The postmortem diagnosis of diffuse cerebral injuries, with special reference to the importance of brain fixation.

In 3 cases of head injury the main finding was the diffuse axonal injury pattern of brain damage. This is characterised post mortem by focal lesions in the corpus callosum and rostral (anterior) brainstem, together with diffuse damage to white matter. In order to diagnose this and other forms of diffuse injury, the importance of fixing the brain before examination is stressed. In addition, microscopic examination is often required, though of relatively few sections from readily predictable anatomical locations. A suggested method of approach is proposed, which will greatly facilitate diagnosis of this surprisingly common condition.

The distally based split soleus muscle flap.

A refinement of the previously described distally based soleus muscle flap is proposed. The essential features of the flap are mobilisation of the tibial origin, splitting the muscle longitudinally, partially along a distinct anatomical plane, and preservation of anatomical continuity of the muscle. We suggest that improved blood supply to this flap derives from the intact major lateral proximal pedicles via the intact lateral portion into the flap. We also think that minimal damage to intramuscular vasculature integrity contributes to the improved circulation. The flap has been designed and studied using ten fresh cadaver leg dissections. Angiographic studies proved adequate blood supply to the flap. The flap has been tested eight times on seven patients with favourable results.

Liver cell dysplasia in normal, cirrhotic, and hepatocellular carcinoma patients.

An assessment was made of the frequency of liver cell dysplasia and the mean age of each group in 56 normal, 13 cirrhotic, and 50 hepatocellular carcinoma (HCC) patients, 40 with cirrhosis, from southern Africa. Dysplasia increased from 7.1% in normal subjects to 38.5% in cirrhotic, 40% in noncirrhotic HCC, and 52.5% in cirrhotic HCC patients, three statistically similar frequencies. Average patient ages were as follows: patients with normal livers, 37.3 years; with cirrhosis, 42.4 years; with noncirrhotic HCC, 36.5 years; and with cirrhotic HCC, 34 years, the mean age with dysplasia being lower than that of the whole group. With no increase in frequency of dysplasia from cirrhosis to HCC with cirrhosis, with a similar high frequency in HCC without cirrhosis, and with a mean age of all HCC patients 8 years less than that of cirrhotics and 3 years less than normals, chronologic evolutionary progression from cirrhosis to dysplasia to HCC in southern Africa cannot be demonstrated.

Liver iron stores and hepatitis B antigen status.

Higher serum iron and ferritin levels noted in hepatitis B antigen (HBAg) carriers than in noncarriers suggests that virus might actively replicate in hepatocytes, stimulate ferritin synthesis, and result in increased liver iron stores. A comparative semiquantitative study of immunohistochemical ferritin (0-12) and hemosiderin (0-9) was performed on 54 normal, 13 cirrhotic, and 70 nonneoplastic livers from patients with hepatocellular carcinoma, in each group, comparing amounts in HBAg-positive and HBAg-negative patients. Mean scores for ferritin and hemosiderin were high in all three groups, normal livers averaging 8.3 and 6, respectively, cirrhotic livers, 8.5 and 7.4, respectively, and carcinoma livers, 5.6 and 6.1, respectively. In each group, there was no significant difference in ferritin and hemosiderin mean scores in HBAg-positive and HBAg-negative patients. The large liver iron stores do not appear to be a consequence of hepatitis B virus infection alone. Their role in the development of hepatocellular carcinoma is still to be elucidated.

Immunohistochemical ferritin in hepatocellular carcinoma.

