Parapharyngeal teratoma in the newborn

A parapharyngeal teratoma in a newborn was the cause of acute respiratory distress, which was relieved by tracheostomy. Subsequent investigations by soft tissue x-rays of the neck, computed tomography, and examination under anesthesia defined the anatomic location of the tumor, its extent, and its likely nature. The tumor was removed completely by the transcervical approach. Mandibulotomy was not required. Histological examination showed the presence of a large amount of mature brain tissue, a moderate amount of collagenous fibers and smooth muscle cells, and a minute amount of cartilage and epithelial structures. The postoperative course was satisfactory. No recurrence was seen 6 years after surgery. The computed tomography scan was found to be the most useful investigative method. To the authors' knowledge, this is the first comprehensive report of a teratoma occupying the parapharyngeal space in a newborn.

Adenomyoma of the small intestine in children

Two cases of adenomyoma of the small intestine occurring in two young children are described. One child presented with intussusception. In the other, the lesion was an incidental intraoperative finding. Underreporting is probably a major reason for the apparent rarity of this lesion in the small intestine. The condition should be considered a cause of small bowel intussusception.

Metachronous pulmonary and cerebral inflammatory pseudotumor in a child

An 8-year-old boy had a right pneumonectomy performed for a large inflammatory pseudotumor. Over the subsequent 8 years he developed multiple similar lesions in the meninges and bilateral cerebral hemispheres as well as new growths within the ipsilateral pleural cavity and contralateral lung. Metachronous pulmonary and intracranial inflammatory pseudotumor has been reported only once. These lesions probably represent a multifocal, exaggerated inflammatory response to some as yet unidentified stimuli.

Prenatal sonographic detection of intra-abdominal extralobar pulmonary sequestration: report of three cases and literature review

Three cases of intra-abdominal extralobar pulmonary sequestration detected antenatally by ultrasound are reported. One case was associated with a large left diaphragmatic hernia. Sonographically, all the cases were found in the left supra-renal region presenting as a well-defined echogenic mass with cystic hypoechoic areas. The condition should be considered in the differential diagnosis of all antenatally detected upper abdominal echogenic masses, particularly when associated with a diaphragmatic hernia. Postnatal ultrasound-guided fine needle aspiration biopsy in one case yielded respiratory type epithelium and this procedure could provide a reasonably confident diagnosis of the lesion.

Subcutaneous T-cell lymphoma presenting as panniculitis in children: report of two cases

Two cases of peripheral T-cell lymphoma with primarily subcutaneous involvement and clinically presenting as panniculitis were reported in two children. One child developed florid hemophagocytic syndrome and was treated by combination chemotherapy but died 14 months later of disseminated fungal infection. The other child had mild systemic symptoms but no histological evidence of hemophagocytosis. Despite a more florid lymphomatous infiltrate, he attained a complete remission after a short course of prednisone and remains symptom-free at 3 years. Our report confirms that subcutaneous T-cell lymphoma is a distinct clinicopathological entity and highlights the two modes of clinical presentation. The development of florid hemophagocytic syndrome indicates a bad prognosis. This entity must be distinguished from other causes of panniculitis and immunophenotypic analysis of the atypical cells is essential in the diagnosis. Combination chemotherapy is the treatment of choice, but in patients who pursue an indolent course the administration of aggressive chemotherapy may be deferred.

Focal and segmental glomerulosclerosis in children with reflux nephropathy

A histological review of 86 pediatric nephrectomy specimens from patients with vesicoureteric reflux (with or without apparent obstruction at the vesicoureteric junction) investigated the relationship between the presence and extent of focal and segmental glomerulosclerosis (FSGS) and coexisting renal hypoplasia and postnatally acquired cortical damage. FSGS was found in 18 patients, 9 of whom were less than 5 years old. There was no significant association between the presence (or grade) or absence of FSGS and age at nephrectomy, gender, presence or absence of obstruction, and severity of hypoplasia and/or postnatally acquired cortical loss. FSGS was absent from 18 hypoplastic kidneys without vesicoureteric reflux (although of relatively young age), 40 normally developed kidneys age-matched with the index population, and 72 nephrectomy specimens without vesicoureteric reflux (except in 2 known cases of focal segmental glomerulonephritis). Within the index population FSGS was significantly (P < .01) associated with hypertension, and hypertension was significantly associated with proteinuria (P < .001) but not with an abnormal contralateral kidney. There was no significant association between FSGS, proteinuria, and an abnormal contralateral kidney. Our results were unexpected when interpreted within a pathogenesis for FSGS of glomerular "hyperfiltration." They may, at least in the pediatric age group, indicate a possible role for other mechanisms in the development of FSGS.

