Airway complication contributing to disseminated fusariosis after lung transplantation.

Fungal infections are common after lung transplantation. However, disseminated fusariosis is rare and we report the first case of airway complications associated with this infectious process. A 77-year-old Caucasian woman, who was status post left single-lung transplant for emphysema, presented to clinic 8 months after lung transplantation with pleurisy, shortness of breath, and declining lung function. Bronchoscopy showed narrowing of the left anastomotic site with dynamic compression during exhalation. An AERO stent was deployed successfully, but 3 weeks later, her symptoms recurred. Bronchoscopy showed total stent occlusion with thick tenacious mucus. Fusarium solani was isolated from cultures, and a new 1.5 cm skin nodule was found on the anteromedial midportion of the patient's left lower leg. Voriconazole and anidulafungin were started. No evidence of mucus accumulation was seen during a follow-up bronchoscopy. It is likely that Fusarium infection contributed to the initial anastomotic complication as well as to obstruction of the stent. Furthermore, the stent may have contributed to establishment and development of disseminated fusariosis. With antifungal therapy, stent patency was maintained and the patient improved clinically.

Clinical and pathologic features of Mycobacterium fortuitum infections. An emerging pathogen in patients with AIDS.

The clinical and pathologic features of Mycobacterium fortuitum infection in 11 patients with AIDS were characterized. Nine patients had cervical lymphadenitis; 2 had disseminated infection. The infection occurred late in the course of AIDS, and the only laboratory abnormality seen in more than half of patients (7/11) was relative monocytosis. Absolute monocytosis also was seen in 4 of 11 patients. In both cytologic and histologic preparations, the inflammatory pattern was suppurative with necrosis or a mixed suppurative-granulomatous reaction. M fortuitum, a thin, branching bacillus, stained inconsistently in direct smear and histologic preparations. Staining was variable with Gram, auramine, Brown-Hopps, Gram-Weigert, Kinyoun, Ziehl-Neelsen, modified Kinyoun, and Fite stains. Organisms, when present, were always seen in areas of suppurative inflammation. Incorrect presumptive diagnosis, based on misinterpretation of clinical signs and symptoms or on erroneous identification of M fortuitum bacilli as Nocardia species, led to a delay in proper therapy for 7 of 11 patients. Definitive therapy after culture identification resulted in complete resolution of infection in all patients except 1.

Anitschkow nuclear changes in postmortem pericardial scrapings.

OBJECTIVE: To document the presence of Anitschkow nuclear changes (ANC) in pericardial mesothelium at autopsy after the incidental finding of ANC in pericardial scrapings from a fatal case of overwhelming sepsis. STUDY DESIGN: Fourteen, nonconsecutive autopsy cases were studied. Using the edge of a scalpel, the visceral pericardium from the left ventricle was scraped, and the sample was smeared onto glass slides, fixed in 95% ethanol, Papanicolaou stained and evaluated for the presence of ANC. Histologic correlation was also performed. RESULTS: ANC were observed in pericardial mesothelial cells in 6 of 14 cases. Sepsis was the cause of death in three. Fatal cardiac arrhythmia, T-cell lymphoma and fulminant hepatic necrosis were found in the remaining cases. While readily seen in cytologic preparations, ANC were found focally in only one case examined histologically. CONCLUSION: Postmortem cytologic evaluation provides information relevant to the autopsy. In this study, ANC were very clearly seen in six pericardial scrapings. Clinical correlation supports the current theory that ANC represent a nonspecific reactive cell change.

Abundant intracytoplasmic hemosiderin in both histiocytes and neoplastic cells: A diagnostic pitfall in fine-needle aspiration of cystic papillary renal-cell carcinoma.

Benign renal tubular cells and renal-cell carcinomas (RCC) may have intracytoplasmic hemosiderin (ICH). The RCC subtype most commonly reported to contain ICH is papillary carcinoma (PRCC). PRCC, usually a low-grade neoplasm, may be associated with cystic degeneration, hemorrhage, and presence of abundant hemosiderin-laden macrophages (HLM). We report a case of PRCC with massive ICH and HLM that created a diagnostic challenge to differentiate from a hemorrhagic cyst. Review of 14 additional nephrectomy specimens with PRCC disclosed ICH in 3 cases. All had coexisting cystic change and hemorrhage. Preoperative FNA had been performed in one of these cases, and both ICH and HLM were found. Papillary epithelial cell features, however, were well-defined in this case. PRCC should be considered in the differential diagnosis of cystic renal lesions with hemosiderin-laden cells. Differentiation of HLM from neoplastic cells with massive ICH may be difficult, especially when epithelial fragments are scanty.

