Pericardial mesothelioma: the diagnostic dilemma of misleading images

A young man with a short history of increasing dyspnea, cough, and ascites was initially diagnosed as having idiopathic constrictive pericarditis and referred for an operation. The procedure revealed an atypical invasive encapsulating disease. Complete resection was impossible, and only partial relief of constriction was achieved. The patient died shortly after. Histology revealed primary mesothelioma of the pericardium. The case illustrates the difficulty in establishing this diagnosis by echocardiography and computed tomography.

Identifying montages that best detect electrographic seizure activity during polysomnography

STUDY OBJECTIVES

Recognizing epileptic seizures during video polysomnography (VPSG) can be challenging, particularly when using standard, limited EEG montages and paper speed. Few sleep laboratories have PSG equipment that allows for the recording of 18 channels of EEG without compromising the ability to detect sleep apnea, periodic limb movements, and parasomnias. We studied the ability of sleep medicine- and EEG-trained polysomnographers to correctly identify epileptic seizures during PSG using 4, 7, and 18 channels of simultaneous EEG, recording at conventional PSG and EEG paper speeds. The purpose of this study was to determine the value of limited EEG montages viewed with EEG reformatting capability in the identification of seizures during PSG.

DESIGN

Blinded EEG analysis of seizures and arousals during VPSG.

SETTING

Tertiary care hospital with sleep laboratory and epilepsy monitoring unit.

PATIENTS

Subjects with focal (partial) epilepsy that underwent video-EEG monitoring.

INTERVENTIONS

We designed two 7-channel EEG montages that might facilitate the identification of seizures arising from the frontal and temporal lobes. Sleep medicine- and EEG-trained polysomnographers were asked to review tracings containing frontal or temporal lobe epileptic seizures and arousals from sleep. Utilizing the capability of our digital recording equipment to reformat EEG channels and change paper speeds, we asked the readers to classify events recorded with 4, 7, and 18 channels of simultaneous EEG, at paper speeds of 10 and 30 mm/sec.

MEASUREMENTS AND RESULTS

6 readers viewed 32 sleep-related events (13 frontal lobe seizures, 11 temporal lobe seizures, and 8 arousals). The following factors were analyzed for their influence on accuracy of event detection: 1) the type of training of the reader (EEG vs. sleep medicine); 2) the number of EEG channels (4, 7, or 18); and 3) paper speed (10 vs. 30 mm/sec). Pair-wise comparisons and generalized estimating equations were used to identify factors leading to more accurate detection of seizures and arousals. 77% of events were correctly identified: 74% of seizures and 88% of arousals. Seizure detection was better using 7 and 18 channels (sensitivity of 82% and 86%, respectively) than 4 EEG channels (sensitivity of 67%) for temporal lobe seizures only. The number of EEG channels did not affect the accuracy of frontal lobe seizure detection. For EEG-trained readers, accuracy was greater using 30 mm/sec than 10 mm/sec paper speed (85% vs. 78% correct, respectively).

CONCLUSIONS

Adding EEG channels and EEG reformatting capabilities to PSG interpretation improves the detection of some types of epileptic seizures. Accuracy of temporal lobe seizure detection using an abbreviated 7-channel montage approximates that of an 18-channel EEG recording. However, the same is not true of frontal lobe seizures in which accuracy was similar regardless of the number of EEG channel available. Further studies are needed to identify specific EEG montages that would best detect epileptiform activity during VPSG.

Acute headache in children and adolescents presenting to the emergency department

OBJECTIVES

Our goals were (1) to investigate the causes of acute headache in childhood from the emergency department perspective and (2) to search for clinical clues that might distinguish headache associated with serious underlying disease.

BACKGROUND

The clinical presentation of headache in children and adolescents can be separated into 5 temporal patterns: acute, acute-recurrent, chronic progressive, chronic nonprogressive, and mixed. Few data exist regarding acute headache in children.

METHODS

Consecutive children who presented to our emergency department with the abrupt onset of severe headache were prospectively evaluated. The headache character, location, severity, and associated symptoms, as well as underlying causes, were recorded using a standardized survey.

