Hemorrhagic cystitis due to adenovirus infection following bone marrow transplantation.

Immunocompromised patients are at significant risk for infection with adenovirus. We report 3 cases of hemorrhagic cystitis in patients following bone marrow transplantation. Of the patients 2 had positive viral urine cultures and 1 had positive stool culture but negative urine culture and biopsy proved viral cystitis. Diagnosis of adenovirus should be considered when gross hematuria follows bone marrow transplantation even when urine culture is negative for adenovirus.

Urinary neutrophil chemotactic factors in interstitial cystitis patients and a rabbit model of bladder inflammation.

The present study investigates a possible source of inflammatory mediators involved in the pathogenesis of bladder inflammation characteristics of interstitial cystitis disease. Our tested hypothesis is that in response to injury, tissues of the urinary bladder participate in the initiation of bladder inflammation by releasing inflammatory mediators such as neutrophil chemotactic factors. Bladders of anesthetized rabbits (n = 7) were instilled with an acidic solution (pH 4.5) for 15 minutes, then washed with saline and instilled with sterile phosphate buffered saline (PBS) (pH 7.2) for an additional 45 minutes prior to sacrificing the rabbits. Control rabbits (n = 7) were instilled with sterile PBS (pH 7.2) for 15 minutes, then 45 minutes. The levels of neutrophil chemotactic factors were measured using modified Boyden chambers and rabbit peritoneal neutrophils as indicator cells. Results indicated the release of high levels of neutrophil chemotactic factors (via a checkerboard analysis) from acid-treated bladders after 15 minutes (70 +/- 4% of standard) and 45 minutes (80 +/- 7%). Electron microscopy analysis of these acid-treated bladders revealed the infiltration of a large number of neutrophils, which correlates with the recovery of neutrophil chemotactic factors. Control rabbits, on the other hand, showed low levels of chemotactic activity (less than 10 percent) and exhibited normal bladder morphology with absence of neutrophils. The glycosaminoglycan (GAG) layer was intact in both acid-treated and control bladders. High levels of neutrophil chemotactic factors were also detected in urine samples from eleven patients with interstitial cystitis (113 +/- 25%) (not due to interleukin-1 or leukotriene B4) which were not detected in urine samples from healthy volunteers (n = 9) or from thirteen control patients with bladder diseases other than interstitial cystitis. These preliminary studies indicate the capability of injured bladder tissues to release neutrophil chemotactic factors which contribute to the initiation of bladder inflammation. The presence of neutrophil chemotactic factors in urine samples of interstitial cystitis patients suggests a possible role of these mediators in the pathogenesis of the disease.

Gas-forming infections in genitourinary tract.

Diabetes mellitus associated with urinary tract infections and ureteral obstruction can be predisposing factors leading to emphysematous pyelonephritis. Fever, flank pains, and a palpable renal mass, associated with dehydration and hyperglycemia, were the most frequent presenting symptoms associated with emphysematous pyelonephritis. Computerized tomography (CT) scan is the best method to identify a renal or perirenal abscess and its ramifications. Intravenous antibiotic therapy is determined by blood and urine cultures. Mortality was zero in patients treated by nephrectomy. One patient who had incision and drainage of a renal abscess died of sepsis, and 1 patient died of sepsis following incision and drainage of a prostatic abscess. Patients with cystitis emphysematosa require antibiotic therapy and relief of bladder outlet obstruction. Prostatic abscess is best treated by perineal incision and drainage. Periurethral scrotal abscesses should be incised, drained, and the overlying necrotic skin debrided. Early diagnosis and aggressive medical and surgical management of gas-forming infections of the genitourinary tract are vital.

Diagnostic pitfalls in the diagnosis of soft tissue bladder tumors in pediatric patients.

This is a case report of a low-grade leiomyosarcoma of the bladder in a four-year-old girl. The pitfalls in diagnosing a soft tissue tumor of the bladder in pediatric patients are discussed. This case is particularly instructive because the differential diagnosis was broad, difficult, and of serious consequence. This report discusses the process by which histologic, immunohistologic and ultrastructural data were used to sidestep the pitfalls in diagnosing this unusual tumor. Clinical follow-up data bearing out our conclusion are also presented.

