Posterior dislocation of the hip while playing basketball.

Injuries in basketball are usually to the ankles and knees. Dislocation of the hip is usually associated with severe trauma--for example, road traffic accidents. A case is reported here in which a 22 year old club basketball player slipped on landing from a jump shot, forcing him into a side splits position from which he sustained a posterior dislocation of the hip resulting in a sciatic nerve palsy.

A biomechanical evaluation of suture anchors in repair of the rotator cuff.

Repair of the rotator cuff requires secure reattachment, but large chronic defects cause osteoporosis of the greater tuberosity which may then have insufficient strength to allow proper fixation of the tendon. Recently, suture anchors have been introduced, but have not been fully evaluated. We have investigated the strength of suture-to-anchor attachment, and the use of suture anchors in repairs of the rotator cuff either to the greater tuberosity or the lateral cortex of the humerus. The second method gave a significant increase in the strength of the repair (p = 0.014). The repairs were loaded cyclically and failed at low loads by cutting into bone and tendon, casting doubt on the integrity of the repair in early mobilisation after surgery. Repairs with suture anchors did not perform better than those with conventional transosseous attachment.

The detection of blood contamination in human follicular fluid.

PURPOSE: The aim of this study was to compare the reliability of the methods conventionally used to identify low levels of blood contamination in human follicular fluid (hFF) as applicable in the clinical environment. METHODS: Follicular fluid (n = 339) and plasma samples (n = 20) were collected from patients (n = 138) attending the Centre for Fertility Studies, HF Verwoerd Hospital, University of Pretoria, South Africa. hFF blood contamination was assessed by means of (a) visual inspection, (b) hematocrit (Hct), (c) spectrophotometric analysis, (d) spectrophotometric hemoglobin kit, and (e) Combur-9-test urine sticks. RESULTS: (1) Neither hematocrit nor spectrophotometry provided reliable detection at low levels of blood contamination. (2) Visual inspection presented with a better discriminatory ability than either Hct or spectrophotometry. (3) Combur-9-test sticks identified up to 50% of blood-contaminated fluids. (4) Spectrophotometrically determined hemoglobin levels presented with weak discriminatory abilities for detecting blood-contaminated fluids. CONCLUSIONS: Visual inspection as performed in this study provides a fast and relatively reliable method for the determination of blood-contaminated hFFs. In a laboratory environment, however, it would be recommended that a combination of visual inspection, Hct, and spectrophotometric evaluation be employed for the selection of blood-free fluids.

Papulonecrotic tuberculid in children. A report of eight patients.

Papulonecrotic tuberculid (PNT), a form of cutaneous tuberculosis (TB), is uncommon in children. We identified eight children (six girls and two boys) with PNT. Their ages ranged from 19 to 139 months (median 47.5 months, mean:64.75 months). Skin lesions had been present for 2-24 weeks (median: 4 weeks) before diagnosis. All patients displayed scattered papulo- and/or pustulonecrotic lesions on the limbs, and the ears were involved in six patients. Lesions healed with varioliform scars. Associated pulmonary TB was present in seven patients. Additional clinical findings included fever (n = 4), hepatomegaly (n = 4), lymphadenopathy (n = 3), phlyctenular conjunctivitis (n = 3), and splenomegaly (n = 2). Histology of eight biopsies showed ulceration (n = 6), dermal necrosis (n = 6) (follicle-centered in two), granulomatous inflammation (n = 6) (palisading granuloma-like in three), superficial and deep infiltrate of lymphocytes (n = 7), erythrocyte extravasation (n = 7), and subepidermal edema (n = 3). Vasculitis was not a feature. A Ziehl-Neelsen stain was negative in all. Glycosaminoglycans were not increased. Immunohistochemistry found a predominance of T lymphocytes, macrophages, a few antigen-presenting cells, and no B lymphocytes, consistent with a type IV hypersensitivity reaction. Polymerase chain reaction (PCR) performed on deparaffinized tissue identified M. tuberculosis DNA in one biopsy. All patients received combination anti-TB treatment for 6 months. Six patients were compliant and were followed up for 6-30 months. Skin lesions and pulmonary TB healed in all. PNT in children resembles the adult form, but phlyctenular conjunctivitis and associated TB are more common, scrofuloderma and concomitant erythema induratum of Bazin are unusual, and vasculitis is not found. In cases where M. tuberculosis DNA can be confirmed with PCR, papulonecrotic TB is perhaps the more appropriate nomenclature.

