Best practice in primary care pathology: review 2.

This second best practice review examines five series of common primary care questions in laboratory medicine: (1) laboratory testing for allergy, (2) diagnosis and monitoring of menopause, (3) the use of urine cytology, (4) the usefulness of the erythrocyte sedimentation rate, and (5) the investigation of possible urinary tract infection. The review is presented in a question-answer format. The recommendations represent a précis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents, and evidence based medicine reviews, supplemented by MEDLINE EMBASE searches to identify relevant primary research documents. They are standards but form a guide to be set in the clinical context. Most are consensus rather than evidence based. They will be updated periodically to take account of new information.

Transferrin receptors in the parkinsonian midbrain.

Several hypotheses have been put forward to explain the pathogenesis of Parkinson's disease (PD) and recently it has been suggested that alterations in iron homeostasis may be implicated. Because of the central role of the transferrin receptor in providing access of iron to cells, we have studied the distribution and density of transferrin receptors using [3H]-transferrin ([3H]-Tf) binding and tritium film autoradiography in the normal and PD midbrain. High levels of [3H]-Tf binding were found in the dorsal raphé, oculomotor nucleus and periaqueductal grey whilst lower levels of [3H]-Tf binding were found in the tegmentum, red nucleus and substantia nigra. Significant reductions in binding were found in the substantia nigra, red nucleus and oculomotor nucleus in PD, the reductions in [3H]-Tf binding being similar to the loss of nigral neurons in PD. The data suggest that the increased iron content of surviving nigral neurons may reflect a compensatory metabolic response rather than abnormal transferrin receptor expression.

Multilobated B-cell lymphoma of the spleen.

We report a case of multilobated B-cell lymphoma presenting with primary splenic involvement. This is a very unusual tumour occurring in an uncommon site.

Evidence for the localization of haemopexin immunoreactivity in neurones in the human brain.

Haemopexin is a 60 kDa serum glycoprotein responsible for the transport of haem to tissues such as liver, by receptor-mediated endocytosis, in an analogous manner to the iron transport protein transferrin, with recycling of intact haemopexin. The immunocytochemical distribution of haemopexin has been investigated, using a monospecific polyclonal antiserum to human haemopexin, in human brain. Neurones in all the brain regions studied showed immunostaining of the soma, axons and dendrites. A few scattered glial cells exhibited positive immunostaining. Oligodendrocytes and choroid plexus epithelial cells lacked haemopexin immunoreactivity. Thus, haemopexin is present within neurones and we propose that this protein may play an important role in haem transport for neuronal iron homeostasis.

Iron and aluminium in relation to brain ferritin in normal individuals and Alzheimer's-disease and chronic renal-dialysis patients.

Ferritin has been isolated and its subunit composition, iron and aluminium content determined in the cerebral cortex and cerebellum of normal individuals and in the cerebral cortex of Alzheimer's-disease and renal-dialysis patients. An e.l.i.s.a. for ferritin has been developed and the ferritin, non-haem iron and aluminium content of the parietal cortex were determined in normal individuals and Alzheimer's-disease patients. It was found that ferritin from the cerebral cortex and cerebellum of normal individuals had a high H-subunit content, similar to that of heart ferritin. The subunit composition of ferritin isolated from the cerebral cortex was not significantly altered in Alzheimer's-disease or renal-dialysis patients. Ferritin from the cerebral cortex of normal individuals had only approx. 1500 atoms of iron per molecule and the iron content of ferritin was not significantly changed in Alzheimer's-disease or renal-dialysis patients. Ferritin isolated from the cerebral cortex of normal, Alzheimer's-disease and renal-dialysis patients had less than 9 atoms of aluminium per molecule. The failure to find increased concentrations of aluminium associated with ferritin in dialysis patients, who had markedly increased concentrations of aluminium in the cerebral cortex, shows that aluminium does not accumulate in ferritin in vivo. This has important implications for the toxicity of aluminium, since it implies that cells are unable to detoxify aluminium by the same mechanism as that available for iron. Comparison of the concentrations of ferritin, aluminium and iron in the parietal cortex from normal and Alzheimer's-disease patients showed that, whereas the concentration of aluminium was not increased, both ferritin and iron were significantly increased in Alzheimer's disease.

