Autopsy demonstration of intramyocardial polymer gel emboli associated with a giant-cell reaction following cardiac catheterization: a case report.

BACKGROUND: Foreign body type granulomatous vasculitis has been reported in blood vessels of the brain, lungs, and skin of the foot following intravascular instrumentation with devices coated with hydrophilic polymer gel. We report a case of intramyocardial polymer gel emboli associated with granulomatous vasculitis following cardiac catheterization. METHOD: Autopsy observations in a 77-year-old woman are presented. The patient experienced an acute myocardial infarction requiring catheterization and coronary stenting. The patient returned with a pseudoaneurysm at the site of catheterization and shortly after suffered a fatal arrhythmia. RESULTS: Microscopically, multiple small vessels within the myocardium were noted to contain a basophilic, amorphous, focally lamellated, focally granular material. A granulomatous inflammatory response was noted in the vessels containing the foreign material. CONCLUSIONS: Our case is the first to our knowledge to document intramyocardial vessel gel emboli following a cardiac catheterization with stenting. Although the microscopic finding of emboli within vessels does not seem to be the immediate cause of death in our case, it is highly possible that it contributed to the patient's demise.

Postmortem demonstration of the source of pulmonary thromboembolism: the importance of the autopsy.

Periprostatic or paravaginal venous thromboses are rarely considered clinically as sites of clot origin in patients with pulmonary thromboembolism. The majority of emboli have been demonstrated to originate in the veins of the legs. This report raises awareness of pelvic vein thrombosis as a potential source of pulmonary embolism that is rarely considered or detected clinically, and which usually requires postmortem examination for recognition. It also reviews the possible routes emboli may take to reach the lungs.

Significance of periductal lymphatic and blood vascular densities in intraductal carcinoma of the breast.

We investigated the significance of periductal lymphatic and blood vascular densities in intraductal carcinomas (IDC) of the breast. Thirty five cases of pure IDC treated by partial or total mastectomy were reviewed. Seven cases with normal breast tissue and 48 cases of invasive breast carcinoma were included as controls. All cases were immunostained with D2-40 and CD31. Positively stained microvessels were counted in densely vascular/lymphatic foci (hot spots) at 400x (=0.17 mm(2)) in the periductal areas. IDC without comedonecrosis showed a mean periductal D2-40 lymphatic microvessel density (LMD) of 5.8 +/- 5 (range 0-18), and a CD31 microvessel density (MD) of 14 +/- 8.9 (range 1-40). IDC with comedonecrosis showed periductal D2-40 LMD of 8.4 +/- 3.8 (range 4-18), and a CD31 MD of 24.3 +/- 7.6 (range 14-40). There was a significant difference between periductal D2-40 LMD and CD31 MD counts in IDC with and without comedonecrosis. There was a positive correlation of periductal D2-40 LMD and CD31 MD counts with high nuclear grade (r = 0.39 and 0.56) of IDC as well as with the presence of comedonecrosis (r = 0.49 and 0.59). Both D2-40 LMD and CD31 MD did not correlate significantly with tumor size, estrogen status, or progesterone status. As IDC with comedonecrosis and/or high nuclear grade has a worse prognosis than IDC without comedonecrosis and/or with low nuclear grade, it appears that lymphatic and blood vascular density evaluated by D2-40 and CD31, respectively, are independent prognostic indicators for patients with IDC of the breast and may be an indicator of early or unrecognized invasion or "regression."

Prognostic significance of intratumoral and peritumoral lymphatic density and blood vessel density in invasive breast carcinomas.

