumina (ICL), anisonucleosis, cell size, and prominent nucleoli, were studied. The only statistically significant findings were cellularity and cell size when compared to CLC. The cellularity in VLC was higher and the cells in VLC were larger when compared to CLC. There are no definite diagnostic features to identify VLC; however, in a cellular specimen with plenty of large cells with other features of LC, one should have a high index of suspicion of VLC.

Detection of Schistosoma mansoni in bronchoalveolar lavage fluid. A case report.

BACKGROUND: Bronchoalveolar lavage (BAL) is a useful tool in the diagnosis of bacterial, viral, fungal and parasitic pulmonary infections. There have been rare reports of parasitic infestations in bronchoalveolar lavage fluid. This is the first case report on detecting a Schistosoma ova in BAL fluid. CASE: A 40-year-old, Egyptian male presented with a fever and productive cough. He had a right pleural effusion and segmental collapse of the right lower lobe. BAL fluid showed several ova of Schistosoma mansoni and established the diagnosis of schistosomiasis. Abdominal ultrasound revealed mild hepatic cirrhosis. CONCLUSION: Schistosomiasis should be considered in the differential diagnosis of pulmonary problems in patients with disseminated disease in endemic areas.

Pasteurella multocida endocarditis.

Human infection with Pasteurella multocida is the leading cause of animal bite wound infection. Life-threatening infection may occur in patients with a variety of underlying disorders and an immunocompromised state. Infective endocarditis with P. multocida is very rare and only a few clinically diagnosed cases have been reported. Described here is an autopsy case of a 61-year-old man with polycystic kidney disease who had P. multocida bacteremia and acute infective endocarditis with multiple bacterial clumps involving bicuspid aortic valve. The organisms were gram negative. Apparently the sepsis with P. multocida was acquired via licking of leg ulcers by his pet dog, establishing an animal-related causal relationship. Because P. multocida is a very common flora of many animals, infection with this organism probably occurs more frequently than is commonly appreciated. High index of suspicion and early diagnosis, especially in immunocompromised patients, are warranted because the disease is potentially life threatening, yet is a readily treatable infection.

A study of lymphoma of large granular lymphocytes with modern modalities: report of two cases and review of the literature.

Two cases of lymphoma of large granular lymphocytes are reported. The first case expressed natural killer (NK) cell, some T-cell (CD 2, CD 5, CD 8), and HLA-DR antigens, but was negative for other T-cell (CD 3, CD 4, CD 7), T-cell receptor (TCR), B-cell, and myeloid antigens. Germline configuration was demonstrated for TCR, and immunoglobulin heavy and light chain genes. The second case expressed NK cell, some T-cell (CD 3, CD 7, CD 8), and TCR antigens, but was negative for other T-cell (CD 4, CD 5), B-cell, myeloid, and HLA-DR antigens. Rearrangement of TCR alpha and beta chains were detected. Thus, the findings of case 1 were consistent with true NK cell lineage and case 2 with NK-like T-cell lineage. Our report underscores the heterogeneity of this newly recognized lymphoma, which nevertheless carries a consistently poor prognosis and is probably more prevalent in the Asian population. This study also provides information concerning immunophenotypes of cellular infiltrates in internal organs and cytogenetic abnormalities in this lymphoma; neither has been reported frequently in the literature. The importance of detecting cytoplasmic granules in tissue imprints or electron micrographs for differentiating other T-cell lymphomas is emphasized, and the classification of large granular lymphoproliferative disorders is discussed.

Use of cyclophosphamide in azathioprine failures in pemphigus.

Four patients with pemphigus vulgaris are presented in which diagnosis was confirmed histologically and immunopathologically. Although these patients responded to high-dose prednisone therapy during the initial stages of acute disease, the addition of azathioprine failed to allow lower steroid doses and did not result in prolonged, complete remission. Indeed, the disease was exacerbated during azathioprine therapy, and significant side effects from prolonged high-dose steroid therapy were observed. Both clinical and serologic remission resulted from the addition of cyclophosphamide and dapsone to prednisone therapy. Thus, when azathioprine fails to produce remission or a steroid-sparing effect, cyclophosphamide may be an effective alternative. During a prolonged follow-up period, no recurrences of pemphigus have been observed, and no significant side effects of cyclophosphamide (Cytoxan) have been encountered. The addition of dapsone produced enhanced anti-inflammatory effects without increasing the existing or potential side effects of steroid therapy. Dapsone was easily withdrawn at the onset of remission. Thus the anti-inflammatory effect of dapsone may prove valuable in patients for whom steroids are contraindicated, who develop significant side effects during long-term steroid therapy, or for whom increases of dose threaten to enhance the possibility of catastrophic side effects.

Cyclophosphamide (Cytoxan). A review on relevant pharmacology and clinical uses.

Cyclophosphamide (Cytoxan; Cy) is an alkylating agent with cytotoxic and immunosuppressive activities. The parent compound is inactive in vitro and exerts its biologic activity through metabolites, mainly phosphoramide mustard generated by hepatic microsomal enzymes. The exact mode of cytotoxic and immunosuppressive action of Cy at cellular level is not completely understood. Myelosuppression, hemorrhagic cystitis, alopecia, and gonadal damage are the main toxic effects. Available data suggest that Cy has carcinogenic potential in humans. Cy is widely used for cancer chemotherapy. As an immunosuppressive agent, it is successfully used in certain nonmalignant diseases in which autoimmune phenomena are established or suspected in the pathogenesis of the disease. It is the drug of choice in Wegener's granulomatosis. Extensive efforts are being made to synthesize Cy analogues with greater selective cytotoxic and immunosuppressive activity. Ifosfamide, a Cy analogue, appears to possess similar cytotoxic activity with less myelosuppression. Further research will help in synthesizing a Cy analogue with specific pharmacologic activity and reduced or absent harmful effects.