Cryptic Mucor infection leading to massive cerebral infarction at initiation of antileukemic chemotherapy.

A 74-year-old man with newly diagnosed acute myelogenous leukemia unexpectedly suffered a massive cerebral infarct on day 2 of induction chemotherapy. Clinically, the hemorrhagic infarct was thought to be due to leukostasis and thrombocytopenia. Necropsy, however, revealed that Zygomycetes-type hyphae had infiltrated cerebral vessels in and near the infarct. The fungal infection was clinically silent otherwise, although fungal elements were also identified in the lung at autopsy. This case illustrates how closely fungal infection may resemble a leukemia-associated cerebrovascular accident.

Transitional cell carcinoma arising in a pyelocaliceal cyst. An unusual cystic renal lesion with cytologic and imaging findings.

The differentiation between benign and malignant cystic lesions of the kidney is a diagnostic challenge. Medical imaging aids in this task, but many cystic renal lesions require further work-up, frequently by computed tomography-guided fine needle aspiration. We report on the pathological findings in a case of moderately differentiated papillary transitional carcinoma, which arose in a pre-existing pyelocaliceal cyst in a 53-year-old man. In the case of this lesion, the distinction between a benign and a malignant renal cyst is blurred. To our knowledge, this is the third such occurrence to be reported and the first to be diagnosed by fine needle aspiration biopsy.

Extramedullary granulopoiesis mimicking recurrent lymphoma after prolonged administration of human recombinant granulocyte colony-stimulating factor.

Human recombinant granulocyte colony-stimulating factor (G-CSF) has become a treatment of choice for neutropenia of diverse etiologies. We describe a 71-year-old man who, while receiving G-CSF for graft failure after peripheral blood stem cell transplant, developed dramatic extramedullary granulopoiesis that mimicked recurrent lymphoma.

Diagnosis of systemic lupus erythematosus in an elderly male by pericardial fluid cytology: a case report.

Although pleural and pericardial effusions are common and may rarely be the initial manifestation of disease, there are few reports of SLE diagnosed in a cytopathology laboratory. We describe an unusual case of SLE in a 75-year-old man who presented with cardiac tamponade. Cytologic examination of the pericardial fluid revealed numerous LE cells and led to the diagnosis of SLE. This case illustrates the importance of careful evaluation of a serous effusion for LE cells in patients of either gender and of any age.

Standardization of the hospital record for osteopathic structural examination: Part 2. Effects of an educational intervention on documentation of palpatory and structural findings and diagnosis.

The purpose of this two-part study was to develop and test an instructional videotape for use in the osteopathic hospital setting; to standardize a procedure for documentation of palpatory and structural findings and diagnoses; and to examine the program's influence on the correlation of palpable and structural findings with a diagnostic impression of somatic dysfunction. To that end, the authors analyzed results of a survey of the medical records of 20 osteopathic training hospitals. Patients' charts were randomly pulled before and after house staff who performed admitting hospital examinations viewed an educational videotape. The videotape emphasized that the structural and palpatory screening examination should simply answer the question, "Is there a problem in the musculoskeletal system?" Chi-square analysis was used to evaluate the frequency of documentation of altered structural findings (structure, motion, tissue changes) and the diagnostic impression of somatic dysfunction and their correlation. Based on more than 300 reviewed charts, the authors found that the frequency of documentation of structural and palpatory examination was not significantly altered after house staff viewed the videotape. A sequence of hospital-based instruction in osteopathic principles and practices has been initiated at more than 50 osteopathic medical institutions, and the problems related to continuing medical education and clinical research in osteopathic medicine are discussed.

Acute gram-negative urosepsis mimicking an acute hemolytic transfusion reaction.

BACKGROUND: The acute hemolytic transfusion reaction (AHTR) is one of the most feared complications of blood transfusion. Over the years, several clinical conditions, as well as errors in blood component preparation and administration, that mimic AHTR have been identified. This report describes a novel variation on the theme of pseudo-AHTR. CASE REPORT: A 47-year-old diabetic man with drug-induced pancytopenia suddenly manifested severe shaking chills, flank pain, and back pain during a red cell transfusion. The passage of bright red urine immediately after the transfusion virtually confirmed for the clinicians administering the transfusion that an AHTR had occurred. In the laboratory, the hematuria was shown to be due principally to red cells and not to free hemoglobin. Further posttransfusion work-up showed a urinary tract infection and overwhelming bacterial sepsis with Escherichia coli. CONCLUSION: As a pseudo-AHTR, gram-negative bacterial sepsis of urinary tract origin may surpass other forms of sepsis. Urosepsis should be considered in the work-up of a suspected AHTR in a pancytopenic patient with a urinary tract infection.

