Choline acetyltransferase (ChAT) immunoreactivity in paraffin sections of normal and diseased intestines.

There is increasing interest in localizing nerves in the intestine, especially specific populations of nerves. At present, the usual histochemical marker for cholinergic nerves in tissue sections is acetylcholinesterase activity. However, such techniques are applicable only to frozen sections and have uncertain specificity. Choline acetyltransferase (ChAT) is also present in cholinergic nerves, and we therefore aimed to establish a paraffin section immunocytochemical technique using an anti-ChAT antibody. Monoclonal anti-choline acetyltransferase (1.B3.9B3) and a biotin-streptavidin detection system were used to study the distribution of ChAT immunoreactivity (ChAT IR) in paraffin-embedded normal and diseased gastrointestinal tracts from both rats and humans. Optimal staining was seen after 6-24 hr of fixation in neutral buffered formalin and overnight incubation in 1 microgram/ml of 1.B3.9B3, with a similar distribution to that seen in frozen sections. In the rat diaphragm (used as a positive control), axons and motor endplates were ChAT IR. Proportions of ganglion cells and nerve fibers in the intramural plexi of both human and rat gastrointestinal tracts were also ChAT IR, as well as extrinsic nerve bundles in aganglionic segments of Hirschsprung's disease. Mucosal cholinergic nerves, however, were not visualized. In addition, non-neuronal cells such as endothelium, epithelium, and inflammatory cells were ChAT IR. We were able to localize ChAT to nerves in formalin-fixed, paraffin-embedded sections. The presence of ChAT IR in non-neuronal cells indicates that this method should be used in conjunction with other antibodies. Nevertheless, it proves to be a useful technique for studying cholinergic neuronal distinction in normal tissues and pathological disorders.

Epstein-Barr virus in non-Hodgkin's lymphomas and lymphoid tissue in children.

In developed countries the majority of adolescent children show serological evidence of past Epstein-Barr virus (EBV) infection. This virus is associated with non-Hodgkin's lymphomas in immunocompromised children, but the relationship of EBV DNA to these tumors in children without documented immunodeficiency has not been investigated by the polymerase chain reaction (PCR). We used a PCR method with primers from the Bam W and Bam HI regions to study non-Hodgkin's lymphomas in children, with tonsillar tissue of age-matched children as controls for the presence of EBV DNA. Six of the 20 tonsils were positive using the Bam W primers; another four showed this DNA with Bam HI primers. EBV DNA was detected in only one tumor (a lymphoblastic lymphoma) by both primer sets. The demonstration of EBV DNA in the tonsils reflects past infections and the incidence is in accordance with that expected from serologic epidemiological studies. The absence of demonstrable EBV DNA in 19 lymphomas suggests that this virus is of little consequence in the pathogenesis of non-Hodgkin's lymphomas in children who are not known to be immunocompromised. The lymphoblastic lymphoma had a mixed cell population, and the virus was not necessarily related to the malignancy.

Hypothesis: pathogenesis of skip areas in long-segment Hirschsprung's disease.

The existence of skip areas in a subset of patients with long-segment Hirschsprung's disease (LSHD) is a rare phenomenon that poses practical and theoretical challenges. In this paper, three new cases are described and compared with preceding reports in the medical literature. In addition, an analogous distribution of ganglion cell precursors is reported in the developing large intestines of murine embryos, homozygous for the lethal spotted (ls) allele. In ls/ls embryos, which were destined to have "classic" short-segment aganglionosis coli, a transient phase was observed in which ganglion cells were present in the middle colon, but absent from the cecum and distal large intestine. This "skip area" is attributed to an extramural phase of neuroblast migration which is unique to the colon. Persistence of an abnormal pattern of neuroblast migration, similar to that observed transiently in ls/ls embryos, is invoked as an explanation for skip areas in humans with LSHD.

Myocardial failure and shock in iron poisoning.

Shock is a well-known complication of iron poisoning. Its aetiology is multifactorial with hypovolaemia due to gastrointestinal blood loss and myocardial depression due to systemic acidosis contributing to its genesis. Primary myocardial dysfunction has not been considered to play a role. Our clinical experiences and autopsy findings in three fatal cases of iron poisoning support myocardial dysfunction and damage as contributing factors to their cardiovascular collapse. The three patients, all female, were 3 1/2, 16 and 28-years-old. Onset of shock occurred at 1, 2 and 5 days post-ingestion. There was no response to vigorous fluid replacement therapy and aggressive catecholamine infusions. Central venous pressures were elevated. Microscopic examination of postmortem tissue showed myocardial damage and the presence of stainable iron. It is speculated that the myocardial depression is mediated by lipid peroxidation of myocyte organelle membranes due to iron catalysed free radical generation. The presence of myocardial dysfunction has therapeutic implications. Patients with severe iron poisoning require early and serial measurements of arterial blood pressure, central venous pressure and cardiac output. If primary myocardial dysfunction is documented then fluid replacement, inotropic support and afterload reduction should be considered.

A new autosomal recessive lethal chondrodystrophy with congenital hydrops.

