Correlation of viral infection, histology, and mortality in immunocompromised patients with pneumonia. Analysis by in situ hybridization and the polymerase chain reaction.

The purpose of this study was to determine the occurrence and histologic correlates of viral infections in immunocompromised patients with pneumonia. Of the 44 immunocompromised patients studied, 37 had AIDS. Lung tissue from these patients, including 34 with pneumocystis pneumonia, was evaluated by in situ hybridization for the presence of cytomegalovirus (CMV), adenovirus, Epstein-Barr virus, and herpes simplex virus. Fifteen of the 44 patients were positive for at least one virus (34%); CMV (13 cases) was the most common. In an additional seven cases, CMV DNA was detected using the polymerase chain reaction (PCR), for an overall viral detection rate of 22 of 44 (50%). Histologic features were diagnostic of a viral infection in nine of 15 cases (60%) of the in situ positive cases and in nine of 22 (41%) of the tissues where viral DNA was detected by PCR. Mortality rate was significantly correlated with viral detection: 77% for the viral-positive cases and 27% for the viral-negative cases (p < 0.05). We concluded that in immunocompromised patients with pneumonitis, the detection of viral DNA is strongly correlated with survival and that histologic features of the inflamed lung tissue are a specific but insensitive means of diagnosing viral presence.

In situ analysis of Paget's disease of bone for measles-specific PCR-amplified cDNA.

Paget's disease of bone is a disease of unknown etiology. The demonstration of viral-like particles on ultrastructural examination and the putative detection of viral antibodies and nucleic acids in the tissues suggest a possible viral association. The purpose of this study was to search for nucleic acid sequences homologous to measles virus using the recently described reverse transcriptase (RT) polymerase chain reaction (PCR) in situ hybridization (ISH) technique. After performing RT PCR ISH utilizing primers specific for the nucleocapsid region of the measles virus, an intense signal was evident in most measles-infected HeLa cells compared with a weak signal in few of these cells using standard cDNA-RNA ISH analysis. Amplified measles nucleic acid was detected in tissue from a patient who died of measles infection and was not detected in any of the 11 cases of Paget's disease of bone studied or in a giant cell tumor of bone that had tubuloreticular inclusions on electron microscopy. Therefore, these data suggest that infection by the measles virus is not associated with Paget's disease of bone.

Myositis ossificans with atypical clinical, radiographic, or pathologic findings: a review of 23 cases.

Myositis ossificans is a relatively rare, well-defined entity. The 23 cases sent for consultation to two of us (L.V.A. and A.N.) were reviewed. Clinical, radiologic, and microscopic information was reexamined, and special attention was given to features infrequently seen in typical myositis ossificans. Average age at presentation was 23 years, but 1 patient was younger than 2 years, and 2 were younger than 10 years. Due to the uncommon location of 15 lesions and an unusual presentation in 5, the correct diagnosis was not obvious in these cases. A history of trauma was elicited in 8 patients, denied by 7, and was not queried in the remainder. Radiologic studies raised the possibility of a malignant bone-forming tumor in at least three instances; myositis ossificans was originally diagnosed in 6 cases radiologically. In 8 cases, histologic evidence suggested malignancy, including osteosarcoma, either parosteal or extraosseous, in 6. Other diagnoses included epithelioid sarcoma and callus formation. Presentation of these variations from the norm highlights the importance of recognizing the evolution of a nonneoplastic fibro-osseous and cartilaginous entity in which conservative treatment is curative.

Pathology of osteonecrosis of the femoral head. A review of experience at the Hospital for Joint Diseases, New York.

Pathological examination of the resected femoral heads from approximately 2000 total hip replacement operations carried out at the Hospital for Joint Diseases from 1984 to 1989 identified the presence of osteonecrosis in 345 patients (377 femoral heads). In 232 patients the osteonecrosis, referred to as "idiopathic," had occurred in the absence of a subcapital fracture. The present paper describes the pathology of the necrotic lesions in these 232 patients. The use of undecalcified sections and microradiography provides evidence of bone marrow calcification which, at the margin of the lesion, is sufficient to influence the radiographic features of the lesion significantly. Although a subchondral fracture is an almost constant feature of osteonecrosis when it occurs in a femoral head with a normal articular cartilage, no such fracture was found in cases in which osteonecrosis had occurred in an osteoarthritic joint.

Case report 662. Bilateral avascular necrosis of femur, with supervening suppurative arthritis of right hip.

We present a case of suppurative arthritis occurring in a patient with bilateral osteonecrosis of the femoral head. Predisposing factors were chronic alcoholism (osteonecrosis) and septicemia due to intravenous drug abuse (suppurative arthritis). Although the association of suppurative arthritis and osteonecrosis is rarely reported in the literature, the prevalence of osteonecrosis and of various factors predisposing to the development of suppurative arthritis should remind us of the possibility that a patient with osteonecrosis who develops sudden worsening of joint pain or fever may have developed suppurative arthritis of the affected joint, particularly when there is evidence of bone destruction.

Benign mesenchymoma of the round ligament. A report of two cases with immunohistochemistry.

