[Foudroyant rhinocerebral zygomycosis]

We present a fatal case of rhino-orbital-cerebral zygomycosis in an 81-year old immunocompromised patient with a 18-year history of multiple myeloma. The patient initially presented with symptoms of an orbital complication, loss of vision after acute sinusitis and agranulocytosis. Endonasal sinus surgery with orbital decompression was performed. Within days a rapid visero-cerebral progression of necrosis developed finally causing the patient's death. Invasive fungal infections are generally characterized by diagnostic difficulties in the early stage and exhibit an extremely high mortality. Definitive diagnosis of rhino-orbital-cerebral zygomycosis caused by Rhizopus microsporus was made by histology, culture and polymerase chain reaction. Early diagnosis and treatment are imperative for the management of patients afflicted with this devastating and life-threatening fungal infection.

[Malignomas of the nasal cavity and the paranasal sinuses: clinical characteristics, therapy and prognosis of different tumor types]

BACKGROUND

Malignomas of the nasal cavity and the paranasal sinuses count for less than 3 % of the ENT-malignancies.

PATIENTS AND METHODS

This retrospective chart review reports about 46 patients that were first diagnosed and treated with a nasal cavity or paranasal sinus malignancy between 1998 and 2002 in the ENT department of the Ruhr-Universität Bochum.

RESULTS

18 of 46 malignomas were squamous cell carcinomas. At initial diagnose, already 52 % of malignomas were staged T4. Accordingly the origin in 17 % of malignomas could not be determined anymore. Additional 43 % of malignomas originated from the nasal cavity, another 20 % from the maxillary sinus. 11 of 46 patients (24 %) showed histological proven nodal involvement at initial diagnose. 92 % of patients underwent surgical therapy. 25 patients were radiated postoperatively. Over-all 1-year-survival-rate was 75 %, over-all 2-year-survival-rate was 47 %. Beside patients age, tumor free margins at initial surgery and absence of nodal involvement correlated to improved survival. 16 (76 %) of the 21 patients who died had local recurrence. Maxillary sinus malignomas recurred more often than malignomas of the ethmoid and the nasal cavity.

CONCLUSIONS

Malignancies of the nasal cavity and paranasal sinuses are very often diagnosed in advanced T-stages because of unspecific symptoms. The limited prognosis mainly depends on free surgical margins at the first resection and nodal involvement at the first diagnose. For improvement in outcome of nasal and paranasal sinuses malignancies, prospective multi-center trials are necessary.

Respiratory chlamydial infection based on experimental aerosol challenge of pigs with Chlamydia suis

An experimental study of aerogeneous challenge in pigs was conducted in order to reveal characteristic features of porcine respiratory chlamydiosis. Eight conventionally raised pigs were exposed to a pathogenic strain of Chlamydia (C.) suis, four controls were mock infected. Besides pathological changes, the acute-phase and humoral immune responses, as well as the dissemination and transmission of the challenge strain was monitored in the course of infection. The data from clinical investigations, LPS-binding protein assay, antibody ELISAs, confocal laser scanning and light microscopy, immunohistochemical staining and PCR provided extensive evidence of the pathogenic potential of C. suis for the porcine respiratory system. This model appears suitable for further pathophysiological and immunological investigations of chlamydial respiratory infections and can also be recommended for studies of Chlamydia-associated infections of the human lung.