Two sibs, the offspring of consanguineous parents, presented with severe short-limb dwarfism and distinct chondro-osseous, radiologic, and histologic appearance. The first sib presented at 30 wk with severe hydrops following fetal death; the second was detected by ultrasonography at 20 wk. Radiologic abnormalities included an unusual "moth-eaten" appearance of the markedly short long bones, bizzare ectopic ossification centers, and marked platyspondyly with unusual ossification centers. Marked extramedullary erythropoiesis was present in both fetuses, and chondro-osseous histology was characterized by marked disorganization of tissue with interspersed masses of cartilage, bone, and mesenchymal tissue. These sibs appear to have a distinct previously unreported autosomal recessive skeletal dysplasia, which can present as hydrops fetalis.

Demonstration of Epstein-Barr virus in immunoblastic sarcoma of B-cells arising in a child with primary immunodeficiency disease.

The subject of this investigation was an 11-month-old infant girl who presented with a pathological fracture of the right femur due to a metastasis from an abdominal immunoblastic sarcoma. Her past history included recurrent, intractable bacterial and fungal infections. Investigations of her immune status revealed low numbers of T-lymphocytes, a reversed T-helper (TH)/T-suppressor (TS) cell ratio, no response of her peripheral blood lymphocytes to pokeweed mitogen, phytohemagglutinin, concanavalin A, and Candida albicans, and an inability of her cells to react in a mixed lymphocyte culture. Serum levels of IgG, IgM, and IgA were all below normal. No thymic shadow was visible on the chest radiograph. There was no evidence of adenosine deaminase or nucleoside phosphorylase deficiencies. The tumor cells exhibited both surface IgM and IgG, and many of the cells contained large amounts of cytoplasmic IgM. Light chain specificity was restricted to lambda chain for both surface and cytoplasmic immunoglobulin. Ultrastructural study of the tumor cells revealed the presence of both intranuclear and cytoplasmic virions in roughly 1% of the tumor cells. These viral particles strongly resembled herpes viruses. DNA-hybridization studies on the neoplasm revealed the presence of 7-10 genome equivalents of Epstein-Barr virus-DNA per tumor cell.

Congenital ependymoblastoma presenting as a sacrococcygeal mass in a newborn: an immunohistochemical, light and electron microscopic study.

We describe a case of congenital ependymoblastoma presenting as a subcutaneous mass in the sacrococcygeal area of a newborn male. The tumor was composed of primitive cells disposed in compact sheets and cords and exhibiting focal ependymal differentiation. No other line of cellular differentiation was identified by either immunohistochemistry or ultrastructural study. Elevated serum alpha-fetoprotein was found, which decreased following surgical extirpation of the tumor. We propose that this tumor had its origin in the ependymal medullary vestige, similar to other sacrococcygeal ependymomas.

An autosomal dominant form of adolescent multinodular goiter.

Eighteen members of an extended pedigree have been found to have a form of euthyroid adolescent multinodular goiter. Histological examination showed multiple adenomata with areas of epithelial hyperplasia, hemorrhage, and calcification. In two subjects there were focal areas of epithelial hyperplasia reminiscent of low-grade papillary carcinoma, but capsular and vascular invasion was not found. The pattern of inheritance appeared to be autosomal dominant, with diminished penetrance in males. Although the patients were euthyroid, the likely basis for this disorder is an abnormality in thyroglobulin structure and function.

Structures mimicking sex cord-stromal tumours and gonadoblastomas in the ovaries of normal infants and children.

A chance finding of structures resembling gonadoblastomas in the ovaries of a child with lissencephaly prompted a detailed review of all ovarian histology obtained at autopsy over a 12 month period. Fifty-five stillbirths, infants and children were studied ranging from 20 weeks gestational age to 2.5 years post-natal age. In 19 infants structures mimicking gonadoblastomas and sex cord tumours with annular tubules were seen. In all but one case these structures were found in association with follicular cysts and they closely resembled the atretic follicles often seen in the stroma surrounding the follicular cysts. They differed from the atretic follicles only by virtue of their being larger. In addition, in several infants structures resembling Sertoli cell tubules or clusters of Leydig cells were found. When present, these structures always co-existed with sex cord tumours with annular tubules and gonadoblastoma-like lesions. The abnormal stromal lesions and follicular cysts were found most frequently at the stage of development when a massive 'physiological' reduction of oocytes occurs. It is suggested that the 'abnormal' structures identified in this report represent the 'first hit' of oncogenesis and could serve as the precursor of many of the sex cord-stromal tumours, and possibly germ cell neoplasms, seen in childhood.

Isolated myocarditis as a cause of sudden death in the first year of life.

