Remission of primary hyperparathyroidism due to spontaneous infarction of a parathyroid adenoma. Case report and review of the literature.

Subclinical infarction of abnormal parathyroid tissue likely occurs relatively frequently, but remission of primary hyperparathyroidism due to spontaneous massive infarction of a parathyroid adenoma is a rare occurrence. We describe a patient who was unique in that spontaneous remission was accompanied by disappearance of the parathyroid adenoma on serial parathyroid scans. We identified 11 other patients in the literature with sufficient documentation of clinical remission of primary hyperparathyroidism due to spontaneous massive infarction of a parathyroid adenoma and review their clinical features as well. Manifestations varied according to the delay in diagnosis, alteration in serum calcium, location, and degree of associated hemorrhage. Ages ranged from 19 to 73 years, and both sexes were affected. Preceding symptoms suggestive of hypercalcemia and/or prior documentation of hypercalcemia were present in 10 cases. Neck pain was present at the time of infarction in 6/12 patients, and a neck mass in 7/12. Only 1 patient died. The initial calcium level done postinfarction was "normal" in 7/12 patients, low in 3/12, and high in 2/12. The parathyroid adenoma was 2 cm or larger in 8/12 patients. In all patients who had parathyroidectomy, histopathology confirmed extensive infarction (bland or hemorrhagic) of the adenoma. The clinical scenarios encountered were 3 hypocalcemic crises, 2 hypercalcemic crises ("acute parathyroid intoxication"), 1 respiratory arrest secondary to a mediastinal hematoma, 2 patients with neck pain as the major complaint, and 4 with no symptoms apart from the premorbid symptoms of hypercalcemia.

Hematopoietic cells in thyroid fine-needle aspirates for cytologic study: report of two cases.

In two patients, hematopoietic cells were found on cytologic study of fine-needle aspirates from the thyroid gland. The cells were thought to have been aspirated from ossified laryngeal tissues and to have no significance for hematologic disorders in these two patients.

Entamoeba polecki infection in Southeast Asian refugees: multiple cases of a rarely reported parasite.

Recently, Entamoeba polecki was identified for the first time in our parasitology laboratory in stool specimens from eight Southeast Asian refugees. This ameba has been reported infrequently in the Western world; most reported cases have been from the New Guinea region. In most previously described patients and in our patients, no definite gastrointestinal symptoms could be directly attributed to E. polecki infection. Morphologically, E. polecki may mimic the pathogen E. histolytica and also nonpathogens such as E. coli. These species are most readily distinguished by studying encysted forms. In contrast to E. histolytica and E. coli, E. polecki characteristically has uninucleate cysts. Both pigs and monkeys naturally harbor E. polecki, but four of the patients in this series had no apparent contact with these animals. Other modes of infection may be human-to-human transmission or acquisition from other domestic animals. Six of our eight patients were treated successfully with one course of metronidazole in a regimen similar to that used for E. histolytica infection. In the two other patients, repeated courses of therapy eradicated the infection. Because of the recent increase in number of Southeast Asian immigrants to the United States, E. polecki may be identified more frequently than in the past. Physicians and laboratory personnel should be familiar with this organism, because it may be confused with E. histolytica or may act as a pathogen.

Comparison of clindamycin, metronidazole, and penicillin for the treatment of experimental infections in mice caused by beta-lactamase-producing Bacteroides intermedius.

Turbid saline suspensions (0.35 ml, approximately 10(9) organisms) of a strain of beta-lactamase-producing Bacteroides intermedius were injected subcutaneously into the right groin of ICR male mice. Therapeutic intraperitoneal doses of clindamycin, metronidazole, or penicillin were administered 4 hr later, and thereafter at successive 8-hr intervals for a total of 12 doses. Necropsy with culture of the infection site was performed 4 hr after the final dose. None of 10 clindamycin-treated animals and none of 10 metronidazole-treated animals developed abscesses, and all cultures taken from the injection sites were sterile. Eight of 10 (80%) penicillin-treated animals developed subcutaneous abscesses; B. intermedius was recovered in pure cultures from all abscesses at necropsy. Nine of 10 (90%) untreated control animals inoculated with the same beta-lactamase-producing B. intermedius strain developed abscesses, all of which were culture-positive. The data indicate that treatment with clindamycin and metronidazole prevented the formation of subcutaneous abscesses in mice inoculated with a beta-lactamase-producing strain of B. intermedius. On the other hand, penicillin failed to prevent the formation of abscesses, 80% of which grew the inoculated organism.

