What will the pathologist be doing in 2001? Speculations of a hospital practitioner.

The 21st century looms ahead, and physicians are increasingly anxious about what the practice of medicine will be like in the future. Pathologists, like other physicians, are holding conferences and writing papers in an attempt to predict what lies ahead. From the perspective of one community pathologist, the future looks bright as far as work opportunities. The jobs that will need to be filled will include familiar ones and numerous new tasks. There will be plenty of jobs; but will there be enough skilled pathologists to fill these positions? The answer depends on our ability to attract the needed physicians into pathology and to give them the needed variety of skills to survive in a new work environment.

Physician education. The challenge of acquired immunodeficiency syndrome.

Acquired immunodeficiency syndrome is a major health problem confronting society. Our communities are looking to physicians to help in both educational efforts, as well as in formulating public policy in the fight against the disease. For physicians to fill this important role, they first must be knowledgeable themselves. There is strong evidence that many physicians have resisted learning about acquired immunodeficiency syndrome. The increasing number of infected individuals requires the medical profession to find ways to overcome the barriers that prevent our colleagues from acquiring needed information. We must understand the reasons for our educational failures and devise methods to reach physicians with the knowledge base that they will need in helping to combat this terrible disease. Pathologists are in a particularly good position to help in this educational process.

Bacterial pseudomycosis (botryomycosis) in an otherwise normal child.

We report what we believe to be the first case in the modern literature of botryomycosis occurring in an otherwise normal 22-month-old child. The term bacterial pseudomycosis is more descriptive of the true nature of the condition and more meaningful to the clinician.

Gallbladder with ectopic gastric mucosa: ultrastructural analysis.

The clinical and pathological findings of two patients with ectopic gastric mucosa within the gallbladder are studied and compared with the findings recorded in the literature. A contrast between incidental and symptomatic ectopia was noted in these cases. Morphologically bountiful parietal cells were noted in our symptomatic case, while sparse parietal cells were found in our incidental case.

Ocular and orbital phycomycosis.

Cerebro-rhino-orbital phycomycosis (CROP) occurs predominantly in individuals with diabetes mellitus in a state of metabolic acidosis. Other forms of metabolic acidosis, especially in infants, may predispose to phycomycotic infections. CROP has also been reported in patients with leukemia or lymphoma. CROP usually begins in the palate or paranasal sinuses and rapidly spreads to the orbital contents. Proptosis, loss of vision, and ophthalmoplegia occur and death from cerebral involvement commonly ensues. The fungus tends to invade arteries and cause thrombosis and tissue infarction. Rhizopus is the most commonly isolated genus in CROP, accounting for almost all cases. The diagnosis can be strongly suspected by the characteristic clinical manifestations. Therapy includes treatment of the underlying disease, surgical excision of the necrotic tissue containing fungal elements and the systemic administration of amphotericin-B. The effect of treatment has improved since the disease was first described, but the condition still has a high mortality, especially if it is not diagnosed early.

Necrotizing retinopathy with herpes zoster ophthalmicus: a light and electron microscopical study.

A necrotizing retinopathy following a vesicular cutaneous eruption in the distribution of the right trigeminal nerve developed in a patient who had been receiving systemic corticosteroid therapy one week prior to the onset of herpes zoster ophthalmicus. Seven weeks after the herpetic symptoms began, the patient died of pneumonia following an intracerebral hematoma. At postmortem examination, unexpected multiple focal and confluent lesions, which corresponded to areas of extensive retinal necrosis, were observed in the fundus of the right eye. Intranuclear inclusions with a perinuclear halo were identified within the affected sensory retina. Electron microscopy of the retinal lesions disclosed round to oval enveloped viral particles that were characteristic of the herpes viruses. A mild lymphocytic infiltrate was evident in a demyelinated right Gasserian ganglion. Demyelination and necrosis of the right trigeminal sensory tract and adjacent areas were evident within the brain stem.

Cytomegalovirus replication and the host immune response.

