Histologic diagnosis of primary hyperparathyroidism: a concordance analysis between three pathologists.

Primary hyperparathyroidism (HPT) is caused by a parathyroid adenoma, hyperplasia or carcinoma. Difficulties for the histologic diagnosis of abnormal parathyroid tissue are widely recognized. The aim of the study was to evaluate the reproducibility of the morphologic criteria through a concordance study among three pathologists. Representative slides of 40 patients with biochemically primary HPT stained with hematoxylin and eosin were blindly reviewed by three pathologists. Each pathologist established the diagnosis of adenoma or hyperplasia and assessed the presence of fat cells, a rim of normal tissue, a fibrous capsule, the number of cellular types, the lobular pattern, and the characteristics of the blood vessel's wall. A concordance analysis was then performed. Mean age of the group was 55 +/- 14 yr, 7 were males and 33 females. The concordance analysis among the three pathologists for the differential diagnosis between adenoma and hyperplasia, showed a Kappa index of 0.5. Kappa index for the presence of fat cells was 0.56, for the presence of a rim of normal tissue 0.47, and for the number of cellular types 0.29. The concordance for the differential diagnosis between parathyroid adenoma and hyperplasia in this study was low.

[Neutropenic enteropathy associated with autoimmune diseases. A more aggressive presentation]. / Enteropatía neutropénica asociada a enfermedades autoinmunes. Una presentación más agresiva.

BACKGROUND: There is just one case report dealing with neutropenic enteropathy associated with autoimmune diseases. METHOD: An autopsy analysis of neutropenic enteropathy in autoimmune and hematologic diseases was carried on. Gross findings and slides were reviewed. A blind analysis is of the mucosal lesions in small and large intestine as well as of the clinical course was made. RESULTS: Seventeen cases of neutropenic enteropathy were found a once period of 13 years (1,068 autopsies). Fourteen cases were seen in patients with hematologic diseases and three in patients with autoimmune diseases. Acute symptoms had a 6-day evolution and were characterized by abdominal pain, diarrhea, ascitis, and fever in autoimmune diseases. Extension of colonic damage was 58 and 13% in small bowel. Cases associated with hematologic diseases had longer clinical course with fever abdominal pain and colonic lesions in 21% of the surface and small bowel lesions in 6% of the mucosa. No acute inflammatory infiltrate around the necrotic zones was observed in either group Azathioprine, steroids, methotrexate, and alkylating agents were associated to neutropenia. CONCLUSIONS: Clinical evolution and morphologic findings were more severe in neutropenic enteropathy associated with autoimmune diseases than in patients with hematologic diseases.

Two cases of psychogenic purpura.

Psychogenic purpura, also known as recurrent painful bruising or autoerythrocyte sensitization syndrome (Gardner-Diamond syndrome) is usually associated with emotionally disturbed patients. It is a troublesome entity for both patient and physician since extensive work-ups yield no diagnosis. We describe two females in their early twenties with recurrent painful bruising and diverse accompanying symptoms which appeared after physical trauma. One of the patients developed a bruise after intradermal injection of her own blood (with no reaction to saline injection). One patient had a personality (borderline) disorder, the other a factitious disorder. Punch biopsies revealed a perivascular inflammatory infiltrate, erythrocyte extravasation and no vasculitis. Psychogenic hemorrhagic disorders are uncommon yet must be considered in the differential diagnosis of purpura. Patients are usually young emotionally troubled females who present painful recurrent bruises on extremities frequently after trauma or surgery. Autoimmune mechanisms and increased cutaneous fibrinolytic activity have been implicated, although further studies are needed. Correct diagnosis is important to avoid aggressive and even mutilating treatments, and an adequate comprehension of these purpuras is important for the attending physician.

[Clear-cell eccrine carcinoma of the plantar region. Follow-up of a case using histochemistry, immunohistochemistry, and flow cytometry]. / Carcinoma ecrino de células claras en región plantar. Seguimiento de un caso por histoquímica, immunohistoquímica y citometría de flujo.

