Clinical challenges in thyroid disease: Time for a new approach?

Thyroid disease is common, and the prevalence is rising. Traditional diagnosis and monitoring relies on thyroid stimulating hormone (TSH) levels. This does not always result in symptomatic improvement in hypothyroid symptoms, to the disappointment of both patients and physicians. A non-traditional therapeutic approach would include evaluation of GI function as well as a dietary history and micronutrient evaluation. This approach also includes assessment of thyroid peroxidase (TPO) antibodies, T3, T4, and reverse T3 levels, and in some cases may require specific T3 supplementation in addition to standard T4 therapy. Both high and low TSH levels on treatment are associated with particular medical risks. In the case of high TSH this is primarily cardiac, whereas for low TSH it is predominantly bone health. This article discusses these important clinical issues in more detail, with some practical tips especially for an approach to the "non-responders" to the current traditional therapeutic approach.

Methods in leukocyte cytochemistry.

During the development and maturation of hematopoetic precursors, certain enzymes and associated substances, such as glycogen, are produced in the developing cells (1,2), which, if detected, can provide important clues to the lineage and classification of leukemias. Although the evaluation of abnormal populations of white blood cells has been greatly refined by the use of immunohistochemistry, flow-cytometric analysis (3), and molecular studies, cytochemistry still plays an important role in the assessment of the abnormal marrow and peripheral blood smear. Cytochemical studies, therefore, still have a role to play in the evaluation of leukemias and other hematological diseases see Fig. 1 ). Fig. 1. Uses of cytochemical studies in the evaluation of blood and bone marrow smears.

Cervical carcinoma demonstrating tumor-associated tissue eosinophilia: a clinicopathological study of 17 patients.

OBJECTIVES: Our objective in this study was to evaluate the clinicopathological significance of tissue eosinophilia associated with invasive cervical carcinomas. MATERIALS AND METHODS: All cases of cervical carcinoma treated at the Medical College of Georgia between October 1982 and October 1989 were reviewed. We obtained data regarding all cases, including age at diagnosis, stage of disease, therapy, and outcome. Pathological review of all cases was undertaken to identify those patients in whom invasive carcinoma was associated with an intense infiltrate of eosinophils. RESULTS: A total of 441 patients with invasive cervical carcinomas were treated at the Medical College of Georgia between October 1982 and October 1989. Of these patients, 403 had squamous carcinomas, 34 had adenocarcinomas, 4 had adenosquamous carcinomas, and 18 demonstrated tumorassociated tissue eosinophilia (TATE). In all cases TATE was associated with squamous cell carcinomas. Patients in whom TATE was identified were younger (range, 20-67 years; mean, 40.2 years) than were those patients without TATE (range, 17.5-93.5; mean, 54.8 years; p = .0004; t = 3.626, with 233 degrees of freedom) No significant difference was noted with regard to size of tumor, stage at diagnosis, outcome, or length of survival. CONCLUSION: Although it is an interesting and unusual finding when identified in relationship to cervical carcinoma, TATE is of no prognostic significance.

Visceral leishmaniasis in North West Saudi Arabia: a new endemic focus of L. donovani or further evidence of a changing pathogenic role for L. tropica?

OBJECTIVES: The objective of this study was to evaluate patients with VL from the city of Tabuk, Kingdom of Saudi Arabia, with particular reference to the possibility that a focus of VL exists in the North West Province of Saudi Arabia, an area where it had not previously been reported. SETTING: North West Armed Forces Hospital, Tabuk, Saudi Arabia. DESIGN: Retrospective evaluation of all cases of infantile visceral leishmaniasis diagnosed in Tabuk, Saudi Arabia between 1989 and 1994. RESULTS: 5 cases of infantile visceral leishmaniasis were reviewed. In four cases, no evidence of travel outside Tabuk could be identified, suggesting primary infection by viscerotropic Leishmanial organisms in this area of Saudi Arabia. CONCLUSIONS: Visceral leishmaniasis has been identified in an area previously not considered endemic for L. donovani. This observation may indicate either, a previously unrecognized focus of L. donovani or provide further evidence of a changing pathogenic role for L. tropica.

