Red coral keratitis.

PURPOSE: We describe a 39-year-old woman who was seen for pain and blurred vision in the right eye that presented immediately after scuba diving several inches from a red coral reef. METHODS: The patient was found to have multiple superficial corneal foreign bodies with adjacent infiltrates on slit-lamp examination. She was treated with long-term topical corticosteroids. RESULTS: The infiltrates and symptoms gradually resolved after nearly 3 months of treatment. CONCLUSION: This case represents a form of keratitis caused by exposure to red coral. Possible mechanisms for the keratitis include type I and 4 hypersensitivities, resulting from the release of vasoactive substances. This is triggered by the red coral's nematocysts, or toxin-releasing organelles. Long-term corticosteroid treatment was effective in resolving the lesions.

The cost-effectiveness of postoperative recovery of RBCs in preventing transfusion-associated virus transmission after joint arthroplasty.

BACKGROUND: The return of joint drainage after hip and knee arthroplasty is a widely used but expensive blood-conservation technique. STUDY DESIGN AND METHODS: A Markov decision analysis model was used to evaluate the cost-effectiveness of postoperative RBC recovery in preventing viral complications of allogeneic transfusion. RESULTS: In the baseline analysis, using an RBC-recovery device saves 5 quality-adjusted minutes of longevity at an average incremental cost of $53. This corresponds to $5.7 million per quality-adjusted life year. This figure was most sensitive to the direct cost differences of allogeneic versus recovered RBCs and to the volume of RBCs recovered per device. Such devices would save health care resources if they cost less than $73 or if they were applied only in cases where joint drainage was between 600 and 1100 mL. CONCLUSION: For most clinical situations, postarthroplasty RBC recovery does not appear to be as cost-effective as most other medical interventions. Clinical attention should be directed toward developing protocols for the preferential use of postoperative RBC-recovery devices in situations where they provide the greatest benefit.

Gynecomastia-like lesions in the female breast.

CONTEXT: Gynecomastia is an abnormal enlargement of the male breast, but the histopathologic abnormalities could theoretically be present in female breasts as well. To my knowledge, however, there have been no reports in the literature to date that have attributed a clinically or radiologically detectable mass in a female breast exclusively to the histopathologic findings seen in gynecomastia. OBJECTIVE: The clinical, radiologic, and histopathologic findings of 4 patients with lesions composed exclusively of the findings of gynecomastia, herein termed gynecomastia-like lesions, are presented and compared with those of 3 patients with lesser degrees of these changes, herein termed gynecomastia-like areas, which were incidental accompaniments to other lesions. SETTING: During a 26-month interval, 1242 breast excisions (excluding needle biopsies or aspirates) were examined in a 170-bed, acute-care, community-medical school teaching hospital. RESULTS: Four patients had gynecomastia-like lesions varying from 1 to 3 cm in greatest dimension with histopathologic features showing the changes of gynecomastia exclusively. Two patients had clinically palpable masses. Two other patients had masses detected only by mammography. One postmenopausal patient was taking estrogen/progesterone replacement medication. Two of the 3 others were not taking birth control pills, and none had a clinical endocrinopathy. Thus far, none of the lesions have recurred. The 3 patients with gynecomastia-like areas were diagnosed separately with infiltrating ductal carcinoma, fibroadenoma, and lipoma. CONCLUSIONS: Pathologists should be aware that clinically palpable or radiologically detected masses in female breasts may be composed exclusively of the histopathologic findings of gynecomastia.

Squamous carcinoma in situ of the skin containing premelanosomes, with melanocytic colonization of the tumor.

Premelanosomes in nonmelanocytic epithelial neoplasms and "colonization" of nonmelanocytic tumors by melanocytes are two phenomena rarely documented in the literature. We report a squamous carcinoma-in-situ of skin displaying both phenomena. Light microscopy showed clusters of tumor cells in the epidermis, some of which contained melanin. Dendritic melanocytes were admixed with the tumor cells. No ulceration was present. Immunoperoxidase stains for keratin showed no staining of tumor cells. Some nondendritic cells stained for HMB-45, consistent with a melanocytic lesion. Electron microscopy showed two cell types, one with desmosomes, tonofilaments, and premelanosomes and a second dendritic type with only premelanosomes. Premelanosomes were also present free in the intercellular space. These findings suggest that premelanosomes may first be discharged by melanocytes into the intercellular space and are then phagocytosed by the neoplastic cells. Thus the presence of premelanosomes in a tumor cell is not pathognomonic for melanoma or other neural crest tumors.

