Concomitant pemphigus vulgaris and pemphigoid gestationis: a case report and review of the literature.

Pemphigus and pemphigoid are two unique acquired immunobullous diseases with distinct clinical presentations, histological findings, and characteristic serology; they are rarely reported to coexist in the same patient. Herein we present a 29-year-old woman with a history of pemphigus vulgaris, diagnosed by histology and positive desmoglein-3 antibodies on ELISA. She presented to our clinic shortly after the delivery of her first child with tense vesicles and bullae on an erythematous base on her abdomen. Biopsy was consistent with pemphigoid gestationis and direct immunofluorescence confirmed the diagnosis. To our knowledge, there are no other reported cases of pemphigoid gestationis occurring in a patient with pemphigus vulgaris.

Hidradenoma papilliferum associated with pregnancy: a case report.

We present the case of a 33-year-old female who developed a cystic nodule on the vulva during pregnancy. Immediately following Cesarean section, the lesion was biopsied and histologic examination revealed a dermal tumor composed of glandular structures arranged in a labyrinth pattern. The glandular structures displayed cytoplasmic vacuolization, large atypical nuclei, prominent nucleoli and scattered eosinophilic luminal secretions. Immunohistochemistry showed the tumor cells to be diffusely positive for CK7 and progesterone receptor with focal expression of mammaglobin and GCDFP-15. The tumor cells were negative for estrogen receptor and CK20. These histologic and immunophenotypic findings were consistent with hidradenoma papilliferum. Our unusual (and to our knowledge first reported) case demonstrates hidradenoma papilliferum in association with pregnancy and raises the possibility of cytologic atypia and lactational change being secondary to hormonal changes in pregnancy.

Ossifying fibromyxoid tumor: a clinicopathologic analysis of 26 subcutaneous tumors with emphasis on differential diagnosis and prognostic factors.

INTRODUCTION: Ossifying fibromyxoid tumor (OFMT) is rare and may present diagnostic difficulty. We describe 26 subcutaneous examples of OFMT emphasizing differential diagnosis and prognostic features. METHODS: Histopathology and follow-up data from archival/consultation cases were reviewed. Prognostic features were assessed according to proposed criteria. RESULTS: Patients (16 female, 10 male) ranged from 26 to 88 years (median 54). The tumors (median 2.3 cm, range 0.8-8.5) involved lower limb (11), trunk (7), head/neck (4), or arm (4). All showed combinations of corded, nested and trabecular patterns in a fibromyxoid stroma. Out of 26 cases 13 had peripheral ossification. Sixteen of 22 cases showed S100 protein expression. Nuclear grade was low (14); intermediate (8) and high (4) while cellularity was low (14); moderate (7) and high (5), with overall good interobserver agreement. Median mitotic rate was 3/50HPF (0-61). Five met criteria for malignant OFMT showing high nuclear grade or high cellularity and mitotic rate >2/50HPF or both. Thirteen OFMTs were atypical. Follow-up (16/26, median 45.5 months, range 8-108) showed that patients with typical OFMT (3) and atypical OFMT (9) remained disease-free. Three malignant examples of OFMT recurred and one metastasized to the lung. No deaths were recorded. CONCLUSIONS: Our results validate proposed prognostic classification of OFMT. Dermatopathologists should be aware of this unusual superficial tumor given its potentially aggressive behavior.

Passage-dependent cancerous transformation of human mesenchymal stem cells under carcinogenic hypoxia.

Bone marrow-derived human mesenchymal stem cells (hMSCs) either promote or inhibit cancer progression, depending on factors that heretofore have been undefined. Here we have utilized extreme hypoxia (0.5% O2) and concurrent treatment with metal carcinogen (nickel) to evaluate the passage-dependent response of hMSCs toward cancerous transformation. Effects of hypoxia and nickel treatment on hMSC proliferation, apoptosis, gene and protein expression, replicative senescence, reactive oxygen species (ROS), redox mechanisms, and in vivo tumor growth were analyzed. The behavior of late passage hMSCs in a carcinogenic hypoxia environment follows a profile similar to that of transformed cancer cells (i.e., increased expression of oncogenic proteins, decreased expression of tumor suppressor protein, increased proliferation, decreased apoptosis, and aberrant redox mechanisms), but this effect was not observed in earlier passage control cells. These events resulted in accumulated intracellular ROS in vitro and excessive proliferation in vivo. We suggest a mechanism by which carcinogenic hypoxia modulates the activity of three critical transcription factors (c-MYC, p53, and HIF1), resulting in accumulated ROS and causing hMSCs to undergo cancer-like behavioral changes. This is the first study to utilize carcinogenic hypoxia as an environmentally relevant experimental model for studying the age-dependent cancerous transformation of hMSCs.