RESULTS

One hundred fifty children, aged from 2 to 18 years, 87 boys and 63 girls, were enrolled over a 10-month period. Upper respiratory tract infection with fever (viral upper respiratory tract infection 39%, sinusitis 9%, streptococcal pharyngitis 9%) was the most frequently identified cause of acute headache (57%). Other causes included migraine (18%), viral meningitis (9%), posterior fossa tumors (2.6%), ventriculoperitoneal shunt malfunction (2%), epileptic seizure (postictal headache) (1.3%), concussion (postconcussive headache) (1. 3%), intracranial hemorrhage (1.3%), and undetermined (7%). Two clinical features were found to have statistically significant associations with serious underlying disease: occipital location of headache and an inability of the patient to describe the quality of the head pain. All children with surgically remediable conditions had clear and objective neurological signs.

CONCLUSIONS

In children and adolescents, the abrupt onset of severe headache is most frequently caused by upper respiratory tract infection with fever, sinusitis, or migraine. Special attention is warranted if the acute headache is occipital in location and if the affected patient is unable to describe the quality of the pain. Serious underlying processes such as brain tumor or intracranial hemorrhage are uncommon and, when present, are accompanied by multiple neurological signs (ataxia, hemiparesis, papilledema).

Chronic deciduitis in the placental basal plate: definition and interobserver reliability

This study tested whether concordance could be achieved for abnormal inflammation in the basal decidua of placental specimens among 6 pathologists experienced in placental pathology. Thirty microscope slides were evaluated by the pathologists for chronic deciduitis. They also scored the severity and extent of inflammation and the presence of plasma cells. No definition of chronic deciduitis was provided. Concordance (5/6 or 6/6 agreement) was achieved in 23 cases (76%). Spearman's rank correlation showed that the diagnosis of chronic deciduitis was almost identical to the assessment of the severity of the inflammation. A regression analysis showed that the perception of severity (and hence chronic deciduitis) was influenced by the other 2 variables, extent and plasma cells. The results were shared with the pathologists, and 25 cases (excluding those with previous 6/6 consensus) were reevaluated. Concordance was now achieved in the 83% of those remaining cases. Using a threshold based on the severity and the extent of lymphocytes, and the presence of plasma cells, pathologists are able to diagnose chronic deciduitis with sufficient concordance to be of value in clinical correlation studies.

General practitioners' beliefs, attitudes and reported actions towards chronic fatigue syndrome

OBJECTIVE

To undertake a survey of Australian general practitioners (GPs) to explore their beliefs, attitudes and reported actions with respect to chronic fatigue syndrome (CFS).

METHOD

A random sample of 2090 Australian GPs, stratified by state, was surveyed in May-August 1995.

RESULTS

A 77% response rate was obtained. For the majority of practitioners who pursue a diagnosis of CFS, six symptoms were considered to be of significance: chronic unremitting fatigue for over 6 months; failure to recover energy after rest; reduced exercise tolerance; prostration for several days after exercise; generalised myalgia and poor concentration. Individual counselling was the most frequently used treatment. Thirty-one percent of practitioners reported that they did not believe that CFS is a distinct syndrome. Of these, 70% reported that the most likely cause of chronic fatigue was depression.

CONCLUSION

There is considerable diversity of opinion between practitioners about CFS. The diversity extends from questioning whether the syndrome even exists to different strategies for diagnosis and management.

Fetal membrane histology in preterm premature rupture of membranes: comparison to controls, and between antibiotic and placebo treatment. The National Institute of Child Health and Human Development Maternal Fetal Medicine Units Network, Bethesda, MD, USA

The objectives of this study were to test the hypotheses that antibiotic therapy will alter the histologic appearance of fetal membranes in preterm premature rupture of membranes (pPROM), and that the membrane histology will demonstrate distinct differences between term and preterm rupture of membranes. We also wished to test interobserver variability of pathologists. Placental membranes were sampled from 268 women participating in a randomized placebo-controlled trial of antibiotic therapy for pPROM at 24-32 weeks of gestation (cases) and from 4 control groups who were not in the randomized trial: (1) preterm labor without pPROM (n = 21), (2) term labor (n = 65), (3) term PROM (n = 21), and (4) term cesarean section (n = 27). The cases and controls were scored for 40 histologic features by pathologists blinded to the identity of each sample (case or control). pPROM histology of samples from patients receiving antibiotics and those receiving placebo was compared using a chi-squared test and with control groups using logistic regression. There were no histological differences between pPROM cases treated with antibiotic and those receiving placebo, nor with respect to duration of membrane rupture greater or less than 48 h. Concordance among pathologists was low for features other than acute inflammation. Logistic regression analysis controlled for race and pathologist, and demonstrated that all of the control groups had significantly fewer common markers of acute inflammation when compared with the pPROM cases. This study suggests that histopathologic evidence of infection is seen more frequently with pPROM than in preterm or term controls. The histologic features used in this study cannot be used to determine the effectiveness of antibiotic therapy.