Serum ferritin concentrations are elevated in 35% to 100% of patients with hepatocellular carcinoma (HCC). With an immunoperoxidase technique, ferritin was demonstrated in tumor tissue from 32 of 74 (43%) black southern African patients, and from 12 of 19 (63%) American patients with HCC (P greater than 0.1). Ferritin was present in nonneoplastic liver in 82% of African and 100% of American patients (P greater than 0.1). Moderate to large amounts of stainable hepatic storage iron (hemosiderin) were present in 76% of African and 67% of American patients (P greater than 0.1). Fifty-two (70%) African patients had macronodular cirrhosis. In the literature, 80% to 90% of American patients with HCC have cirrhosis. High serum ferritin levels in patients with HCC may be due to ferritin production by the tumor, or related to the associated iron overload and/or cirrhosis.

Alpha-1-antitrypsin deficiency in Southern African hepatocellular carcinoma patients. An immunoperoxidase and histochemical study.

An increased frequency of alpha-1-antitrypsin deficiency (AATD) has been reported in patients with hepatocellular carcinoma (HCC) in Scandinavia and England. Using a specific immunoperoxidase technique for alpha-1-antitrypsin (AAT) and periodic acid-Schiff (PAS) with and without diastase predigestion, the authors examined nonneoplastic autopsy liver tissue from 58 black southern African patients with HCC and from 54 controls. No periportal PAS-positive diastase-resistant globules containing AAT (specific for AATD) were found in liver tissue from either group. A finely granular diffuse cytoplasmic AAT staining (not removed by diastase predigestion) was present in hepatocytes in a "checkerboard" pattern within the lobule in 33 (57%) HCC patients and in 20 (37%) controls (P greater than 0.1), and was particularly prominent adjacent to tumor in 11 HCC patients. Alpha-1-antitrypsin was present in neoplastic cells in 18 of the 40 HCC examined (45%). These findings suggest no major role for AATD in the etiology of HCC in southern Africa.

Chordoid sarcoma of the hand. A case report.

Chordoid sarcoma is a rare, distinctive neoplasm that usually occurs in the soft tissue of the extremities. Despite its striking histological resemblance to chordoma at light microscopic level, both clinical and ultrastructural differences exist and chordoid sarcoma may in fact be related to tendosynovial sarcoma. Previous reports of extraskeletal myxoid chondrosarcoma, however, show that this tumour bears a striking light microscopic and ultrastructural similarity to chordoid sarcoma, which suggests that the latter may be a variant of extraskeletal myxoid chondrosarcoma. In this report a further case of chordoid sarcoma is presented; clinical, radiological, histological and ultramicroscopic features support a tendosynovial origin.

Cutaneous necrosis caused by the bite of Chiracanthium spiders.

Spiders of the genus Chiracanthium are very common in and about homes in southern Africa. The bite of this spider results in cutaneous necrosis. The clinical and histopathological features and the natural history and identification of these spiders are discussed briefly.

Hepatitis B surface antigen and hepatocellular carcinoma in Southern Africa.

Most series in Africa show a high percentage of hepatitis B surface antigen in hepatocellular carcinoma. Two groups of cases were investigated in this study. The one was derived from the autopsy material at Baragwanath hospital from subjects who had lived in Soweto, a large Black urban town. The second group consisted of male Black mineworkers generally originating from rural areas. A combination of the aldehydefuchsin stain and immunoperoxidase technique was used. The two groups showed totally different results. The Baragwanath series consisted of 24 hepatocellular carcinomas of which only 4 (17%) were HBsAg positive. Of the 24 cases, 14 had cirrhosis of which 9 were macronodular and 5 micronodular. Ten of these cases showed heavy iron overload. The series of male Black mineworkers comprised 22 cases of which 16 (72%) were HBsAg positive. Twelve of the 22 cases showed a macronodular cirrhosis and there were no micronodular cirrhoses. Only one case showed severe iron overload. These findings delineate two different populations of hepatocellular carcinoma in Southern Africa.

Liver cell dysplasia: association with hepatocellular carcinoma, cirrhosis and hepatitis B antigen carrier status.

