Phaeohyphomycosis fungal infections in solid organ transplant recipients: clinical presentation, pathology, and treatment.

BACKGROUND: Dematiaceous, or dark-pigmented, fungi are known to cause infections such as phaeohyphomycosis, chromoblastomycosis, and mycetoma. These fungi are becoming increasingly important opportunistic pathogens in solid organ transplant recipients (SOTR). We present a retrospective chart review of 27 SOTR who developed phaeohyphomycosis infections post transplant from 1988 to 2009. METHODS: Cases were reviewed for fungal species isolated, date and source of culture, immunosuppressive and fungal therapy used, and outcome. The majority of isolates obtained were from the skin and soft tissue, with 3 pulmonary and brain abscesses. RESULTS: The time from transplantation to onset of infection ranged from 2 months to 11 years. The species isolated were Exophiala (11), Ochroconis (3), Alternaria (2), Phoma (2), Wangiella (1), Cladosporium (1), Aureobasidium (1), Chaetomium (1), Coniothyrium (1), and non-sporulating fungi (2). An additional 4 patients had infections confirmed by pathology, but no cultures were done. Most of the affected skin lesions were surgically debrided and treated with itraconazole; 2 patients were treated with voriconazole and 2 with amphotericin D. Death from fungal disease occurred only in patients with pulmonary and brain abscesses. CONCLUSIONS: As the number of SOTR increases, so does the incidence of fungal infections in that population. Surgery, along with antifungal therapy and a reduction in immunosuppression, are the cornerstones of treatment.

Spontaneous rupture of splenic hamartoma.

Hamartoma of the spleen is a rare benign tumor. Only one spontaneously ruptured splenic hamartoma has been reported that presented with an acute surgical abdomen. A second case of a ruptured hamartoma of the spleen is illustrated; however, this case is unique in that it presented as a nonsurgical abdomen. This case stresses the importance of serial physical examinations of the patient and appropriate diagnostic studies in correctly determining the diagnosis when preliminary findings are inconclusive. Surgeons should include splenic hamartomas in the differential diagnoses of splenic defects seen on radiologic studies or splenic masses palpated during abdominal exploration.

Neuromuscular hamartoma (benign "triton" tumor) of the brachial plexus. Case report.

Neuromuscular hamartoma (choristoma) or benign "triton" tumor is a very rare peripheral-nerve tumor composed of mature nerve fibers and well-differentiated striated muscle fibers. Only seven cases have been reported in the literature. A new case of this rare entity is described in a 36-year-old white woman with a recurrent left supraclavicular mass in the brachial plexus area. Unlike the previous cases, this patient had continued to have proliferation of her tumor since childhood, requiring total resection in adulthood. It is concluded that total resection of these tumors should be attempted at initial diagnosis. The histogenesis of these tumors remains unclear. They may represent proliferation of neuroectodermal-derived or limb mesodermal tissue in the elements of a peripheral nerve.

Normal reticulin level in iliac bone marrow.

While the level of marrow reticulin may be a factor that is used when the presence of a hematologic disorder is being considered, to our knowledge no study has graded the amount of reticulin present in normal iliac bone marrow. Grading reticulin stains of bone biopsy specimens from 100 hematologically normal patients documented that the normal amount of reticulin in the marrow is low. Twenty-seven percent of the patients had marrow reticulin grade 0 using the Bauermeister scale, 42% had grade N, 27% had grade 1, and 4% had grade 2; no patient had a Bauermeister grade 3 or 4 reticulin level. Knowledge of the normal range of reticulin is essential when the reticulin level is used as a factor in evaluating the possibility of a hematologic disorder.

Pulmonary dirofilariasis. The largest single-institution experience.

Pulmonary dirofilariasis caused by Dirofilaria immitis, the dog heartworm, is a rarely reported pulmonary lesion. It appears as a solitary pulmonary nodule, and the diagnosis is not established until thoracotomy and subsequent histologic examination of the specimen are performed. Sporadic reports of pulmonary dirofilariasis in the United States total only 70 cases. The six resections of pulmonary dirofilariasis at the Ochsner Clinic represent the largest reported series of cases originating at a single institution. We present an overview of the pathogenesis of this disease, its clinical manifestations, pathologic and epidemiologic features, and geographic distribution. The prevalence of pulmonary dirofilariasis appears to be increasing; hence, thoracic surgeons and pathologists need to be alert to this cause of granulomatous pulmonary lesions.

Synovial sarcoma with an overwhelming epithelial component.

A patient 20 years of age had a synovial sarcoma, 90% of which was composed of very well-developed epithelial elements identical to moderately well-differentiated adenocarcinoma. Awareness of this histopathologic variant is important in establishing the proper diagnosis and in indicating prognosis.

Multicystic renal oncocytoma.

