Hospital autopsies: still valuable in their traditional role but in need of reform.

In 1997, 158 autopsies were performed at Charleston Area Medical Center, a community-based, teaching tertiary care center. The autopsies revealed 29 (18.4%) clinically undiagnosed principal causes of death, of which 79% were considered treatable. The five leading undiagnosed causes were: infarctions, 27.6%; malignant neoplasms, 17.2%; pulmonary emboli, 13.8%; dissecting or ruptured aortic aneurysms, 13.8%; and genetic or congenital disorders 10.2%. These results were significantly different from those reported from some other major tertiary care centers. Reports were completed in 5-302 days (average 59, median 32 days). For more than 40 (25%) of these autopsies, the purpose was only to confirm specific disorders such as occupational injury, which can be accomplished by a highly selective, cost-effective posthumous analysis. In summary, an autopsy in today's high-technology era is still useful, however, the high cost, long length of reporting time, and number of clinically non-enlightening cases are a reasons to reform both the format and procedure in which these procedures are conducted.

Cytologic findings from a nipple discharge in an infant with premature telarche.

Premature telarche is a condition of isolated unilateral or bilateral breast development without additional signs of sexual maturation in girls primarily under 2 yr of age presumably occurring as a response to hormonal stimulation by estrogens. Prior reports concerning pathologic findings in premature telarche have been scarce. We report the cytologic findings from a nipple discharge in a 10-mo-old girl with unilateral breast enlargement due to premature telarche. The discharge showed an increased number of clusters of breast ductal epithelium, with a few in a papillary configuration. There was a moderate degree of nuclear irregularity in the epithelial cells, but no significant nuclear overlapping. No atypical single cells were present, and a rare myoepithelial cell was noted. These cytologic findings are in accord with a prior study describing the histology in three cases of premature telarche.

The diagnosis of desmoplastic malignant mesothelioma and its distinction from fibrous pleurisy: a histologic and immunohistochemical analysis of 31 cases including p53 immunostaining.

We studied 31 patients with fibrotic pleural lesions and classified them as desmoplastic malignant mesothelioma (DMM) or fibrous pleurisy (FP) using predetermined histologic criteria, including a paucicellular fibrotic pleural lesion with a storiform pattern or the "patternless pattern " of Stout, plus 1 or more of the following: invasion of chest wall or lung, bland necrosis, frankly sarcomatoid areas, and distant metastases. Staining for p53 was performed in 22 cases. Follow-up was obtained on all cases and compared with the histologic diagnoses. For 24 cases, the consensus diagnosis was DMM; 19 of these displayed frankly sarcomatoid areas, 16 showed invasion, and 8, bland necrosis. Of the 24, 23 patients died of disease and 1 was alive with disease. The remaining 7 cases were classified as FP, and all were alive without disease. The concordance among 3 pathologists using the criteria was excellent. Staining for p53 was more common in DMM than in FP, but the difference was not statistically significant. The concordance in interpreting the p53 stains by the same 3 pathologists was moderate. The distinction between DMM and FP in a predominantly fibrotic pleural lesion can be made in most cases with adequate sampling and the use of specific criteria.

Pathologic assessment of cerebellar atrophy following acute lithium intoxication.

Lithium carbonate is a widely used pharmacologic agent for acute bipolar disorder, long term prophylaxis of mania in a bipolar patient, and prevention of "manic overshoot" with an antidepressant in acute depression in a bipolar patient. Although clinical neurological associations with lithium overdose have been-established, there has been a dearth of reports of pathologic changes related to lithium toxicity. We report a case of a 52-year-old Black female with bipolar disorder who had been treated with lithium for over 5 years and who expired 24 days after presenting in a stuporous state with an elevated lithium level of 3.2 mEq/l. Postmortem neuropathologic examination revealed severe cerebellar atrophy of the internal granule and Purkinje cell layers with attendant Bergmann gliosis presumably resulting from chronic lithium use and toxicity. There was also Alzheimer type II cell change in the thalamus and lentiform nuclei possibly due to terminal uremia. In summary, this is a unique case which appears to illustrate cerebellar atrophic changes related to lithium therapy and acute lithium intoxication.

Use of viral cultures and serologic tests for cytomegalovirus infection. Rational or random?

To assess their applied clinical utility, viral cultures and serological tests for cytomegalovirus (CMV) were reviewed at Duke University Medical Center (DUMC), a 1,125-bed tertiary-care hospital. Less than 1% (3 of 1,216) of CMV cultures were positive, and 8% of serum samples (45 of 587) were positive by single sera IgM ELISA. Sixteen percent (32 of 199) of IgG acute to convalescent sera pairs were positive. Four hundred five of 588 (69%) serum samples were positive for the IgM/IgG passive latex agglutination test, consistent with the results for random blood donors. Review of hospital records showed that fewer than 1% of the positive-test patients (excluding the latex test) received treatment for CMV. Comparisons of tests ordered on individual patients did not disclose a coherent diagnostic strategy. The authors conclude that the majority of testing for CMV in their medical center does not yield useful clinical information, but carries a substantial financial burden. A new diagnostic strategy to attempt to diagnose CMV disease is needed.