Thymoma mimicking lymphoblastic lymphoma: a pitfall in fine-needle aspiration biopsy interpretation.

Lymphocyte-rich thymoma often contains lymphoblasts and lymphoblastic lymphoma often infiltrates the thymus gland. Although these two neoplasms are clinically distinct in most case, their cytologic features may be similar on biopsy. We describe a fine-needle aspiration biopsy of a thymoma in a 50-yr-old man to increase awareness of this pitfall in cytologic interpretation.

Recent-onset myelodysplastic syndrome mimicking acute leukemia during infection.

A previously healthy 74-year-old patient without a prior history of hematological disease presented with an acute respiratory infection. Peripheral pancytopenia led us to perform a bone marrow biopsy, and the diagnosis of undifferentiated acute myelogenous leukemia (AML, 61% blasts) was made. Following antibiotic treatment and resolution of the infection, the blast count in the bone marrow fell to 2%, leaving a clinicopathologic picture consistent with myelodysplastic syndrome (MDS, French-American-British type refractory anemia), and the patient survived for a total of 16.5 months following the initial presentation with cytokine support. A preterminal blast proliferation occurred during a bacterial ear infection and rapidly responded to a withdrawal of cytokine support, antibiotic therapy, and hydroxyurea. The patient succumbed ultimately to an apparent myocardial infarct. Clinicians should consider transient acceleration of MDS in their differential diagnosis when confronted with apparent AML and acute infection.

Whipple's disease presenting as chronic wastage and abdominal lymphadenopathy.

We describe a 24-year-old man who presented with chronic wastage and massive abdominal lymphadenopathy which strongly resembled a malignant neoplasm. Biopsy of mesenteric lymph nodes with ancillary studies led to the correct diagnosis of Whipple's disease. These symptoms began 2 months after the patient returned from military service in the Persian Gulf.

Acute agranular CD4-positive natural killer cell leukemia. Comprehensive clinicopathologic studies including virologic and in vitro culture with inducing agents.

BACKGROUND: A 63-year-old male presented with fever, a subcutaneous nodule, gingival hypertrophy, lacrimal gland enlargement, and no lymphadenopathy or hepatosplenomegaly, but had anemia, thrombocytopenia, and peripheral blood (PB) plus bone marrow (BM) involvement by leukemic cells. There was minimal response to multiagent chemotherapy and local radiotherapy, with a survival of 6.5 months from disease diagnosis. METHODS: The PB and/or BM leukemic cells were evaluated using electron microscopy (EM), immunohistochemistry, flow-cytometric immunophenotyping, cytochemistry, cytogenetics, Southern blot analysis for gene rearrangement and Epstein-Barr virus (EBV), polymerase chain reaction for EBV and human herpes virus-6 (HHV-6), and in vitro culturing with inducing agents. RESULTS: The leukemic cells were agranular and monocytoid, with a hairy cell-like bone marrow biopsy infiltrate. Myeloperoxidase (MPO) and alpha-naphthyl butyrate esterase staining was negative, and periodic acid-Schiff staining was positive by light microscopy. Electron microscopy showed MPO negativity and a lack of parallel tubular arrays. The immunophenotype was CD3-, CD56+, CD4+, CD8-, CD15+, TCR1-, and TCR2-, with germline immunoglobulin and T-cell receptor genes and an abnormal karyotype (44XY, 5q-, -13, 13q+, -15). No genomic material for EBV or HHV-6 was detected. Cell cultures with butyrate and N,N-hexamethylene bis-acetamide suggested the possible induction of tumor cells to express a T-cell immunophenotype. CONCLUSION: A case of clonal acute natural killer (NK) cell leukemia with an unusual morphology (agranular) and unique phenotype (CD3-, CD56+, CD4+, CD15+) is presented. Unlike as in other acute NK leukemias, EBV was negative; there was no evidence of HHV-6. The tumor cell, after culturing with differentiating agents, may have been induced to express a T-cell immunophenotype.