Intestinal spirochetosis in children: report of two cases

Two cases of intestinal spirochetosis in two children are reported. The first patient, a 7 1/2-year-old boy, presented with diarrhea and rectal bleeding. After the diagnosis was made by a rectal biopsy, he was given metronidazole and neomycin. Symptoms persisted despite a further rectal biopsy that showed clearance of the organisms. Appendiceal spirochetosis was an incidental finding in our second patient, an 8-year-old girl who presented with acute abdominal pain and in whom mesenteric adenitis was diagnosed clinically at laparotomy. The possible pathogenic mechanisms causing clinical symptoms are discussed.

Aggressive angiomyxoma of the vulva in an 11-year-old girl

A rare case of aggressive angiomyxoma involving the vulva of an 11-year-old girl is reported. The pathologic features that distinguish this lesion from other myxoid tumors or tumorlike conditions of the perineum and vulva in children are discussed.

Factors affecting the incidence of polyploidy in a human in vitro fertilization program

OBJECTIVE

To study the factors affecting the incidence of polyploidy in an assisted reproduction program.

DESIGN

Retrospective analysis.

SETTING

University-based subfertility clinic.

PATIENTS AND METHODS

Subfertile patients were treated in 163 treatment cycles of in vitro fertilization (IVF) or pronuclear stage tubal transfer (PROST). The relationship between the incidence of polyspermy and the indication of subfertility, the stimulation protocol, the oocyte, and the semen parameters were analyzed.

RESULTS

Eighty-nine of the 1,149 oocytes were polyploid (7.8%). The incidence of polyploidy was not affected by the indication for IVF, the age of the patients, the stimulation protocol, the maturity of oocytes as assessed by the appearance of the cumulus, the sperm concentration, the number of sperm inseminated, the serum estradiol level, and the number of oocytes retrieved. The incidence was increased when: (1) the serum estradiol fell before the administration of human chorionic gonadotrophin; (2) the oocyte retrieval-insemination interval was 6 hours or more; (3) the sperm motility was 70% or more; (4) the percentage of sperm with normal morphology was 50% or more.

CONCLUSION

The incidence of polyploidy was affected by the serum estradiol pattern, the preinsemination interval, sperm motility, and percentage of morphologically normal sperm.

Luteinizing hormone (LH) surge in patients using buserelin spray during ovarian stimulation for assisted reproduction

The incidence of luteinizing hormone surge was studied in patients who were downregulated with a short protocol of gonadotrophin releasing hormone agonist before ovarian stimulation for assisted reproduction. Buserelin nasal spray 100 micrograms was given 5 times daily from day 2 of the cycle, followed by ovarian stimulation with human menopausal gonadotrophin and follicle stimulating hormone from day 3 onwards. Of the 159 cycles studied, luteinizing hormone surge was detected in 9 cycles (5.7%). The occurrence of LH surge was usually (67%) but not always associated with a fall in serum oestradiol level before administration of human chorionic gonadotrophin. None of the patients developed luteinizing hormone surge after day 10. Even in patients without luteinizing hormone surge the serum luteinizing hormone levels on the day of administration of hCG were significantly higher than those on day 2 before administration of buserelin. It is concluded that a short protocol with intranasal buserelin 500 micrograms per day is inadequate to suppress endogenous luteinizing hormone surge.

The value of transabdominal pelvic ultrasonography in monitoring of ovulation induction with gonadotropins

Seventy-five patients with a total of 306 human menopausal gonadotropin treatment cycles over the period 1984-1989 were analysed retrospectively to evaluate the value of transabdominal pelvic ultrasonography in prevention of complications arising from ovulation induction with human menopausal gonadotropins. There were 60 pregnancies giving a pregnancy rate of 19.6% per cycle. There was positive correlation between the number of follicles > or = 14 mm in mean diameter and the incidence and degree of hyperstimulation (p < 0.005) as well as the incidence of multiple pregnancies (p < 0.01). Ultrasonography is a useful adjunct for monitoring in such a program.

