Lung transplantation: the pathologic diagnosis of pulmonary complications

The reliability of bronchoscopy with transbronchial biopsies for the diagnosis of acute graft rejection has recently been questioned. We present our experience with 59 transbronchial and bronchial biopsies and two open-lung biopsies from 12 patients that underwent lung transplantation. The diagnosis of acute rejection was established in 14 biopsies based on the absence of infection and presence of one or more of the following features: perivascular lymphoid infiltrates, usually associated with endothelial swelling; bronchial "acute on chronic" inflammation; and/or angiitis. Problems and potential pitfalls in the diagnosis of acute graft rejection in lung transplant patients are discussed. The biopsies were also sensitive for the diagnosis of cytomegalovirus pneumonitis and fungal infections but were not helpful for the diagnosis of bacterial pneumonias. Indeed, one patient died with Legionella sp. pneumonia diagnosed only on open-lung biopsy after two negative transbronchial biopsies. The significance of other histologic changes, such as nonspecific interstitial pneumonitis, diffuse alveolar damage, acute alveolitis, goblet cell hyperplasia of the bronchial mucosa, and pulmonary infarction, is discussed.

Epithelioid angiomatosis or cat scratch disease with splenic and hepatic abnormalities in AIDS: case report and review of the literature

Cat scratch disease (CSD) in the setting of HIV infection is associated with lesions of epithelioid angiomatosis but not with granulomatous lesions seen in the normal host. We report a case of CSD in a patient with AIDS and Kaposi's sarcoma with epithelioid angioma of skin, thrombocytopenia, and abnormalities of liver, spleen, lymph node, and pleura that responded to antimicrobial therapy. We also review reported cases of epithelioid angiomatosis in HIV infections. 12 of these resolved, including 3 without antimicrobial therapy; 18 demonstrated pleomorphic organisms with Warthin-Starry silver stain. Six involved visceral or bony as well as skin lesions. CSD should be considered in the setting of HIV infection with skin nodules even in the presence of biopsy-proven Kaposi's sarcoma. CSD may in these patients be responsible for a variety of disseminated lesions which respond to antimicrobial therapy.

Lymphocytic interstitial pneumonia in patients at risk for the acquired immune deficiency syndrome

Three patients with the acquired immune deficiency syndrome (AIDS) or AIDS-related complex and lymphocytic interstitial pneumonia are reported. All patients presented with progressive dyspnea, nonproductive cough, fever, anorexia, weight loss, and arterial hypoxemia. Chest roentgenograms exhibited bilateral diffuse reticular-nodular densities. The diagnosis of lymphocytic interstitial pneumonia was made by fiberoptic bronchoscopy or open lung biopsy. Two patients were treated with corticosteroids, with significant improvement. The third patient died of pneumonia due to Pneumocystis carinii six months after the diagnosis of lymphocytic interstitial pneumonia was established. Serum antibodies to human immunodeficiency virus (HIV) were demonstrable in the two patients in whom the test was performed. Lymphocytic interstitial pneumonia is probably another pulmonary manifestation of AIDS or AIDS-related complex. Although the clinical presentation may be identical to the more common opportunistic infections, the treatment differs, and the prognosis may be better.

Endometrial cyst of the liver

A 21-yr-old woman with a history of epigastric pain and a right upper quadrant mass was found to have a large parenchymal hepatic cyst on CT scan. The cyst was removed at surgery and found to be lined by ectopic endometrial tissue. This is, to our knowledge, the first recorded instance of endometriosis of the liver. The clinicopathological features of this patient and the possible pathogenesis of her most unusual hepatic lesion are discussed.