Enhanced diagnostic yields of bacteremia and candidemia in blood specimens by PCR-electrospray ionization mass spectrometry.

A prospective study was performed to determine the value of direct molecular testing of whole blood for detecting the presence of culturable and unculturable bacteria and yeasts in patients with suspected bloodstream infections. A total of 464 adult and pediatric patients with positive blood cultures matched with 442 patients with negative blood cultures collected during the same period were recruited during a 10-month study. PCR amplification coupled with electrospray ionization mass spectrometry (PCR-ESI-MS) plus blood culture reached an overall agreement of 78.6% in the detection and species-level identification of bacterial and candidal pathogens. Of 33 culture-negative/PCR-ESI-MS-positive specimens, 31 (93.9%) were judged to be truly bacteremic and/or candidemic based on a medical chart review and analytical metrics. Among the 15 culture-positive specimens in which PCR-ESI-MS detected additional bacterial or yeast species, 66.7% and 20.0% of the additional positive specimens by PCR-ESI-MS were judged to be truly or possibly bacteremic and/or candidemic, respectively. Direct analysis of blood samples by PCR-ESI-MS rapidly detects bacterial and yeast pathogens in patients with bloodstream infections. When used in conjunction with blood culture, PCR-ESI-MS enhances the diagnostics of septicemia by shortening test turnaround time and improving yields.

Blood ordering from the operating room: turnaround time as a quality indicator.

BACKGROUND: Quality indicators in transfusion medicine are necessary for patient safety and customer satisfaction. The turnaround time (TAT) of issuing red blood cells (RBCs) has emerged as a quality indicator but is not an established benchmark. We examined the TAT for issuing RBCs from the blood bank to the operating rooms (ORs) at Vanderbilt University Medical Center (VUMC) and Stanford University Medical Center (SUMC). STUDY DESIGN AND METHODS: TAT was defined from time of request to when RBCs exited the blood bank. Cases eligible for analysis had completed type-and-screen results with requests for four or fewer RBC units. Patients with a positive antibody screen had serologically crossmatched units prepared and reserved for intraoperative use. We also e-mailed surveys to academic institutions to establish the current state of TAT monitoring and to anesthesiologists at VUMC to gauge the TAT expectations of the OR. RESULTS: The mean TATs at the two institutions were comparable (VUMC, 10 ± 3.8 min; SUMC, 14 ± 7.2 min) for orders of RBCs. The most common reasons for delayed TAT were overlapping orders, medical technologists occupied by phone calls, and oversaturation of pneumatic tube stations. Only 3 of 24 surveyed institutions actively monitored RBC TAT. Surveyed anesthesiologists (n = 7) reported an expectation for RBC TAT of 5 to 15 minutes for urgent cases. Established internal TAT policies were 15 and 20 minutes at VUMC and SUMC, respectively, for crossmatched RBC requests for patients with complete diagnostic testing. CONCLUSION: Many of the surveyed institutions do not monitor stat RBC issue TAT as a quality indicator. This study serves as a starting point for establishing a benchmark for TAT for issuing RBCs from the blood bank to ORs.

Localized cutaneous argyria: two case reports and clinicopathologic review.

We report 2 cases of patients who presented with blue macules clinically suspicious for blue nevi. One patient had no documented history of trauma or silver exposure, and the other reported exposure to silver over 30 years ago. Microscopic examination revealed a dermal population of brown-black globules predominantly adhering to collagen fibers. In both cases, no melanocytic proliferation was identified by immunohistochemistry. Analysis of the skin biopsies with scanning electron microscopy and energy dispersive x-ray spectroscopy demonstrated the presence of silver and selenium. These findings were diagnostic of localized cutaneous argyria. Our case reports highlight the importance of including localized cutaneous argyria in the differential diagnosis of pigmented lesions.