The usual gross appearance of a renal oncocytoma is that of a well-circumscribed homogeneous tan-brown tumor with no evidence of necrosis or hemorrhage, but with a central fibrous scar. We describe a case of renal oncocytoma with the unusual gross appearance of a cystic tumor. While cystic change has occasionally been mentioned in an oncocytoma to our knowledge, this degree of cyst formation has not previously been described.

Plasma cell infiltrates in atherosclerotic abdominal aortic aneurysms.

Thirty-one of 156 abdominal aortic resection specimens containing atherosclerotic aneurysm wall had an inflammatory infiltrate with a prominent plasma cell component of the media or of plaque replacing the media. The specimens in general were not examples of the so-called "inflammatory variant" of atherosclerotic aneurysm. No association between the infiltrate and syphilis, collagen vascular disease, furosemide exposure, chronic aneurysm leakage, aneurysm diameter, or duration of symptoms was found. The plasmacytic inflammation may be part of an immune response to atherosclerosis.

Endometriosis of the prostate.

Endometriosis occurred within the prostate of a 78-year-old man after a long course of estrogen therapy. The presence of endometrial tissue in the region of the urethral crest has potential histogenic and therapeutic implications for some of the neoplasms that arise in this area.

The histopathology of Mycobacterium marinum synovitis.

Eight patients with culture-proven Mycobacterium marinum synovitis had synovial specimens with a remarkably similar histologic appearance. There was considerable synovial hyperplasia, and the synovium was thickened by a moderately intense lymphohistiocytic infiltrate, notably devoid of plasma cells. Fibrin covered some synovial surfaces. Giant cells were both of the Langerhans' and foreign body types. Granulomas were noncaseating but varied in frequency and degree of definition. Knowledge of this morphologic picture has proved to be useful in patient care.

A potentially brighter prognosis for colon carcinoma in the third and fourth decades.

In contrast to earlier studies that suggested that colon carcinoma is unusually lethal in the young, 69 patients, ages 20 to 39 years, had a relatively good prognosis. Fifty-nine percent lived over 5 years after diagnosis, and 51% were cured. Furthermore, 67% were cured if they did not have distant spread of the carcinoma at the time of the initial operation. Neither age, sex, tumor size, location, mere presence of lymph node metastases, depth of tumor invasion, nor predisposing disease of the colon was a strong prognostic factor. Metastases to six or more lymph nodes and distant spread of the tumor at the time of initial surgery were ominous findings. Mucinous carcinoma was relatively frequent (28%) and was also an ominous feature (only 5 of 20 patients cured as opposed to 26 of 43 with classical adenocarcinoma).

Persistent renal blastema in an adult.

To the authors' knowledge, this is the first reported case of any form of nephroblastomatosis occurring in an adult. Such a lesion is the presumed precursor of the rare Wilms' tumors that arise in adults.

Progressive myelofibrosis in agnogenic myeloid metaplasia.

Progression of myelofibrosis in agnogenic myeloid metaplasia (AMM) has only rarely been documented because of the paucity of patients with sequential bone marrow examinations. At our institution, 27 patients with AMM underwent marrow examinations, separated by at least six months. Of the 20 patients who did not have maximal myelofibrosis shown by the original biopsy, 18 displayed temporal progression of the process; 11 of them had an increase of two or more grades using the Bauermeister scale. The grade remained constant in the remaining two patients. Several cases of a decreased degree of fibrosis or variation of grade in concomitant specimens showed that fibrosis may not proceed at an identical rate throughout the marrow and that the degree may vary with location.

Renal cell carcinoma: the Ochsner Medical Institution experience (1945-1978).

We reviewed 161 patients operated upon for renal cell carcinoma between 1945 and 1978. Life table and survival analyses were computed to compare the effects of stage, tumor differentiation, cell type, surgical technique, renal vein involvement and sex on the years of survival. Patients with stage I and well differentiated tumors had the best prognosis. All patients surviving 10 years or more had well differentiated tumors. The type of nephrectomy did not affect survival and lymphadenectomy was only of value in staging the disease. The stage and differentiation of the tumor were more important to outcome than choice of therapy.

Diagnostic use of CFU-E formation from peripheral blood in polycythemia vera.

Peripheral blood mononuclear cells from five patients with polycythemia vera (P. vera) and three with other polycythemias were cultured in a methylcellulose system. Colony-forming unit-erythroid (CFU-E) colonies appeared after seven days in the absence of added erythropoietin (Ep) in all P. vera cultures. A pattern of growth similar to the one seen for P. vera patients occurred in the culture from a patient in whom that disease was suspected. In the cultures from two of the patients with other polycythemias, erythroid colonies did not appear even in the presence of Ep. These findings emphasize the potential value of culturing peripheral blood for CFU-E colonies in diagnosing polycythemia vera.