Primary lymphoma of the liver in the acquired immunodeficiency syndrome

We describe a 78-year-old man with a diffuse large-cell lymphoma that was limited to the liver and was associated with micronodular cirrhosis and Kaposi's sarcoma that involved abdominal lymph nodes and gastric mucosa. The serum of the patient reacted positively to a test for human T-cell lymphotropic virus type III antibodies. We discuss the clinical and autopsy findings for this unusual patient, the criteria for the diagnosis of primary lymphoma of the liver, and its occurrence in patients with the acquired immunodeficiency syndrome.

Computerized interactive morphometry as a potentially useful tool for the classification of non-Hodgkin's lymphomas

The use of a simple form of Computerized Interactive Morphometry (CIM) is proposed as a tool to achieve a reproducible classification of non-Hodgkin's lymphomas. This system combines a random sampling method for cells with simple size measurements and additional subjective criteria such as a shape, mitotic counts, and follicular or diffuse features. In this system, which utilizes a high resolution touch screen as interactive peripheral, the video image of the specimen is superimposed to a computer generated reference system which consists of a test area and four fixed points for random sampling of cells and a series of concentric circles to serve as internal standard for nuclear size; the computer tabulates and facilitates data processing. Forty-four lymphoid lesions have been characterized with the CIM system and specific criteria for diagnoses according to the Working Formulation of non-Hodgkin's lymphomas for clinical usage are derived. Studies of inter- and intraobserver variations in data collection are discussed, and a diagnostic algorithm that categorizes non-Hodgkin's lymphomas according to the relative proportions of various lymphoid cells and densities of mitotic counts is proposed. The potential applications of touch screen-based CIM for the study of malignant lymphomas and its practical technical advantages over other quantitative systems based on either gray-level analysis or tracings of cell contours on photographs or digitizer pads are emphasized.

Mixed tumor of the mediastinum

A 36-year-old asymptomatic man was found to have a large middle mediastinal mass on a chest x-ray film. At surgery the tumor was located adjacent to the carina and beneath the aortic arch. It measured 7.0 X 5.0 X 4.0 cm and was well circumscribed and soft, with mucoid areas. The histologic features were those of a benign pleomorphic adenoma of salivary gland origin. This is, to our knowledge, the first reported case of primary pleomorphic adenoma of the mediastinum. We propose an origin from the ectopic salivary gland tissue. We also describe an additional patient in whom ectopic benign salivary gland tissue was found within mediastinal lymph nodes to support our hypothesis.

Diagnosis of pulmonary complications of the acquired immune deficiency syndrome

Forty eight patients with the acquired immunedeficiency syndrome (AIDS) presented to the Mount Sinai Hospital in New York with persistent cough and dyspnoea or an abnormal chest radiograph, or both. Thirty two (67%) were found to have Pneumocystis carinii pneumonia, either alone or in combination with another pathogen. Of these patients, eight (25%) had a normal chest radiograph. Abnormalities in the single breath carbon monoxide diffusing capacity and alveolar-arterial oxygen gradient [A-a) DO2) suggested infection with Pneumocystis carinii. Fibreoptic bronchoscopy with transbronchial biopsy was 100% sensitive in the diagnosis of pneumocytis pneumonia. Fibreoptic bronchoscopy should be undertaken in patients suspected of having a pulmonary complication of AIDS, even if the chest radiograph is normal.

Pulmonary complications of the acquired immunodeficiency syndrome: a clinicopathologic study of 70 cases

The pulmonary complications of 70 patients with the acquired immunodeficiency syndrome (AIDS) are reviewed. Pneumocystis carinii pneumonia (PCP), present in 67 per cent of the patients, was diagnosed by fiberoptic bronchoscopy with transbronchial biopsies in all of the patients except two adults, who required open lung biopsy, and two children, in whom the infection was detected only at autopsy. Other opportunistic infections, such as cytomegalovirus pneumonitis, mycobacterial infections, invasive candidiasis, toxoplasmosis, cryptococcosis, and histoplasmosis, were more difficult to diagnose by fiberoptic bronchoscopy. In only four cases were these conditions detected during life. Neoplasms and lymphoproliferative processes also presented diagnostic problems, and only one case each of Kaposi's sarcoma and lymphoid interstitial pneumonitis were detected by fiberoptic bronchoscopy. In four other cases these conditions, as well as two pulmonary lymphomas, diffuse large cell immunoblastic type, were detected only at autopsy. Sixty-eight per cent of the patients in this study died, usually with progressive intractable respiratory failure and pulmonary complications that had not been diagnosed during life, including potentially treatable diseases, such as bacterial pneumonias, PCP, nontuberculous mycobacteria, invasive candidiasis, toxoplasmosis, and invasive aspergillosis. The need for earlier detection of pulmonary complications in patients with AIDS is discussed.

