Primary sclerosing cholangitis, Crohn's disease and HLA-B27 in black South African women.

Crohn's disease is rare in South African black people and primary sclerosing cholangitis (PSC) is also rare in black patients with IBD, from South Africa. The presence of HLA-B27 is generally associated with seronegative spondylo-arthropathies and correlates with the occurrence of ankylosing spondylitis, recurrent mouth ulcers and uveitis, in patients with IBD. We describe two women with the combination of Crohn's disease, PSC and HLA-B27 from our cohort of the last 5 years of three black patients with Crohn's disease. Crohn's disease, PSC and HLA-B27 respectively, occur rarely in black South Africans and their concurrent presence in two black women suggests a pathogenetic link of HLA-B27 between Crohn's disease and PSC in this population. Female gender might be an additional determinant in this setting.

Screening for cervical neoplasia in a developing country utilizing cytology, cervicography and the acetic acid test.

OBJECTIVE: To compare three screening tests for cervical neoplasia. METHOD: Women (6301) were screened simultaneously with cytology, cervicography and the acetic acid test (AAT). Biopsies were taken from the acetowhite lesions and every fifth seemingly normal cervix. Positive cases (both at screening and histology) were referred for colposcopy. The histology results served as the golden standard. RESULTS: Cytology was positive in 1.7% of cases, cervicography in 10.7% and the AAT in 17.8%. The sensitivity of cytology was 19.3%, of cervicography 41.8% and the AAT 49.4%. Corresponding specificities were 99.3%, 78.8% and 48.5%. In 23% of biopsies showing cervical intraepithelial neoplasia (grade I--III), all three screening tests were negative. By combining the three tests, a sensitivity of 76.9% was achieved. CONCLUSION: The sensitivity of cytology alone is not great enough for implementing as a screening test in a developing country where screening programs are often inadequate. Screening with a combination of tests, once or a few times per woman's life, is a more acceptable alternative since it allows for less screening events without sacrifying sensitivity.

Gadolinium ring enhancement and mass effect in acute disseminated encephalomyelitis.

A 9-year-old boy presented with a subacute history of optic neuritis followed by brainstem involvement, with fever and a lymphocytic pleocytosis in the cerebrospinal fluid. Gadolinium-enhancing ring lesions were demonstrated in the white matter of the cerebrum, brain-stem and cerebellum on day 17 of the illness, all appearing simultaneously as part of a monophasic illness. A parietal lesion exerted mass effect. Needling and biopsy yielded no evidence of a pyogenic lesion, tumour or tuberculosis and showed vasculitis. There was insufficient material for myelin staining. Dexamethasone therapy lead to rapid improvement of the radiological lesions: MRI and CT on day 34 of the illness showed complete clearing of the lesions except for residual abnormality at the biopsy site.

The role of mammography to evaluate palpable breast tumours.

Mammography is the best screening tool at present available to detect early breast cancer in asymptomatic women. Its diagnostic ability to clarify the true nature of a palpable tumour in symptomatic breast disease remains controversial. To investigate this, case records of 115 women over 35 years, who presented clinically with a palpable and solid breast tumour over a 5 1/2-year period at Universitas Hospital, Bloemfontein, were retrospectively reviewed. All women were pre-operatively evaluated by clinical examination, mammography and fine-needle aspiration cytology and all patients subsequently underwent open surgical biopsy. Results of this triple diagnostic regimen were correlated to the final histopathological diagnosis. No differences in diagnostic accuracy could be found between mammography and either clinical or cytological diagnosis alone. Combining the clinical finding with that of either mammography or cytology significantly improved the diagnostic ability of both. Malignant disease diagnosed by cytology alone negated the additional diagnostic role of mammography in this context. However, to enable confirmation of a benign tumour, mammography proved to be an essential addition to clinical and cytological evaluation. Mammography correctly detected multicentricity in 7% of malignant tumours, proving it to be essential before breast-conserving surgery could be carried out for malignant tumours.

Pre-operative evaluation of palpable breast tumours.

The diagnostic accuracy of clinical examination, mammography and fine-needle aspiration cytology in identifying malignancy was retrospectively assessed in 207 women with palpable breast masses undergoing breast biopsy for histological examination. Clinical examination was more sensitive (96%) than mammography (81%) or cytology (69%). Cytological examination was totally specific for malignancy. The combined evaluation of clinical examination, mammography and cytological examination revealed a 100% diagnostic accuracy for concordant triplet results. Where discordant triplet results were recorded, 75% of tumours were malignant. Biopsy and frozen section are thus recommended if the 'triplet' provides conflicting results. Preliminary biopsy and frozen section may be unnecessary when the diagnostic triplet unequivocally demonstrates malignancy, or when cytological examination reliably reveals the presence of malignancy. Where the components of the triplet all point to benignity, the patient may be confidently followed up without the necessity of biopsy. The adoption of these guidelines may safely reduce the number of open breast biopsies by about 50-60%.

Paired membrane-filament complexes in an acoustic neuroma.

An acoustic neuroma that developed in the posterior fossa of a 43-year-old black man was studied ultrastructurally. Unusual paired membrane-filament complexes were noticed in the cytoplasm of many tumor cells and appeared as multilayered parallel and concentric arrays in various planes of section. The paired membranes were found to be discontinuous with other membrane systems of the tumor cells. The cisternal space measured 25 nm across and housed a regularly arranged, single file of filaments 9 nm in diameter spaced 12 nm apart. In view of the biologic significance and possible origin of these structures, the paired membrane-filament complexes are morphologically compared with the myelin sheaths and cytoplasmic processes in this tumor.

Cervical cytological services in the Orange Free State. Demographic characteristics.

In the Bloemfontein academic hospitals the incidence of infiltrating cervical cancer is four times that of severe cervical intra-epithelial neoplasia (CIN III). A cross-sectional survey was therefore conducted to identify the extent of cervical cytological services in the Orange Free State. From the four major laboratories dealing with the population of the OFS all cytological reports of one randomly chosen working day per month in 1985 were analysed for three demographic variables: age, race, and locality according to census district. As a control, similar demographic variables were identified from national census figures for 1980, limited to females aged 15-65 years. The follow-up of patients with CIN III diagnosed cytologically in the academic hospitals in Bloemfontein was determined. Results showed significant differences (P less than 0.001) in age, race and locality between the census population and that submitted to cytological screening. Acceptable figures were virtually limited to Bloemfontein, predominantly in white patients, while three-quarters of the population of the OFS is black. The peak frequency in the age distribution in the screened population was 25-35 years and 15-24 years for the census population. Follow-up for patients with CIN III was 65.5%. The conclusion is that the female population of the OFS is not representatively reached by existing cytological services.

Placental site trophoblastic tumour (trophoblastic pseudotumour). A case report.

The term 'gestational trophoblastic disease' includes hydatidiform mole (invasive and non-invasive), choriocarcinoma and a rare condition initially called trophoblastic pseudotumour and more recently placental site trophoblastic tumour. Originally this condition was viewed as benign, but recent reports indicate that it may be fatal. The first report of a South African patient with this uncommon condition is presented.

The association between ulcerative colitis and chronic liver disease at Tygerberg Hospital.

Twenty consecutive patients with ulcerative colitis were evaluated at the Gastro-intestinal Clinic, Tygerberg Hospital, with special reference to the biochemical tests and histological findings in the liver. Abnormal liver function tests warrant a liver biopsy, since the underlying liver disease influences the subsequent prognosis and treatment.