Autopsy findings in the acquired immunodeficiency syndrome (AIDS). A report of 395 cases from the south of France.

Necropsy findings in 395 adult patients with the acquired immunodeficiency syndrome (AIDS) who died in Nice, France, between March 1983 and May 1996 were compared retrospectively with antemortem diagnoses, risk factors and number of positive T CD4 lymphocytes at the time of death. Special emphasis on bacterial infections was made in this study. Lesions observed from 1983 through 1989 and from 1990 through 1996 were compared. We assessed the role of organ lesions in the immediate cause of death. The organ system distribution of major opportunistic infections and neoplasms was similar throughout the years of the study. The most common diagnostic disease entities in all organ sites were cytomegalovirus infection, toxoplasmosis and candidiasis. Toxoplasmosis was more common in the intravenous drug abuser group. Bacterial infections were frequent and contributed to the mortality and morbidity of all risk factor groups. Kaposi' sarcoma continued to occur more frequently in the homosexual population. Cytomegalovirus infection remained one of the most common causes of death from 1983 to 1996. Mortality from fungal and bacterial infections, and mycobacteriosis increased in frequency during the course of this study whereas deaths from pneumocystosis declined. The death rate from malignant lymphoma and carcinoma increased after 1989. The clinical cause of death concurred with the pathological cause in 55% of the cases. Lung was the most frequent organ involved followed by the central nervous system the gastrointestinal tract and the heart.

Oral cryptococcosis: case report of salivary gland involvement in an AIDS patient.

Salivary cryptococcosis was disclosed at autopsy in an AIDS patient with disseminated C. neoformans infection. H & E staining was not suitable to demonstrate the occurrence of C. neoformans in many tissues; Alcian blue gave the best results.

[Coral as support of traumatic articular compression. A prospective study of 23 cases involving the lower limb]. / Le corail comme soutien d'un enfoncement articulaire traumatique. Etude prospective au membre inférieur de 23 cas.

INTRODUCTION: Infection risk makes the management of a bone bank more and more difficult. On the other hand, realizing an autologous graft is not always without consequences. That is why we estimated the mechanical quality, the osteo-integration and the biocompatability of a coral graft. MATERIAL AND METHODS: Between 1988 and 1992, two of us systematically used coral graft as "support" after lifting of some articular depression in fractures of inferior limb. Osteosynthesis was systematically associated. In this way, we operated 13 fractures of the lateral tibial plateau, 8 thalamic fractures of the calcaneus and 2 fractures of the inferior extremity of the tibia. Average follow-up is 20 months, with extremes of 68 and 12 months. Material ablation was realized 13 times and coral graft biopsy 4 times. Bone integration was estimated radiologically in 3 stages: stage 1: non union = "margin" around the coral, stage 2: possible integration = the coral is perfectly visible, but its borders grow indistinct, stage 3: certain integration = peripheral disparition of the coral weft, radiological interpenetration between coral and bone framework. We systematically searched for secondary displacements and complications. RESULTS: Mechanical conditions were respected, there was no secondary displacement. "Possible integration" (stage 2) was found in 8 cases at an average follow-up of 20 months. In 9 cases, we found "certain integration" (stage 3), at an average follow-up of 28 months. It is possible that a more important follow-up time would allow to find more integration cases. Biocompatibility is debatable under the operating conditions of the authors. We counted 5 aseptic serous flows which continued to be aseptic (1 tibial plateau, 1 inferior extremity of the tibia, 3 calcaneum). Three coral grafts were removed to obtain healing. DISCUSSION: When biocompatibility is satisfactory the integration is certain. The longer the follow-up time, the more stage 3 cases can be observed. Nevertheless, this integration runs out with time. We did not find any explication to aseptic serous flows. It may result from some impurities. On the other hand, use of the coralin hydroxyapatite does not seem to drive to allergic complications. CONCLUSION: In accordance with this study, we use the coral graft only in case of tibial plateau fracture. Our experience with coral graft in the other fields of bone surgery is not sufficient to express an opinion.

[Colonic Histoplasma capsulatum pseudotumor in AIDS. Morphological and immunohistochemical diagnosis of an isolated lesion]. / Pseudotumeur colique à Histoplasma capsulatum au cours du SIDA. Diagnostic morphologique et immunohistochimique d'une lésion isolée.