Metanephric adenoma-like tumors of the kidney: report of 3 malignancies with emphasis on discriminating features.

BACKGROUND: Metanephric adenoma is a very rare benign renal tumor; only 80 well-documented cases have been reported to date. We have seen several renal tumors that were originally incorrectly diagnosed as metanephric adenoma. DESIGN: We present 3 unusual renal tumors (2 primary and 1 metastatic), each of which illustrates important pathologic features useful in discriminating metanephric adenoma from malignant mimics. RESULTS: Case 1 involved a 46-year-old man with multiple small, cortical, solid, papillary (chromophil) renal cell carcinomas in his right kidney; the patient developed multiple, histologically identical, solid, papillary (chromophil) carcinomas in the opposite kidney 17 months later. Case 2 involved a 32-year-old woman with a 14-cm right renal tumor who developed soft tissue and bone metastases over a 17-year period. Case 3 involved a 52-year-old woman who presented with a 1.8-cm corticomedullary renal nodule, which eventually proved to represent a metastasis from a poorly differentiated (insular) carcinoma of the thyroid. All 3 tumors superficially resembled metanephric adenoma and consisted of primitive, dark-staining cells arranged in tubules or sheets. Each tumor, however, also had features inconsistent with the diagnosis of metanephric adenoma, including multifocal lesions with a variable nuclear-cytoplasmic ratio and diffuse cytokeratin 7 and epithelial membrane antigen immunopositivity in case 1, a 14-cm-diameter tumor with occasional mitoses in case 2, and a distinct fibrous capsule with capsular and vascular invasion in case 3. In addition, all 3 tumors lacked the cytologic features of bland overlapping nuclei with imperceptible cytoplasm consistently seen in metanephric adenoma. CONCLUSION: Adherence to strict histopathologic criteria will discourage misdiagnosis of a malignant or potentially malignant renal neoplasm as the rare and always benign metanephric adenoma.

Comparison of transillumination and histologic slide measurements of choroidal melanoma.

OBJECTIVE: To compare transillumination and histologic slide measurements of choroidal melanomas in 479 eyes randomized to enucleation in the Collaborative Ocular Melanoma Study. DESIGN: Transillumination defects were measured during gross examination of enucleated eyes. Tumor basal diameter and height were measured on histologic slides and each tumor was assigned to 1 of 8 distinct shape categories. Comparison of the transillumination and histologic slide measurements revealed 3 categories of difference: underestimation (transillumination measurement more than 4 mm smaller than the histologic slide measurement), overestimation (transillumination measurement more than 4 mm larger than the histologic slide measurement), and agreement within 4 mm. RESULTS: There was good correlation between transillumination and histologic slide estimates of largest basal diameter, particularly when the basal diameter was 16 mm or less. Measurement discrepancies were related to the shape of the tumors but not to the presence of subretinal fluid or fixation. CONCLUSION: Agreement was high between measurements of transillumination defect and histologic sections.

Orbital lesions in the blue rubber bleb nevus syndrome.

PURPOSE: To identify ophthalmologic manifestations of the blue rubber bleb nevus syndrome, a rare cutaneovisceral hemangiomatosis. METHODS: The authors report two patients with a diagnosis of blue rubber bleb nevus syndrome with orbital hemangiomas. RESULTS: In one patient, the orbital lesion presented with signs and symptoms similar to an orbital varix and in the other with lid ecchymosis from an eyelid lesion. CONCLUSION: Patients with the blue rubber bleb nevus syndrome may have vascular orbital lesions associated with intermittent proptosis. Ophthalmologists should be familiar with the syndrome and its life-threatening complication of gastrointestinal hemorrhage.

Red cell loss following orthopedic surgery: the case against postoperative blood salvage.

