Skin Necrosis Associated With Heparin-Induced Thrombocytopenia and Thrombosis.

Skin necrosis is a rare complication of heparin therapy. Strong evidence suggests an immune-mediated mechanism in which heparin-antibody complexes bind to platelets, resulting in platelet aggregation, thromboembolism, and ischemic necrosis. Heparin-induced thrombocytopenia (HIT) may also occur in response to immune-mediated platelet aggregation. The presence, of heparin-dependent antibodies can be confirmed by platelet aggregometry, (14)C-serotonin release assay (SRA), or enzyme-linked immunosorbent assay (ELISA). Clinical suspicion, early detection and immediate cessation of heparin therapy are important in preventing the potentially severe complications of heparin-induced platelet aggregation. Potential therapeutic approaches include plasmapheresis and alternative forms of anticoagulation such as warfarin, aspirin, dipyridamole, or other novel investigational agents.

Nature and significance of epicardial lymphoid infiltrates in cardiac allografts.

BACKGROUND: Myocardial lymphocytic infiltration after transplantation is usually a manifestation of acute cellular rejection. However, purely endocardial infiltrates are generally not regarded as rejection (so-called "Quilty lesions"). The nature of epicardial lymphoid infiltration in cardiac allografts and its significance when observed in endomyocardial biopsies or autopsies are uncertain. METHODS: Twenty-seven cases of transplant-associated epicardial lymphoid infiltration were identified; 16 cases were identified from 1602 consecutive transplant biopsy specimens from 125 patients, and 11 from 14 autopsies, ranging from 1 to 35 months (mean 7.8 months) after transplantation. RESULTS: The infiltrates were composed of aggregates of lymphocytes and histiocytes distributed throughout the epicardium. Plasma cells were found in 52% of cases, with occasional eosinophils and rare neutrophils. Most were vascular, and four autopsy cases had follicle formation. Twenty-four cases (93%) showed a mixed population of cells in a random distribution consisting of T cells in association with fewer B cells and histiocytes. Fifteen cases (nine autopsies, six biopsies) had acute rejection, and nine autopsies had chronic vascular rejection. Fourteen of twenty-four cases (58%) showed concurrent Quilty lesion (nine autopsies, five biopsies), and the remainder showed at least one Quilty lesion in an earlier biopsy. CONCLUSION: Epicardial lymphoid infiltrates occur with significant frequency after heart transplantation and can be associated with, and mimic, acute cellular rejection. However, they exhibit morphologic and immunophenotypic features which are distinguishable from rejection-associated infiltrates.

[Importance of Perls stain in histologic diagnosis of Kaposi sarcoma]. / Intérêt de la coloration de Perls dans le diagnostic histologique du sarcome de Kaposi.

The authors studied 27 cases of Kaposi's sarcoma, 23 cases of pyogenic granuloma, 18 cases of hemangioma, 17 cases of stasis dermatitis and 9 cases of dermatofibroma. In all these cases, they used the hematoxylin-eosin stain and Perls' stain', and they showed the presence of hemosiderin in all the cases of Kaposi's sarcoma and stasis dermatitis. The hemangioma and the dermatofibroma presented 50% of positivity, and the pyogenic granuloma, only 26.1%.

Healed enteroportal fistula as a complication of liver transplantation.

The development of a fistula between the intestinal tract and the portal vein has been reported as a complication of trauma, inflammation, and surgical intervention. It has not, however, been specifically reported in a patient who has undergone orthotopic liver transplantation. We recently had the opportunity to study a patient who sustained this rare complication.

Fungal sinusitis in patients with AIDS: report of 4 cases and review of the literature.

We report here 3 cases of aspergillus sinusitis in patients with AIDS and the 1st fully described case, to our knowledge, of sinusitis associated with Pseudallescheria boydii in a patient with AIDS. We review the microbiology and pathology of fungal sinusitis in patients with AIDS and the morphologic and clinical features and treatment of P. boydii infection and aspergillus sinusitis. Fungal sinusitis in patients with HIV or AIDS generally occurs later in the course of primary disease with low CD4+ lymphocyte counts (< 50/mm3), unlike bacterial sinusitis which may occur at any time. Differentiation between invasive and noninvasive forms is likely not important, in contrast to fungal sinusitis in noncompromised patients. The number of cases is likely to increase as the number of patients with AIDS increases, patients survive longer, and other opportunistic infections are prevented or treated. Causative agents are likely to be resistant to fluconazole, which is in widespread use. Aspergillus sinusitis in patients with HIV or AIDS occurs in both those with and without traditional risk factors. Fungal sinusitis may present vexing management problems and be relentlessly progressive in the face of therapy. Ideal therapy has yet to be defined but an early combined surgical and medical approach in these compromised patients is preferred.

Circulating immune complexes in leprosy sera: demonstration of antibodies against mycobacterial glycolipidic antigens in isolated immune complexes.

Circulating immune complexes (CIC) were assayed in sera of leprosy patients. Using an immunoassay for two mycobacterial antigens--phenolic glycolipid-I (PGL-I) and glycolipid IV (SL-IV)--sera from 65 patients with leprosy (38 lepromatous, 18 borderline, and 9 tuberculoid) were studied. The CIC were isolated by polyethylene glycol (PEG) precipitation, washed, treated with an acid buffer, neutralized, and tested using an enzyme-linked immunosorbent assay (ELISA). We demonstrated that CIC could contain IgG and IgM antibodies reacting against PGL-I and SL-IV. The high levels of antibodies in the precipitable CIC showed concordance with high levels in the original sera, although some patients presented high levels of precipitable CIC in the absence of high titers of antibodies in their sera. It was concluded that some of the CIC observed in patients with leprosy were composed of IgG and IgM immunoglobulins against specific mycobacterial antigens.

Evaluation of a novel 2,3-diacyl-trehalose-2'-sulphate (SL-IV) antigen for case finding and diagnosis of leprosy and tuberculosis.

Serum IgG and IgM antibodies against a 2,3-diacyl-trehalose-2'-sulphate (SL-IV) antigen using ELISA were determined in controls (n = 288) and in leprosy (n = 210) and tuberculosis (n = 99) patients. In all assays, the amount of antigen per well was 100.0 ng and sera were diluted 1/250. In the case of leprosy, anti-SL-IV IgG and IgM antibody titres increased from the tuberculoid towards the lepromatous pole of the spectrum. In the tested population, the sensitivity of the assay was 93.2% in multibacillary leprosy and 33.3% in paucibacillary leprosy (specificity of 88.7%). Multibacillary patients with erythema nodosum leprosum (ENL) had lower titres than non-ENL. ELISA results were similar to those obtained using the Mycobacterium leprae phenolic glycolipid-I (PGL-I) antigen. In the case of tuberculosis (pulmonary and extrapulmonary), significant titres of anti SL-IV IgG and IgM antibodies were detected in about 75% of the patients using a cutoff point of 0.150, and in 51.6% using a cutoff of 0.300 (specificities were, respectively, 88% and 100%). We concluded that the determination of IgG and IgM antibodies against SL-IV was useful in leprosy and tuberculosis case finding program using a cutoff point of 0.150, and for serodiagnosis using a cutoff of 0.300.

[Association of Virchowian hanseniasis, dermatopolymyositis and gastric adenocarcinoma. Report of a case]. / Associação entre hanseníase virchowiana dermatopolimiosite e adenocarcinoma gástrico--relato de um caso.

The authors report a case of lepromatous leprosy associated with dermatopolymyositis and gastric adenocarcinoma. The literature is reviewed and the authors discuss about this association.