Identification of coronary thrombus with a IIb/IIIa platelet inhibitor radiopharmaceutical, technetium-99m DMP-444: A canine model.

BACKGROUND: A diagnostic test that could distinguish between stable and unstable coronary atherosclerotic plaques would be useful. We tested the ability of a new glycoprotein IIb/IIIa platelet inhibitor DMP-444, labeled with technetium (Tc)-99 m, to identify platelet-rich thrombus by nuclear imaging in a canine model. METHODS AND RESULTS: Combinations of a flow-limiting stenosis and 0 to 15 minutes of endothelial electrical stimulation at a site in the left anterior descending coronary artery were used to induce varying amounts of thrombus formation. In 10 animals with markedly positive nuclear images after the injection of Tc-99m DMP-444, the presence of platelet-rich thrombus was confirmed postmortem by gross appearance, high nuclear counts, and abundant platelets on electron microscopy. The 10 animals with negative images had lower counts, smaller thrombus weights (P<0.05 for each), and fewer platelets by electron microscopy. CONCLUSIONS: Activated platelets participating in acute thrombus formation can be accurately detected by nuclear imaging using Tc-99 m DMP-444.

Lymphangioma of the kidney: a pathologic entity distinct from solitary multilocular cyst.

A case of primary renal lymphangioma is reported. This represents the first documented example of such a lesion confirmed by immunocytochemical and ultrastructural studies. Whereas previously regarded as synonymous terms, the recognition of lymphangioma as a pathologic entity distinct from solitary multilocular cyst of the kidney appears warranted. Although rare, lymphangioma should be considered in the differential diagnosis of multicystic lesions of the kidney.

Pulmonary abnormalities in Klippel-Trenaunay syndrome. A histologic, ultrastructural, and immunocytochemical study.

Klippel-Trenaunay (KT) syndrome is a rare, sporadic, congenital vascular disease of unknown etiology. We describe pulmonary findings in an 18-year-old male patient followed up since birth with the KT syndrome. The patient developed pleural and pericardial serous effusions that led to an open lung biopsy. Previous pulmonary findings have been limited to thromboembolic phenomena and pulmonary vein varicosities. On the other hand, reports of lymphatic hyperplasia, aplasia, and hypoplasia in KT have been limited to the extremities. For the first time, we describe lymphatic involvement of the lung in KT. The plexiform hyperplasia of the lymphatic channels with smooth muscle hyperplasia leading to lymphatic obstruction, pleural and pericardial effusions are new findings. The lymphatic nature of the plexiform channels was confirmed by immunohistochemistry. Von Willebrand factor and QD-END/10 monoclonal antibodies either did not react or reacted poorly with lymphatic endothelium, features used to distinguish lymphatic and venous endothelium. Ultrastructurally, the absence of basement membrane continuity further substantiated the lymphatic nature of the channels. From our findings, the lymphatic abnormality in the syndrome appears to be more generalized than previously thought. This entity should be distinguished from lymphangioleiomyomatosis to which it bears a superficial morphologic appearance.

Comparison of cardiac troponin I, creatine kinase-MB, and myoglobin for detection of acute ischemic myocardial injury in a swine model.

To study the comparative value of the levels of cardiac troponin I (cTnI), creatine kinase-MB isoenzyme (CK-MB), and myoglobin in the detection of acute ischemic myocardial injury, we serially measured plasma concentrations of these cardiac proteins in 12 pigs with myocardial ischemia subtending severe coronary artery stenoses and in 5 pigs with a sham operation performed, but without coronary artery stenosis. In the stenosis group, flow in the left anterior descending (LAD) artery was reduced by 36% and maintained for 24 hours (n = 3), 7 days (n = 6), or 4 weeks (n = 3). Flow in the coronary artery was measured by a flowmeter, and regional left ventricular dysfunction was monitored by echocardiography. Myocardial infarction was identified with triphenyltetrazolium chloride staining. All pigs with stenosis of the LAD had significant ultrastructural abnormalities consisting of loss of myofibrils and an increase in mitochondria and glycogen deposition. Cardiac proteins were released in all pigs with stenosis of the LAD artery during the development of myocardial ischemia; the levels of cTnI, CK-MB, and myoglobin increased significantly relative to the baseline. The sensitivity and specificity for cTnI were higher than for CK-MB or myoglobin. Results of this study show that cTnI is the better marker for the detection of acute ischemic myocardial injury. Increased levels of cTnI can be found in reversible and irreversible myocardial ischemic injury in this model.