Ontogeny of recurrent hydrocephalus: presentation in three fetuses in one consanguineous family

A consanguineous couple had 3 pregnancies in which prenatally diagnosed hydrocephalus was observed (in 1 female and 2 male fetuses). This case appears to represent an autosomal recessive form of hydrocephalus, given the consanguinity, affected sibs of both genders, and no evidence for intrauterine infection, chromosome abnormality, or neural tube defect.

Immature teratomas of the genital tract in older women

We report the clinicopathologic features of three women, 40 years of age or older, with malignant genital tract immature teratomas. All had FIGO stage III, grade II or grade III tumors. One tumor arose from the fallopian tube, the second from the ovary, and the third involved the cortical surfaces of both ovaries with minimal parenchymal involvement. The tumors weighed 1700, 5660, and 330 g and had histologic features similar to those generally seen in younger women. Two of the women died within 1 year of diagnosis. Interval growth of tumor after treatment with chemotherapy was documented in the third patient; she was reexplored and all of the excised tumor was composed of mature tissues. These cases affirm that, although rare, malignant germ cell tumors can occur in older peri- or postmenopausal women.

Conservative surgery in a young patient with peritoneal psammocarcinoma

Psammocarcinoma is a rare epithelial neoplasm of the ovary and peritoneum. The reported management of patients with this tumor includes radical surgery and chemotherapy. We report the case of a young woman with metastatic psammocarcinoma treated with conservative surgery who is alive 6.5 years following positive second-look laparotomy.

Tumor angiogenesis in vulvar squamous cell carcinoma

OBJECTIVE

Angiogenesis has been shown to correlate positively with the presence of metastatic disease in some tumors, but has not been studied in invasive vulvar squamous cell carcinoma. Fifty cases of invasive vulvar squamous cell carcinoma were studied in an effort to correlate angiogenesis with stage, survival, and pattern of invasion.

METHODS

These patients were diagnosed between 1987 and 1993. Microvessels were identified immunohistochemically using antibody to Factor VIII, and areas of greatest microvessel density associated with tumor were counted. The pattern of invasion was categorized as "spray," "pushing," or "mixed." The mean microvessel count was correlated with surgical and clinical stage, pattern of invasion, and survival.

RESULTS

Mean microvessel counts in surgical stage I/II cases (31.1 +/- 7.3) were not significantly different from stage III/IV cases (26.3 +/- 8.6) (P = 0.089). Similarly mean microvessel counts in clinical stage I/II cases (31.6 +/- 11.9) were not significantly different from stage III/IV cases (27.0 +/- 8.7) (P = 0.198). Seventeen patients who died of disease had mean counts of 26.1 +/- 6.4, while 21 patients alive with or without evidence of disease had counts of 31.1 +/- 10.8 (P = 0.087). Mean microvessel counts did not vary significantly with the spray pattern (30.1 +/- 8. 7), pushing pattern (31.4 +/- 12.9), or mixed pattern of invasion (31.4 +/- 12.9) (P = 0.920).

CONCLUSIONS

Tumor angiogenesis in vulvar squamous cell carcinoma does not correlate positively with stage, survival, or pattern of invasion and cannot be used as a prognostic indicator.