Benign mesenchymomas are tumors composed of an admixture of two or more mature mesenchymal tissue types. Clinically and histologically they are benign lesions. However, they are seldom encapsulated and therefore may recur locally if incompletely excised. The authors report on two benign mesenchymomas composed of mature fat, thin-walled small and medium size vessels, and spindle cells demonstrated to be smooth muscle by immunohistochemical studies. They were diagnosed in women in their 50s. Both were located in the round ligament of the uterus. One was discovered incidentally during hysterectomy, and the other was unusually large, being diagnosed preoperatively as a retroperitoneal liposarcoma. Most round ligament tumors are leiomyomas or fibromas. To the authors' knowledge, this is the first report of benign mesenchymomas occurring in this location.

Intracapsular paraarticular chondroma of the knee.

Intracapsular or paraarticular chondromas are seldom mentioned in the literature. They generally occur in the area around the knee, and must be recognized and differentiated from other soft-tissue tumors that appear at this site such as sarcomas containing focal calcification or ossification, and from other cartilaginous lesions such as synovial chondromatosis. We present a case of intracapsular chondroma of the knee in a 63-year-old woman. A biopsy was performed to rule out the possibility of a soft-tissue sarcoma.

Tumor-induced osteomalacia and rickets.

Tumor-induced osteomalacia is a clinicopathological entity in which vitamin D-resistant osteomalacia or rickets occurs in association with a tumor. A total of 72 cases (three current, 69 from review of literature) has been reported to date. Men and women are equally affected. The majority are adults over 30 years old who exhibit progressive lower leg and back pain. Forty bone and 31 soft-tissue tumors were responsible for this syndrome; two-thirds occurred in the extremities. Chemical findings are typical: low serum phosphorus, normal serum calcium, and elevated alkaline phosphatase. Serum levels of 1,25-dihydroxyvitamin D were low or undetectable. Histologically, more than a third were classified as vascular tumors, and half of these cases were hemangiopericytomas that were distributed equally between bone and soft tissues. Other common diagnoses included nonossifying fibromas, "mesenchymal" and giant-cell tumor variants. Features common to all tumors were prominent vascularity, and giant and primitive stromal cells. Only 10 were histologically malignant. Ultrastructural studies have not shown any secretory granules suggestive of a hormone-secreting tumor. It is clear, however, that the tumor is responsible for the osteomalacia because the complete removal generally results in a dramatic reversal of all symptoms and signs.

Endometrial polyps in postmenopausal patients receiving tamoxifen.

The histologic features of an endometrial polyp include irregular, often dilated glands, thick-walled blood vessels, and a fibrotic stroma. Such polyps may be responsive to some chemotherapeutic drugs that can exert hormonal effects. We report on endometrial polyps detected in three postmenopausal patients who were receiving tamoxifen for treatment of metastatic breast carcinoma. The clinical presentation in all cases was vaginal bleeding and all had documented uterine enlargement suggestive of an intrauterine malignancy. The polyps were large, measuring up to 9 cm in largest diameter. On histologic examination each polyp had extensive cystic glandular hyperplasia. In one case foci of atypical epithelial proliferation and predecidualization were noted. The atypical proliferation suggested a borderline neoplastic process and was strongly positive for carcinoembryonic antigen. These findings underscore the marked proliferative changes that can be induced in endometrial polyps in postmenopausal women receiving hormonally active chemotherapeutic agents.

Fusarium solani osteomyelitis with probable nosocomial spread.

A case of Fusarium solani osteomyelitis is reported in a previously healthy adult male who received multiple injuries during an automobile accident. Combined histologic and mycologic data proved it to be a case of hyalohyphomycosis resulting from Fusarium. To the best of the authors' knowledge, this is the first reported case of osteomyelitis resulting from F. solani. A concurrent case of saprophytic wound colonization by the same organism is reported in another patient in the same ward who had sustained similar injuries. Evidence suggests that this represents nosocomial spread from the first case.

Histological correlates of clinically occult human papillomavirus infection of the uterine cervix.

Occult infection of the uterine cervix by human papillomavirus (HPV) is assumed when viral DNA sequences are detected from cervical swabs but no lesion is detectable and the Papanicolaou smear is negative. In an attempt to identify what histological changes correlate with occult infections, DNA was extracted from 200 cervical swabs taken from hysterectomy specimens. The DNA was analyzed by Southern blot hybridization for the presence of HPV sequences. Eleven cases (5.5%) were positive. The entire cervix from each case as well as from 28 negative cases was processed for histological analysis. One of the positive cases contained a CIN 2 lesion. The other 10 showed parakeratosis, papillomatosis, acanthosis, as well as focal nuclear pleomorphism and perinuclear halos (borderline koilocytotic atypia) in proportions equal to the negative controls. In situ hybridization analysis of the cases that showed borderline koilocytotic atypia were negative. These findings confirm that clinically and cytologically occult HPV infection of the uterine cervix is not associated with diagnostic histological changes. This underscores the need for caution when interpreting cervical biopsies that show changes suggestive, but not absolutely diagnostic, of HPV infection. Further, the precise epithelial location of the virus remains unclear.