BACKGROUND: Expensive devices have been developed for the collection and transfusion of blood salvaged after hip or knee arthroplasty. STUDY DESIGN AND METHODS: The volume of salvaged red cells was measured for the first 6 hours after operation. This volume was compared to total red cell loss during hospitalization and to the volume of allogeneic red cells transfused. RESULTS: Mean postoperative red cell loss in 31 patients following hip replacement was 55 +/- 29 mL and that in 20 patients following knee replacement was 121 +/- 50 mL. The 6-hour wound drainage represented 8.7 and 16.8 percent of overall red cell loss during hospitalization for hip and knee replacement, respectively. The transfusion of postoperatively salvaged red cells would have supplanted transfusion of less than one-third of a unit of allogenic blood after hip replacement and two-thirds of a unit after knee replacement. Only three patients (5.9%) lost red cell volume in the drainage equivalent to or in excess of 1 unit of red cells (180 mL). The volume of red cells salvaged postoperatively bore no relationship to perioperative red cell losses as a whole. CONCLUSION: The relatively small red cell loss in the postoperative period in most arthroplasty patients does not appear to justify the routine use of this technique for the recovery of autologous blood.

Antibodies to hydrocortisone in reagent red cells causing positive antibody screening tests.

When a patient's serum contains a temperature-independent antibody reacting with all antibody screening and antibody identification panel cells but with few or no units of blood used for crossmatching, one should suspect an antibody against a constituent of the suspension medium of the reagent blood cells. This observation is confirmed by negative reactions with a) washed reagent cells or b) another manufacturer's cells that do not contain the same additives. Two patients are described with antibodies to hydrocortisone that are present in one manufacturer's antibody screening cells and identification panels. The hydrocortisone was added by the manufacturer to prevent hemolysis of the reagent red cells. The patient's antibodies were IgM, complement independent, and nonneutralizable by prior incubation with hydrocortisone. The addition of hydrocortisone to other manufacturers' reagents converted previously negative reactions to the same level of positivity as was seen with the reagent from the index manufacturer. Antibodies to reagent constituents can cause delays in finding compatible blood. It is suggested that manufacturers delete irrelevant additives or those of questionable necessity from their reagents.

Survival and half-life of red cells salvaged after hip and knee replacement surgery.

The survival of autologous red cells collected intraoperatively has been reported previously. This study measures the survival and half-life of red cells collected 3 hours after hip and knee arthroplasty. For six patients, four having knee replacements and two having hip replacements, the salvaged red cells were labeled with radioactive 51Cr. Peripheral blood was simultaneously labeled with nonradioactive 52Cr. There was no significant difference in the survival or half-life of the salvaged and the venous blood.

Spindle cell pseudotumor due to Mycobacterium avium-intracellulare in patients with acquired immunodeficiency syndrome (AIDS). Positive staining of mycobacteria for cytoskeleton filaments.

A rare spindle-cell pseudotumor caused by Mycobacterium avium-intracellulare (MAI) that mimics a mesenchymal tumor, was recently reported (7,14). We report on three such pseudotumors in patients with the acquired immunodeficiency syndrome (AIDS), two involving lymph nodes and one involving the bone marrow. In the course of investigating the first-encountered example of this tumor for evidence of smooth-muscle origin of the spindle cells, it was noted that these cells stained positively for desmin by immunoperoxidase techniques (IPX), as did a variety of other cytoskeleton filaments of all sizes. Electron microscopic examination of one of these lesions revealed spindle cells containing lysosomes and large numbers of microorganisms compatible with MAI but no filaments or organelles suggestive of smooth-muscle cells. Further studies revealed that the typical lesions produced by MAI in patients with AIDS, namely aggregates of histiocytes or individual histiocytes laden with organisms, rather than the expansile spindle-cell pseudotumor, also strain strongly for cytoskeleton filaments, as do M. tuberculosis and Mycobacterium leprae. Awareness of the existence of this unusual manifestation of MAI infection in AIDS patients and its desmin positivity can avoid misdiagnosis of a primary or metastatic smooth-muscle neoplasm. The cell of origin appears to be the histiocyte.

Suitable survival and half-life of red cells after frozen storage in excess of 10 years.

