Improving the success rate of human corneal endothelial cell cultures from single donor corneas with stabilization medium.

Main objective of this study was to improve the success rate of human corneal endothelial cell (hCEC) cultures from single donor corneas. We could show that the use of stabilization medium prior to cell isolation may have a positive effect on the success rate of hCEC cultures from single research-grade donor corneas by allowing growth of otherwise possibly not successful cultures and by improving their proliferative rate. hCEC were obtained from corneo-scleral rims of 7 discarded human research-grade cornea pairs. The Descemet membrane-endothelium (DM-EC) sheets of each pair were assigned to 2 experimental conditions: (1) immediate cell isolation after peeling, and (2) storage of the DM-EC sheet in a growth factor-depleted culture medium (i.e. stabilization medium) for up to 6 days prior to cell isolation. hCEC isolated by enzymatic digestion were then induced to proliferate on pre-coated culture plates. The success rate of primary cultures established from single donor corneas were higher for DM-EC sheets kept in stabilization medium before cell isolation. All cultures (7/7) initiated from stabilized DM-EC sheets were able to proliferate up to the third passage, while only 4 out of 7 cultures initiated from freshly peeled DM-EC sheets reached the third passage. In addition, for the 4 successful paired cultures we observed a faster growth rate if the DM-EC sheet was pre-stabilized prior to cell isolation (13.8 ± 1.8 vs 18.5 ± 1.5 days, P < 0.05). Expression of the phenotypical markers Na+/K+-ATPase and ZO-1 could be shown for the stabilized cultures that successfully proliferated up to the third passage.

Floating device for donor corneas in organ culture.

AIM: To introduce a new floating device for donor corneas to avoid accumulation of debris onto the endothelial surface during organ culture and to facilitate handling of the tissue during preservation and surgery. METHODS: From 11 donors, one randomly chosen cornea was stored in organ culture attached to a floating device, while the contralateral cornea was attached to the lid of the phial by a suture ("hanging by suture"). Endothelial cell density (ECD) was evaluated prior to tissue storage and after 2-3 weeks of culture. Furthermore, we compared ECD in a larger group of corneas sent off for transplantation with the device (n = 281) to a historical group of control corneas "hanging by suture" (n = 444). RESULTS: There was no significant difference in ECD between corneas attached to the floating device or "hanging by suture" (n = 11; p > or = 0.1). Similarly, no different ECDs were observed between corneas sent off for transplantation with the device (n = 281) and the historical group of control corneas "hanging by suture" (n = 444) (p > or = 0.1). CONCLUSION: The use of the floating device may not affect tissue quality. Since its introduction, the use of the device has been uneventful and greatly facilitated tissue handling.

Pulmonary arterial fibromuscular dysplasia: a rare cause of fulminant lung hemorrhage.

Arterial fibromuscular dysplasia (FMD) represents a collection of noninflammatory and nonatherosclerotic vascular diseases with a poorly understood etiology. Classically occurring in renal and cerebral arteries, this entity has also been reported in coronary, carotid, and other medium and small arteries. One case occurring in the pulmonary vasculature has been reported. Fatal hemothorax and lung hemorrhage have multiple causes, including other vascular malformations and connective tissue disorders; however, cases of pulmonary FMD are exceedingly rare. We report what appears to be the second such association, occurring in a 69-year-old man. The patient presented with a 3-week history of increasing dyspnea, fatigue, and productive cough; 3 days of increasing back and chest pain; and syncope. Chest radiograph showed a "white-out" of the left lung. The patient died shortly after admission from a fulminant respiratory disease of undetermined etiology. At autopsy he was found to have a massive left hemothorax resulting from an unsuspected pulmonary arterial fibromuscular dysplasia.

Infantile disseminated visceral giant cell arteritis presenting as sudden infant death.

The rare clinicopathological entity 'disseminated visceral giant cell arteritis' (DVGCA) was first described in 1978. It is characterized by widespread small-vessel giant cell angitis and extravascular granulomas. A normal and healthy 7-month-old boy who presented unexpectedly with sudden infant death syndrome (SIDS) is reported. Histological examination at autopsy revealed giant cell angitis of the aorta, common carotid, coronary, pulmonary, celiac, mesenteric and common iliac arteries. There were also granulomas in the tracheal wall and liver. To our knowledge, this is the first documented case of DVGCA occurring in an infant younger than 12 months of age. A review of the literature on DVGCA is presented in this report, and the differential diagnosis is discussed.

Catastrophic antiphospholipid syndrome. Clinical and laboratory features of 50 patients.