Ovarian smooth muscle metaplasia: an uncommon and possibly underrecognized entity

Smooth muscle differentiation in the ovary is rare, and its histopathologic spectrum, including ovarian smooth muscle metaplasia (SMM), has not been well described. The clinicopathologic findings in 48 ovaries with SMM from 40 women are reported. The average age of women with ovarian SMM was 55.6 years (range, 34 to 86 years). Foci of SMM were semiquantitatively characterized as 1+ in 46% (1 to 3 foci), 2+ in 37% (4 to 6 foci), and 3+ in 17% (> 6 foci). SMM was bilateral in 8 (23%) of the 35 patients who had bilateral oophorectomies. SMM was intimately associated with another ovarian process in 28 (58%) cases, including ovarian cysts (11), endometriosis (3), granulosa cell tumors (3), extensive stromal luteinization (1), ovarian fibroma (1), adhesions (1), and folliculogenesis (8). Ovaries with 2+ to 3+ SMM were associated with another ovarian lesion significantly more often than those with 1+ SMM (p < 0.01). Most women with ovarian SMM (86%) also had uterine leiomyomas. Significant endometrial pathology was present in 13 (37%) of 35 simultaneously removed uteri. In conclusion, SMM occurs most often in perimenopausal or postmenopausal women, most of whom also have uterine leiomyomas. Ovarian SMM is usually confined to a few microscopic fields, is bilateral in < 25% of patients, and is often associated with other ovarian lesions.

Ovarian leiomyomas: clinicopathologic features in fifteen cases

Ovarian leiomyomas are uncommon and have not been systematically studied. The clinical and histopathologic features of 15 ovarian leiomyomas were evaluated, including their clinical presentation, size, cellularity, mitotic index, presence of degeneration, and hyalinization. The mean age of women with ovarian leiomyomas was 45.8 years. The presenting sign was an adnexal mass in 7 (47%), uterine leiomyomas in 4 (26%), contralateral adnexal mass in 2 (13%), and other signs in 2 (13%) women. Thirteen leiomyomas had mitotic indices < 1/10 high-power-fields (HPFs), including one cellular leiomyoma, and 2 had mitotic indices between 1 and 2/10 HPFs. The cellular leiomyoma and those with a mitotic index of > or = 1/10 HPFs had an average size of 3.4 cm. Two leiomyomas exhibited central degeneration, and hyaline change was present in 5 leiomyomas, 4 of which were at least 4 cm in size. The majority of ovarian leiomyomas (78%) were associated with uterine leiomyomas; hyperplastic endometrial polyps were present in 2 cases. Follow-up (mean, 9.6 months) was available in 8 cases, and all had no evidence of recurrence. In conclusion, ovarian leiomyomas exhibit a spectrum of features that are similar to uterine leiomyomas. Although the prognosis is presumed to be good, the short follow-up period of this series precluded definitive evaluation of their natural history.

Twin reversed arterial perfusion sequence in conjoined, acardiac, acephalic twins associated with a normal triplet. A case report

BACKGROUND

Twin reversed arterial perfusion (TRAP) sequence and development of an acardiac monster is a rare event. Even more rare are conjoined acardiac, acephalic twins complicating a triplet pregnancy with TRAP sequence. The mortality for the acardius is 100%, and morbidity for the normal, pump fetus is 50%. The morbidity of the pump twin or triplet is attributed mostly to in utero congestive heart failure.

CASE

A 24-year-old woman, gravida 1, para 0, at 35 weeks' intrauterine pregnancy, gave birth via low transverse cesarean section to a normal female and a pair of conjoined, acardiac, acephalic, pelvipagus twins.

CONCLUSION

The diagnosis of acardius in multiple gestation pregnancy, with no fetal heart tone on ultrasound, must be ruled out in every case so that proper counseling, management and avoidance of complications in these patients can be achieved.

Chronic chorioamnionitis: a clinicopathologic and immunohistochemical study

Lymphocytic inflammation of the fetal membranes is unusual and has been termed chronic chorioamnionitis. We report the clinicopathologic and immunohistochemical findings in 31 placentas with chronic chorioamnionitis. The most common histopathologic association was chronic villitis of unknown etiology, which was identified in 22 (71%) of the 31 placentas. The severity of the chronic villitis did not correlate with the severity of chronic chorioamnionitis. Additional placental findings included chronic intervillositis in two, fetal vessel thrombosis in five, hemorrhagic endovasculitis in four, decidual chronic vasculitis in three, and atherosis in one. Maternal history included pregnancy-induced hypertension in six and diabetes in one. Twelve infants were preterm, and five had intrauterine growth retardation. There was no neonatal sepsis or death. Immunohistochemical staining in areas of chronic chorioamnionitis showed CD3+ and CD8+ cells present in moderate numbers, and CD4+ cells in smaller numbers. CD20+ and CD56+ cells were rare or absent. Chronic chorioamnionitis is commonly associated with chronic villitis of unknown etiology, shares similar clinical associations, and may have a related cause, possibly immunologic.