The authors report a case of a 35-year-old man with acquired immunodeficiency syndrome (AIDS) and a left colonic mass with Histoplasma capsulatum (H. capsulatum). The look-up performed looking for disseminated infection was negative. In the absence of positive cultures, the diagnosis was determined morphologically based on the presence of yeast observed by light and electron microscopy. The diagnosis was also verified by positive immunofluorescence using specific anti-Histoplasma antibodies. Gastrointestinal histoplasmosis is a frequent complication of AIDS, particularly in some endemic areas of America. Association with a disseminated mycotic infection is then common. Histoplasmosis is less frequently diagnosed in Europe and isolated involvement of the colon is exceptional. When the mycological study is not performed or is negative, only morphological and immunohistochemical methods are able to establish the diagnosis and eliminate other mycotic diseases occurring during AIDS.

Intestinal and extraintestinal Isospora belli infection in an AIDS patient. A second case report.

A 30-year-old black female, from Burkina Faso, had AIDS in 1990. She died in March 1993 following a cachexia secondary to a chronic intestinal isosporiasis. The autopsy revealed a massive parasitic infection by I. belli of the small intestine mesenteric and mediastinal lymph nodes and liver and spleen. The parasite stage observed in extra intestinal sites corresponded to unizoite tissue cysts. This is the first report of I. belli infection in liver and spleen.

[Acute toxoplasmic pancreatitis. An unusual cause of death in AIDS]. / Pancréatite aiguë toxoplasmique. Une cause inhabituelle de décès au cours du SIDA.

We report a case of an acute toxoplasmic pancreatitis that led to the death of an AIDS patient. Aetiological diagnosis was performed by the post mortem histological examination. On haematein-eosin staining, toxoplasmic cysts and pseudocysts were noted in the pancreatic acini. Immunohistochemical study using anti-Toxoplasma gondii polyclonal antibodies showed free parasitic forms or tachyzoites in the necrotic areas. Toxoplasmic cysts without any inflammatory reaction were observed in the lungs. In the acquired immunodeficiency syndrome, involvement of the pancreas by toxoplasmosis is very rare and associated with a multivisceral dissemination. Even if this diagnosis is exceptional, acute toxoplasmic pancreatitis must be considered in an AIDS patient when the other causes of pancreatitis, as drugs or infectious diseases, have been eliminated.

Oral leishmaniasis and Kaposi's sarcoma in an AIDS patient.

In the Mediterranean basin area, visceral leishmaniasis is an endemic disease caused by Leishmania donovani infantum. This study describes the clinical and pathological features of one patient with AIDS who had oral (tonsillar) leishmaniasis, caused by a viscerotropic zymodeme, concurrent with a Kaposi's sarcoma and with a CMV infection.

Cutaneous spindle-cell pseudotumors due to Mycobacterium gordonae and Leishmania infantum. An immunophenotypic study.

We report two patients with AIDS who had cutaneous spindle-cell pseudotumors caused by Leishmania infantum in one instance and by an atypical mycobacterium in the other. The lesions mimicked neoplasms with predominantly spindled macrophages, similar to those seen in the histoid variant of leprosy. This histoid reaction is known to be related to mycobacteria. To our knowledge, this is the first case of histoid reaction due to leishmania. In both cases, the histiocytic cells were positive for vimentin and desmin but negative for alpha-smooth muscle. In addition, the immunostaining by lysosyme and alpha 1 antitrypsin was positive in both and in one the S-100 protein was positive. This reaction suggests dual myofibroblast and histiocytic differentiation.

[Acute Staphylococcus aureus myocarditis in AIDS. 2 cases]. / Myocardite aiguë à Staphylococcus aureus au cours du sida. Deux observations.

The authors report two cases of acute myocarditis due to Staphylococcus aureus in patients with AIDS. There was no history of opportunist infections in either case but the CD4 lymphocyte levels were very low. The myocarditis caused acute cardiac failure and death. Histological examination showed microabscesses filled with Gram positive cocci throughout the myocardium. Bacteriological studies identified the Staphylococcus aureus. Staphylococcus aureus myocarditis without endocardial or pericardial involvement is very rare. It is the result of septic emboli in the cardiac microcirculation. Bacterial myocarditis has rarely been diagnosed in HIV positive patients. Both our cases featured severe cell-mediated immunodeficiency without associated neutropaenia. The decreased bactericidal activity of the neutrophil polynuclears and/or a deficit in the immunity mediated by the B-cell lymphocytes in AIDS could explain the lethal septic complications observed in our two cases.

[Sertoli-Leydig tumors in children. 2 case reports]. / Tumeurs de Sertoli-Leydig de l'enfant. A propos de deux observations.