We analyzed the clinical and laboratory characteristics of 50 patients with catastrophic antiphospholipid syndrome (APS) (5 from our clinics and 45 from a MEDLINE computer-assisted review of the literature from 1992 through 1996). Thirty-three (66%) patients were female and 17 (34%) were male. Twenty-eight (56%) patients had primary APS, 15 (30%) had defined systemic lupus erythematosus (SLE), 6 (12%) had "lupus-like" syndrome, and 1 (2%) had rheumatoid arthritis. Mean age of patients in this series was 38 +/- 14 years (range, 11-74 yr). Three (6%) patients developed the clinical picture of catastrophic APS under the age of 15 years, and 11 (22%) were 50 years old or more. In 11 (22%) patients, precipitating factors contributed to the development of catastrophic APS (infections in 3, drugs in 3, minor surgical procedures in 3, anticoagulation withdrawal in 2, and hysterectomy in 1). The presentation of the acute multi-organ failure was usually complex, involving multiple organs simultaneously or in a very short period of time. The majority of patients manifested microangiopathy--that is, occlusive vascular disease affecting predominantly small vessels of organs, particularly kidney, lungs, brain, heart, and liver--with a minority of patients experiencing only large vessel occlusions. Thrombocytopenia was reported in 34 (68%) patients, hemolytic anemia in 13 (26%), disseminated intravascular coagulation in 14 (28%), and schistocytes in 7 (14%). The following antibodies were detected: lupus anticoagulant (94%), anticardiolipin antibodies (94%), anti-dsDNA (87% of patients with SLE), antinuclear antibodies (58%), anti-Ro/SS-A (8%), anti-RNP (8%), and anti-La/SS-B (2%). Anticoagulation was used in 70% of the patients, steroids in 70%, plasmapheresis in 40%, cyclophosphamide in 34%, intravenous gammaglobulins in 16%, and splenectomy in 4%. Most patients, however, received a combination of nonsurgical therapies. Death occurred in 25 of the 50 (50%) patients. In most, cardiac problems seemed to be the major cause of death. In several of these, respiratory failure was also present, usually due to acute respiratory distress syndrome and diffuse alveolar hemorrhage. Among the 20 patients who received the combination of anticoagulation, steroids, and plasmapheresis or intravenous gammaglobulins, recovery occurred in 14 (70%) patients. The use of ancrod and defibrotide appeared to be effective in the 2 respective patients in whom they were used.

Segmental mediolytic arteriopathy of the splenic and hepatic arteries mimicking systemic necrotizing vasculitis.

Segmental mediolytic arteriopathy, a rare, noninflammatory arterial disease, is fundamentally a variant of fibromuscular dysplasia. The characteristic angiographic findings of segmental mediolytic arteriopathy include the "string of beads" and microaneurysms which are indistinguishable from those of vasculitis, and the correct diagnosis can be made only after histopathologic evaluation of the arterial lesions. Thrombosis, arterial wall hemorrhage, and dissection are among the complications of segmental mediolytic arteriopathy. We describe herein a patient with segmental mediolytic arteriopathy who presented with hemoperitoneum. The patient underwent urgent surgical repair of a ruptured hepatic artery aneurysm. The postoperative visceral arteriography findings led to a clinical diagnosis of polyarteritis nodosa, and immunosuppressive therapy was initiated. This treatment was stopped as soon as the correct biopsy diagnosis of segmental mediolytic arteriopathy was obtained through outside consultation. The patient recovered without drug treatment and was spared the potentially life-threatening complications of immunosuppression.

Pathology of isolated nonclassical and catastrophic manifestations of Takayasu arteritis.

Takayasu arteritis is usually defined as a chronic, progressive, inflammatory, occlusive disease of the aorta and its branches. However, we should remind Takayasu arteritis as a systemic disease. Here I describe nonclassical and catastrophic manifestations of the Takayasu arteritis, which often go unrecognized until after the event. Especially I stress that we should focus on cardiopulmonary complications in Takayasu arteritis.

Visceral intestinal Buerger's disease.

Buerger's disease is a non-arteriosclerotic, segmental, progressive, inflammatory vaso-occlusive disease of unknown etiology. Buerger's disease occurs almost exclusively in susceptible young men who are habitual tobacco users; usually with onset of symptoms before the age of 40 years. Buerger's disease affects both arteries and veins of principally lower and upper limbs and, rarely, of the viscera. To date, only 16 confirmed cases of visceral-intestinal Buerger's disease have been reported in the English-language literature; and all 16 patients were men. We describe here, for the first time, two young women with intestinal Buerger's disease who died of complications of ischemic bowel disease.

Vasculitis unlimited in rheumatoid arthritis an illustrated review.

Rheumatoid arthritis has a multitude of extra-articular manifestations, of which systemic vasculitis is a clinically significant co-morbidity and co-mortality determinant in the prognosis of the disease. Rheumatoid vasculitis may occur in the early stage of the disease but, more commonly, in patients who have had seropositive rheumatoid arthritis for 10 years or longer. Rheumatoid vasculitis has a wide variety of histopathologic expressions and it may affect blood vessels of all sizes (from vasa nervorum or vasa vasorum to the aorta; and occasionally veins and venules). The diagnosis ideally requires biopsy or autopsy tissue confirmation, which is discussed and illustrated in this review.

Vasculopathies of Neurofibromatosis Type 1 (von Recklinghausen Disease).