Impact of delayed reperfusion of myocardial hibernation on myocardial ultrastructure and function and their recoveries after reperfusion in a pig model of myocardial hibernation.

UNLABELLED: This study examined the effect of delayed reperfusion of myocardial hibernation from 24 hours to 7 days on myocardial ultrastructural and functional changes and their recoveries after reperfusion. BACKGROUND: We have previously shown in pigs that after reperfusion the functional and structural alterations in short-term myocardial hibernation which was reperfused in 24 hours can recover in 7 days. The effect of delayed reperfusion of hibernating myocardium on the extent and severity of cellular and extracellular structural changes of hibernating myocardium, and their recoveries after reperfusion is not known. METHODS AND RESULTS: A severe LAD stenosis was created in 27 pigs, reducing resting flow by 30-40% immediately after placement of the stenosis and producing acute ischemia as evidenced by regional lactate production, a decrease in regional coronary venous pH, reduced regional wall thickening (from 38.5 +/- 5.1% to 10.4 +/- 8.0%) and a 33% reduction of regional oxygen consumption. The stenosis was maintained either for 24 hours in 9 pigs (group 1) with LAD flow of 0.65 +/- 0.13 ml/min/g (38% reduction), or for 7 days in 17 pigs (group 2) with LAD flow of 0.67 +/- 0.14 ml/min/g (36% reduction). There were no differences (p = NS) in the reduction of wall thickening, rate-pressure product, lactate production, or regional oxygen consumption between group 1 and group 2. Quantitative morphometric evaluation of the ultrastructure on electromicrographs revealed a greater decrease in sarcomere volume and a higher incidence of myocytes with reduced sarcomere volume in 7-day than in 24-hour hibernating regions (53 +/- 19% versus 33 +/- 14%, p < 0.05). Patchy myocardial necrosis with replacement fibrosis was common, but 6 of the 18 pigs had no myocardial necrosis or replacement fibrosis in the 7-day hibernating group, and 4 of 9 pigs had no patchy myocyte necrosis in the 24 hour hibernating group. In 6 pigs in group 1 in which the stenosis was then released and hibernating myocardium reperfused in 24 hours, regional wall thickening recovered to 30 +/- 6% (p = NS compared to baseline) after one week of reperfusion. In 12 pigs in group 2 in which the stenosis was released and hibernating myocardium reperfused in 7 days, regional wall thickening recovered slowly, from 10.1 +/- 7.2% to 18.1 +/- 8.3% at one week (n = 5) and to 28.0 +/- 3.6% at 3-4 weeks of reperfusion (n = 7, p < 0.05 compared to baseline). Similarly, the sarcomere volume or myofilament recovered significantly (p < 0.01) and was not different compared to the normal region (p = NS) in the 24-hour hibernating region of group 1, but the recovery was much slower and was incomplete at 4 weeks (p < 0.01) compared to baseline in the 7-day hibernating region of group 2. Recovery of regional wall thickening correlated with ultrstructural recovery (p < 0.01). By multivariate stepwise regression analysis, the degree of LAD flow reduction, the extent of fibrosis, and myofilament loss were independent predictors of the extent of functional recovery. CONCLUSIONS: In a porcine model of myocardial hibernation with myocardial hypoperfusion, systolic dysfunction, and metabolic adaptations, a longer period of myocardial hibernation with delayed reperfusion was associated with more severe abnormalities of myocytes. an increasing interstitial fibrosis, and more protracted myofibrillar and functional recoveries after reperfusion. The extent of functional recovery is related to the degree of coronary flow reduction, the severity of the ultrastructural changes, and the extent of interstitial fibrosis.

The use of monoclonal antibody R92F6 and polymerase chain reaction to confirm the presence of parvovirus B19 in bone marrow specimens of patients with acquired immunodeficiency syndrome.