Fetal cloacal anomalies: prenatal sonographic findings and differential diagnosis.

Serial sonographic findings are presented in three cases of cloacal anomalies. The following sonographic signs were noted: transient fetal ascites, bicystic intra-abdominal structure arising from the fetal pelvis, and oligohydramnios and impaired interval growth. This sequence of sonographic findings may help clarify the natural history of the developing cloacal anomaly: In the early state of its formation, urine enters the abdominal cavity via the fallopian tubes, causing ascites; later, chronic urinary and meconium irritation of tubal mucosa may cause tubal obstruction, which in turn may lead to the formation of genitourinary tract distention, hydronephrosis, and oligohydramnios. Timely diagnosis of cloacal anomalies improves the outcome of pregnancies (delivery in the tertiary care center, early operative correction).

The blue scrotum sign of Bryant: a diagnostic clue to ruptured abdominal aortic aneurysm.

A 73-year-old man presented to the emergency department twice with nonspecific abdominal pain. He was diagnosed as having mild diverticulitis and was discharged. Four days later he presented to the emergency department in severe abdominal pain with scrotal and penile ecchymoses. After an initial urologic consultation the correct diagnosis of ruptured abdominal aortic aneurysm was made. We discuss the pathogenesis of the genital discoloration and make the correct historical attribution of this sign to John Henry Bryant, a turn-of-the-century physician at Guy's Hospital.

Brain metastases from transitional cell carcinoma.

We report 2 cases of transitional cell carcinoma, each with a single metastasis to the brain. Both patients underwent craniotomy with resection of the metastatic deposit and adjuvant whole brain radiotherapy. One patient died 4 months later of leptomeningeal carcinomatosis, while the other patient survived 1 year with no evidence of intracranial disease at autopsy despite widespread metastatic involvement of other organs.

Endoscopic vesicourethropexy. Experience and complications.

Thirty-one patients with stress urinary incontinence were treated with the optical vesicourethropexy. Of these patients, 70.9 per cent had previous pelvic or vaginal operations, of which 59 per cent also had failed stress incontinence procedures. In 90 per cent of the cases, cure or improvement was obtained. However, the procedure is not free of complications (38%). Aside from the problems reported by others, vaginal bleeding or discomfort due to erosion of the mucosa by the Dacron pledget was observed. We also had a case complicated by an obstruction of the small bowel secondary to fixation of a jejunal loop to the retropubic area. We believe that excellent results may be obtained with this technique in patients with previous pelvic surgery or concomitant medical problems. Remarks in the evaluation of these patients and technical aspects of the procedure are presented.

ABH cell surface isoantigens in invasive bladder carcinoma associated with schistosomiasis.

The immunoperoxidase technique for demonstrating blood group ABH isoantigens was used to compare 33 patients with invasive stages T2 and T3 bladder carcinoma with (18) and without (15) schistosomiasis. Of the 18 patients with schistosomiasis 11 (61 per cent) had cell surface antigens present (9 with squamous cell carcinoma and 2 with transitional cell carcinoma and areas of squamous metaplasia), while isoantigens were absent in the remaining 7 (1 with well differentiated squamous cell, 2 with moderately to poorly differentiated squamous cell and 4 with transitional cell carcinoma). Cell surface isoantigens were present in only 3 of the 15 patients (20 per cent) without schistosomiasis (2 with squamous cell and 1 with transitional cell carcinoma) and absent in the remaining 12 with transitional cell carcinoma. This preliminary study shows that a significant percentage of patients with schistosomiasis-associated invasive bladder carcinoma maintain the blood group isoantigens, in contrast to those with bladder carcinoma not associated with schistosomiasis. The better prognosis of schistosomiasis-associated carcinoma could be linked conceivably to isoantigen maintenance. If this speculation is supported by further studies the determination of blood group isoantigens in these patients would be of prognostic value.