We studied tumor lymphatic and vascular densities and lymphovascular invasion (LVI) as prognostic markers in 48 cases of invasive breast cancer treated with partial or total mastectomy and lymph node dissection. All cases were immunostained with D2-40 and CD31. Positively stained microvessels were counted in densely vascular/lymphatic foci (hot spots) at x400. The mean+/-SD peritumoral lymphatic microvessel density (LMD) was significantly higher than intratumoral LMD (9+/-7 vs 4+/-6; P< .01). There was a positive correlation of D2-40 LMD (peritumoral and intratumoral) and CD31 microvessel density counts with lymph node metastasis (r=0.35, 0.5, and 0.38), nuclear grade (r=0.36, 0.28, and 0.3), and stage (r=0.42, 0.56, and 0.49), respectively. Peritumoral and intratumoral D2-40 LMD correlated significantly with the presence of angiolymphatic invasion (detected by D2-40; r=0.54 and 0.54, respectively). D2-40 detected more LVI than H&E- and CD31-detectable vascular invasion (18/48, 5/48, 11/48, respectively). Increased D2-40 detected LVI, and high CD31 microvessel counts showed significant adverse effect on survival status.

Amebiasis presenting as acute appendicitis.

Amebiasis presenting as acute appendicitis is extremely rare. The case of a 38-year-old Hispanic man who presented to the hospital with symptoms and signs suggestive of acute appendicitis is reported. He underwent laparoscopic appendectomy and the pathologic examination of the appendix revealed multiple trophozoites of Entamoeba histolytica. The patient was treated postoperatively with metronidazole for amebiasis, and follow-up stool studies showed no sign of residual infection. The patient has remained asymptomatic.

Para-arytenoid cartilage pseudodiverticulum formation as a sequela of endotracheal intubation.

CONTEXT: Laryngotracheal injury secondary to endotracheal intubation results from ischemic necrosis, which develops within hours of intubation, with injury severity increasing with duration of intubation. Postextubation and postmortem observations demonstrate that laryngotracheal injury still occurs in a large number of intubated patients. OBJECTIVE: To demonstrate laryngeal injury, specifically pseudodiverticulum formation, as a result of intubation. DESIGN: A total of 41 autopsy cases from February 1970 to February 2006 were retrospectively reviewed. All patients had been intubated during their hospital course and had an endotracheal tube in place at the time of death. Continuous endotracheal intubation ranged from several hours to 33 days. RESULTS: The earliest manifestations of laryngeal injury occurred within hours and included hyperemia, edema, and ovoid mucosal lesions over the arytenoid and inner posterolateral cricoid cartilages. Within 48 hours, superficial epithelial denudation progressed to mucosal ulceration, with inflammatory infiltrate into the submucosa. These ulcerations enlarged and deepened, and within 3 to 6 days they showed gross excavations and, in some cases, confluence with other ulcerations. Four cases had pseudodiverticulum formation in the area of the arytenoid cartilages, with deep, excavated lesions that extended to the underlying cartilage. Pseudodiverticulum formation occurred as early as 8 days of continuous intubation. CONCLUSIONS: Although endotracheal intubation is required for airway maintenance in many patients with respiratory dysfunction, the procedure carries risks. Laryngeal injury from intubation is very common, and the severity of injury is directly related to the duration of intubation. We add para-arytenoid pseudodiverticulum formation to the list of possible complications of endotracheal intubation.

Black pigmentation of atherosclerotic plaques associated with chronic minocycline therapy.

Minocycline is a broad-spectrum antimicrobial agent used chronically in many clinical settings. Pigmentation is a well-recognized side effect of minocycline therapy. It has been reported in numerous sites, especially the skin, bones, and thyroid gland. We report an unusual case of pigmentation of atherosclerotic plaques in the aorta and arteries of the leg in a patient on chronic minocycline therapy.

Colouterine fistula secondary to endometriosis with associated chorioamnionitis.

BACKGROUND: Intestinal endometriosis may be complicated by bowel obstruction, colonic rupture, sepsis, and rarely, malignant transformation. Fistula formation is extremely rare. CASE: A 26-year-old woman presented at 16 weeks of gestation with an acute abdomen suggestive of ruptured appendicitis. Blood cultures were positive for Bacteroides fragilis. At laparotomy, she was found to have a colouterine fistula with pelvic sepsis. The resected specimens demonstrated extensive uterine adenomyosis and endometriosis of the cecum, with a fistulous tract lined by endometriosis and suppurative inflammation extending from the cecum to the uterine endometrial cavity associated with severe chorioamnionitis and endomyometritis. CONCLUSION: This case illustrates a rare complication of colouterine fistula secondary to intestinal endometriosis.