BACKGROUND: Parvovirus B19 infection is a cause of chronic anemia and red cell aplasia in patients with acquired immunodeficiency syndrome (AIDS) and in other immunocompromised hosts. Anemia in AIDS patients has a multifactorial etiology, with parvovirus B19 infection being an infrequent but nevertheless treatable cause. Therapy with intravenous immune globulin can result in rapid improvement of parvovirus-induced anemia. This treatment is expensive, therefore accurate and rapid confirmation of parvovirus infection is important in providing appropriate and cost-effective therapy. METHODS: Bone marrow samples from 2 AIDS patients with severe anemia and reticulocytopenia were studied. Bone marrow morphology and serologic studies were evaluated for parvovirus B19 infection. An immunohistochemical method using a monoclonal antibody, R92F6, to B19 capsid proteins was utilized on decalcified, B5-fixed, paraffin-embedded bone marrow biopsies. Bone marrow aspirate cells were examined by electron microscopy for evidence of viral particles. In addition, polymerase chain reaction (PCR) studies using a nested PCR assay to the parvovirus B19 viral genome were performed in a case for which fresh cells were available. RESULTS: Bone marrow findings included marked erythroid hypoplasia with characteristic giant pronormoblasts and intranuclear inclusions. Serologic studies were negative in one case, while the second case showed positive parvovirus B19 immunoglobulin M antibody. Immunohistochemical studies for parvovirus B19 were positive in both cases. The presence of intranuclear virions was demonstrated by electron microscopy and was confirmed by PCR analysis. Both patients were treated with intravenous immune globulin, and subsequent improvement was noted. CONCLUSIONS: Both immunohistochemistry and PCR studies on bone marrow specimens from AIDS patients with anemia are rapid and sensitive methods for the confirmation of parvovirus B19 infection. They are valuable tools, particularly when serologic studies are negative. When PCR is not available, immunohistochemical methods can be useful. The rapid confirmation of parvovirus B19 infection will allow for early and cost-effective therapy.

Canine carotid allograft changes after photochemotherapy and external polyester sheathing.

BACKGROUND: The purpose of this study is to define and refine the changes in canine carotid allografts after photochemotherapy and polyester sheathing. Photochemotherapy with 8-methoxy psoralen (8MOP) and UVA (PUVA) was given alone or combined with intraluminal visible light (VL) 450 nm in proper dosages to speed the depopulation of endothelial (EC) and smooth muscle cells (SMC) and to modulate the immune response. METHODS: Novel apparati were made for photochemotherapy of 19 right canine carotid arterial allografts with 19 paired untreated controls in the left carotid. External UVA and internal visible light (VL 450 nm) were used with 8-methoxy psoralen (8-MOP) as a sensitizer. RESULTS: With moderate dosage of 8-MOP (1 microg/cc) and 2-4 J/cm2 of external UVA (PUVA), smooth muscle cells (SMC) disappeared faster from the media and fibroblasts (FB) appeared earlier in the adventitia of the treated right allografts, reducing but not eliminating the immune response. Intraluminal VL did not enhance the PUVA effect. At 68 days, treated and control allografts showed similar dimensions with subsided immune reactions. The media thickness was reduced from 0.38 mm to 0.18 mm and the host adventitia increased from 0.22 to 0.60 mm. Variable reactions peaked between two and three weeks and subsided after one month. All allografts remained open with canine carotid i.d.s of 2-3 mm and 80 to 100 cc/ minute arterial flows. Although the UVA dosage was moderate) similar doses sterilized log 7 of staph aureus cultures in saline. The allografts without smooth muscle showed moderate but stable cylindrical dilatation without spasm or stenosis and with an adequate adventitial buttress for a small vessel. A polyester sleeve around four treated grafts was inseparable from the allograft in less than 3 weeks and tolerated well over a 70-day period. CONCLUSIONS: Biodegradable graft sheaths with bioerodible hydrogels with growth factors (FGF) for local delivery may provide a faster and more complete matrix remodeling for a superior conduit in the future.

Sarcoma of possible nerve sheath origin in a captive muskrat.

A captive adult female muskrat (Ondatra zibethicus) was found dead without previous signs of disease. At necropsy, abdominal organs were infiltrated with a poorly demarcated, soft, tan tissue. Microscopically this tissue was composed of neoplastic cells assuming two distinct growth characteristics consistent with Antoni A and B patterns. Ultrastructurally, the neoplastic cells were pleomorphic, lacked junctional devices, had abundant mitochondria and ergastoplasm, and frequently were closely associated with extracellular collagen. Immunocytochemical examination of tumor cells demonstrated sporadic expression of neuron specific enolase. Microscopic tumor metastases to the myocardium, ascending aorta, lungs and visceral pleura were present. This is the first report of a sarcoma compatible with a malignant peripheral nerve sheath tumor in a muskrat.

Glial fibrillary acidic protein expression in pleomorphic adenoma of salivary gland: an immunoelectron microscopic study.