Characteristics of patients with rapidly growing cervical cancer.

Between April 1983 and December 1990, 387 newly diagnosed cervical cancer cases were managed at our institution. We retrospectively reviewed 59 of those cases, which were identified as having developed within 3 years of the patients' last normal Pap smear. Squamous cell carcinoma was found in 45 patients, and 33 had poorly differentiated lesions. Six cases had typical histology. However, 27 cases (82%) had distinctive histologic features that have not been previously described in rapidly progressive cervical cancer. Thirty-seven patients had surgical treatment; 7 (19%) died of disease. Twenty-two patients had radiation; 10 (45%) died of disease. Patients who have invasive cervical cancer after a recent normal Pap smear may have unusual histologic types, and some with early-stage disease may have better outcome if treated with radical surgery.

Atypical glandular cells of undetermined significance and adenocarcinoma in situ: summoning colposcopic expertise?

In comparison with cervical squamous neoplasia, glandular cell neoplasia is uncommon. The evaluation of a patient with atypical glandular cells of undetermined significance is challenging because subtle colposcopic signs are frequently inaccessible to view and cytologic interpretations are extremely challenging for many cytopathologists.

Epidermal inclusion cysts of the clitoris as a complication of female circumcision and pharaonic infibulation.

Female circumcision and pharaonic infibulation is still performed on young females in many parts of the world. It is estimated that two thousand young women living in Britain undergo this ritual every year. The most common complication of this procedure is epidermal inclusion cysts within the infibulation cicatrix. We report the clinical and pathological findings in 10 cases of clitorial inclusion cysts seen at the North West Armed Forbes Hospital, Tabuk, Saudi Arabia between 1989 and 1993. The clinical diagnosis in six cases was that of "clitoral tumor". Two patients presented with complaints of localized pain, one patient presented with dyspareunia and one patient presented with the complaint of a sporadic discharge of white fluid from the circumcision scar. The pathological findings were those of an implantation dermoid in all cases except in two patients where cysts had ruptured and had become inflamed and/or infected. Four cysts were multilocular.

Pilomatrical carcinosarcoma of the cheek with subsequent pulmonary metastases. A case report.

We report a case of malignant pilomatrixoma with a pronounced biphenotypic morphology. The lesion, which was excised from the cheek of a 36-year-old man, was composed of a large pilomatrixoma lying within a spindled, sarcomatoid stroma. Fourteen months later, the tumor metastasized to the right upper lobe of the lung. We describe the tumor's pathology, histology, and immunochemistry and discuss the differential diagnosis. We also speculate on its histogenesis.

Inverted papilloma of the middle ear.

Inverted papilloma is a benign neoplasm confined almost exclusively to the sinonasal tract. We present the first known case report of an inverted papilloma arising from the middle ear. In this paper we discuss the pathophysiology and review the literature of this interesting clinical entity.

Case report: salmonellosis complicated by leukocytoclastic vasculitis.

We report the case of a healthy young Hispanic man with Salmonella typhimurium bacteremia and leukocytoclastic vasculitis. Leukocytoclastic vasculitis has not been previously reported as a complication of salmonella gastroenteritis and bacteremia. Salmonella gastroenteritis is rarely associated with bacteremia in healthy young adults.

Acute tropical polyarthritis in Zimbabwe: a prospective search for a gonococcal aetiology.

Fifteen consecutive patients with acute arthritis were studied. Careful culture and microscopy of swabs from mucosal sites were performed to examine the hypothesis that the acute tropical polyarthritis commonly seen in Zimbabwe is due to undiagnosed gonococcal infection. Rheumatic fever and Reiter's disease accounted for two cases each. Gram negative intracellular diplococci were found in three patients who would otherwise have been diagnosed as having tropical polyarthritis. Except for two of the remaining eight patients, who had raised anti-streptolysin O titres suggesting recent streptococcal infection, no explanation for the arthritis was found. The clinical entity of tropical polyarthritis may not be due to a single aetiological agent.