Sertoli-Leydig tumors stem from the mesenchyma and sexual cords of the embryonic gonad. Two cases are reported. One manifested as symptoms of virilization in a 12 year old girl. The other patient developed adnexal torsion at the age of five years. Pelvic ultrasonography visualized the tumor in both cases. Increased production of ovarian androgens suggested the diagnosis in the first case. Histological studies disclosed intermediate differentiation in the first case and tubular differentiation in the second. These tumors usually exhibit low-grade malignancy and unilateral salpingo-oophorectomy ensures recovery in most instances.

Extracerebral toxoplasmosis in the acquired immunodeficiency syndrome (AIDS).

Although Toxoplasma gondii frequently causes lesions of the central nervous system in AIDS, the exact incidence of extracerebral toxoplasmosis in these immunodepressed patients remains difficult to determine. Isolation of the parasite outside the central nervous system is rarely performed ante mortem, and most diagnoses of extracerebral toxoplasmosis are made post mortem. This article describes 23 cases of extracerebral toxoplasmosis diagnosed between 1987 and 1991 in an autopsy series of 170 patients infected with the human immunodeficiency virus (HIV). Ante mortem diagnosis of extracerebral involvement was affirmed in 4 of these 23 patients by identification of trophozoites in bronchoalveolar lavage fluid (2 cases), a surgical pulmonary biopsy specimen, and a bladder biopsy. Clinical and paraclinical findings suggested cardiac involvement in 4 other patients. Post mortem examination demonstrated disseminated toxoplasmosis in 18 cases and extracerebral monovisceral involvement in 5 cases. Extracerebral toxoplasmosis was directly responsible for the death of 6 patients. The most frequent extracerebral sites of Toxoplasma gondii involvement were the heart (21/23 cases; 91%), the lungs (14/23 cases; 61%) and the pancreas (6/23 cases; 26%). The tissular consequences of toxoplasmic involvement varied considerably, from formation of pseudocysts or cysts without any surrounding inflammatory reaction to necrotic lesions rich in neutrophilic polynuclear cells containing numerous free parasites. Immunoperoxidase study using antitoxoplasmic antibodies contributed to the diagnosis of 8 extracerebral localizations. Electron microscopy examination of a surgical lung biopsy and myocardial specimens (2 cases) demonstrated the ultrastructural characteristics of Toxoplasma gondii trophozoites.(ABSTRACT TRUNCATED AT 250 WORDS)

[The endometrium under the effects of hormone replacement therapy in menopause with percutaneous estradiol and low-dose micronized progesterone]. / L'endomètre sous traitement hormonal substitutif de la ménopause par estradiol percutané et progestérone micronisée à faible dose.

AIM: The aim of our study is to evaluate the effects of a new combined association of percutaneous estradiol with oral micronized progesterone during 25 days/month and to confirm that a low dose of progesterone (100 mg/day) can adequately counteract endometrial proliferation induced by estradiol. METHODS: 78 endometrial tissue samples were obtained in a multicenter study on the effects of hormonal replacement therapy of the menopause. Endometrial biopsies were performed on average at the 6.6 month of the hormonal substitution (range: 5-13 months) after 12 days minimum exposure to progesterone. The morphological evaluation was performed blindly. RESULTS: All endometria are only slightly developed, without hyperplasia. Four groups were individualized: subatrophic endometrium (3), quiescent endometrium (48), slightly active endometrium (18), and endometrium with marginal secretion (6). Rare mitosis images have only been found in slightly active endometria. Their number is always very much below the normal proliferative phase with only 3 cases between less than 3 and 6 mitoses per 1000 glandular epithelial cells. CONCLUSION: A low micronized progesterone dose (100 mg/day) over a long period (25 days per month) allows to efficiently control the estrogen-induced endometrial proliferation. This adequate endometrial response is responsible for a high incidence of amenorrhea, often asked by patients, and for rare spottings.

Pathological features of intestinal microsporidiosis in HIV positive patients. A report of 13 new cases.

Enterocytozoon bieneusi is a microsporidian parasite found only in the enterocytes of the small bowel of HIV positive patients, producing chronic diarrhea and malabsorption. Since January 1990, we have seen the 13 first Mediterranean cases, diagnosed on duodenal pinch biopsy samples. Diarrhea was the major symptom in all instances, and E. bieneusi was the sole identified pathogen in 6 cases. The diagnosis was made on HES or Giemsa-stained paraffin sections and on Giemsa-stained smears (9 cases). In 3 cases, the parasite was also found on ileal biopsies, but was never encountered in the colonic mucosa. In all patients, transmission electron microscopy of the duodenal mucosa was used, and it confirmed the diagnosis of intestinal microsporidiosis. No instance with negative optic examination had evidence of an infection by E. bieneusi with electron microscopy. Due to the small size of the spores, routine fecal parasitological diagnosis is still a difficult procedure, but it is possible that greater experience may avoid many of today's invasive investigations. Cytologic and histologic routine examination of paraffin sections of the distal duodenal or ileal mucosae is a reliable method to diagnose intestinal microsporidiosis in HIV-positive patients with diarrhea.