Mycosis fungoides involving an acrochordon: a case report.

We present the case of a 77-year-old male undergoing treatment for mycosis fungoides (MF) who presented for removal of an acrochordon on his mid back. Histopathologic examination of the acrochordon revealed a dense, band-like lymphocytic inflammatory infiltrate in the dermis with epidermotropism of single lymphocytes and small nests of lymphocytes into the lower epidermis. Immunohistochemical staining characterized the dermal and epidermal lymphocytic population as CD3-positive T lymphocytes with a predominance of CD4-positive over CD8-positive lymphocytes. These findings were consistent with the patient's known MF and molecular identification of a clonal T-cell receptor gene rearrangement further supported the diagnosis. Our unusual case reports MF involving an acrochordon and provides evidence to support the importance of submitting acrochordons for histopathologic examination.

Mdm2 and aurora kinase a inhibitors synergize to block melanoma growth by driving apoptosis and immune clearance of tumor cells.

Therapeutics that induce cancer cell senescence can block cell proliferation and promote immune rejection. However, the risk of tumor relapse due to senescence escape may remain high due to the long lifespan of senescent cells that are not cleared. Here, we show how combining a senescence-inducing inhibitor of the mitotic kinase Aurora A (AURKA) with an MDM2 antagonist activates p53 in senescent tumors harboring wild-type 53. In the model studied, this effect is accompanied by proliferation arrest, mitochondrial depolarization, apoptosis, and immune clearance of cancer cells by antitumor leukocytes in a manner reliant upon Ccl5, Ccl1, and Cxcl9. The AURKA/MDM2 combination therapy shows adequate bioavailability and low toxicity to the host. Moreover, the prominent response of patient-derived melanoma tumors to coadministered MDM2 and AURKA inhibitors offers a sound rationale for clinical evaluation. Taken together, our work provides a preclinical proof of concept for a combination treatment that leverages both senescence and immune surveillance to therapeutic ends.

Fibrous hamartoma of infancy: a clinicopathologic analysis of 60 cases.

Fibrous hamartoma of infancy is a benign soft tissue tumor with a characteristic triphasic organoid histologic appearance. It typically occurs within the first 2 years of life. The usual anatomic locations include the upper extremities, axilla, and upper back. Diagnostic challenges occur when this tumor arises in older children, outside of the usual anatomic sites, or when unusual histologic features are encountered. This study reports 60 cases of fibrous hamartoma of infancy from institutional and consultation files. All had a triphasic organoid histologic pattern, but half also displayed an unusual pseudoangiomatous histologic pattern. The male to female ratio was 2.0 (40 boys, 20 girls), with a mean age of 1.5 years (range, 16 d to 8 y) at diagnosis. Tumor size ranged from 0.5 to 9 cm, with a mean of 3.7 cm. Sites included the trunk (40 cases), extremities (17 cases), and head and neck (3 cases). All cases had triphasic elements of mature fibrous tissue, mature adipose tissue, and immature mesenchymal tissue in varying proportions, with the additional pseudoangiomatous pattern in 32 cases. Immunohistochemical analysis demonstrated reactivity for smooth muscle actin and CD34 in the mature fibrous tissue, S100 protein in the mature adipose tissue, and variable CD34 reactivity in immature mesenchymal and pseudoangiomatous foci. Ki-67 proliferative activity was noted in the immature mesenchymal and pseudoangiomatous foci, and Bcl-2 reactivity was restricted to mesenchymal and pseudoangiomatous foci. Follow-up information in 12 cases revealed no evidence of recurrence in 10 patients and local recurrence in 2 patients, each at 3.5 years after primary excision. This study demonstrates an expanded age range (up to 8 y) and anatomic distribution (30 cases outside of the classic locations of the upper extremities, axilla, and upper back) of fibrous hamartoma of infancy. The pseudoangiomatous morphologic variation can lead to challenges in diagnosis and may reflect a maturational phenomenon from the immature mesenchymal component.

Infectious Colitis Associated With Ipilimumab Therapy.