Distribution of transferrin receptors in relation to cytochrome oxidase activity in the human spinal cord, lower brainstem and cerebellum.

Neuronal activity and oxidative energy metabolism are tightly coupled. There is evidence that cytochrome oxidase, the terminal enzyme of the electron transport chain, can serve as a metabolic marker of neuronal activity. All the respiratory chain enzymes have iron containing prosthetic groups and therefore represent an important component of iron utilisation. Since iron entry into cells is mediated by the transferrin receptor, this receptor may also serve as marker of neuronal activity. The histochemical distribution of cytochrome oxidase has therefore been compared with the autoradiographic distribution of the transferrin receptor in the human spinal cord, brainstem and cerebellum. Cytochrome oxidase activity showed a very similar pattern of distribution to the transferrin receptor in the spinal cord, brainstem and cerebellum. The highest levels of cytochrome oxidase activity and transferrin receptor binding were associated with; in the spinal cord, the substantia gelatinosa, laminae II and III and the motor neurones; in the medulla and pons, the spinal trigeminal nucleus, hypoglossal nucleus, dorsal motor nucleus of the vagus, inferior and superior olives, nucleus praepositus, nucleus paramedianus, central grey, superior central nuclei and locus coeruleus; in the cerebellum, the molecular layer. The results suggest that the transferrin receptor may provide a useful marker of total neuronal respiratory activity.

Brain iron homeostasis.

The anatomical and cellular distribution of non-haem iron, ferritin, transferrin, and the transferrin receptor have been studied in postmortem human brain and these studies, together with data on the uptake and transport of labeled iron, by the rat brain, have been used to elucidate the role of iron and other metal ions in certain neurological disorders. High levels of non-haem iron, mainly in the form of ferritin, are found in the extrapyramidal system, associated predominantly with glial cells. In contrast to non-haem iron, the density of transferrin receptors is highest in cortical and brainstem structures and appears to relate to the iron requirement of neurones for mitochondrial respiratory activity. Transferrin is synthesized within the brain by oligodendrocytes and the choroid plexus, and is present in neurones, consistent with receptor mediated uptake. The uptake of iron into the brain appears to be by a two-stage process involving initial deposition of iron in the brain capillary endothelium by serum transferrin, and subsequent transfer of iron to brain-derived transferrin and transport within the brain to sites with a high transferrin receptor density. A second, as yet unidentified mechanism, may be involved in the transfer of iron from neurones possessing transferrin receptors to sites of storage in glial cells in the extrapyramidal system. The distribution of iron and the transferrin receptor may be of relevance to iron-induced free radical formation and selective neuronal vulnerability in neurodegenerative disorders.

Angiodysgenetic necrotising encephalopathy: presentation as an intrauterine death.

The various morphological manifestations of intracranial vascular anomalies include the rare diffuse meningo-cerebral angiomatosis, sometimes termed "angiodysgenetic necrotising encephalopathy" on account of the severe associated hypoxic damage to the cerebral cortex and white matter. It may occur in any age group and displays both sporadic and familial forms. A further case is reported which is apparently unique in presenting as an intrauterine death with extensive subarachnoid haemorrhage. Associated pathological abnormalities of the adrenal glands indicate that cerebral damage may have commenced from as early as the 20th week of pregnancy. Possible relationships of this entity to other central nervous system vascular malformations are discussed.

Platyspondylic lethal osteochondrodysplasia: Shiraz type with radiological-pathological correlation.

We report two cases of a platyspondylic lethal osteochondrodysplasia in siblings. The condition affects predominantly the metaphyses of the axial skeleton associated with limb shortening and mild platyspondyly. The radiological and pathological features correlate very closely with Sedaghatian's lethal metaphyseal chondrodysplasia, which has previously been described only in Iranian Nationals. Both the radiological and pathological appearances will be described, together with a discussion of the differential diagnosis, the genetical implications and a review of literature.

Histochemical distribution of non-haem iron in the human brain.