[Neuroma of the common bile duct]. / Névrome de la voie biliaire principale.

After a surgical operation on the biliary tract, stenoses can occur, most of the time due to fibrotic lesions, and more rarely due to granulomas or traumatic neuromas. The latter generally develop on the cystic stump after a cholecystectomy. The occurrence of a traumatic neuroma on the common bile duct is much more rarely described. We report the case of a 64 year-old man presenting, four years after a surgical removal of the gallbladder, with a cholangitis, due to neuroma located on the choledochus. He was treated by surgical resection of the common bile-duct at the site of the stenotic zone, and choledocojejunal anastomosis; post-operative course was satisfactory.

[Toxoplasmosis in AIDS patients. Pathoclinical study of 78 cases]. / Toxoplasmose au cours du SIDA. Etude anatomoclinique de 78 cas.

We report 78 cases of toxoplasmosis diagnosed between 1987 and 1992, from an autopsy study of 205 patients infected by the human immunodeficiency virus (HIV). Of the 78 patients 22 were females (28%) and 56 males (72%). Risk factors were as follows: intravenous drug addiction (44 cases, 56%), homosexuality or bisexuality (18 cases; 36%) and multiple blood transfusions (6 cases). Cerebral toxoplasmosis (CT) was diagnosed in 73 cases (93%) and was characterized by abscesses (59 cases), diffuse encephalitic lesions (8 cases), isolated cysts without inflammation (3 cases) and hemispheric involvement with ventricular hemorrhage (3 cases). Cerebral involvement were isolated (55/78 cases; 70%) or associated with multi-visceral diffusion (18/78 cases; 23%). Isolated extracerebral localization was observed in 5 cases. The most frequent extracerebral sites were: cardiac (21 cases), pulmonary (14 cases) and pancreatic (7 cases). Immunohistochemical study with anti Toxoplasma gondii antibodies allowed to a diagnosis of extracerebral localization in 8 cases. Ultrastructural features of Toxoplasma gondii were studied on post mortem myocardial samples (2 cases) open lung biopsy (1 case) and bladder biopsy specimen (1 case). Antemortem diagnosis of cerebral toxoplasmosis was performed on CT-scan in 59/73 (80%). Antemortem diagnosis of extracerebral toxoplasmosis was performed or suspected in 8/23 cases (34%): by isolation of trophozoites in bronchoalveolar lavage (2 cases), on an open lung biopsy (1 case) and on a bladder biopsy specimen (1 case), and by clinical and echocardiographic data (4 cases). Anti-toxoplasmic serology allowed to the diagnosis of toxoplasmosis in 12/78 cases (15%) by showing high levels of IgG in the serum.(ABSTRACT TRUNCATED AT 250 WORDS)

[Histological aspects of mycotic infections in acquired immunodeficiency syndrome (AIDS)]. / Aspects histologiques des infections mycotiques au cours du syndrome d'immunodéficience acquise (SIDA).

After some general epidemiological data concerning mycoses occurring during the acquired immunodeficiency syndrome (AIDS), the role of the pathologist in the diagnosis of mycotic diseases is reviewed. Histological methods and criteria allowing fungal identification in tissues are described. Changes in the inflammatory reaction in contact with mycoses arising in these immunodeficient hosts are reported. The various mycoses observed in HIV positive patients are then reviewed as well as their morphological features and their various sites.

[Rhino-orbito-cerebral mucormycosis caused by Rhizopus oryzae.A typical case in a cirrhotic patient]. / Mucormycose rhino-orbito-cérébrale due à Rhizopus oryzae. Un cas typique survenu chez une patiente cirrhotique.

The rhino-orbito-cerebral mucormycosis is an acute rapidly progressive fungal infection. This disease is caused by a zygomycetes fungus, most often from the Rhizopus genus. This fungus is saprophitic of the nasal cavity and paranasal sinuses. It becomes pathogenic in some particular conditions, specially during diabetes mellitus. Histopathological study is the only method allowing the diagnosis, by revealing the tissue invasion by characteristic hyphae. Mycologic study allows a definitive identification of the fungus. The authors report a case of rhino-orbito-cerebral mucormycosis in a 44 year-old woman with cirrhosis. She presented an acute blindness and ophthalmoplegia. Despite of a rapid histologic diagnosis from the nasal and ethmoidal biopsies, the patient died 3 days after.