Infection of murine precision cut lung slices (PCLS) with respiratory syncytial virus (RSV) and chlamydophila pneumoniae using the Krumdieck technique

The Krumdieck technique allows the investigation of the so-called precision cut lung slices (PCLS) with a special microtome. It is thus possible to evaluate morphologic changes over a longer period of time using only a small group of animals. Chlamydophila pneumoniae (Cp) and respiratory syncytial virus (RSV) proved to be important causes of pneumonia, rhinitis and exacerbations of asthma bronchiale, as well as of lower respiratory tract infections in young children. PCLS should be tested for their suitability as an in vitro model for these infections. The PCLS were infected with Cp and RSV over different periods of time. Investigations were carried out by light and transmission electron microscopy (TEM). Furthermore, immunofluorescence (IF) studies with antibodies against bacterial or viral proteins and cell-specific markers were done using confocal laser scanning microscopy (CLSM). Non-infected and infected PCLS showed a well-preserved morphology up to 72 hours. After short infection intervals, typical inclusions of Cp or RSV were detected in vacuoles of different cell types. Infection and cell types could be verified using IF. Cytopathic effects were not prominent. Ciliary beat was detectable up to 96 hours after infection. This in vitro technique offers the possibility of studying mechanisms and effects of bacterial and viral infections on viable tissue complexes.

Fluorescence in situ hybridization (FISH) for direct visualization of bacteria in periapical lesions of asymptomatic root-filled teeth

Whether micro-organisms can live in periapical endodontic lesions of asymptomatic teeth is under debate. The aim of the present study was to visualize and identify micro-organisms within periapical lesions directly, using fluorescence in situ hybridization (FISH) in combination with epifluorescence and confocal laser scanning microscopy (CLSM). Thirty-nine periapical lesions were surgically removed, fixed, embedded in cold polymerizing resin and sectioned. The probe EUB 338, specific for the domain Bacteria, was used together with a number of species-specific 16S rRNA-directed oligonucleotide probes to identify bacteria. To control non-specific binding of EUB 338, probe NON 338 was used. Alternatively, DAPI (4',6'-diamidino-2-phenylindole) staining was applied to record prokaryotic and eukaryotic DNA in the specimens. Hybridization with NON 338 gave no signals despite background fluorescence of the tissue. The eubacterial probe showed bacteria of different morphotypes in 50 % of the lesions. Rods, spirochaetes and cocci were spread out in areas of the tissue while other parts seemed bacteria-free. Bacteria were also seen to co-aggregate inside the tissue, forming microcolonies. Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythensis and treponemes of phylogenetic Group I were detected with specific probes. In addition, colonies with Streptococcus spp. were seen in some lesions. A number of morphotypes occurred that could not be identified with the specific probes used, indicating the presence of additional bacterial species. CLSM confirmed that bacteria were located in different layers of the tissue. Accordingly, the FISH technique demonstrated mixed consortia of bacteria consisting of rods, spirochaetes and cocci in asymptomatic periapical lesions of root-filled teeth.

Idiopathic bronchiolitis mimicking diffuse panbronchiolitis

Diffuse panbronchiolitis (DPB) is a distinct sinobronchial syndrome which has been almost exclusively reported in East Asia; only a few cases have been observed in non-Asians so far. Since 1990, when one of us described the first European case, we have screened all patients presenting with a clinical, physiopathological and radiological pattern compatible with DPB, in order to assess if the paucity of proven cases in Europe could reflect a lack of awareness of this disease among both pulmonologists and pathologists. Over a 10-years period we identified four additional DPBs, but also interestingly observed five cases of "idiopathic" bronchiolitis (IB) that had both clinical symptoms and high-resolution computed tomography (HRCT) findings indistinguishable from those of DPB, but did not show the typical histological changes. All these patients were Caucasians and presented with dyspnea, productive cough, an obstructive or mixed impairment on pulmonary function tests and chest HRCT features strongly suggesting a grade II to IV DPB. We suggest that diseases classified as IB in this study might be homogeneous entities which are clinically and radiologically similar to DPB.

Detection of Chlamydophila pneumoniae in mouse respiratory ciliated epithelium using targeted sections of the lung tissue

Chlamiophila pneumoniae were detected in targeted sections of mouse lung tissue by means of transmission electron microscopy and immunofluorescent staining. Incorporation of microorganisms into the axonemal matrix of cilia was observed 24 h after infection. The ciliary axoneme was characterized by pronounced swelling. At the late stages Chlamiophila pneumoniae were present in cytoplasmic vacuoles. Structural abnormalities and dysfunction of mucociliary clearance followed by incorporation of Chlamiophila pneumoniae into the cytoplasm of epitheliocytes were revealed in the early stage of infection. The proposed method allows studying the very early events of Chlamiophila pneumoniae infection.