Standardization of the hospital record for osteopathic structural examination: recording of musculoskeletal findings and somatic dysfunction diagnosis.

The diagnosis of somatic dysfunction is supported by the recording of positive musculoskeletal findings (altered structure, motion, tissue). We conducted a national survey to assess the status of the documentation of this relationship in the hospital setting. The 26 participating osteopathic training hospitals submitted 719 admitting physical examination forms, of which 417 (58%) met study criteria (adult patients on medicine or surgical service with a musculoskeletal examination documented on the chart). On 234 charts (56%), at least one positive finding was recorded but no diagnosis of somatic dysfunction was stated. Of 14 charts with a diagnosis of somatic dysfunction, 10 had a positive musculoskeletal finding recorded. The relationship between positive musculoskeletal findings and somatic dysfunction is not being documented on osteopathic training hospital admitting physical examination forms. Proper documentation of a somatic dysfunction diagnosis and related positive musculoskeletal findings will enable multisite research on the relationship between somatic dysfunction and other health problems documented on the hospital medical record. A multiple data collection system that is workable, reliable, and reproducible was developed as a result of this study.

CD8+ polylobated T-cell leukemia/lymphoma. A case report with immunophenotypic, ultrastructural, gene rearrangement, karyotypic, and DNA content analysis and autopsy description.

Polylobated lymphoma is a morphologic variant of malignant lymphoma characterized by large pleomorphic neoplastic cells with polylobated nuclei. We report an unusual case in a 57-year-old man with a 9-year history of an antecedent low-grade peripheral T-cell lymphoma with dermal involvement. The polylobated lymphoma expressed the CD2, 8, 45, and DR surface antigens and had a clonally rearranged T-cell receptor beta-chain gene. The DNA content analysis indicated that most of the neoplasm was DNA diploid and tetraploid, with a high S phase. Cytogenetic analysis demonstrated the presence of a clone with an abnormal karyotype 45, X, -Y, -1, -10, -10, -17, -19, +5 mar. Serology and polymerase chain reaction analysis showed no evidence of retroviral infection (human immunodeficiency virus types 1 and 2 and human T-cell lymphotropic virus types I and II). We review the literature on polylobated T-cell lymphoma.

Concurrent invasive thymoma and T-cell lymphoblastic leukemia and lymphoma. A case report with necropsy findings and literature review of thymoma and associated hematologic neoplasm.

Thymoma is associated with benign and neoplastic diseases. The authors report the concurrence of invasive thymoma and T-lymphoblastic leukemia/lymphoma in a 95-year-old man. The hematologic malignancy was suspected terminally, whereas the thymoma was discovered at necropsy. The lymphoblastic leukemia/lymphoma had a clonally rearranged T-cell receptor beta-chain gene and a mature thymocyte immunophenotype. No retroviral gene sequences (human immunodeficiency virus 1 and 2, and human T-cell leukemia virus 1 and 2) were identified by polymerase chain reaction and hybridization analysis. The association of thymoma with hematologic neoplasm is reviewed.

Pleomorphic fibrohistiocytoma of the breast: a potential pitfall in breast biopsy interpretation.

We describe a benign mammary mesenchymal tumour with atypical stromal giant cells in the contralateral breast of a 66-year-old woman with infiltrating ductal carcinoma. The clinical, morphological and immunohistochemical features of this tumour suggest a pleomorphic variant of fibrous histiocytoma. This benign lesion represents a possible pitfall in breast pathology when interpreting a frozen section or fine needle aspiration biopsy.

Etiology of neutrophilic granulocytic hypoplasia in a case of large granular lymphocytic leukemia with paraproteinemia.

The association between large granular lymphocytic leukemia (LGLL) and neutropenia is poorly understood. We attempted to assess whether neutropenia in LGLL with paraproteinemia has a different etiology than LGLL without paraproteinemia. We found neither direct serum inhibition of granulocyte/monocyte-colony forming units in vitro nor increased immunoglobulin binding to granulocytic neutrophils, neutrophil precursors, or granulocyte/monocyte-colony stimulating factor. Clonogenic assay experiments suggested that suppression of the patient's granulocyte/monocyte-colony forming units by the neoplastic T-cells and decreased granulocyte/monocyte-colony stimulating factor production contributed to the pathogenesis of neutropenia in this particular case.