The detailed anatomical distribution of iron in the post-mortem human brain has been studied using Perl's and Turnbull's methods with the diaminobenzidine intensification procedure for the demonstration of non-haem Fe3+ and Fe2+, respectively. Attention to methodological procedures has revealed that even brief immersion of tissue in routinely used fixatives causes a reduction of staining intensity in areas of high iron content and, often, loss of staining in areas of low iron content. Optimal staining is obtained using frozen section briefly fixed for 5 min in 4% formalin and Perl's stain (Fe3+) with diaminobenzidine intensification. Highest levels of stainable iron were found in the extrapyramidal system with the globus pallidus, substantia nigra zona reticulata, red nucleus and myelinated fibres of the putamen showing highest staining reactivity. Moderate staining intensity with Perl's technique was found in the majority of forebrain, midbrain and cerebellar structures with the striatum, thalamus, cortex and deep white matter, substantia nigra zona compacta, and cerebellar cortex showing consistent staining patterns with intensification of Perl's stain. The brain-stem and spinal cord generally only showed staining with the intensification procedure and even this was of low intensity. Microscopically the non-heam iron appears to be found predominantly in glial cells as fine cytoplasmic granules which in heavily stained areas coalesce to fill the entire cell. Iron-positive granules appear to be free in the neuropil and also around blood vessels in the globus pallidus, striatum and substantia nigra. The neuropil shows a fibrous impregnation when stained for iron which is, in part, derived from glial processes, myelinated fibres and fibre bundles. Neurones, in general, show only very low reactivity for iron, and this is difficult to discern due, often, to the higher reactivity of the surrounding neuropil. In the globus pallidus and substantia nigra zona reticulata, neurones with highly stainable iron content are found with granular cytoplasmic iron reactivity similar to that seen in the local glial cells. Our results are comparable with those of early workers, but with the use of intensification extend the distribution of non-haem iron to areas previously reported as negative. No apparent correlation of iron staining with known neurotransmitter systems is seen and the predilection for the extrapyramidal system is not easily explained, though the non-haem iron in the brain appears to be as a storage form in the iron storage protein ferritin. The localization of iron in the brain provides a foundation for the study of iron in certain neurodegenerative diseases such as Parkinson's disease, where iron has been implicated in the pathogenesis.

Immunocytochemical localisation of transferrin in the human brain.

Immunocytochemical studies on the adult human brain have shown that transferrin is localized within three main compartments in the adult human brain. Oligodendrocytes and some astrocytes together with cells of the choroid plexus showed the highest intensity of staining. Neuronal staining occurred mainly within pyramidal or large polygonal cells, but this showed considerable regional variation being most marked in areas such as the cerebral cortex, amygdala, hippocampus, brainstem and cerebellar Purkinje cells. Small neurones such as caudate interneurones and granule cells showed relatively low activity. Diffuse immunostaining of the neuropil was evident, particularly where heavy neuronal or glial staining occurred. Immunostaining was also observed in white-matter fibre tracts. This pattern of distribution helps to provide a model for the mechanisms responsible for iron homeostasis in the normal brain.

Halo eczema--resolution after excision of the central naevus alone.

We describe a patient with halo eczema around a benign pigmented compound naevus. The eczema resolved after excision of the central naevus alone; this allowed histological assessment of the naevus without the need for a large excision or for additional topical therapy.

Disseminated zygomycosis and systemic lupus erythematosus.

A young woman with long-standing systemic lupus erythematosus and rheumatic fever presented with deteriorating renal function. She had severe gastritis treated with cimetidine and received methylprednisolone when her blood cultures were repeatedly negative. She developed spontaneous bruising and bleeding from venepuncture sites, leading to clotting studies and a diagnosis of thrombotic thrombocytopenic purpura. At post-mortem, extensive evidence of disseminated zygomycosis was found. The likely portal of entry was the gastric route.

Bladder carcinosarcomas: three cases with diverse histogenesis.

Carcinosarcomas of the bladder are rare. We describe three such tumours, including an apparently unique case in which the components comprised liposarcoma and poorly-differentiated transitional cell elements. A second example included chondrosarcomatous elements. These two tumours showed architectural and immunocytochemical features which suggested that they had originated as carcinomas but had subsequently differentiated along both epithelial and mesenchymal pathways. The third tumour contained both carcinoma and osteosarcoma and may represent a collision tumour.