Cytomegalovirus (CMV) is closely associated with host cellular structures, and this has a significant impact upon the immunologic response following infection. CMV may be recovered from a variety of body secretions and fluids during acute infection, and protracted shedding may supervene in some instances. The reasons for a variable host response to CMV infection remain unclear, and the mechanisms responsible for the establishment of persistence have not been worked out. CMV persistence and latency are discussed, and some recently derived relevant data are presented. An animal model has been developed consistent with clinical observations pertaining to CMV transmission with blood. Results obtained in the course of these and other studies support the concept of immunological activation of latent CMV. The timing of CMV infection relative to an unrelated antigenic challenge is probably critical in determining the emergence of immunodepression or enhancement. Some aspects of CMV sero-diagnosis are also reviewed.

Comparison of angiographic and postmortem findings in patients with coronary artery disease.

The accuracy of coronary cineangiography in predicting the degree of stenosis in coronary arteries was evaluated by comparing autopsy and premortem cineangiographic findings in 25 patients. Coronary cineangiograms and autopsy specimens were reviewed independently by two cardiologists and two pathologists. Identical diagrams dividing the cononary arteries into 12 segments were used by both groups to record the location and degree of stenosis observed. Cineangiographic findings were in agreement with pathologic findings (less than 25 percent difference in cross-sectional luminal area) in 178 (79 percent) of the 226 segments examined, but overestimated the degree of stenosis in 13 (6 percent) and underestimated it in 34 (15 percent). Thus, cineangiography appears to be a reliable tool in evaluating coronary artery disease. When diagnostic errors are made, they are usually underestimations of the degree of disease; common causes of error are circumferential stenosis, eccentric lesions, obstruction of view by artifical valves and poor opacification due to severe proximal stenosis.

Lymphoid cell necrosis, thymic atrophy, and growth retardation in newborn mice inoculated with murine cytomegalovirus.

During studies on the effect of murine cytomegalovirus on the developing retina, virus was inoculated into the eyes of newborn Swiss mice, and the animals were sacrificed at various times thereafter. Controls consisted of mice inoculated with ultraviolet-inactivated murine cytomegalovirus and uninjected mice. Marked lymphoid cell necrosis, thymic atrophy, pronounced growth retardation, bacteremia, and death occurred in the animals inoculated with live virus. this virus-induced injury resulted in a marked depletion of lymphocytes in the subcapsular and cortical areas of the thymus as well as in the spleen, lymph nodes, and Peyer's patches. Areas of necrosis with viral inclusions were present at the site of inoculation and in various other organs including the spleen and bone marrow. Since growth retardation has been associated with thymic atrophy due to other causes, the observed abnormal physical development in the present study was interpreted as a sequel to the thymic injury. An implication of this study is that some human infants with concomitant immune deficiency and viral infection may have a primary viral disease with resultant secondary lymphoid tissue alterations, rather than a thymic disorder with a subsequent viral infection.

Experimental cytomegalovirus ophthalmitis.

Cytomegalovirus can produce a severe necrotizing chorioretinitis in patients on immunosuppressive therapy and infants born with congenital cytomegaloviral inclusion disease. To study the effect of cytomegalovirus on the eye, murine cytomegalovirus was injected into the eyes of nonimmunosuppressed Swiss CD-1 weanling mice. The eyes were then prepared for virus titer, as well as light and electron microscopy at variable periods after inoculation (1 to 28 days). From days 2 to 6, the hallmarks of cytomegalovirus infection, intranuclear and intracytoplasmic viral inclusions, were evident within cytomegalic cells. The major site of reaction was in the uveal tract, where necrosis and inflammation were prominent. Viral particles budding through the nuclear membranes into the perinuclear cisternae and vacuoles with viral particles could be seen in the cytoplasm of infected cells. In lesions older than 2 weeks, only a mild mixed inflammatory infiltrate and fibrosis were observed. Morphologic alterations unaccompanied by inflammation occurred in the outer sensory retina overlying infected retinal pigment epithelial cells. Multiple necrotic foci with inclusion-bearing cells in the liver indicated the systemic spread of virus from the eye. The titer of virus recovered from the eye peaked at day 4 and then declined to low levels, but infectious virus could still be isolated at day 28, even though viral particles were not seen morphologically at or after day 14. Many of the alterations seen in the model resemble those found in the human cytomegaloviral ophthalmitis.