Semiquantitative postembedding characterization of intermediate filaments in central nervous system lesions using immunoelectron microscopy.

Standardized postembedding immunoelectron microscopy was performed to demonstrate glial fibrillary acidic protein (GFAP) and vimentin in individual intermediate filaments to determine the diagnostic value of demonstrating ultrastructural and immunophenotypic characteristics of intermediate filaments in routine brain biopsy specimens. Dual expression of GFAP and vimentin was observed in the astroblastoma and astrocytes of Alexander's disease. The antigen availability for vimentin, however, was too low to allow reliable assessment of the GFAP:vimentin ratio in individual intermediate filaments and/or filament bundles. In meningioma, only vimentin positive intermediate filaments were found. GFAP positive intermediate filaments were present in all other specimens except the oligodendroglial components of the mixed glioma, which were devoid of intermediate filaments. GFAP positivity in the filamentous periphery and electron-dense core of Rosenthal fibers was demonstrated. Technical and tissue processing factors had a significant effect on particle density values obtained for individual specimens. Although the number, distribution, and density of glial intermediate filaments varies in different astroglial entities, correlation of particle density values determined by immunoelectron microscopy with relative GFAP concentrations in different lesions requires utmost caution. Nevertheless, application of the postembedding approach to routinely fixed biopsy specimens indicated an association of different entities with the exclusive presence of GFAP and/or vimentin in individual intermediate filaments, thus emphasizing the diagnostic value of intermediate filament typing for pathological characterization.

Erythema induratum of Bazin. A clinicopathological study of 20 cases and detection of Mycobacterium tuberculosis DNA in skin lesions by polymerase chain reaction.

Erythema induratum of Bazin (EIB) is a chronic, recurring panniculitis that is found predominantly on the legs of women with tuberculin hypersensitivity. A causal relationship between EIB and Mycobacterium tuberculosis remains elusive because of the absence of demonstrable organisms in skin lesions. We reviewed the clinicopathological features of 20 patients (all women) with positive Mantoux tests (1:10,000 dilution) and characteristic skin lesions of EIB that cleared up with combined antituberculous treatment. Histological examination of skin lesions confirmed panniculitis with varying combinations of granulomatous inflammation, primary vasculitis, and necrosis. Sections from 20 formalin-fixed, paraffin-embedded skin biopsies obtained from the 20 patients were submitted for polymerase chain reaction (PCR) using oligonucleotide primers for the detection of a 123-bp DNA fragment specific for the M. tuberculosis complex. M. tuberculosis DNA was identified in five of the 20 biopsies. Meticulous care was taken to prevent contamination as a source of false-positive results. Mycobacterial DNA was absent in all negative controls and in normal skin biopsies from purified protein derivative-positive patients with and without EIB. These results provide direct evidence that mycobacterial components are present in EIB lesions and strongly suggest that M. tuberculosis is involved in the pathogenesis of EIB.

Simultaneous occurrence of viral-associated hemophagocytic syndrome and Langerhans cell histiocytosis: a case report.

Langerhans cell histiocytosis (LCH) is a class I histiocytosis characterized by the presence of the pathologic Langerhans cell, an unique histiocyte. In contrast to LCH, class II histiocytosis is characterized by the proliferation of mononuclear phagocytes other than Langerhans cells and includes sinus histiocytosis with massive lymphadenopathy, viral-associated hemophagocytic syndrome, and familial hemophagocytic lymphohistiocytosis. Until now, these two classes have been considered separate, if related, entities. We report a 10-month-old girl who presented with pyrexia, hepatosplenomegaly, an eczematous skin rash, anemia, thrombocytopenia, and a markedly elevated serum IgG and IgM antibody level to cytomegalovirus. Histologic proof of both hemophagocytosis in the liver and bone marrow and LCH in the skin was obtained at presentation. The clinical course and response to treatment over 6.5 years is recorded. Although the etiology of both class I and class II histiocytosis remains unknown, we speculate that the monocytic/macrophage disorder, as well as the LCH, were both triggered by virus or viral-related monokines secreted by activated macrophages.