False-negative results in cervical cytologic studies.

The appropriate interval between cervical cytologic screening studies is a matter of considerable controversy, with a major consideration being the problem of false-negative results. To determine the rate of false-negative cervical cytologic results in our laboratory and to determine how these failures occur, tissue-proven cases of carcinoma in situ, invasive squamous-cell carcinoma, endocervical adenocarcinoma and lymphoid malignancy involving the cervix with negative Papanicolaou smears obtained within one year prior to the tissue diagnosis were reviewed. Over the four-year period from 1980 through 1983, 339 patients had tissue-proven cervical malignancies. Of these, 66 had false-negative Papanicolaou smears, representing a 20% overall false-negative rate. These false-negative smears were rescreened. For all types of cervical malignancy, the majority of errors were due to sampling. No malignancy was missed disproportionately by either cytotechnologists or cytopathologists. We plan to utilize these data for quality control purposes and for continued review of future performance.

First Report of a Leaf Blight, Seed Stalk Rot, and Bulb Decay of Onion by Pantoea ananas in Georgia.

In May 1997, sweet onions (Allium cepa L.) grown in Toombs County, GA, displayed symptoms of blighted leaves, bleached and rotted seed stalks, and rotted bulbs. Gram-negative bacteria were isolated from infected tissues on nutrient agar and shown to be from the genus Pantoea on the basis of cell morphology (rod-shaped), yellow pigmentation, utilization of glucose in an oxidative and fermentative manner, presence of catalase, and absence of oxidase. These characteristics are typical of bacterial strains belonging to the Enterobacteriaceae (facultative anaerobes). Initially, these bacteria were thought to be P. agglomerans, a common saprophyte associated with plant material. However, fatty acid analysis, using bacterial identification software (MIDI, Dewark, DE), identified (second choice) some strains as possibly being P. ananas.. Further testing indicated that all strains utilized cellobiose, melibiose, inositol, glycerol, and sucrose, but not pectin, starch, or gelatin. However, those strains identified by fatty acid analysis as P. ananas were differentiated from P. agglomerans on the basis of indole production, lack of phenylalanine deaminase, and lack of nitrate reductase. To confirm pathogenicity, three strains of each species (total of six strains) were grown overnight in nutrient broth shake cultures. Bacterial cells were harvested by centrifugation and suspended in 0.01 M phosphate-buffered saline (0.85%). Inoculum was adjusted to approximately 5 × 108 CFU/ml with a spectrophotometer and misted with a chromatography sprayer onto onion leaves of approximately 10-week-old onion plants in the greenhouse. Onions were predisposed by placing them under plastic bags for 18 h prior to inoculation. Inoculated plants were left covered with plastic bags for an additional 24 h after inoculation. There were two plants per pot, each test had three pots, and the test was conducted twice. The three strains of P. agglomerans and buffer control resulted in no symptoms. The three strains of P. ananas produced severe blighting, rapid collapse of tissues, and rapid drying so that leaves were light tan and dry within 3 days. Disease on plants infected with P. ananas continued to develop until death of all foliage and bulbs shriveled and collapsed. Results were consistent for all replications and both trials. Bacteria recovered from diseased tissues were gram-negative, yellow, and facultative anaerobic, and produced indole but not phenylalanine deaminase or nitrate reductase; i.e., the bacteria demonstrated the same characteristics as P. ananas. Although P. agglomerans has been reported to produce similar symptoms in South Africa (1), our P. agglomerans strains were nonpathogenic. To our knowledge this is the first report of P. ananas causing a disease of onion. Reference: (1) M. J. Hattingh and D. F. Walters Plant Dis. 65:615, 1981.

First Report of Tomato Spotted Wilt Tospovirus Infection of Watermelon in Georgia.