Liver cell dysplasia was noted on histological examination of nontumorous liver from 24 of 50 (48%) black southern African males with hepatocellular carcinoma (HCC). Macronodular cirrhosis was present in 40 (80%). There was no statistically significant difference between the frequency of dysplasia in 50% of 40 cirrhotic and 40% of 10 noncirrhotic livers, or in 52.6% of 38 hepatitis B antigen (HBAg) positive and 33.3% of 12 HBAg negative HCC patients. HBAg positivity was present in 80% of 40 cirrhotic and in 60% of 10 noncirrhotic HCC patients. This lack of significant correlation between liver cell dysplasia, and both cirrhosis and HBAg positivity in HCC patients in contrast to findings in Uganda and the United States, suggests a different pathogenetic mechanism for dysplasia in southern Africa. Liver cell dysplasia in man appears to be analogous to preneoplastic experimentally-induced hyperplastic foci or areas.

Biochemical studies of the matrix of craniovertebral chordoma and a metastasis.

Glycosaminoglycans of human chordoma and a metastasis were studied. The glycosaminoglycans were derived from the extracellular matrix and consisted of chondroitin 4- and 6-sulphate, keratan sulphate and hyaluronate. The ratio of chondroitin sulphate to keratan sulphate was much lower in the metastasis than in the primary. Proteoglycan extracted with 4M guanidinium chloride and purified by associative density-gradient centrifugation was assessed on Sepharose 2B before and after reduction and alkylation. The result of this experiment suggested that only a small proportion of the proteoglycans were aggregated.

Hepatitis B antigen in black patients with hepatocellular carcinoma: correlation between orcein stained liver sections and serology.

Formalin-fixed paraffin-embedded autopsy tissue of liver and tumor from 50 male black mineworkers with hepatocellular carcinoma were examined by orcein stain for the presence of cytoplasmic hepatitis B surface antigen. The results were correlated with the serum hepatitis B antigen (HBAg). In 72% serum HBAg was positive. Orcein staining of nontumor liver cell cytoplasm was present in 18 (36%). Sixteen (89%) of these orcein-positive cases were serum HBAg positive. The two false negative serum HBAg results were obtained by immunodiffusion, immunoelectrophoresis and complement fixation. Serum HBAg, measured by radio-immunoassay and hemagglutination, was positive in 14 orcein-negative cases. Six other negative orcein results appeared to be due to sampling error. Orcein staining was noted in tumor cells of three serum HBAg positive patients. Provided the limitations of the technique are realized, orcein staining of liver tissue from hepatocellular carcinoma patients may prove useful for retrospective screening surveys to assess the prevalence of HBAg positivity in these patients.

Primary pulmonary sporotrichosis with unusual fungal morphology.

Primary pulmonary sporotrichosis is a rare disease. Comstock and Wolson (1975) were able to trace approximately 30 such cases. We report a further case; to our knowledge, the various stages in the development of sporotrichosis, from a cigar body to the mature asteroid body with radiations which were present in our case, have not been so well demonstrated in a single case.

Blastomycosis of the tongue: a case report.

A clinically malignant tongue ulcer in a 63-year-old White man was proved by histological examination and culture to be due to Blastomyces dermatitidis. In addition, pulmonary lesions caused by B. dermatitidis were found at autopsy.

Pulmonary disease associated with mycobacteria other than tubercle bacilli in miners.

Five patients with lung disease caused by mycobacteria other than tubercle (MOTT) bacilli are described. Mycobacterium kansasii was the causative organism in 4 patients and M. scrofulaceum in 1 patient. The species were repeatedly isolated from sputum specimens cultured on Löwenstein-Jensen medium. The clinical features, mycobacterial isolations, bacteriological properties of the pathogens and the therapeutic problems encountered are discussed.

Disseminated histoplasmosis associated with disseminated tuberculosis: a case report.

Disseminated histoplasmosis is reported in a 70-year-old White man. There was also evidence of a previous disseminated tuberculosis infection. This is the 9th reported case of disseminated histoplasmosis in the Republic of South Africa.