Ipilimumab is a monoclonal antibody against cytotoxic T lymphocyte-associated molecule-4 and is thought to promote anti-tumor activity by enhancing cell mediated immunity. It is one of the few therapies shown to improve overall survival in metastatic melanoma. Given its mechanism of action, the drug is associated with significant immune-related adverse events with the gastrointestinal system being commonly involved. Our patient is a 22-year-old female with stage IVA melanoma on ipilimumab therapy who presented with fever, diarrhea and abdominal pain. She gave a history of recent travel to a wedding where several other guests in attendance had also developed diarrheal illnesses. Her colonoscopy and pathology were consistent with ipilimumab-induced colitis. Her stool culture returned positive for Salmonella enteritides. She was treated with prednisone and ciprofloxacin with resolution of her symptoms. In our case, we describe ipilimumab-induced colitis where an infectious pathogen was identified with temporal relationship to symptoms and could be suggestive of a causal relationship.

Alveolar soft part sarcoma and granular cell tumor: an immunohistochemical comparison study.

Although the histologic features of alveolar soft part sarcoma and granular cell tumor are typically distinctive, occasional cases show a significant morphologic overlap. Differentiating these entities is crucial because granular cell tumor is almost always benign and alveolar soft part sarcoma is invariably malignant. We evaluated a panel of immunohistochemical stains (S-100 protein, inhibin, SOX10, nestin, calretinin, and TFE3) in 13 alveolar soft part sarcomas and 11 granular cell tumors. Tissue sections were also stained by the periodic acid-Schiff method after diastase digestion (PAS-D) and evaluated for coarse cytoplasmic granularity or crystalline cytoplasmic inclusions. S-100 protein, inhibin, SOX10, and nestin each distinguished granular cell tumor and alveolar soft part sarcoma with 100% sensitivity and specificity. PAS-D staining also distinguished cases with 100% accuracy, as granular cell tumor consistently demonstrated coarsely granular, PAS-D-positive cytoplasm and alveolar soft part sarcoma showed only focal intracytoplasmic crystalline inclusions. Although all granular cell tumors were calretinin positive, so were 46% of alveolar soft part sarcomas. TFE3 was positive in 91% of granular cell tumors and all alveolar soft part sarcomas. Together with PAS-D, immunohistochemical stains for S-100 protein, inhibin, SOX10, and nestin accurately identify alveolar soft part sarcoma and granular cell tumor. Although TFE3 has been reported as a relatively specific marker for alveolar soft part sarcoma, it should be recalled that it is also expressed in most granular cell tumors.

Predicting dedifferentiation in liposarcoma: a proteomic approach.

There are no known morphologic characteristics, cytogenetic aberrations, or molecular alterations predictive of dedifferentiation in liposarcomas. Identification of such a prognostic marker could potentially affect surgical and adjuvant therapy and/or follow-up surveillance for these patients. Two-dimensional difference gel electrophoresis was utilized to characterize protein expression patterns in lipoma, atypical lipomatous tumor (ALT), and the well-differentiated components of dedifferentiated liposarcoma (DDL). Protein spots were identified by peptide mapping/fingerprinting using matrix-assisted laser desorption ionization time-of-flight mass spectrometry. No significant differences in protein expression were identified between lipoma and ALT or DDL. Proteins that were significantly down-regulated in the well-differentiated component of DDL compared to ALT included mitochondrial aldehyde dehydrogenase 2 (ALDH2, >3-fold reduction) and selenium-binding protein-1 (SELENBP1, >4-fold reduction). Subsequent validation studies were performed by immunohistochemistry (IHC) on a separate series of ALT (n = 30) and the well-differentiated components of DDL (n = 28). IHC stains were evaluated in a semi-quantitative manner, and the results were analyzed using the Mann-Whitney test and receiver-operator curve analysis. Decreased IHC staining for SELENBP1 in the well-differentiated component of DDL was confirmed. Cytoplasmic ALDH2 levels determined by IHC were not significantly different in ALT and DDL; no nuclear staining for ALDH2 was observed. Expression of SELENBP1 is decreased in the well-differentiated component of DDL compared to ALT. However, variability in the staining patterns in liposarcoma precludes its use as a predictive marker for dedifferentiation.

Kikuchi-Fujimoto lymphadenitis: role of parvovirus B-19, Epstein-Barr virus, human herpesvirus 6, and human herpesvirus 8.