Vasculopathies are the least publicized but most important manifestation of neurofibromatosis type 1 (NF1, or, von Recklinghausen disease) as the cause of morbidity and mortality in children and young adults afflicted with the disease. Occlusive or aneurysmal disease of arteries of all sizes may occur almost anywhere in the body. Coarctation or segmental hypoplasia of the abdominal aorta with or without renal artery ostial stenosis is a common cause of renovascular hypertension. Although rare, occlusive coronary artery disease in NF1 may result in myocardial infarction and sudden unexpected death. Visceral vasculopathy causes ischemic bowel disease; and catastrophic retroperitoneal or abdominal hemorrhage has been attributed to spontaneously ruptured arterial aneurysms. Peripheral vascular disease in NF1 with limb ischemia requiring an amputation is described for the first time here. Scanty information exists in the current pathology literature on NF1 vasculopathies, hence the presentation of this review.

Gastrointestinal vasculitis and vasculitis associated with gastrointestinal diseases.

Vasculitis and the gut may be linked in two different sets of circumstances. In one, which is more common, the gut is merely one of the several organ-systems affected by systemic vasculitis and vasculitis associated with rheumatic connective tissue diseases or inflammatory bowel disease (secondary vasculitis). In the other, which is more uncommon, the vasculitis is isolated to the gastrointestinal tract (primary vasculitis). In either category, intestinal ischemia with hemorrhage, perforation, or gangrene may be the catastrophic complications that, even with timely surgical intervention, could still carry a high mortality rate. Familiarity with the histopathologic spectrum of primary and secondary gastrointestinal vasculitis is a prerequisite for correct interpretation of biopsy and surgical resection specimens that will determine the appropriate choice of treatment.

Wegener's granulomatosis: histological documentation of common and uncommon manifestations in 216 patients.

BACKGROUND: Wegener's granulomatosis is the prototype of pulmonary angiitis and granulomatosis and a systemic vasculitic syndrome of unknown etiology. Wegener's granulomatosis can involve virtually any and often a multitude of organ-tissues. PATIENTS AND METHODS: This survey of 216 patients provides a histological documentation and pertinent literature review of both the common and uncommon, but with emphasis on the uncommon, manifestations of Wegener's granulomatosis. RESULTS: The common manifestations of the disease include the classic triad of upper airway, lung, and kidney, in 87%, 69%, and 48% of the patients, respectively. The less common manifestations involve the skin, central nervous system, eye and orbit, heart, breast, salivary gland, gastrointestinal tract, spleen, and male and female urogenital tracts; each of these accounts for less than 15% in all cases and below 5% for most of the patients. CONCLUSIONS: The manifestations of Wegener's granulomatosis in many of the uncommon anatomical sites of involvement may be distinctive or atypical and therefore, the histopathological diagnosis must be correlated with clinical and laboratory test findings.

Giant cell granulomatous pulmonary and myocardial lesions in necrobiotic xanthogranuloma with paraproteinemia.

OBJECTIVE: To report three cases of pulmonary or myocardial disease (or both) and necrobiotic xanthogranuloma. MATERIAL AND METHODS: Giant cell granulomas of the lung and myocardium were demonstrated in three patients who had pulmonary and myocardial lesions of necrobiotic xanthogranuloma in conjunction with skin lesions, leukopenia, paraproteinemia, and complement deficiencies. The patients were two men who were 47 and 64 years of age and a 39-year-old woman. RESULTS: Biopsies of skin and visceral lesions showed asteroid and cytoplasmic inclusions. B-cell lymphoid nodules were found. In one of the male patients, a major clonal T-cell receptor gene rearrangement was detected in the peripheral blood. Prednisone was ineffective in two of the patients. The other patient experienced regression of skin lesions and diminishment of a chest nodule after receiving alkylating agent therapy. CONCLUSION: Establishing the correct diagnosis is important, and apparently it is possible to establish the nature of the myocardial and pulmonary lesions with use of appropriate scans and by biopsy. Successful treatment of necrobiotic xanthogranuloma skin lesions with corticosteroids or alkylating agents (or both) implies that evolution of serious disease that compromises the heart and lungs could be controlled.

Intramural sarcoma of the carotid artery with adventitial inflammation and fibrosis resembling 'inflammatory aneurysm'.

A rare case is described of an intramural sarcoma of the right common carotid artery coexisting with adventitial inflammation and fibrosis, resembling 'inflammatory aneurysm', which was resected from a 33-year-old Japanese woman who had presented with a pulsatile mass on the right side of the anterior neck. Grossly, the wall of the carotid artery showed an intimal tear with dissection of the media filled with thrombus. A grayish area, abutting directly onto the dissected space and involving the media and inner adventitia, was composed of alpha-smooth muscle actin-positive and desmin-negative polygonal and spindle cells with large blunt-ended nuclei and coarse granular chromatin arranged into a well-organized interlacing bundle pattern. This portion was thus considered to represent leiomyosarcoma. White to yellow-tan fibrotic tissue present in the adventitial area consisted of extensive lamellar fibrosis with scattered foci of lymphoplasmacytic aggregates and obliterated arteries, and lacked atypical spindle and polygonal cells. These changes accorded with the histopathological findings hitherto described in cases of 'inflammatory aneurysm', which is known to almost exclusively involve the abdominal aorta. We consider this case unique in that the leiomyosarcoma involved an artery other than the aorta, with an 'inflammatory aneurysm'-like reaction in the same site. The possible relationship between these two conditions is discussed.