Blood loss in termination of early pregnancy by vacuum aspiration and by combination of mifepristone and gemeprost

Blood loss was measured in 17 subjects undergoing surgical termination of pregnancy and in 96 subjects undergoing medical termination of pregnancy with sequential mifepristone (200 mg, 400 mg, 600 mg) and 1 mg prostaglandin analogue gemeprost. The median blood loss were 53.2, 84.1, 99.9 and 101.4 ml, respectively. There was a statistically significant difference between the surgical and each of the medical termination group of subjects but there was no difference among the subgroups in the medical termination group. The pattern of bleeding was also similar, being heaviest on the day and the days shortly after prostaglandin administration. Majority of them (> 90%) experienced blood loss of < 300 ml and there was no significant drop in hemoglobin level during the 6-week follow-up period. A few women experienced heavy bleeding and, hence, strict supervision on medical termination of pregnancy is recommended.

Intrauterine insemination after ovarian stimulation as a treatment for subfertility because of subnormal semen: a prospective randomized controlled trial

OBJECTIVE

To determine whether intrauterine insemination (IUI) after ovarian stimulation with human menopausal gonadotropin (hMG) gives a better pregnancy rate (PR) than natural intercourse in couples with subfertility because of subnormal semen.

DESIGN

Prospective randomized controlled trial.

SETTING

University based subfertility clinic.

PATIENTS

Couples with subnormal semen as the only identifiable cause of subfertility.

INTERVENTIONS

In control cycles, the couples had natural intercourse. In IUI cycles, IUI was performed after ovarian stimulation with hMG and human chorionic gonadotropin.

MAIN OUTCOME MEASURE

The clinical PRs and complications of IUI cycles and control cycles were compared.

RESULTS

There were six clinical pregnancies in the 42 IUI cycles, whereas there was no clinical pregnancy in the 42 control cycles. The clinical PR in IUI cycles (14.3% per cycle) was significantly higher than that in control cycles (0%). Six patients (14.3%) developed moderate degree of ovarian hyperstimulation syndrome in IUI cycles.

CONCLUSION

Intrauterine insemination after ovarian stimulation with hMG is useful in treatment of subfertile couples with subnormal semen.

Renal hypoplasia and postnatally acquired cortical loss in children with vesicoureteral reflux

We reviewed histologically 86 nephrectomy specimens from patients with vesicoureteral reflux (with or without ureterovesical obstruction) to investigate the relationship between coexisting hypoplasia and postnatally acquired cortical damage. Hypoplasia was assessed independently of the acquired cortical loss using medullary ray glomerular counting. Severe hypoplasia (glomerular number < 25% of normal) was detected in 47 of 86 patients. These patients underwent nephrectomy at a significantly younger age than those with minimal or no hypoplasia (P < 0.01). There was no significant relationship between the severity of hypoplasia and the presence or absence of obstruction. Severe acquired cortical loss was found in 68 of 86 patients. There was no significant association between the severity of cortical loss and the presence or absence of obstruction, age at nephrectomy or degree of coexisting hypoplasia. The findings suggest a strong association of hypoplasia and vesicoureteral reflux. Therefore, early postnatal presentation with minimal renal function need not necessarily reflect a failure of management but rather a pre-existing limitation of renal capacity. Furthermore, in a significant proportion of fetuses with ultrasonographic evidence of urinary tract abnormality, renal pathology may be present prior to the time at which in utero surgical intervention may be considered.

Treatment of premenstrual syndrome with fluoxetine: a double-blind, placebo-controlled, crossover study

OBJECTIVE

Although its etiology is unknown, it has been hypothesized that premenstrual syndrome (PMS) is linked to a deficiency of central serotoninergic activity. In the present study, we evaluated the effect of fluoxetine, a specific serotonin uptake inhibitor, on PMS symptoms.

METHODS

Following extensive screening, including several psychological inventories, eight women with severe persistent PMS participated in a 6-month double-blind, placebo-controlled, crossover study which included three months each of daily fluoxetine 20 mg or placebo, administered in a randomized order. Symptoms were evaluated using the Calendar of Premenstrual Experiences and other psychometric measures.