Induction of cytochrome P450 1A1 in multiple organs of minipigs after oral exposure to soils contaminated with polycyclic aromatic hydrocarbons (PAH)

We have used the minipig as a prospective animal model for human risk characterization to study primary biochemical alterations upon oral contaminant intake. The effects of three orally administered soils containing polycyclic aromatic hydrocarbons (PAH) on the expression pattern of the cytochrome P450 enzyme CYP1A1 in various organs have been analyzed. Dependent on the soil sample, subchronic daily oral PAH doses ranged from 0.38 to 1.90 mg PAH(EPA)/kg body weight. In all cases, soil administration lead to significant CYP1A1 induction in several organs of minipigs to a different extent, following the order liver approximately = duodenum >lung >kidney approximately = spleen. Hepatic ethoxyresorufin- O-deethylase activities were elevated to 310, 1250 and 1780 compared with a background level of 200 pmol resorufin/mg protein per min. Induced duodenal activities appear to be even higher than in the liver, namely 405, 1280 and 2500 compared with a basal activity of 11 pmol resorufin/mg protein per min. CYP1A1 induction in several organs is clear evidence for successful contaminant mobilization and absorption in the duodenum and subsequent distribution of contaminant into diverse body compartments. As is shown in one case, impairment of CYP1A1 induction in the liver and thus breakdown of its PAH-metabolizing activity appears to have no effect on induced CYP1A1 levels in other organs. It appears important with respect to risk assessment that induction of CYP1A1 is particularly sensitive in the duodenum of minipigs and is achieved with soil doses which are in the range of amounts ingested by playing children due to hand-to-mouth activities. Induced duodenal CYP1A1 activities obtained in minipigs by oral exposure to PAH largely exceed maximal duodenal activities so far observed in rats. This is equally relevant for risk assessment and for selection of a suitable animal model that reflects effects of PAH exposure in humans.

Detection of Chlamydia pneumoniae in unexplained pulmonary hypertension

The pathogenesis of primary pulmonary hypertension is still unclear. The case of a 68-yr-old female patient who complained of recurrent dizzy spells and collapses over a period of 6 weeks and died of global cardiac failure is presented. Autopsy revealed severe pulmonary hypertension, slight chronic bronchitis, and bronchiolitis as well as intra-alveolar accumulation of macrophages. Chlamydiae were detected within the pulmonary arteries and in intramural and intra-alveolar macrophages by immunofluorescence, confocal laser scanning microscopy, scanning and transmission electron microscopy. Nested-polymerase chain reaction (PCR) and nonradioactive deoxyribonucleic acid (DNA) hybridization of PCR products from pulmonary arteries revealed Chlamydia pneumoniae DNA. Chlamydia pneumoniae has already been detected in atherosclerosis and in pulmonary emphysema. It can induce proliferation of smooth muscle cells. Chlamydia pneumoniae might be relevant in aggravation of primary pulmonary hypertension and might perhaps be a trigger factor in some cases.

Transformation of Hodgkin's disease to high-grade B-cell lymphoma: remission after Rituximab monotherapy

PURPOSE

We demonstrate the usefulness of immunotherapy with the CD20 antibody Rituximab in a case of transformation of Hodgkin's disease (HD) to high-grade non-Hodgkin's lymphoma (NHL).