Cyclosporin as a treatment for interstitial lung disease of unknown aetiology.

Ten patients with progressive, symptomatic interstitial lung disease of unknown aetiology who were treated with cyclosporin A were reviewed. Five had clinical and histopathological features of cryptogenic fibrosing alveolitis and five a progressive restrictive lung disease characterised by interstitial infiltration with lymphocytes and minimal fibrosis, which could not be classified precisely. Three patients with lymphocytic infiltration showed a response to initial treatment with cyclosporin A alone at high dosage, but toxicity precluded further treatment. All 10 patients then received low doses of cyclosporin A and prednisone. Three of the patients with cryptogenic fibrosing alveolitis and all five patients with lymphocytic infiltration responded with a reduction in dyspnoea or an increase in vital capacity, or both; cyclosporin A appeared to be effective, or at least to have a corticosteroid potentiating effect. A high incidence of side effects occurred, though these do not necessarily prohibit the long term use of cyclosporin A when it is indicated clinically. Cyclosporin A may be effective in the treatment of interstitial lung disease of unknown aetiology. Further studies are required to determine the long term outcome of treatment.

Has the character of gastric cancer changed? A descriptive study of a 10-year period.

Over the 10-year period January 1976-December 1985, 446 patients with histologically verified adenocarcinoma of the stomach were treated at Tygerberg Hospital. Coloured patients made up 63.4% of the study population and a significant increase in the annual proportion of this group was observed. Coloured men comprised 47.6% of the total group. The mean age of white and coloured patients differed significantly (68.9 v. 56.5; P less than 0.001). The symptom complex was essentially similar in the two racial groups and in general the character of the symptoms had no bearing on the prevalence of resection. Although antral tumours were most common in whites and in coloureds, there was a significant increase in tumours located in the fundus in whites. The resection rate remained unchanged over the 10-year period. Only 4 cases of early gastric cancer were detected during this period without any signs of an increased yield of early lesions over time. This audit revealed no beneficial changes over time, which is in stark contrast with reports from Japan regarding the proportion of curable lesions.

Lupus nephritis. Part I. Histopathological classification, activity and chronicity scores.

Renal biopsy has made a major contribution to the understanding and management of patients with lupus nephritis. In a 5-year retrospective study the renal morphology of 55 biopsies from 51 patients with lupus nephritis was classified according to World Health Organisation criteria. In addition, semi-quantitative activity and chronicity scores were documented. The findings were similar to series from other parts of the world. Of the biopsies reviewed, 6 were class II, 13 class III, 32 class IV and 4 class V. In situations of overlap, segmental proliferative features determined the class to which a biopsy specimen was assigned. Twenty-five of the patients, all WHO class IV, showed activity scores in the severe range. Most of the activity score features were common and easily recognised but necrotising angiitis was only seen in 1 patient. Haematoxylin bodies were difficult to document and the nature and value of the haematoxylin body is questioned.

Digital papular calcific elastosis: a histopathological, histochemical and ultrastructural study of 20 patients.

In 1960, 5 patients were reported with a condition termed "degenerative collagenous plaques of the hands". Ultraviolet light and chronic pressure seem to be the inciting factors. Clinically, it is characterized by keratotic, translucent papules, in linear array, on the radial border of the hands. Histology shows hyperkeratosis and dermal elastosis. The current study documented the histopathological, histochemical and ultrastructural features of 20 patients with this condition and considered the differential diagnoses. The findings were in accordance with those of previous studies, but peculiar, basophilic elastotic masses (BEMs), were a prominent finding. Ultrastructurally, elastic tissue appeared in the form of degenerated non-fragmented and fragmented elastic fibres, degenerated fibres showing foci of increased density, with or without a fibrillar component and as amorphous, structureless material. BEMs arose almost exclusively from degenerated elastic tissue and contained calcium. Disintegrated collagen may be incorporated in the amorphous material and, subsequently, form a minor part of BEMs. Solar elastosis, and its variants, show some similarity to degenerative collagenous plaques of the hands, but lack the constant presence of these calcified angular elastotic masses. BEMs show resemblance to elastic globes, and elastotic bodies found in elastotic nodules of the anthelix and cartilage-hair hypoplasia. In the clinical setting of "degenerative collagenous plaques of the hands", BEMs seem to be unique and due to their extensive presence serve as a non-specific marker for this condition. Digital papular calcific elastosis therefore seems to be more appropriate nomenclature.