In 1996, volunteer watermelon plants in a tobacco field in Coffee County, GA, exhibited foliar symptoms that included necrotic ring spots and veinal necrosis. Watermelon plants from experimental plots of the Coastal Plain Experiment Station in Tifton, GA, similarly showed necrotic lesions, often resulting in necrotic ring spots during the late summer of 1997. Out of 16 samples tested for the presence of tomato spotted wilt tospovirus (TSWV) with a commercially available enzyme-linked immunosorbent assay (ELISA) kit (Agdia, Elkhart, IN), six were positive for TSWV. Primers specific to the nucleocapsid gene of TSWV were used in a reverse transcription-polymerase chain reaction assay (RT-PCR) (1) to verify the presence of TSWV. RT-PCR gave an expected PCR product of approximately 350 bp. The amplicon was cloned in pGEM-T vector and the recombinant clone was sequenced. The sequence of the cloned PCR product confirmed the identity of TSWV, thus verifying TSWV infection of watermelon. The potential impact of TSWV on watermelon crop in Georgia will be investigated. This is the first report of natural infection of watermelon by TSWV in Georgia. Reference: (1) H. R. Pappu et al. Tobacco Sci. 40:74, 1996.

Bacterial Streak and Bulb Rot of Sweet Onion: II. Epiphytic Survival of Pseudomonas viridiflava in Association with Multiple Weed Hosts.

A semiselective agar medium (T-5) was used to sample environment and plant material as a habitat for Pseudomonas viridiflava. Soil, irrigation water, soybean foliage, and foliage from various weeds in an onion-growing area were assayed over a 5-year period. P. viridiflava was recovered only as an epiphytic resident from weed species that included cutleaf evening primrose, dandelion, common fumitory, purple cudweed, spiny sowthistle, Virginia pepperweed, and wild radish. The bacterium apparently overseasons in association with these weeds, because its presence was detected prior to, as well as during, the onion-growing season. Preliminary tests indicated that weed control may suppress bacterial streak and bulb rot levels.

Squamous cell carcinoma of the tongue arising in lichen planus: a case report and review of the literature.

Lichen planus is a relatively common inflammatory disorder of unknown cause that affects the skin and mucosal surfaces. The relationship of oral lichen planus to oral squamous cell carcinoma is a matter of concern and debate. We present a case of squamous cell carcinoma of the dorsal surface of the tongue that arose in a previously biopsy-confirmed area of lichen planus. The literature on the development of oral cancer in patients with lichen planus is reviewed.

Radial fracture as an indicator of osteoporosis: a 10-year follow-up study.

Of 136 patients studied at an average of 10.6 years after a distal radial fracture, 37.6% of the 109 women and 7.4% of the 27 men suffered a subsequent fracture. "Osteoporosis-related" fractures accounted for the majority of subsequent fractures sustained by the women. The prognostic significance of distal radial fracture in the adult female is discussed.

Hyperparathyroidism in Paget's disease of bone.

The association between Paget's disease and hyperparathyroidism was explored in 12 patients by means of a calcium loading test. Parathyroid adenomata were discovered at surgery in 2 and parathyroid hyperfunction was found in varying degrees in 4 others. Differing responses to the calcium loading test were interpreted as reflecting different stages in the bone formation-resorption disequilibrium found in Pagetic bone. A prolonged imbalance in favour of formation is suggested as constituting a stress on the homeostasis of extracellular fluid calcium levels that leads to parathyroid hyperfunction.

Sodium fluoride in the treatment of osteoporosis.

Twenty-five patients treated with sodium fluoride, calcium, and Vitamin D (183 person-years of observation) and 24 patients treated with calcium and Vitamin D alone (107 person-years of observation) were compared. The incidence of vertebral fracture was reduced (p less than 0.01) only in the 8 fluoride treated patients who developed radiographic fluorosis. These 8 patients were younger and closer to menopause than those who did not develop fluorosis. Femoral fracture could not be shown to be related to fluoride treatment, but interval from menopause and fall in metacarpal index were found to be useful predictors of this event.

Idiopathic hypoparathyroidism with impaired vitamin B 12 absorption and neuropathy.