Nontuberculous mycobacteria in pleural fluid. Assessment of clinical significance

We reviewed the case records of 22 patients from whose pleural fluid a nontuberculous Mycobacterium (NTM) was isolated. Three patients had pleural effusions definitely due to NTM infection, with evidence of NTM infection in other tissues; 16 had pleural effusions of known etiology unrelated to the isolated NTM and no other evidence of NTM infection; and three had pleural effusions of undetermined etiology and no other evidence of NTM infection. The case histories of the three patients with pleural effusions due to NTM are presented and the significance of the isolation of NTM from the remaining 19 patients is discussed. Criteria are proposed for evaluating the significance of NTM isolated from pleural fluid.

Diagnosis of lung cancer by fibreoptic bronchoscopy: problems in the histological classification of non-small cell carcinomas

Specific cell typing in lung cancer has important implications for assessment of prognosis and the planning of treatment. Cell typing is, however, often difficult and the problem has been compounded by the universal use of the flexible fibreoptic bronchoscope, which yields specimens only 2 mm in diameter. We have reviewed the records of 107 patients who had a diagnosis of lung cancer established by fibreoptic bronchoscopy and who subsequently underwent staging biopsy or surgical resection. Examination of tissue obtained by surgical resection yielded a different cell type from that identified in specimens obtained at fibreoptic bronchoscopy in 11 of 32 patients with a bronchial biopsy specimen diagnostic of squamous cell, three of 44 patients with a diagnosis of adenocarcinoma, six of seven thought to have a poorly differentiated carcinoma, and 21 of 24 patients with a diagnosis of large cell carcinoma. In all, 41 of the 107 surgically removed specimens (38%) differed in cell type from their corresponding bronchoscopic specimens. Accurate cell typing by specimens obtained at fibreoptic bronchoscopy may be extremely difficult. If clearcut morphological criteria cannot be satisfied, the diagnosis of "lung cancer, non-small cell type" should be made.

Localized lymphoid nodules of lung. A reappraisal of the lymphoma versus pseudolymphoma dilemma

Eleven patients with localized lymphoid nodules of the lung (LLN) were seen at the Mount Sinai Hospital from 1962-1981. The diagnosis of pseudolymphoma was made in six instances based on the following criteria: (1) solitary or multiple nodules discovered on chest roentgenograms composed of cytologically benign lymphoid cells (small lymphocytes); (2) polymorphic character of the infiltrate, including plasma cells, histiocytes and monocytes; and (3) presence of germinal centers in the lesion. Five lesions were classified as lymphomas and exhibited: (1) solitary or multiple nodules composed of atypical lymphoid cells; (2) absence of germinal centers; (3) lack of mediastinal lymph node involvement. Bronchial and/or pleural infiltration by lymphoid cells was present in lymphomas as well as in pseudolymphomas. Five lesions were studied with immunofluorescent techniques for the presence of intracytoplasmic immunoglobulins and in one pseudolymphoma, lymphocyte marker studies were performed. The procedures were not useful in separating benign from malignant lesions. All patients underwent surgery; three with lymphoma and one with pseudolymphoma received adjuvant chemotherapy. Patients were followed post surgically for up to 13 years. None of the six patients with pseudolymphoma died as a result of their lesions but two had either recurrences or developed extrapulmonary lymphoid lesions. All five lymphoma patients did well. Only one died while on chemotherapy with invasive pulmonary aspergillosis but no tumor. One-hundred and sixty-seven reported cases from the literature are analyzed. Pulmonary pseudolymphomas do not necessarily follow a benign course and malignant lymphomas limited to the lungs do not usually undergo progressive disease. Present pathologic criteria do not allow prediction of recurrence or progression of disease and are not acceptable for determining the advocacy of chemotherapy in patients with LLN.

