Fatal accelerated rejection with a prominent natural killer cell infiltrate in a heart transplant recipient with peripartum cardiomyopathy.

Accelerated rejection is uncommon after cardiac transplantation. The mechanism is hypothesized to be mediated by cytotoxic T cells and anti-HLA antibodies resulting from a memory response to the donor allograft in sensitized patients. A role for Natural Killer (NK) cell in cellular rejection has also been suggested. We report a case of fulminant accelerated rejection in a heart transplant recipient, with a history of peripartum cardiomyopathy (PPMC). The patient had no pre-transplant donor specific antibody and flow cytometric T and B cell crossmatches were negative. Autopsy revealed left ventricular subendocardial and intramyocardial hemorrhage with diffuse lymphocytic infiltrates and myocyte damage (Grade 3R rejection). Immunohistochemistry revealed a large proportion (50-70%) of mature CD16+ NK cells with cytotoxic potential in the interstitium and the intra capillary compartments. This case highlights the need for evaluating the potential role of NK cells in accelerated rejection in heart transplant recipients.

Normonatremic osmotic demyelination in the setting of acquired immune deficiency syndrome and malnutrition: case report and literature review.

In this report, we present the case of a 43-year-old woman with AIDS, disseminated aspergillosis, and malnutrition who developed osmotic demyelination syndrome. AIDS-related osmotic demyelination has only been documented in a handful of cases to date, and it appears independent of the classic mechanism of rapid correction of hyponatremia. In this manuscript, we review the six prior cases of osmotic demyelination in AIDS patients and compare their circumstances to that of our own patient. It appears that complications of malnutrition, possibly related to depletion of organic osmolytes in the central nervous system, may place AIDS patients at greater risk of osmotic demyelination. These, and other proposed mechanisms, deserve further inquiry.

Lymph node content of supraclavicular and thoracodorsal-based axillary flaps for vascularized lymph node transfer.

OBJECTIVE: Microvascular transfer of lymph node flaps has recently gained popularity as a treatment for secondary lymphedema often occurring after axillary, groin, or pelvic lymph node dissections. This study aimed to delineate the lymph node contents and pedicle characteristics of the supraclavicular (SC) and thoracodorsal (TD)-based axillary flaps as well as to compare lymph node quantification of surgeon vs pathologist. METHODS: SC and TD flaps were dissected from fresh female cadavers. The surgeon assessed pedicle characteristics, lymph node content, and anatomy. A pathologist assessed all flaps for gross and microscopic lymph node contents. The κ statistic was used to compare surgeon and pathologist. RESULTS: Ten SC flaps and 10 TD flaps were harvested and quantified. In comparing the SC and TD flaps, there were no statistical differences between artery diameter (3.1 vs 3.2 mm; P = .75) and vein diameter (2.8 vs 3.5 mm; P = .24). The TD flap did have a significantly longer pedicle than the SC flap (4.2 vs 3.2 cm; P = .03). The TD flap was found to be significantly heavier than the SC flap (17.0 ± 4.8 vs 12.9 ± 3.3 g; P = .04). Gross lymph node quantity was similar in the SC and TD flaps (2.5 ± 1.7 vs 1.8 ± 1.2; P = .33). There was good agreement between the surgeon and pathologist in detecting gross lymph nodes in the flaps (SC κ = 0.87, TD κ = 0.61). CONCLUSIONS: The SC and TD flaps have similar lymph node quantity, but the SC flap has higher lymphatic density. A surgeon's estimation of lymph node quantity is reliable and has been verified in this study by comparison to a pathologist's examination.

Trauma-induced schwannoma of the recurrent laryngeal nerve after thyroidectomy.

Laryngeal schwannomas are rare, benign tumors, most often arising from the superior laryngeal nerve. We describe a case of a 68-year-old female with a laryngeal schwannoma of the recurrent laryngeal nerve after traumatic injury. We postulate that trauma to the recurrent laryngeal nerve during thyroidectomy or thyroplasty incited growth of a nerve sheath tumor. This is the first reported case of a trauma-induced schwannoma of the recurrent laryngeal nerve and second case of a recurrent laryngeal nerve schwannoma. Although rare, this case demonstrates that these tumors should be considered during workup of vocal cord paresis after surgery or failed thyroplasty. Laryngoscope, 126:1408-1410, 2016.

Feasibility of the internal mammary lymph node flap as a vascularized lymph node transfer: A cadaveric dissection study.

BACKGROUND: We performed cadaveric dissections to examine the feasibility of an internal mammary-based lymph node flap as a donor site for vascularized lymph node transfer. METHODS: Internal mammary vessels and adjacent nodes were dissected in ten fresh cadaver specimens. Surgeon inspection and palpation identified the number of nodes in the specimen. Specimens were examined macro- and microscopically by a pathologist for correlation of lymph node counts. Kappa statistic correlated surgeon- and pathologist-reported node counts. RESULTS: Surgeon- and pathologist-reported node counts were moderately correlated (kappa 0.57). Inspection and palpation correctly predicted node presence or absence in 80% of specimens. Sixty percent of flaps contained between 1 and 3 nodes, with a mean of 2.0 nodes when nodes were present. CONCLUSIONS: Inspection and palpation predicts the presence or absence of nodes in 80% of flaps. Nodes were present in 60% of internal mammary-based flaps, and one to three nodes can be transferred. © 2015 Wiley Periodicals, Inc. Microsurgery 36:485-490, 2016.

The Pituitary Gland: An Infrequent but Multifaceted Contributor to Death.

The pituitary gland has an important role in homeostasis and disorders of it can result in endocrine dysfunction and/or produce mass effect on surrounding structures, including the hypothalamus, which can cause significant morbidity and mortality. A definitive clinical diagnosis may be delayed or remain elusive and lead to life-threatening conditions. Specifically, pituitary adenomas, pituitary necrosis, hypophysitis, and abscesses have all been reported in the literature to cause sudden and unexpected death and may only be first encountered at autopsy. Recognition by the forensic pathologist of these rare entities is crucial for appropriate death certification. This review emphasizes the need for a comprehensive, detailed forensic examination, including autopsy and routine histologic sampling of the pituitary gland, in order to ascertain its potential role in sudden unexpected death with no other apparent cause.

Fatal Catecholamine-Induced Cardiotoxicity Associated with Pheochromocytoma: Report of a Postpartum Case and Review of the Literature.

Pheochromocytomas and paragangliomas are catecholamine-secreting tumors characterized by excessive adrenergic stimulation. Common manifestations include hypertension, headache, sweating, and palpitations; however, rare life-threatening conditions have also been reported and include cardiovascular shock, myocardial infarction, arrhythmias, and cardiomyopathy. We report a case of a previously healthy 31-year-old postpartum female presenting with headache who died suddenly in an emergency room. Autopsy revealed a pheochromocytoma of the right adrenal with significantly elevated metanephrine concentrations and acute "myocarditis." Sudden excessive catecholamine release can cause cardiovascular complications and be rapidly fatal without significant elevation of blood pressure. Awareness of this association by the medical examiner/coroner is vital in order to properly classify the death and apprise relatives of the potential utility of genetic screening.