RESULTS

Compared with placebo, treatment with fluoxetine was associated with an improvement in PMS symptoms as judged by highly significant decreases in behavioral (P less than .005), physical (P less than .05), and total (P less than .005) Calendar of Premenstrual Experiences scores; Beck Depression Inventory scores (P less than .005); Profile of Mood States subscales scores including depression (P less than .005), tension (P less than .005), and anger (P less than .01); and State-Trait Anxiety Inventory scores. The use of fluoxetine was associated with a greater mean reduction in behavioral (75%) than in physical scores (40%), with a mean decrease in total Calendar of Premenstrual Experiences scores of 62%, which rendered these scores similar to follicular phase values. Thus, the luteal phase symptomatology of PMS was effectively abolished. At this dose, no significant side effects or complications were noted during treatment.

CONCLUSION

Fluoxetine appears to be a highly effective, well-tolerated treatment for the psychological and physical symptoms accompanying severe PMS.

"Medullary ray glomerular counting" as a method of assessment of human nephrogenesis

Renal weight (left-right combined), as a parameter of renal development, is required to be less than half the normal value for age for a statistically confident diagnosis of hypoplasia. "Medullary ray glomerular counting" (MRGC), counting cortical glomerular generations, has been proposed as a simple technique of possibly greater sensitivity. Recent development of the Disector method for the unbiased stereological estimation of total glomerular number has provided a, hitherto unavailable, "golden standard" with which to determine the diagnostic potential of MRCG. Both "true" (actual number of generations seen) and "assumed" (a subjective "guess" of the total number of generations) MRGC counts were determined in 11 pairs of kidneys from spontaneously aborted, normally developed, non-malformed fetuses (gestational age: 15-40 weeks). Each kidney was randomly analysed blind and on two separate occasions by two paediatric pathologists using a written protocol. Results were compared with unbiased stereological estimates of glomerular number. Intra- and inter-observer and intra- and inter-(left-right)renal reproducibility were analysed. In conclusion, MRGC, using "real" counts, is a highly reproducible parameter of renal development from 15-36 weeks' gestation. Sensitivity for detection of both hypoplasia and maturation delay increase with gestational age and generally exceeds that of renal weight.

Cryptococcal peritonitis in a CAPD patient

A 50-year-old diabetic woman with end-stage renal disease, who had been on continuous ambulatory peritoneal dialysis for 8 months, developed peritonitis caused by Cryptococcus neoformans var. neoformans. The patient was completely asymptomatic and infection was confirmed by detection of budding yeast cells in Gram-stained smears of turbid peritoneal fluid. The infection was cleared after intravenous fluconazole with delayed removal of the catheter. Fluconazole may be a suitable alternative drug in treating cryptococcal peritonitis.

Human intrauterine renal growth expressed in absolute number of glomeruli assessed by the disector method and Cavalieri principle

The disector method, a stereologic procedure unbiased by feature size, shape, or tissue-processing methods, for the estimation of total glomerular number was performed on pairs of human kidneys from 11 normal spontaneous second trimester abortions and stillbirths (15 to 40 weeks gestation). In addition, gestational age-dependent patterns of change in the average volume of the nephron and its cortical and medullary segments were analyzed. Mean glomerular number, plateauing at 36 weeks, increased from 15,000 at 15 weeks to 740,000 at 40 weeks. Average volume of the medullary nephron segment (Henle's loop) increased throughout pregnancy. Average volume of the cortical nephron segment (Tubuli Contorti) decreased from 15 weeks to 25 weeks, then increased after 36 weeks. Fractional volume of the renal cortex decreased from 15 weeks to 40 weeks. Three to 4 hours of microscopic analysis time were required per kidney on routinely processed 5-microns hematoxylin and eosin-stained paraffin sections. Average coefficient of error for number estimation was 8.02%. Average intra- and interobserver reproducibilities were 96.8 and 93.7%, respectively. The demonstrated temporal differences in the development of the cortical and medullary nephron components may result in a dissociation of function, which may explain the increased incidence of fetal hydrops in the second trimester of pregnancy, and which must be taken into account in the treatment of (very) premature infants. Although the number of kidneys included in this study is limited, as they reflect the whole period of antenatal development relevant to neonatal intensive care, the disector method of glomerular number estimation shows significant potential for the analysis and increased understanding of the development of renal function. The method appears to be more sensitive in detecting small and early deviations from normal renal growth and development than previously available parameters e.g., renal weight and (cortical) volume.