CASE REPORT

A 45-year-old women suffering from lymphocyte predominant HD of paragranuloma type (stage IVb) since 1995 showed mediastinal relapse despite of 6 cycles of chemotherapy following the COPP/ABVD-protocol in 1998. Again complete remission could be achieved after escalated BEA-COPP II therapy in May 1998. Six months later chest radiograph and CT depicted pulmonary nodules. The non-typical resection of the lung revealed pulmonary involvement of a high-grade T-cell rich large B-cell lymphoma with 100% of the tumoral cells CD20 positive. Since the symptoms occurred shortly after the BEA-COPP-escalated protocol chemotherapy resistance had to be assumed. Because of this problems and supported by the refusal of a high-dose chemotherapy with stem-cell transplantation by the patient we decided to perform a mono-immunotherapy with the monoclonal CD20 antibody Rituximab. Today, 14 months later, the patient is still in complete remission including the absence of B symptoms.

CONCLUSIONS

Immunotherapy against CD20 positive cells in cases of sequential HD and NHL seems to be an effective therapy in chemotherapy resistant cases because of the suspected clonally relation of both diseases.

[Osteoma of the maxillary sinus]

BACKGROUND

Osteoma of the paranasal sinuses is a rare and benign entity that develops slowly. If they occur, locations within the frontal sinus and ethmoid cells are more frequent, whereas osteomas in the sphenoid or maxillary sinus are very rare.

CASE

We report on a 25-year old female patient presenting with a bony mass in the right maxillary sinus. A standard external approach using a modified Caldwell-Luc procedure was successfully employed as endoscopic endonasal surgery was limited by the size of the bony lesion.

CONCLUSIONS

Trauma or infection are often suggested as an etiologic factor in the pathogenesis of osteoma. In our case the development of maxillary osteoma was related to dental extraction and postoperative fistula. External standard procedures remain mandatory if endonasal endoscopic surgery fails in the removal of osteoma of the paranasal sinuses.

The role of chlamydia in the pathogenesis of pulmonary emphysema. Electron microscopy and immunofluorescence reveal corresponding findings as in atherosclerosis

Chlamydia pneumoniae has been detected in atherosclerotic plaques by various means. Chlamydiae are able to cause persistent infections. Serologically elevated antibody titers are found in severe chronic obstructive pulmonary disease. In atherosclerosis and pulmonary emphysema, inflammatory reactions can be seen by means of light microscopy. Specimens from patients with obliterative arteriosclerosis undergoing thrombendarteriectomy and with advanced emphysema undergoing lung volume reduction surgery were examined using scanning (SEM) and transmission (TEM) electron microscopy, and using immunofluorescence with monoclonal antibodies and antiserum against chlamydiae. SEM shows spherical bodies (SBs) with a diameter from 0.3 microm to 0.6 microm on the surface of the alveoli and bronchioles, as well as in atherosclerotic plaques. In atherosclerosis and emphysema, SBs reveal a double membrane, adherence to collagen fibers, tissue destruction, as well as intracellular and interstitial localization in TEM. They show in parts a densely packed central structure. SBs are seen both in alpha-1-antitrypsin deficiency emphysema and smoker's emphysema. Using immunofluorescence microscopy, spots are seen in corresponding distributions to the SBs. Morphological findings are typical for aberrant chlamydiae seen in persistent infections. Chronic infection and bacterial colonization associated with progressive disease seems to be relevant not only in atherosclerosis but also in pulmonary emphysema.

Mesalazine changes apoptosis and proliferation in normal mucosa of patients with sporadic polyps of the large bowel

BACKGROUND AND STUDY AIMS

Regular intake of nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce the occurrence of colorectal adenoma and carcinoma, possibly by inducing apoptosis and/or decreasing proliferation in colorectal epithelial cells. Mesalazine is widely used in the treatment of patients with inflammatory bowel disease, and well tolerated. We investigated its effect on apoptosis and proliferation of colorectal mucosa in 21 patients with sporadic polyps of the large bowel.