Urinary cytologic findings in patients with benign and malignant adenomatous polyps of the prostatic urethra.

CONTEXT: Urethral adenomatous polyps with prostatic epithelium (also known as benign prostatic epithelial polyps [BPEPs]) are a documented cause of hematuria, dysuria, and hematospermia, conditions that may prompt cytologic evaluation of urine. DESIGN: The urine cytologic test findings in 5 cases of biopsy-proven BPEPs and in 1 case of prostatic ductal adenocarcinoma (PDA) that presented as a urethral polyp were retrospectively evaluated. Immunocytochemical stain for prostate-specific antigen (PSA), prostatic acid phosphatase (PAP), and high-molecular-weight cytokeratin (34betaE12) were used in evaluation of the lesions. RESULTS: In 4 of 5 cases of BPEPs, clusters of bland columnar cells with uniform, oval nuclei were seen. Positive immunostaining for PSA and PAP confirmed the prostatic origin of the clusters in 2 cases. One urine sample contained abundant goblet cells and extracellular mucin, consistent with intestinal metaplasia coexisting in the bladder biopsy specimen. The urine sample in the fifth case of BPEPs contained no columnar cells. The last case had multiple urine cytologic evaluations that demonstrated PSA-positive, malignant-appearing clusters of columnar cells. A biopsy specimen of the polyps was described as a high-grade prostatic intraepithelial neoplasm in adenomatous polyp. However, in this patient, PDA was diagnosed on transurethral resection of the prostate specimen 4 years after the initial urine cytologic test. CONCLUSION: Benign prostatic epithelial polyps should be considered in the differential diagnosis of clusters of columnar cells in urine cytologic testing. Cells with malignant nuclear features should instigate a careful search for a (prostatic) neoplasm, which may present as urethral polyps (e.g., PDA). Stains for PSA or PAP are useful adjuncts in differential diagnosis of this condition.

Allergic fungal sinusitis. A report of two cases with diagnosis by intraoperative aspiration cytology.

BACKGROUND: Allergic fungal sinusitis (AFS) is a newly recognized form of sinusitis characterized by opacification of the paranasal sinuses by "allergic mucin" (AM) admixed with scattered fungal organisms. AM consists of necrotic, or partially necrotic, eosinophils and Charcot-Leyden crystals suspended in lakes of laminated, mucinous material. AFS is characterized by the absence of bone or soft tissue invasion, purulent exudate or granulomatous inflammation. Clinically, it is important to differentiate AFS from both acute invasive fungal sinusitis and noninvasive mycetoma because the three diseases are treated with different modalities and have different prognoses. Although the radiologic features of AFS are often characteristic, occasionally it may be difficult to exclude neoplasia. CASES: Two cases of AFS, in which intraoperative diagnosis was made on the basis of the presence of both AM and fungal organisms, are reported. CONCLUSION: Cytologic diagnosis of AFS can be made from intraoperative sinus aspirates from the presence of AM and fungal elements. AM and fungi provide presumptive evidence for a noninvasive, allergic fungal disease and can help reassure clinicians intraoperatively and guide clinical management.

Chlamydoconidia formation in zygomycosis due to Rhizopus species.

An unusual case of endobronchial zygomycosis, which was caused by Rhizopus species and which disseminated to one kidney, occurred in a 36-year-old, diabetic man. The patient recovered fully following lobectomy, nephrectomy, amphotericin B therapy, and control of diabetes mellitus. An interesting histologic finding was the presence of chlamydoconidia formation within the resected lung lesion. To our knowledge, only one previous culture-proven case of zygomycosis has described chlamydoconidia formation in tissue.

Mycobacterium kansasii osteomyelitis presenting as a solitary lytic lesion of the ulna: fine-needle aspiration findings and morphologic comparison with other mycobacteria.

A 35-yr-old woman, with acquired immunodeficiency syndrome, presented with right arm pain, erythema, and swelling. A lytic lesion of the ulna was found by radiograph. Ultrasonic and fluoroscopic guided fine-needle aspiration (FNA) yielded a neutrophilic and histiocytic exudate admixed with abundant long, bacillary forms that appeared as negative images on Papanicolaou stain and as very coarsely beaded acid-fast bacilli, resembling candy canes, on Kinyoun stain. These morphologic features permitted a preliminary diagnosis of mycobacteriosis, possibly of M. kansasii (MK) etiology. Appropriate therapy was initiated and resulted in not only marked symptomatic improvement of osteomyelitis and cellulitis, but resolution of chronic pulmonary infiltrates, presumed to be caused by fibrosis. Culture confirmed MK infection 3 wk after FNA. MK is one of the few mycobacteria that has a sufficiently characteristic morphology to permit presumptive diagnosis by smear. Culture, however, still remains the definitive method of speciation.