Muscarinic M3 acetylcholine receptor immunostaining in paraffin-embedded normal and neoplastic prostatic gland tissue.

Recent in vitro studies suggest that muscarinic receptors are important indicators of prostatic epithelial differentiation. Using choline in the mapping of prostatic lesions, radiographic studies have been interpreted as showing malignant transformation when high levels of receptors are found, but to our knowledge no correlation with the grade of prostatic cancer has been reported. To demonstrate the relationship of muscarinic receptors to differentiation, we immunostained normal and neoplastic prostatic tissue with antibodies that recognize receptors of acetylcholine, dividing the neoplastic tissue into two groups according to grade of differentiation. As far as we know, this is the first time that immunostaining of benign and neoplastic prostatic gland tissue with cholinergic receptors has been reported. Thirty-five cases of prostatic carcinoma were retrieved from our files and subdivided into two groups; a well to moderately differentiated group and a poorly differentiated group. Both groups were immunostained with M3 muscarinic receptor, along with a proliferation marker (Ki-67). The proliferating index measured with Ki-67 in the well to moderately differentiated group was low (<5% of the cells) and high in the poorly differentiated group (>20% of the cells). A strong correlation was observed between the strength of expression of the muscarinic M3 receptor and the differentiation of the lesion. The 18 cases of well to moderately differentiated carcinoma showed a mean staining intensity of approximately 1 with no case showing an intensity grade greater than 2. Normal controls along with normal peritumoral prostatic tissue also demonstrated a staining intensity of approximately 1. However, none of the 11 cases of poorly differentiated carcinoma showed staining. Our conclusion is that the presence of muscarinic acetylcholine receptor M3 by immunostaining distinguishes normal glandular epithelium and low-grade carcinomas from poorly differentiated tumors, which suggests that its demonstration in vivo could be a useful tool in distinguishing grade of tumor clinically.

Phlegmonous gastritis associated with Kaposi sarcoma: a case report and review of the literature.

We report a case of phlegmonous gastritis associated with Kaposi sarcoma in a 37-year-old, human immunodeficiency virus (HIV)-positive man who presented with an acute abdomen. Computed tomographic scan revealed free fluid in the abdominal cavity and a thickened gastric wall. A partial gastrectomy was performed. The resected portion of stomach had a hemorrhagic, necrotic thickened wall and showed extensive, acute suppurative inflammation, especially in the submucosa, with focal transmural involvement. Beneath an area of healing ulceration, a focus of Kaposi sarcoma was present. Group A beta-hemolytic streptococcus was grown from peritoneal fluid, and treatment with numerous antibiotics was initiated. After a difficult postoperative course that responded to 8 weeks of antibiotic therapy, the patient was medically stable and discharged from the hospital on antiretroviral therapy for HIV. Phlegmonous gastritis is a rare and rapidly progressive bacterial infection of the gastric wall. Kaposi sarcoma is one of the most common malignancies in HIV-positive patients, and gastric involvement is relatively common in those patients with systemic Kaposi sarcoma. To our knowledge, this is the first reported case of phlegmonous gastritis associated with Kaposi sarcoma, and it represents a rare survival following surgical and antibiotic therapy.

Kaposiform hemangioendothelioma associated with nonimmune fetal hydrops.

We describe the case of a 31-week fetus who died in utero with an invasive retroperitoneal kaposiform hemangioendothelioma. This rare vascular neoplasm usually presents as a localized violaceous skin lesion in infants and behaves in a benign fashion; however, kaposiform hemangioendothelioma may present as an invasive neoplasm of the chest or abdominal cavity, where it can lead to the Kasabach-Merritt syndrome, which consists of thrombocytopenia, consumptive coagulopathy, and microangiopathic anemia in association with a vascular anomaly. The case we describe is unique in that the tumor presented in utero and led to intrauterine nonimmune fetal hydrops. Kaposiform hemangioendothelioma has been described in utero; however, to our knowledge, intrauterine fetal death as a direct consequence has not been reported previously in the literature.