A possible etiology of the infertile 46XX male subject.

We report on an infertile male patient with the predominant 46XX female karyotype. A testicular biopsy revealed widely separated testicular tubules, absence of sperm formation and large numbers of Leydig cells. Chromosome studies, including measurements of the X chromosomes, showed a significant difference between the lengths of the short arm of the 2 X chromosomes. This information lends support for an X-Y chromosome interchange as the etiology of this syndrome. The clinical features of this rare syndrome and other theories of etiology of XX male subjects are discussed.

A unique Y/Y translocation in an infertile male.

A monocentric and submetacentric Y/Y translocation without evidence of mosaicism was observed in a male with tall stature and azoospermia. Chromosome measurements of the abnormal Y of this patient and the normal Y of his father were undertaken to determine more precisely the chromosome break points in this translocation. The measurements failed to show a definite loss of chromatin from the original short arm of the proband's Y chromosome. The azoospermia and infertility in our patient, in contrast to his father, suggest that infertility may be associated with this specific Y/Y translocation in human males.

Familial factors in bladder carcinoma.

Surprisingly, little is known about host factors in cases of bladder carcinoma. We investigated 2 families prone to transitional cell carcinoma of the bladder. A high degree of pathology verification of cancer of all anatomic sites and a meticulous recording of genealogy, associated diseases and environmental exposures, when known, have allowed a more cogent appraisal of cancer etiology. It is reasonable to assume that members of the subject families may be more susceptible to variable carcinogenic exposures, a concept that is in accord with a genetic-environmental interaction hypothesis for cancer etiology. In addition to increased surveillance of high risk patients for earlier detection of bladder cancer, cancer control measures also should take into consideration preventive programs directed toward the avoidance of known carcinogenic exposures, such as cigarette smoking in high risk relatives of cancer-affected probands. We propose that the etiology of familial bladder cancer may be complex, involving possible other associated malignant neoplasms and/or certain non-neoplastic disorders, in addition to specific carcinogenic exposures. There is a serious need for the detailed reporting of families prone to bladder cancer wherein all of these potentially important associated factors are considered, so that a fuller appraisal of etiology might be achieved.

Familial pheochromocytoma, hypercalcemia, and von Hippel-Lindau disease. A ten year study of a large family.

Long-term epidemiological and laboratory studies were carried out in a kindred with familial pheochromocytoma associated with von Hippel-Lindau disease. Thirteen members were affected by the syndrome and the trait appears to be transmitted in an autosomal dominant fashion. Of 13 patients, 7 had pheochromocytoma alone. Of the remaining six patients, one had pheochromocytoma combined with von Hippel-Lindau disease, four had pheochromocytoma with retinal disease only, and a single patient had a retinal lesion without pheochromocytoma. In four patients, pheochromocytoma antedated the development of retinal lesions. Ten members also had mild hypercalcemia without accompanying elevations of PTH in the 4 patients in whom this was determined. In all, hypercalcemia was corrected with removal of tumors, and no patient had a return of hypercalcemia in the absence of recurrent increases in urinary catecholamines. The clinical presentations in 12 patients varied markedly, as did their urinary excretion rates of norepinephrine, epinephrine and their metabolites. However, an analysis of the data revealed significant correlations not previously described between the urinary excretion of free catecholamines (norepinephrine plus epinephrine), blood pressure, the free catecholamine content of the tumor and the age of the patient. Urinary excretion of free norepinephrine plus epinephrine appear to be decreased with advancing age (p less than 0.001). Both systolic and diastolic blood pressures and the age of the patient were inversely correlated (p less than 0.01). A significant inverse relationship between the tumor content of free catecholamines and the age of the patients was, although to a lesser degree, also present (p less than 0.05). As a whole, the size of the tumors and their norepinephrine content were not correlated. We present a concept that, in familial pheochromocytoma, the metabolism of catecholamines is altered by the process of aging, and that this change modifies the clinical presentations of the disease.