Malignant transformation of recurrent respiratory papillomatosis associated with integrated human papillomavirus type 11 DNA and mutation of p53.

Recurrent respiratory papillomatosis (RRP), usually confined to the nasopharynx, trachea, and larynx, occasionally can progress to extensive bronchopulmonary disease. Most cases of bronchopulmonary and laryngeal papillomatosis are cytologically benign and do not undergo malignant transformation; however, squamous cell carcinoma (SCC) can arise in RRP in the absence of known risk factors such as radiation and smoking. In this study, the authors investigated molecular genetic alterations occurring in a case of metastasizing SCC that arose in long-standing bronchopulmonary papillomatosis. Genomic DNA from tracheal papillomata, tracheobronchial papillomata, SCC of the lung, and a lymph node metastasis was extracted. The physical state of the human papillomavirus type 11 (HPV-11) DNA was investigated by two-dimensional gel electrophoresis. Molecular genetic alterations of the host genome were studied by direct sequencing of polymerase chain reaction-amplified gene fragments and restriction fragment length polymorphism (RFLP) analysis. Episomal and integrated forms of HPV-11 sequences were detected in histologically benign tumors, but only the integrated form of the viral DNA could be found in malignant tissue samples. Molecular genetic studies revealed that an allelic loss of the interferon-beta gene (IFNbeta-1) and an endogenous type of mutation of the p53 antioncogene were found only in the malignant lesions. Mutations were not observed in the ras, neu, or multiple tumor suppressor (MTS1/p16) genes in any specimens. The authors' data indicated that the p53 genetic mutation was associated with integration of HPV-11 in histologically malignant lesions. This association may promote a progressive genetic instability that can lead to the development and clonal expansion of malignant lesions in RRP.

Management of cervical intraepithelial neoplasia during pregnancy: a simplified and cost-effective approach.

OBJECTIVES: To determine the cost-effectiveness of managing an abnormal Papanicolaou (PAP) smear during pregnancy with a single colposcopic exam and biopsies, followed by Pap smears in each subsequent trimester of pregnancy and 8 weeks postpartum. MATERIALS AND METHODS: We reviewed 84 pregnant women with cervical intraepithelial neoplasia (CIN) between 1983 and 1991, testing the accuracy of an initial biopsy and subsequent Pap smears, to follow the progression (or regression) of disease as determined by postpartum biopsy or Pap smears. RESULTS: In 26 women with CIN1, 2 (8%) progressed to CIN3. In 29 women with CIN2, 5 (17%) progressed to CIN3. Of 29 patients with CIN3, 20 (69%) remained at CIN3 and 2 (6%) progressed to microinvasive carcinoma postpartum, confirmed by conization. No invasive carcinoma was missed. The cost of colposcopy with biopsies and Pap smear is $304, whereas cost of a Pap smear only is $30. CONCLUSIONS: Single colposcopy with biopsies at the beginning of pregnancy and Pap smears during subsequent trimesters and postpartum should be adequate follow-up to prevent progression to invasive cancer and represents a significant cost savings.

Disseminated Histoplasma capsulatum infection presenting as genital ulcerations.

BACKGROUND: Histoplasma capsulatum infection in adults is most often subclinical but can result in disseminated disease with weight loss, fever, hepatosplenomegaly, and oropharyngeal ulcerations. Genital ulceration as the presenting sign of the disease has been reported rarely. CASE: A 63-year-old woman presented with multiple vaginal ulcerations due to chronic disseminated H capsulatum infection. Initial diagnosis was made by Papanicolaou and Giemsa-stained vulvar smears. Ketoconazole therapy resulted in clearing of the lesions in 5 weeks. CONCLUSION: Chronic disseminated histoplasmosis is an insidious and potentially fatal disease that can present rarely as genital mucocutaneous ulcerations in women. Prompt presumptive diagnosis can be accomplished by examination of smears obtained by ulcer abrasion, permitting institution of appropriate therapy.

Outpatient loop electrosurgical excision procedure for cervical intraepithelial neoplasia. Can it replace cold knife conization?

OBJECTIVE: To determine if loop electrosurgical excision procedure (LEEP) can replace cold knife conization. STUDY DESIGN: In a population at high risk for invasive carcinoma, 163 cases of LEEP conization were performed with the same indications as cold knife for cervical conization. RESULTS: Seventy-five percent of LEEP surgical specimens were positive for dysplasia. Six cases showed invasive squamous cell carcinoma. No complications were seen. CONCLUSION: LEEP conization is a quick, simple and economical procedure that can safely replace most cases of cold knife conization.