A 68-year-old man presenting with chronic intermittent diarrhea and progressive ataxia was found to have idiopathic hypoparathyroidism. Intrinsic factor-resistant vitamin B(12) malabsorption was demonstrated. Both the diarrhea and vitamin malabsorption were reversed by correction of hypocalcemia.His neurological profile was a combination of peripheral nerve, posterior column and cerebellar deficits. He had calcifications in the dentate nuclei of the cerebellum. Possible etiological factors such as vitamin B(12) deficiency, folic acid deficiency and steatorrhea have been excluded. Posterior column and cerebellar abnormalities improved with treatment. It is postulated that hypocalcemia causes functional, reversible spinal cord and cerebellar dysfunction.

Comparison of processing techniques for detection of Pneumocystis carinii cysts in open-lung biopsy specimens.

Methenamine silver stain was used to compare the number of cysts of Pneumocystis carinii contained in lung concentrate smears of homogenized lung tissue with the number in impression smears. Results were also compared with histopathological examination of methenamine silver-stained paraffin-embedded sections. Of slides from 23 preparations, a greater number of cysts were contained in concentrate smears than in impressions (P less than 0.001). In four preparations, cysts were noted in concentrate smears only. All concentrate smears were positive, whereas 11 of the 23 histopathological sections were negative (P less than 0.01). The ability to detect the cyst phase of P. carinii in lung tissue is enhanced by the use of concentrate smears.

In vitro activities of norfloxacin and ciprofloxacin against Mycobacterium tuberculosis, M. avium complex, M. chelonei, M. fortuitum, and M. kansasii.

The activities of ciprofloxacin and norfloxacin against 100 mycobacteria isolates were studied in vitro by the 1% standard proportion method. Ciprofloxacin was more active against M. tuberculosis and M. fortuitum with MICs of 1.0 and 0.25 microgram/ml, respectively, against 90% of isolates; norfloxacin had MICs of 8.0 and 2.0 micrograms/ml, respectively, against 90% of isolates.

Clinical and morphologic features of lipomatous hypertrophy ("massive fatty deposits") of the interatrial septum.

Lipomatous hypertrophy of the interatrial septum ("massive fatty deposits in the atrial septum") may represent an incidental autopsy finding or may be associated with atrial arrhythmias, obstructive symptoms, or sudden death. Antemortem diagnosis is becoming much more common. In a literature review and in a review of our 12 cases, this condition was found to occur more frequently in obese middle-aged or elderly subjects, who frequently demonstrated atherosclerotic coronary artery disease. The unencapsulated mass generally occurred anterior or superior to the fossa ovalis, and histologically was characterized by mature fat with varying quantities of fetal fat, inflammation and fibrosis, and entrapment of myocardial fibers with cytologic atypia. Cases were included that had a minimum atrial septal thickness of 1.0 cm. The septum ranged up to 7.0 cm in maximum thickness (2.6 cm average). In our cases, no deaths were directly attributed to this disorder. It is important that forensic pathologists become more generally aware of this condition. To further delineate the true pathological significance, the atrial septum should be routinely examined by palpation and sectioning to determine its thickness and fat content.

Wolfram (DIDMOAD) syndrome: a complex long-term problem in management.

We describe five patients with Wolfram syndrome (diabetes insipidus, diabetes mellitus, optic atrophy and deafness). Three of the patients appear to have had very gradual onset of diabetes mellitus at an early age yet all patients when tested for C-peptide response to glucagon were severely deficient. All patients are registered blind from primary optic atrophy, two have severe hearing difficulties and three high tone sensorineural hearing loss on audiometry. Four patients have cranial diabetes insipidus which in two cases is partial and of gradual onset and was attributed to poor control of the diabetes mellitus. In one case treatment of the insipidus relieved enuresis. All five patients have evidence of dilatation of the urinary tract and one patient is managed in the long-term by self-catheterisation which has resulted in one episode of bacteraemia. One patient has marked testicular atrophy and investigation reveals this to be due to primary hypogonadism and not to hypothalamic-pituitary dysfunction. One female patient had her menarche delayed until the age of 19 years but has subsequently had the only successful pregnancy in a patient with this syndrome of which we are aware.