A series of three cases of isolated myocarditis, presenting as sudden death in infancy, occurred over a period of 3 months. This prompted a review of the autopsy records of the Children's Hospital of Winnipeg. Over a period of 40 years, 24 cases of isolated myocarditis were traced from 3196 autopsies. Most (21 of 24) cases of isolated myocarditis occurred in infants less than 12 months of age. In 16 of the infants there were either no antecedent clinical signs (sudden deaths), or a short clinical history of less than 24 h duration. Heart weights, however, were greater than the 99th percentile of published normals in three infants and above the 95th percentile in a further 16 infants. Areas of hypertrophied fibres were seen even in infants with a short history. These latter findings suggest that a latent phase of myocarditis may exist. The responsible pathogens were identified very rarely, due to a lack of suspicion of the existence of myocarditis, and it is suggested that samples of myocardium should be submitted for virologic examination in all cases of sudden death in the first year of life.

Isolated myocarditis in the first year.

Over a period of nearly 40 years, 20 cases of isolated myocarditis were traced from 3086 necropsies. Seventeen occurred in infants less than 12 months of age, often with no antecedent clinical signs (sudden deaths) or with a short clinical history of less than 24 hours' duration.

Intrauterine infections with group B beta-haemolytic streptococci.

The case records of 15 infants with intrauterine infections due to group B beta-haemolytic streptococci were traced from the records of two geographically separate centres over a 4-year period (1979-1982). Six infants were stillborn and the other nine died within the first 6 h. All the infants weighed less than 1000 g and were less than 28 weeks gestation. Placental examination in 14 of the 15 infants showed the presence of chorioamnionitis and funisitis. The infants also showed evidence of pneumonitis. Four infants had evidence of otitis media, two had evidence of an early meningitis. A history of antepartum bleeding was present in six infants and abundant retroplacental clot was noted in four of them. The membranes had been ruptured for greater than 24 h in only three infants. In six of the infants the membranes were intact at the time of delivery. A history of intact membranes at the time of delivery does not exclude a diagnosis of an intrauterine infection with this organism, and this series of infants highlights the importance of routine bacteriologic studies of all perinatal deaths.

The inflammatory response in candidal chorioamnionitis.

Fetal infection with Candida organisms has not commonly been reported. Umbilical cords and placentas from 23 cases of chorioamnionitis collected over a nine-year period were examined by electron microscopy and immunoperoxidase staining. Gross features, especially of the umbilical cord, were distinctive and included the pale yellow plaques pathognomonic of candidal funisitis. Histopathologically, the lesions were found to be focal and subamniotic and were often embedded in a "fibrinoid" exudate and surrounded by inflammatory cells. In some cases the exudate and inflammatory cells were deposited in dense bands. Immunoperoxidase staining showed the lesions to contain IgG, IgM, and IgA, which probably originated in dense-staining plasmacytoid and immunoblastic cells in the inflammatory infiltrates. Additional findings in two fetal cases of giant cell pneumonitis suggested that the fetus can mount a brisk inflammatory and immune response to Candida organisms as early as 18 weeks' gestation and that mucosal exposure to this antigen can result in production of IgA by the lung.

45,X/46,XX mosaicism in discordant monozygotic twins.

Monozygotic twins discordant for Turner's syndrome were both mosaic for 45,X/46,XX in the blood with the same low frequency of 2% to 3% 45,X cells. However, the fibroblasts of the abnormal girl were all uniformly 45,X whereas her normal twin had only 46,XX cells. Monozygosity was confirmed by genetic markers, chromosome variants, and a single monochorionic placenta with a shared vascular circulation. The mechanism by which this disparate pair developed from a single zygote is suggested.

Mucosal metaplasia and chronic inflammation in the middle ear of infants receiving intensive care in the neonatal period.

The histological findings in the middle ear cavity of 72 infants of varying gestations, birthweights, and ages are presented. All infants died after receiving ventilatory support and oxygen for longer than 14 days. In 5 infants there was no detectable histological abnormality. In the remainder, a wide range of lesions was seen including glandular metaplasia, retained squamous debris, squamous polyps, otitis media, and destruction of ossicles. None of the cases of otitis media was diagnosed before necropsy; all were associated with pneumonia. No single specific infectious agent predominated. Several factors could contribute to the spectrum of lesions, and these include persistent amniotic squamous debris, infection, and the effects of oxygen and a nasal airway. The possible implications of these findings are discussed, and it is argued that similar changes of lesser severity could be present in survivors in whom otitis media and conduction hearing defects could be expected.

Adenocarcinoma of the appendix.

The experience in Hamilton, Ontario, with adenocarcinoma of the appendix, between 1974 and 1980, is reviewed and the findings are compared with those of a previous report from Hamilton. There were seven patients (five men and two women) in the current series. The average age was 55.6 years. The unusual presenting signs and symptoms of this tumour are noted; the diagnosis is rarely made preoperatively. This tumor often cannot be distinguished from cecal or ileal malignant tumours. Detailed histologic examination of all specimens is essential to identify epithelial types and to plan treatment. While appendectomy alone may suffice for tumours confined to the appendiceal mucosa, radical right hemicolectomy is still the standard therapy. The authors' study shows no improvement in preoperative diagnosis, or in prognosis, over the earlier report. The authors recommend (a) that this condition be considered in the diagnosis of any appendiceal mass that is not obviously inflammatory, and (b) the frequent use of frozen-section examination to confirm the diagnosis.