The spectrum of pathology of nontuberculous mycobacterial infections in open-lung biopsy specimens

The diagnosis of pulmonary nontuberculous mycobacterial (NTM) infection may be difficult to establish unless open-lung biopsy is performed. Mycobacteria were present in resected lung tissues from forty patients at the Mount Sinai Hospital during the period 1969-1980. M. avium-intracellulare was cultured in 24 patients, M. tuberculosis in six, M. gordonae in three, and M. fortuitum in two. In five instances, mycobacteria were seen in smears of lung tissues but failed to grow in culture. Three distinct clinicopathologic groups of patients with NTM were recognized. (1) Eighteen patients had solitary pulmonary nodules resected with the clinical diagnosis of lung cancer. Histologically, they exhibited granulomas with varying degrees of necrosis. Mediastinal lymph nodes had no granulomas, except in one case. (2) Seven patients presented with roentgenologic evidence of bilateral, diffuse interstitial infiltration. M. avium-intracellulare or M. gordonae were isolated from lung tissue which histologically showed interstitial fibrosis and organizing pneumonia. In only one instance a few non-caseating epitheloid cell granulomas were found. Three of these patients had underlying malignancies treated with chemotherapy and one other had arthritis. The other three had no underlying diseases. (3) Three patients had multiple discrete infiltrates on chest roentgenograms. M. avium-intracellulare was isolated from their lung tissues. One of these patients exhibited necrotizing granulomatous vasculitis indistinguishable from Wegener's granulomatosis. It is apparent that classical "tuberculosis-like" granulomatous reaction is the most common histologic pattern but should not be expected in all patients with NTM infections.

Quantitative studies of argyrophilic APUD cells in airways: II. The effects of transplacental diethylnitrosamine

The effects of transplacental administration of diethylnitrosamine (DEN) on the densities of epithelial and APUD cells in the large and small airways of developing hamsters have been studied quantitatively. The APUD cells are quantitated by relating them to the number of airway epithelial cells; APUD cells are present in similar densities in the large airways (0.12 APUD cells/100 cells) and small airways (0.14) of 2-day-old control hamsters. At 4 days an increase in the densities of APUD cells and an increase in epithelial cells is observed in the small airways, whereas those in the large airways decrease slightly. At later periods there is a progressive decline in the density of APUD cells in the control hamsters. Exposure in utero to DEN results in a generalized increase in APUD cells in 2-day-old hamsters, which is more pronounced in bronchioles (fivefold increase). The effect disappears in older animals. It also results in a transient increase in tracheal epithelial cell density in 7-day-old hamsters. Whether the selective and transient APUD cell hyperplasia induced by transplacental administration of DEN results from proliferation of these cells or from differentiation of other types of epithelial cells into APUD cells requires further study.

Pulmonary tumorlets in cases of "tuberculoma" of the lung with malignant cells in brush biopsy

Two cases of pulmonary nodules associated with Mycobacterium intracellulare infection were initially interpreted as carcinomas of the lung after brush cytology specimens were reported to contain malignant epithelial cells. In both instances, the cells observed in the cytology specimens exhibited marked cytologic atypia. These cells were identical to those present in tumorlets adjacent to the granulomatous lesion. Tumorlets may thus represent a source of false-positive cytologic findings or constitute a type of microscopic neoplasms of the lung.