PATIENTS AND METHODS

In total, 17 patients with sporadic colorectal polyps (> or = 5 mm) underwent polypectomy and biopsy of uninvolved mucosa before and after treatment with 1 g/d mesalazine for 1, 3, 7 or 14 days. Four additional patients served as untreated controls. Apoptotic index (AI) was measured by terminal deoxynucleotidyl transferase-mediated d-uridine triphosphate nick-end labeling (TUNEL) assay; proliferation index (PI) was measured by immunohistochemical examination with anti-Ki67 antibody.

RESULTS

AI was significantly increased 1 and 3 days after initiation of treatment with mesalazine compared with controls (P= 0.0107 for the 1-day treatment group and P=0.0142 for the 3-day treatment group), and seemed to remain largely unchanged after longer treatment duration. Proliferation appeared to be decreased by mesalazine in all treatment groups, while proliferation in controls did not change (P=0.0107 for the 1-day treatment group and P= 0.0142 for the 3-day treatment group compared with controls.

CONCLUSIONS

Mesalazine significantly induces apoptosis and decreases proliferation in colorectal mucosa in patients with sporadic polyps of the large bowel. This may be clinically relevant in that it may lower the rate of polyp recurrence after polypectomy, thereby possibly contributing to the chemoprevention of sporadic colorectal carcinoma.

The role of persisting infections in the pathogenesis of pulmonary emphysema. Electron microscopy reveals a probable bacterial colonization of the alveolar space and the bronchioles

Lung volume reduction surgery (LVRS) yields resection specimens from patients with advanced pulmonary emphysema. Regarding the development of lung function parameters, recent results obtained by light microscopy revealed an unfavorable prognosis in patients with remarkable inflammation, particularly in the bronchioli. Tissue from ten patients (alpha1-antitrypsin level in the normal range) was furthermore investigated by electron microscopy. Scanning electron microscopy shows 0.4-0.6 micron spherical bodies variably densely arranged in the whole alveolar space and in the bronchioles of all patients. These bodies are mostly seen on the microvilli of type II pneumocytes. An immunological reaction with activation of macrophages and granulocytes occurs simultaneously. Macrophages show cytoplasmic extensions to the spherical bodies, which exhibit a cellular membrane but no cellular wall. This favors the diagnosis of bacterial colonization of the alveolar space and the bronchioles by mycoplasmas or L-forms of other bacteria. As patients undergoing lung volume reduction surgery are under optimal medical treatment and without any infection clinically, these findings appear to be relevant for the pathogenesis and/or progression of pulmonary emphysema.

[Pathologic-anatomic findings in surgical lung volume reduction of advanced emphysema]

Surgical lung volume reduction is a method for treatment of advanced pulmonary emphysema after all other therapeutic approaches have failed. 280 atypical lung resection specimen of 81 patients were examined pathologico-anatomically using routine stains. In all cases combinations of various forms of emphysema were found; in 65.8% there were also bullous changes (with > or = 1 cm diameter) focally. Acute bronchiolitis was seen in 41.8% of the specimens, an only slight (if at all) chronic bronchiolitis in 26.7% and bronchioloectasia in 45.4% of the cases. Focal intraalveolar aggregates of granulocytes were identified in 16.1%, and the process of permanent scarring resulting in "organised pneumonia" in 20.6% of the specimens. Occult neoplasms were found in 9.9% of the patients and specific changes in 27.2%. Bronchiolitis is relevant for postoperative prognosis and an indication for intensifying antibiotical and antiinflammatory therapy. Preoperative diagnostical procedures should be intensified to find out these patients. Inflammatory changes must be investigated in respect of etiology and pathogenesis.