Multiple endocrine neoplasia type IIb: a clinicopathological report.

The clinicopathological findings in a 12-year-old boy with multiple endocrine neoplasia type IIb (MEN-IIb) are presented. He demonstrated the characteristics of a Marfanoid habitus and had mucosal neuromas of the lips, tongue, eyelids, and cornea. The enlarged right thyroid lobe showed an increased thallium-201 chloride uptake, and the serum calcitonin level was markedly raised. A total thyroidectomy was performed. Histopathological examination showed an infiltrating medullary carcinoma of the thyroid (MCT) and metastatic spread to supraclavicular lymph nodes. Special stains, immunocytochemistry, and electron microscopy revealed mucin-containing follicular structures lined by calcitonin-positive and thyroglobulin-negative tumour cells. Ultrastructurally the mucosal neuromas consisted of proliferating perineurial and Schwann cells. The serum calcitonin level fell below 300 pmol/L, and his stools returned to normal postoperatively. Because the incidence of MCT in MEN-IIb is virtually 100%, a total thyroidectomy in high risk patients--even before clinical evidence of malignant tumours--may be the only hope of cure.

Electron microscopic analysis of the specific granule content of human atria. An investigation of the role of atrial pressure and atrial rhythm in the release of atrial natriuretic peptide.

Knowledge about the stimulus for the release of atrial natriuretic peptide (ANP) from human atria is incomplete. Atrial stretch is known to be a stimulus and atrial tachyarrhythmias are thought to be another. The effects of atrial size (by two-dimensional echocardiography) and atrial fibrillation on the atrial specific granule content of human atria were studied to gain insight into the secretory mechanisms of ANP. An electron microscopic analysis of the atrial granule content was used to study 12 patients--5 with mitral stenosis and sinus rhythm, 3 with mitral stenosis and atrial fibrillation and 4 controls. Granules were counted using a free count and montage method. This is the first report of such a morphometric analysis in humans. Granule counts were significantly raised in the patients with mitral stenosis compared with controls (P less than 0.014). This observation probably reflects a high turnover state induced by elevated atrial pressures. Further support for this conclusion is provided by the demonstration of a positive correlation between granule counts and left atrial size (r = 0.86; P less than 0.01). The tendency for higher counts in patients with atrial fibrillation may be related to the rhythm disturbance itself, but clinical and echocardiographic data suggest more severe atrial pressure overload in this group.

Allografted keratinocytes used to accelerate the treatment of burn wounds are replaced by recipient cells.

Cultured keratinocytes were used as allografts on burn wounds in two patients. In both patients successful covering of the wounds was obtained. DNA fingerprinting of the epidermis covering the wounds 21 days later showed that the cultured keratinocytes were replaced by the patients' cells.

Lafora-body disease with optic atrophy, macular degeneration and cardiac failure.

A 17-year-old boy was admitted to hospital in acute cardiac failure and psychosis. The clinical course, EEG records and tissue diagnosis, including biopsies of brain, skin, skeletal muscle, peripheral nerve and liver were compatible with Lafora-body disease (LBD). Unusual features were those of optic atrophy and macular degeneration, signs generally regarded as negative criteria for the diagnosis of this disease. We also present the findings on endomyocardial biopsy which was performed because cardiac failure as an early symptom of LBD has not been previously described. The patient died in status epilepticus a few months after discharge from hospital.

Spontaneous rupture of adult Wilms' tumor.

Wilms' tumor is uncommon in adults, and spontaneous retroperitoneal hemorrhage as the presenting sign of renal malignancy also is rare. A 22-year-old man with spontaneous rupture of a Wilms' tumor, who died within 5 months, is described. The factors that probably contributed to his rapid demise included preoperative tumor spilling, unfavorable histology, and the omission of radiotherapy owing to poor patient compliance. Although Wilms' tumor is known to have a poorer prognosis in adults than in children, the reason for this is not known. Due to the limited number of cases reported, the optimal treatment for adult Wilms' tumor remains to be defined. However, the recent literature indicates that radical surgery combined with maximal radiotherapy dosage and modification of the chemotherapy schedules used in children may be required to improve the prognosis for adults with Wilms' tumor.