Clear cell eccrine carcinomas of the skin are rare and have been reported with several names. Of the 47 cases found in the literature, only one had the lesion in the sole. The present case is a 38 year old woman with an 18 year history of a 3.2 cm lesion in the lateral portion of the sole in the right foot. The patient developed inguinal metastases four and five months after the plantar resection, and suffered a local recurrence on two occasions. The histopathologic analysis of the sole lesion showed a neoplasm with more than 80% of clear cells, and less clear cells in the metastatic and recurrent lesions. Clear cells showed diffuse positivity to PAS with diastase lability. PAS reactivity was related to the presence of clear cells. Focal reactivity of mucin and colloidal iron in sebaceous-like cells and tubular structures was seen. Also, we found diffuse cytoplasmic and membrane surface positivity of epithelial membrane antigen in the clear cells, and focal in poroid and sebaceous cells and in tubular structures. The carcinoembryonic antigen showed a focal positivity in poroid and sebaceous cells and in tubular structures. We also identified focal positivity of S-100 protein in the sebaceous-like cells. Cytophotometric measurement of the nuclear DNA showed euploid cells in the primary and metastatic lesions. We conclude that clear cell eccrine carcinomas comprise a heterogeneous group of lesions with variable biological behavior, but with morphological, histochemical and immunohistochemical markers useful in their diagnosis.

[2 cases of neutropenic enteropathy and bone marrow hypoplasia. An association not reported in Mexico]. / Dos casos de enteropatía neutropénica e hipoplasia medular. Asociación no informada en México.

Neutropenic enterocolitis (NE) is a serious complication in neutropenic patients; it often affects the cecum and the ascending colon. Most cases have been reported in neutropenic patients after chemotherapy for hematologic neoplasms, and some in association with conditions such as rheumatoid arthritis, benign cyclic neutropenia, and solid neoplasms. As far as we know, four cases of NE associated to AA (aplastic anemia, hypoplastic bone marrow) have been previously reported, two of them with autopsy studies. The macroscopic findings in the enterocolonic lesions were not illustrated. We report the first two cases in Mexico. The NE was neither clinically nor radiographically suspected initially, i.e. the morphologic diagnosis of their colonic lesions were amebic colitis in one and edematous ulcerated colitis in the other. Medical treatment without surgery was instituted. Both died. The macroscopic aspect of the enterocolonic lesions in NE associated to aplastic anemia in our two patients was similar to that in NE associated to hematologic neoplasms. In Mexico there is little experience in the clinical, radiographic or morphologic diagnosis of this rare association.

[Neutropenic enteropathy associated with multiple myeloma]. / Enteropatía neutropénica asociada a mieloma múltiple.

Neutropenic enteropathy and multiple myeloma. Neutropenic enteropathy (NE) is an acute entity with an aggressive clinical behavior. The most common reported association of NE is with neutropenic children under chemotherapy for leukemias and lymphomas, other less common causes include: neutropenic adults with treatment for autoimmune diseases, aplastic anemia, cyclic benign neutropenia or solid-neoplasms. There are two cases of NE associated to multiple myeloma (MM). There was a 62 year old man with MM diagnosed ten months earlier and under chemotherapy. He developed abdominal pain, nausea, vomiting, diarrhea and rectal bleeding three days before death. The autopsy study revealed ulcers and thickening of the colonic wall in 40% of the entire surface, and in 5% of the ileum. The microscopic analysis revealed mucosal and submucosal ischemic necrosis, and bacterial invasion without acute inflammatory response. As the two previously reported cases, he received vincristine and steroids a few days before developing neutropenia. This report shows the clinical and morphologic findings of the third case of the association of NE and MM, and the first one illustrated in Mexico.

[Phlegmonous colitis]. / Colitis flemonosa.

Phlegmonous inflammation of the digestive tract is a rare lesion related in the majority of the previously described cases to systemic infections and chronic hepatic diseases. Both process may promote gastric and intestinal loss of the mucosal local defenses mechanisms against bacterial invasion. The term phlegmonous enterocolitis or gastritis defines an acute inflammatory process with purulent or nonpurulent character, that selectively damages the gastric, small and large intestines submucosal layer. The intestinal lesions are more frequently located in the small portion, followed by the colonic involvement. In the present paper we describe the postmortem findings and clinical course of a case with phlegmonous colitis in a 53 years old woman with cirrhosis and S pneumoniae septicemia.

[Esophageal candidiasis in AIDS. Clinical, endoscopic, and histopathologic analysis of 19 cases]. / Candidiasis esofágica en SIDA. Análisis clínico, endoscópico e histopatológico en 19 casos.