Maternal scleroderma: placental findings and perinatal outcome

Pregnancy after the onset of scleroderma is uncommon; therefore, placental findings and perinatal outcome have rarely been correlated. The histopathologic features of placentas from 13 pregnancies in eight women with scleroderma were recorded and correlated with the clinical features of the mother and fetus. Adverse perinatal outcome included intrauterine fetal demise in five, and previable or preterm delivery in four. A decidual vasculopathy was seen in 5 of the 13 placentas, four of which were associated with intrauterine fetal demise. Decidual blood vessels in the scleroderma patients were evaluated immunohistochemically for platelet-derived growth factor (PDGF), transforming growth factor beta1 (TGF-beta1), T-helper and T-suppressor lymphocytes, macrophages, immunoglobulin (Ig) M, and IgG, and compared with those from hypertensive and uncomplicated third-trimester pregnancies. The atherotic blood vessels in scleroderma were characterized by mural macrophages and IgM and IgG deposition and were similar to those seen in placentas from hypertensive pregnancies. CD8-positive T cells predominated in normal and hypertensive decidua compared with scleroderma, in which CD4-positive T cells were more frequent. No difference in PDGF or TGF-beta1 staining was found between scleroderma and control groups. In conclusion, decidual vasculopathy is common in scleroderma, is similar to that seen in hypertension, and is associated with poor perinatal outcome. A trend toward a reversed ratio of decidual CD4 to CD8-positive T cells is seen in scleroderma compared with hypertension and uncomplicated pregnancies. PDGF and TGF-beta1 do not appear to be involved in the pathogenesis of decidual vasculopathy in scleroderma.

Placental involvement in congenital hepatoblastoma

We describe extensive placental involvement by hepatoblastoma in a 2600 g, 33-week estimated gestational age (EGA) hydropic female fetus with the hepatoblastoma otherwise limited to the liver. The placenta weighed 1190 g and histopathologic examination revealed diffuse tumor emboli in chorionic villous vessels. The placental tumor exhibited a cytologic appearance similar to the primary tumor and showed strong alpha-fetoprotein staining. Although unusual, other congenital tumors, including neuroblastoma and leukemia, have also been described metastatic to the placenta. This case emphasizes the important role of careful histopathologic examination of the placenta which, combined with immunohistochemistry and clinicopathologic correlation, may establish a diagnosis and possibly obviate the need for invasive neonatal diagnostic procedures.

Effect of nebulized ipratropium on the hospitalization rates of children with asthma

BACKGROUND

Anticholinergic medications such as ipratropium improve the pulmonary function of patients with acute exacerbations of asthma, but their effect on hospitalization rates is uncertain.

METHODS

We conducted a randomized, double-blind, placebo-controlled study of 434 children (2 to 18 years old) who had acute exacerbations of moderate or severe asthma treated in the emergency department. All the children received a nebulized solution of albuterol (2.5 or 5 mg per dose, depending on body weight) every 20 minutes for three doses and then as needed. A corticosteroid (2 mg of prednisone or prednisolone per kilogram of body weight) was given orally with the second dose of albuterol. Children in the treatment group received 500 microg (2.5 ml) of ipratropium bromide with the second and third doses of albuterol; children in the control group received 2.5 ml of normal saline at these times.

RESULTS

Overall, the rate of hospitalization was lower in the ipratropium group (59 of 215 children [27.4 percent]) than in the control group (80 of 219 [36.5 percent], P=0.05). For patients with moderate asthma (indicated by a peak expiratory flow rate of 50 to 70 percent of the predicted value or an asthma score of 8 to 11 on a 15-point scale), hospitalization rates were similar in the two groups (ipratropium: 8 of 79 children [10.1 percent]; control: 9 of 84 [10.7 percent]). For patients with severe asthma (defined as a peak expiratory flow rate of <50 percent of the predicted value or an asthma score of 12 to 15), the addition of ipratropium significantly reduced the need for hospitalization (51 of 136 children [37.5 percent], as compared with 71 of 135 [52.6 percent] in the control group; P=0.02).