Kikuchi-Fujimoto lymphadenitis is a self-limited disorder that typically presents in young females as painless cervical lymphadenopathy with fever, anemia, and leukopenia. The clinical manifestations and pathologic findings suggest a viral etiology, yet specific etiologic agents remain unknown. Although there are studies reporting positive associations between Kikuchi-Fujimoto lymphadenitis and parvovirus B19 and herpesviruses, other studies have failed to find an association with these viruses. To our knowledge, this current study is the largest study of Kikuchi-Fujimoto lymphadenitis in Western patients that used polymerase chain reaction testing for 4 different common viral pathogens often implicated as etiologic agents in Kikuchi-Fujimoto lymphadenitis. Archival material from 3 institutions was included, following confirmation of the diagnosis of Kikuchi-Fujimoto lymphadenitis by 2 independent pathologists. Polymerase chain reaction from the paraffin-embedded tissue sections for parvovirus B19, Epstein-Barr virus, human herpesvirus 6, and human herpesvirus 8 was performed. Eighteen cases of Kikuchi-Fujimoto lymphadenitis were analyzed, 12 of which (60%) were cervical lymph nodes. All the cases showed typical geographic necrosis with abundant apoptotic debris, although the degree of necrosis was variable. Polymerase chain reaction revealed a high prevalence of parvovirus B19 in the controls (44%); there were fewer positive cases seen in the Kikuchi-Fujimoto lymphadenitis cases (11%), but this did not reach statistical significance (P = .25).There were no significant differences between cases and controls in the prevalence of Epstein-Barr virus, human herpesvirus 6, and human herpesvirus 8 (P = .50 for all 3). Polymerase chain reaction failed to reveal a positive association between Kikuchi-Fujimoto lymphadenitis and 4 common suspected viral agents. These findings do not support a role for Epstein-Barr virus, human herpesvirus 6, human herpesvirus 8, or parvovirus B19 in the pathogenesis of Kikuchi-Fujimoto lymphadenitis.

Coccidioides, cryptococcus, or blastomyces? A diagnostic dilemma encountered during frozen section evaluation.

Intraoperative consultation via frozen section is an important part of modern day surgical pathology. Recognizing fungi in tissues on frozen and permanent sections is not always a simple task, and correctly identifying the agent can be a significant challenge, even for experienced microscopists. We present a case of a 17-year-old boy with chronic osteomyelitis involving the right proximal ulna. During an irrigation and debridement operation, a frozen section was sent to surgical pathology for evaluation. A limited patient history coupled with sparse organisms present in the frozen section led to the diagnosis of fungal osteomyelitis, favor Coccidioides . Follow-up permanent sections with special staining and successful fungal culture clarified the causal agent to be Blastomyces dermatitidis . The role of frozen sections is not to perfectly speciate the fungal pathogen but to describe the morphology and infectious process and provide a differential diagnosis of the candidate fungi. The importance of intraoperative culture in infectious cases cannot be understated, and it is the responsibility of pathologists to inform surgeons that tissue is needed for culture. A brief overview of Blastomyces , including histopathologic features and key microscopic differences from Coccidioides and Cryptococcus , is discussed.

Heterogeneity of publicly accessible online critical values for therapeutic drugs.

INTRODUCTION: Critical values are reported to clinicians when laboratory values are life threatening and require immediate attention. To date no definitive critical value limit recommendations have been produced regarding therapeutic drug monitoring. Some laboratories choose to publish critical value lists online. These publicly available values may be accessed and potentially utilized by laboratory staff, patient care providers, and patients. MATERIALS AND METHODS: A web-based search of laboratories associated with the Accreditation Council for Graduate Medical Education pathology residency programs was initiated to determine which therapeutic drugs had critical values and to examine the degree of variation in published critical values for these institutions. RESULTS: Of the 107 institutions with university-based pathology training programs, 36 had published critical values online for review. Thirteen therapeutic drugs were investigated and the number of institutions reporting critical value limits for the drug, as well as the median, range, standard deviation, and the coefficient of variation of critical value concentration limits for each drug were determined. A number of the online critical value limits were deemed to be erroneous, most likely due to incorrectly listed units of measurement. CONCLUSIONS: There was a large degree of heterogeneity with regard to the chosen critical value limits for therapeutic drugs. This wide variance in critical values appears to be greater than that observed in interassay proficiency testing. Institutions should reexamine the rationale for their current critical value parameters and ensure that critical value limits and associated units are accurately published online.