From May 1988 to December 1989, fiberoptic endoscopy of the upper digestive tract was performed in 53 patients with AIDS. In 19 cases a presumptive diagnosis of candida esophagitis was made: 13 were men and six women; the median age was 38.9 years. The Kodsi grading scale was used to evaluate the extent of the fungal colonization. In five patients no symptoms were found, eight did not show oral candidiasis; dysphagia in seven cases and odynophagia in five cases were the main esophageal complaints. Eleven cases showed pan-esophagitis, but three cases showed only the distal portion involvement. Grade II lesions were observed in ten patients, and four had grades I or III. No correlation was found between the symptoms and the grade score. Direct brushing cytology of the esophageal lesions corroborated the endoscopic diagnosis. Association with other opportunistic infections were detected only in one case. Our findings corroborates the usefulness of the fiberoptic esophageal endoscopy to improve the diagnosis of AIDS-related esophageal candidiasis in patients without symptoms or oral lesions.

[Sporadic trichinosis]. / Triquinosis esporádica.

A retrospective analysis was carried out to disclose the clinical and laboratory characteristics of 13 cases with sporadic trichinosis, proved by muscle biopsy at the "Salvador Zubirán" National Nutrition Institute and studied between 1977 and 1986. The number of cases per year was one or two with an increase to five in 1986. None of this patients showed a direct correlation between the type of diet or a specific area of the city. The clinical symptoms and physical findings were similar to those described previously for trichinosis, regardless of the clinical setting. In 69.1 percent of the cases the diagnosis was suspected based on clinical and physical data, and 84.6 percent had blood eosinophilia. Muscle biopsy was taken due to predominant muscular symptoms (92.3%) and this method was the most useful test to establish a specific diagnosis; no correlation was found between the number of larvae or cyst and the clinical symptoms. Thiabendazole and/or prednisone was administered and resulted in apparent improvement of the myopathy and blood eosinophilia during the follow-up (x: 7 months). A discussion is presented in relation to the usefulness of the muscle biopsy when a lack of specific enzyme tests exists; we emphasize the clinical manifestations and laboratory findings to suspect this zoonosis when a multisystemic inflammatory disease with striking myopathy is detected.

[Immunoreactive urinary thromboxane B2 in experimental mesenteric thrombosis in dogs]. / Tromboxano B2 urinario inmunorreactivo en trombosis mesentérica experimental en perros.

Thromboxane B2 (TxB2) the stable metabolite of thromboxane A2 may be released as a response to ischemia. With the aim of investigating its role as an early diagnostic test in mesenteric thrombosis, immunoreactive TxB2 was measured in urine aliquotes in six sham operated dogs, nine dogs subjected to superior mesenteric artery ligation, and twelve dogs with superior mesenteric vein ligation. One hour urine volumes were collected before surgery and during the eight hours after the experimental procedures, and urinary osmolarities were also determined in each sample. Basal TxB2 levels were comparable in all groups. Although all groups showed a significant and rapid (one hour) increase in TxB2 as a response to surgery, in the controls it returned to normal after six hours, whereas in the rest a continuously increased production persisted throughout the study period. There was no difference in t-test comparisons depending on the sort of thrombosis. In spite of the urinary dilution induced during the study, a persistent increase in TxB2 excretion was found. We conclude that urinary TxB2 levels could prove useful in the early diagnosis of mesenteric ischemia.

[Xanthogranulomatous cholecystitis. Clinical entity or pathologic curiosity]. / Colecistitis xantogranulomatosa. Entidad clínica o curiosidad patológica.

Xanthogranulomatous cholecystitis is an uncommon variety of gallbladder inflammation. Its histologic appearance is quite specific but its clinical characteristics, prognostic and physiopathologic implications are unknown. The present study has the aim of analyzing a group of 40 patients with xanthogranulomatous cholecystitis and another of 80 patients with non-xanthogranulomatous inflammation. The clinical characteristics, risk factors, morphologic expression, complications and mortality of both groups were compared. Diffuse xanthogranulomatous cholecystitis comprised 1.8% of all cholecystectomies done between January 1976 and July 1987. This variety was more frequent in males (p less than .05) without any specific risk factors. There was a higher frequency of acute pyogenic inflammation sometimes associated to extrinsic compression of the biliary duct and fistulization, but without any difference in the overall complication rate or mortality. We conclude that xanthogranulomatous cholecystitis is a specific entity which occurs with a higher frequency in males and that has a different clinical behavior than that of other types of gallbladder inflammation.