To examine the appropriateness of the Food and Drug Administration's 10-year storage time for previously frozen red cells, 24-hour posttransfusion survival studies were performed, and the half-life of 3 units of autologous red cells that had been stored for 13.5, 14, and 17 years, respectively, was measured. The units had acceptable freeze-thaw-wash recovery (83.3-91.4%). When a 51Cr label was used for the previously frozen red cells and a simultaneous 52Cr label for freshly drawn autologous red cells was used as a comparison, it was seen that the previously frozen cells had normal 24-hour posttransfusion survival (75.1-88.4%) as well as normal half-life (23-33.7 days). These findings support further extension of the maximum allowable storage time for previously frozen red cells.

A cryoglobulin with cold agglutinin and erythroid stem cell suppressant properties.

A 93-year-old woman presented with profound anemia (hematocrit 23% [0.23]); there was clumping of her red cells in test tubes and on peripheral blood smears. There was also a marked decrease in erythroid precursors in the bone marrow and reticulocytopenia in the peripheral blood. An IgM kappa monoclonal gammopathy was found in low concentration (approximately 1%) in her serum, and the cold agglutinins had a titer of 2560. However, the cold agglutinin titer of the supernatant after cryoglobulin precipitation was 40. Redissolving the cryoglobulin in the supernatant resulted in a cold agglutinin titer of 1280. Moreover, the addition of the patient's whole serum inhibited erythroid colony formation in culture. The inhibition was removed by cryoprecipitation of the cryoglobulin. The patient was given steroid therapy, to which she responded with reticulocytosis and an elevation of hematocrit. By 3 months, the cold agglutinin titer had fallen to 10. She remained well 4 years later. Whereas reports of cryoprecipitable cold agglutinins are rare, this case is unique because there have been no previous reports that these cold active proteins also have erythroid stem cell-suppressant properties.

Heterotopic pancreas: gastric outlet obstruction secondary to pancreatitis and pancreatic pseudocyst.

Heterotopic pancreas, usually a silent gastrointestinal anomaly, may become clinically evident when complicated by a pathologic process. We report a unique case in which pancreatitis and pseudocyst formation in an antral lesion produced gastric outlet obstruction. The nature of heterotopic pancreas, its diagnosis, and management are discussed.

The ultrastructure of fiber cells in primate lenses: a model for studying membrane senescence.

We have compared the surface morphology of the youngest (cortical) fiber cells with that of the most senescent (nuclear) fiber cells in monkey and baboon crystalline lenses by stereo scanning electron microscopy (SEM) and thick-section stereo transmission electron microscopy (TEM). Both the broad and the narrow faces of the most senescent fiber cells featured distinctive, polygonal areas (domains) of furrowed cell membrane. The domains ranged in size from 2.42 to 8.78 microns2. Stereopair SEM and TEM micrographs demonstrated precisely oriented microvilli measuring approximately 0.14 micron in diameter and ranging in length from 1.27 to 4.65 microns overlying each ridge in the domains. Formation of microvilli on senescent cells has been noted in other types of aging cells but they are imprecisely arranged and their function is unknown. Since every fiber cell remains in a fixed location (relative to other fiber cells) throughout life, the lens provides a unique model to study structure-function relationships of senescent microvilli in situ. The discovery of an age-related elaboration of numerous microvilli on senescent fiber cells of noncataractous lenses invalidates the currently accepted theory that close, parallel apposition of the broad faces of lens fiber cells is necessary for the lens to be transparent.

Warfarin-induced alopecia.

Earlier reports of the association between oral anticoagulation and alopecia describe a high incidence of this complication (42 to 78 percent). However, judged by its extreme rarity in a survey of eight experienced, busy academic dermatologists in Boston, this association is not common, nor is the assumption that the alopecia tends to occur soon after the administration of warfarin necessarily true. Nevertheless, alopecia persists in the face of continued warfarin administration; the time required for hair to regrow after discontinuation of the drug may be too long to be practical if continued anticoagulation is necessary; the effect of oral substitutes for warfarin is unknown; and alopecia may recur if the patient is rechallenged with warfarin.

Acquired immunodeficiency syndrome and directed blood donations. A dilemma for American medicine.

The devastating consequences of transfusion-associated acquired immunodeficiency syndrome have led some patients and physicians to propose recipient-orchestrated (directed) donations as a method of improving the safety of blood transfusions. This method is not safer than volunteer blood donation and introduces several legal, ethical, and administrative problems. Blood banks should discourage the use of directed blood donations, and physicians should work to educate the public about the lack of benefit of directed donations and their potential risks.