CONCLUSIONS

Among children with a severe exacerbation of asthma, the addition of ipratropium bromide to albuterol and corticosteroid therapy significantly decreases the hospitalization rate.

Intraplacental choriocarcinoma associated with viable pregnancy: pathologic features and implications for the mother and infant

Choriocarcinoma arising in the placenta, or intraplacental choriocarcinoma, has seldom been reported, particularly in the absence of maternal metastases. Reluctance to diagnose choriocarcinoma in the presence of chorionic villi can delay diagnosis; however, timely diagnosis of choriocarcinoma is prognostically important, both for the mother and infant. We report the clinicopathologic findings in five mothers and infants in whom choriocarcinoma was identified in the placenta. None of the mothers had a history of gestational trophoblastic disease in previous pregnancies. Three placentas were similar with a single small lesion grossly suggesting a small infarct; microscopically these consisted of infarcted areas surrounded by choriocarcinoma. These three mothers were unusual in that none had metastatic choriocarcinoma; two were treated with chemotherapy and remained disease-free; the third was lost to follow-up shortly following delivery. The remaining two mothers had known pulmonary metastases at time of delivery. One of these latter two placentas contained a large marginal lesion microscopically identified as choriocarcinoma. The fifth placenta had rare microscopic foci of choriocarcinoma, and sheets of necrotic choriocarcinoma were identified in "blood clot" submitted with the placenta. In four of the five cases the choriocarcinoma appeared to be arising from otherwise normal chorionic villi, and in no case was there invasion of the villous stroma. All of the infants survived, and none had evidence of choriocarcinoma. These cases support the concept that choriocarcinoma associated with otherwise normal pregnancy arises in the placenta and may be more common than reported.

Psoas abscess following extracorporeal shock wave lithotripsy

Different studies have reported renal effects like swelling of parenchyma, subcapsular and intracapsular haematoma and perinephric fluid collections. These effects were usually transient and by 2-3 months returned to normal. We report an early complication of extracorporeal shock wave lithotripsy (ESWL). A patient with solitary renal calculus who had ESWL developed psoas spasm and became unwell with elevation of white cell count and erythrocyte sedimentation rate. Psoas abscess extending from renal hilum to the groin was diagnosed and drained surgically.

Neuropathologic findings in a case of OFDS type VI (Váradi syndrome)

Oral-facial-digital syndrome type VI (OFDS VI) or Váradi syndrome is a rare autosomal-recessive disorder distinguished from other oral-facial-digital syndromes by metacarpal abnormalities with central polydactyly and by cerebellar abnormalities. Histopathologic characterization of the cerebellar abnormalities has not been described previously. We describe the neuropathologic findings in a stillborn, 21-week estimated gestational age (EGA) male fetus diagnosed antenatally with signs of OFDS VI. Autopsy findings included: facial abnormalities, postaxial central polydactyly of the right hand, bilateral bifid toes, and absence of cerebellar vermis with hypoplasia of the hemispheric cortex. Microscopic analysis of the cerebellum demonstrated absence of the subpial granular cell layer and disruption or dysgenesis of the glial architecture. These histopathologic findings suggest that a primary neuronal or glial cell defect, rather than an associated Dandy-Walker malformation, may account for the cerebellar abnormalities in this form of oral-facial-digital syndrome.

Candida funisitis: A clinicopathologic study of 32 cases

We report on 32 cases of Candida funisitis and describe the associated clinicopathologic features. The Candida funisitis was characterized grossly by small, circumscribed, yellow-white nodules on the umbilical cord surface and, microscopically, by subamnionic microabscesses in which fungal organisms were demonstrable. Chorioamnionitis was present in all cases. Twenty-four (75%) of the 32 infants were premature. There were 7 perinatal deaths, all in immature fetuses. Five (16%) of the 32 fetuses had congenital candidiasis. Five (16%) of the mothers had a history of intrauterine foreign body, including intrauterine contraceptive device in three and cervical cerclage in two. The diagnosis of Candida funisitis should prompt a careful examination for fetal infection, even though it is associated with congenital candidiasis in only a minority of the cases.