Previous immunocytochemical studies of pleomorphic adenomas have demonstrated consistent labeling with glial fibrillary acidic protein (GFAP). Cross-reactivity with other intermediate filaments of similar structure and chemical composition has been suggested to account for this seemingly inappropriate pattern of immunoreactivity. To investigate further this phenomenon, we examined five pleomorphic adenomas by immunoelectron microscopy. Ultrastructural features were similar to those described by other investigators, with ductal epithelium being surrounded by myoepithelial cells and modified cells becoming detached to form the isolated stellate and spindle cells of the stroma. As part of this process, many neoplastic myoepithelial cells appeared to lose their specialized ultrastructural features, assuming a rather undifferentiated appearance. Single and double immunoelectron microscopic labeling showed vimentin filaments in all these neoplastic myoepithelial cells. In contrast, GFAP filaments were identified only in the most undifferentiated cells. Such restriction of GFAP filaments to an ultrastructurally definable subset of neoplastic cells provides strong evidence against nonspecific staining due to cross-reactivity. Given the previously described coexpression of vimentin and GFAP by neoplastic cartilage, it appears likely that this immunophenotype in neoplastic myoepithelial cells reflects early chondroid differentiation.

Intraductal carcinoma of major salivary gland.

The clinicopathologic features of the cases of three patients with intraductal carcinoma of major salivary gland are described. As in the breast, these lesions of salivary ducts appear to represent an in situ or preinvasive phase of the disease. On follow-up, one patient had a local recurrence, and in another patient, the tumor subsequently became invasive. This experience suggests that wide surgical excision (preferably total parotidectomy) may be curative but that resections limited to grossly visible disease will result in local recurrence and/or the development of invasive ductal adenocarcinoma.

Catheter-based local thrombolysis with urokinase: comparative efficacy of intraluminal clot lysis with conventional urokinase infusion techniques in an in vivo porcine thrombus model.

Local delivery of urokinase directly to the site of intraluminal clot using catheter-based technology has recently been introduced as a new technique to treat intracoronary thrombus and thrombus-containing stenoses. The purpose of this study was to compare the efficacy of urokinase therapy administered by local drug-delivery catheters with conventional urokinase-infusion techniques in dissolving intraluminal clot and intramurally depositing drug at the site of arterial injury in an in vivo porcine model. Five techniques of urokinase administration were studied in 65 pigs, including intravenous systemic bolus (1,000,000 units), guiding catheter infusion (500,000 units), local intraluminal infusion with a Roubin catheter (150,000 units), local infusion by the Dispatch catheter (150,000 units), and local delivery by the hydrogel-coated balloon (700 units). All five techniques were initially compared with respect to the quantity of intraluminal lysis of 123I-fibrinogen-labeled thrombus in an in vivo thrombus model. Conventional balloon angioplasty was also assessed in this model as a nonpharmacologic, mechanical control. In addition, all five techniques were compared with respect to the quantity and efficiency of intramural urokinase deposition at coronary angioplasty sites. In the in vivo thrombolysis experiments, the quantity of artificial clot lysis measured 6.8% for systemic therapy, 20.8% for guiding catheter infusion, 25.2% for Roubin catheter infusion, 62.8% for Dispatch catheter infusion, 98.8% for hydrogel balloon delivery, and 53.6% for conventional balloon angioplasty. Both the Dispatch catheter and the hydrogel balloon resulted in more clot lysis than the systemic, guiding catheter, or Roubin catheter approaches (P < 0.05). In comparison with conventional balloon angioplasty, only the hydrogel balloon resulted in higher levels of thrombus dissolution (P < 0.05). In the intramural deposition studies, the efficiency of urokinase delivery was 0.0004% for systemic therapy, 0.004% for guiding catheter infusion, 0.004% for Roubin catheter infusion, 0.08% for Dispatch catheter infusion, and 1.8% for hydrogel balloon delivery. The Dispatch catheter resulted in higher intramural drug levels than did all other techniques (P < 0.05), whereas the efficiency of urokinase deposition was higher with the hydrogel balloon than with all other approaches (P < 0.05). In the porcine model, it is subsequently concluded that local delivery of urokinase by catheter-based techniques can result in more complete lysis of intraluminal thrombus by using similar or lower doses of drug than by using conventional urokinase infusion techniques. Mechanical deformation of thrombus, possibly to increase the surface area available for thrombolysis and to physically disrupt clot, may be an important component of the mechanism of site-specific thrombolysis, particularly with the hydrogel balloon. Local delivery techniques also deposit significant quantities of urokinase at balloon angioplasty sites, creating an intramural reservoir of drug that may result in prolonged local thrombolysis.