Two-year results after lung volume reduction surgery in alpha1-antitrypsin deficiency versus smoker's emphysema

Lung volume reduction surgery (LVRS) improves exercise capacity and relieves dyspnoea in patients with smoker's emphysema (SE). It is unclear, however, whether LVRS similarly improves lung function in alpha1-antitrypsin-deficiency emphysema (alpha1 E). To address this question, this study prospectively compared the intermediate-term functional outcome in 12 consecutive patients with advanced alpha1E and 18 patients with SE who underwent bilateral LVRS. Before surgery there were no statistically significant differences between the two groups in the six-minute walking distance, dyspnoea score, respiratory mechanics or lung function data, except for the forced expiratory volume in one second, which was lower in the deficient group (24 versus 31% of the predicted value; p<0.05). In both groups, bilateral LRVS produced significant improvements in dyspnoea, the six-minute walking distance, lung function and respiratory mechanics. In the alpha1E group, the functional data, with the exception of the six-minute walking distance, returned to baseline at 6-12 months postoperation and showed further deterioration at 24 months. The functional status of the SE group remained significantly improved over this period. In conclusion, the functional improvements resulting from bilateral lung volume reduction surgery are sustained for at least 2 yrs in most patients with smoker's emphysema, but this type of surgery offers only short-term benefits for most patients with alpha1E.

Mixed malignant germ cell tumour of the liver

Germ cell tumours of the liver are rare neoplasms, with fewer than 20 cases reported in the literature following presentation as teratomas, choriocarcinomas or yolk sac tumours. We report a 52-year-old patient who complained of upper abdominal pain and anorexia. Ultrasonography and computed tomography of the abdomen revealed a large hepatic mass. Among the laboratory values we found elevated levels of alpha-fetoprotein and beta-chorionic gonadotropin. Repeated biopsies via CT scan, laparoscopy and laparotomy disclosed a poorly differentiated adenocarcinoma. Subsequently liver function deteriorated and, on the basis of clinical data highly suggestive of a malignant germ cell tumour, a modified chemotherapeutic protocol (PEI) was initiated. The elevated levels of alpha-fetoprotein and beta-chorionic gonadotropin declined rapidly, but the patient died 10 days later of liver dysfunction and bronchopneumonia. Subsequent autopsy confirmed the initial clinical diagnosis of a multilocular extragonadal malignant germ cell tumour of the liver with components of choriocarcinoma and embryonal carcinoma.

Proliferative activity, p53 accumulation and neoangiogenesis in pulmonary carcinosarcomas and pulmonary blastomas

Carcinosarcoma and pulmonary blastomas are rare biphasic tumors. Lung cancer pathogenesis is a multistep process. Proliferative activity, p53 accumulation and angiogenesis are of well-known relevance and ought to be evaluated in the epithelial and mesenchymal components of these tumors. Using antibodies against Ki-67 epitope MIB1 and proliferating cell nuclear antigen (PC 10) in 10 carcinosarcomas, tumors revealed a significantly higher proliferative activity in the epithelial component compared with the mesenchymal component in the MIB1 reaction (p = 0.013). In three pulmonary blastomas of the biphasic subtype, proliferative activity was similar in both parts. In five of 10 carcinosarcomas and in one of three pulmonary blastomas, accumulation of the p53 epitopes Pab 1801 and/or DO-1 was found. At the tumor front, a significantly higher vessel density was found compared with the central parts (p < or = 0.015) using a monoclonal antibody against human endothelium (CD 31). No differences were found between carcinosarcomas and pulmoblastomas. Higher proliferative activity in carcinosarcomas revealed a better prognosis regarding metastasis behavior (p = 0.05) and tumor-associated death in the follow-up (p < or = 0.017). p53 accumulation and microvessel density were of no prognostic value. This is in contrast to results in non-small cell lung cancer, pointing to a different biologic behavior.

[Expression of proliferation markers PCNA and MIB 1 in verrucous squamous epithelial carcinoma of the oral cavity]

Expression of proliferation markers PCNA and MIB 1 was evaluated in 17 verrucous carcinomas and in five cases of normal squamous epithelium of the oral cavity. Immunohistochemistry revealed no significant differences in the proliferative activities. Highest expression was seen in the basal zones. Proliferative activity in more than 26% of cells is no longer compatible with verrucous carcinoma, but favours the diagnosis of squamous cell carcinoma.