Bone metastasis in epithelial ovarian carcinoma.

Two cases of bone metastasis in patients with epithelial ovarian carcinoma and a review of the literature are presented. Bone metastases detected antemortem are rare and herald a poor prognosis.

Plasma cell myeloma in patients who are HIV-positive.

This report describes the occurrence of plasma cell neoplasia in three young HIV-positive males. Two patients presented with massive ascites. On cytologic examination of the fluid, many immature plasma cells were noted. Genotyping of fluid demonstrated clonal rearrangement of immunoglobulin heavy and kappa light chain genes in both cases. Postmortem examination on one of these revealed neoplastic plasmacellular infiltrate in various organs, including the bone marrow. The third case presented with a hemorrhagic, rapidly enlarging gingival mass with a histologic appearance of an undifferentiated neoplasm. Immunoperoxidase studies revealed positive staining only for epithelial membrane antigen. On flow cytometry, the neoplastic cells did not mark with leukocyte common antigen or any of the B- or T-cell markers. Cytoplasmic kappa light chain restriction, as well as genotypic studies, confirmed the diagnosis of anaplastic plasmacytoma. In two cases a clonal population was detected using a probe to the terminal repeat region of the Epstein-Barr virus. These results suggest that plasma cell malignancy is another AIDS-associated neoplasm. Its occurrence in this group of patients is not only coincidental.

Metastatic squamous cell carcinoma of the tonsil presenting as multiple cystic neck masses. Report of a case with fine needle aspiration findings.

A case of squamous cell carcinoma with multiple cystic metastases to the neck is reported. The tumor originally presented as a tender left neck mass clinically misdiagnosed as an abscess secondary to infected dental caries. Subsequently, multiple cervical neck cysts developed, and fine needle aspiration (FNA) of two of them demonstrated metastatic squamous cell carcinoma. A tonsillar primary was found. Metastatic squamous carcinoma of the tonsil often presents as a solitary neck cyst that may be confused with a benign lesion. On FNA the lesion must be distinguished from branchial cleft cyst and Warthin's tumor with squamous metaplasia.

A teflon granuloma presenting as an endotracheal nodule.

A 55-year-old woman underwent bronchoscopic evaluation for hemoptysis. A small polypoid endotracheal nodule was discovered approximately 2.0 cm distal to the left true vocal cord. The lesion was sampled with a cytologic brush. Epithelioid histiocytes and numerous giant cells with asteroid bodies were seen, and there was abundant intracellular refractile material of irregular shape. Review of the medical history revealed that the patient had undergone Teflon injection of a paralyzed left true vocal cord. A diagnosis of Teflon granuloma was made.

Interventional procedures used for diagnosing and treating lung cancer.

In recent years interventional radiology has played an increasingly important role in the diagnosis and treatment of lung cancer. Useful interventional procedures include biopsy techniques, direct infusion of chemotherapeutic agents into neoplasms, and a number of palliative procedures. The article reviews the indications, contraindications, techniques, and complications of these procedures with emphasis on some of the newer procedures.

Interobserver variability in the interpretation of brush cytologic studies from head and neck lesions.

A study was conducted to evaluate the usefulness of brush cytology as a diagnostic tool for lesions of the head and neck. Brush specimens were obtained from patients for whom surgical biopsy was recommended by the Otolaryngology Service of the University of Texas Medical Branch Hospitals, Galveston. Specimens were interpreted independently by three cytologists, and interobserver variability was calculated. If a surgical biopsy was performed, histopathologic diagnosis was used as the reference standard to assess the accuracy of each cytologic interpretation. Correspondence of cytopathologic interpretation with histologic diagnosis was sufficient to conclude that brush biopsy is a useful screening technique for unsuspected or clinically undetected malignant tumors of the upper aerodigestive tract. Because of its ability to sample large surface areas with minimal tissue trauma, brush biopsy can be a useful screening technique in combination with selective surgical biopsy for the detection of cytologic changes of malignant neoplasia. Brush cytology costs less than surgical biopsy, yet its relatively high sensitivity and specificity for both benign and malignant grades support its utility. Brush cytology, furthermore, has a low interobserver variability for the benign and malignant grades, suggesting that in the hands of an experienced cytopathologist it can be relied on with confidence. For grades 2 or 3 (inconclusive), brush cytology, however, demonstrated much higher interobserver variability. Based on the findings of this and other studies, brush cytology can be effective in identifying clinically unsuspected malignant tumors of the upper aerodigestive tract, especially in patients with mucosal changes suggestive of "field cancerization."