Intranasal dermal analogue tumor (membranous basal cell adenoma). Ultrastructure and immunohistochemistry.

To our knowledge, this is the first case of an intranasal monomorphic salivary gland adenoma (dermal analogue type) arising in a man exhibiting the salivary gland-skin adnexal tumor diathesis. Ultrastructurally, this tumor is composed of cells displaying squamous, secretory, luminal, and, very rarely, myoepithelial differentiation. Additionally, this is the first ultrastructural demonstration of intralobular Langerhans' cells in a dermal analogue tumor from any site. These Langerhans' cells can be demonstrated histologically by S-100 protein immunostaining. Epithelial tumor cells per se display no glial fibrillary acidic protein immunoreactivity, but rare epithelial cells stain faintly for S-100 protein. These findings seem to be distinct from pleomorphic adenoma and adenoid cystic carcinoma, the principal histologic differential diagnosis.

Malignant primitive neuroectodermal tumor presenting as a scalp nodule.

We report a case of a 20-year-old woman who presented with a 3-year history of a stable cystic nodule on the scalp. Light microscopy of the excised nodule demonstrated a malignant small round cell undifferentiated neoplasm. Immunohistochemical studies suggested a neural crest origin, while ultrastructural examination revealed characteristics of schwannian differentiation. Both of these special techniques were essential in establishing the diagnosis of a malignant epithelioid schwannoma of superficial tissue (neurotropic melanoma, desmoplastic melanoma). We discuss the differential diagnoses and describe the immunohistochemical and ultrastructural characteristics of this tumor. This case illustrates the difficulty of diagnosing this rare malignant tumor, which masqueraded as a benign-appearing scalp lesion.

Functional and structural alterations with 24-hour myocardial hibernation and recovery after reperfusion. A pig model of myocardial hibernation.

BACKGROUND: Short-term myocardial hibernation of 3 hours resulting from a moderate resting coronary flow reduction has been reproduced in pigs. This study was designed to determine whether any structural changes accompany short-term hibernation caused by a moderate flow reduction maintained for 24 hours and whether any such structural alterations are reversible after reperfusion. METHODS AND RESULTS: A severe left anterior descending coronary artery (LAD) stenosis was created with a reduction of resting flow to approximately 60% of baseline and maintained for 24 hours. Regional coronary flow was measured by a flowmeter; wall thickening was determined by echocardiography, and local metabolic changes were measured. Of 17 pigs, 11 completed the study protocol of 24 hours. The LAD flow was reduced from 0.91 +/- 0.11 to 0.52 +/- 0.13 mL.min-1.g-1, a 43% mean decrease, at 15 minutes after the LAD stenosis and was maintained at 0.56 +/- 0.11 mL.min-1.g-1 at 24 hours. The reduction of regional coronary flow initially produced acute myocardial ischemia, as evidenced by reduced regional wall thickening (from 37.2 +/- 6.9% at baseline to 11.5 +/- 6.8%), regional lactate production (-0.34 +/- 0.28 mumol.g-1.min-1), and a decrease in regional coronary venous pH (from 7.41 +/- 0.035 at baseline to 7.30 +/- 0.030). At 24 hours, the reductions in coronary flow and wall thickening were maintained relatively constant and the rate-pressure product was relatively unchanged, but lactate production ceased and regional H+ concentration normalized, with a tendency toward a further reduction in regional oxygen consumption, from 3.10 +/- 0.90 mL.min-1.100 g-1 at 15 minutes after stenosis to 2.52 +/- 0.95 mL.min-1.100 g-1 at 24 hours (P = .06), indicating metabolic adaptation of the hypoperfused regions. Of 11 pigs, 6 were free of myocardial infarction; 3 had patchy necrosis involving 4%, 5%, and 6% of the area at risk; and 2 other pigs had a few scattered myocytes with necrosis, detected only by light and electron microscopy. Ultrastructural changes consisted of a partial loss of myofibrils and an increase in mitochondria and glycogen deposition. Regional wall thickening recovered 1 week after reperfusion in most pigs, and the ultrastructural changes reverted to normal. CONCLUSIONS: In this pig model, moderately ischemic myocardium undergoes metabolic and structural adaptations but preserves the capacity to recover both functionally and ultrastructurally after reperfusion.