Immune response to Staphylococcus aureus endophthalmitis in a rabbit model

Staphylococcus aureus is an important cause of severe bacterial endophthalmitis. Both immunoglobulin (Ig) G and A antibody titers to ribitol teichoic acid (RTA), the major antigenic determinant of the S. aureus cell wall, were measured by an enzyme-linked immunosorbent assay in serum, tears, aqueous, and vitreous on days 3, 7, 10, 14, 21, and 30 after intravitreal injection of viable S. aureus in rabbits. Clinical examination showed vitreous opacification in all rabbits from days 7-30. Histopathologic examination showed acute inflammation on day 3 and chronic inflammation on days 7-30 in the conjunctiva, cornea, iris, ciliary body, and trabecular meshwork. The vitreous cavity contained neutrophils and necrotic cells on all days. Retinal necrosis was present on days 14-30. Lymphoid follicles with plasma cells were identified in the conjunctiva, ciliary body, and choroid. The vitreous of experimental eyes showed increasing numbers of bacteria from days 3-14, followed by a decrease in numbers on day 21 and absence of viable bacteria on day 30. Increases in IgG antibody levels to RTA were first detected in serum where they were higher than in tears, aqueous, and vitreous until day 14. Vitreous IgG antibody levels to RTA in experimental eyes exceeded all other samples on day 14 and progressively increased thereafter; the other samples declined. The IgA antibody levels were increased in tears on day 14 and in the vitreous of experimental eyes on days 14, 21, and 30. Vitreous IgG antibody levels to RTA were substantially higher than vitreous IgA antibody levels. An inverse correlation was found between vitreous IgG antibody levels and positive vitreous cultures, suggesting that the humoral immune response may be important in the spontaneous sterilization of the vitreous in this model.

Fine-needle aspiration biopsy of orbital and periorbital masses

We present the cytologic findings of 18 fine-needle aspirates performed on orbital and periorbital masses. An accurate specific diagnosis was confirmed by histology in ten cases. In eight cases the diagnostic evaluation and/or therapeutic regimen was significantly altered by the results of the fine-needle biopsy. In three cases the cytologic diagnoses obviated the need for open biopsy. Two specimens were insufficient for diagnosis. No false positive diagnosis of malignancy occurred. Electron microscopy was useful in three cases to confirm the correct cytologic diagnosis. Immunocytochemistry helped to define a lymphoid proliferation as monoclonal. The cytologic findings from an unusual case of sebaceous carcinoma are presented.

Rhabdomyosarcomatous differentiation in a neuroblastoma: a potential pitfall in the cytologic diagnosis of small round-cell tumors of childhood

Rhabdomyoblasts demonstrating immunoreactivity for muscle-specific actin, desmin, and myoglobin were identified in smears obtained by aspiration from a large retroperitoneal mass in a 14-mo-old girl. Following a tentative diagnosis of a rhabdomyogenous neoplasm, retroperitoneal exploration and adrenalectomy demonstrated a stromal poor neuroblastoma with extensive rhabdomyogenous differentiation. The presence of a subpopulation of rhabdomyoblasts was not diagnostic of rhabdomyosarcoma when obtained by fine-needle aspiration from a retroperitoneal tumor composed predominantly of primitive small round cells.

Traumatic neuroma of the eyelid associated with ptosis

A 17-year-old boy presented with persistent swelling and ptosis of the eyelid after blunt injury. Histologic examination revealed a clinically unsuspected traumatic neuroma. Ptosis and the traumatic neuroma persisted despite two eyelid operations. Traumatic neuroma is rare after blunt trauma; it has not been previously reported in the eyelid. It is important to identify this lesion because complete excision may help to prevent recurrence.

Necrotizing retinopathy after intraocular inoculation of murine cytomegalovirus in immunosuppressed adult mice

A light microscopic study was done to investigate retinal changes in healthy and immunosuppressed mice after intraocular inoculation of murine cytomegalovirus (MCMV). A 0.01-ml inoculum containing 10(5) plaque-forming units of MCMV was placed behind the lens in 138 4-week-old Swiss Webster mice. Ninety-eight mice were immunosuppressed with 0.2 mg/g of cyclophosphamide given intraperitoneally at the time of inoculation and 0.1 mg/g of cyclophosphamide every 5 days thereafter. Selected eyes were examined on postinoculation days 5, 10, 15, and 16-20. Evidence of viral infection was most prominent in uveal tissue. Uveal infection developed whether or not animals received cyclophosphamide, but retinal necrosis developed only in immunosuppressed mice. Focal retinal necrosis, primarily involving the outer retinal layers and retinal pigment epithelium, was first observed in an eye examined on day 10. Retinopathy from MCMV was present in three of five eyes (60%) examined on day 15, and in six of 16 eyes (37.5%) examined between days 16-20. Retinal disease was characterized by full-thickness retinal necrosis, scattered cytomegalic cells, intranuclear and intracytoplasmic viral inclusions, and acute and chronic inflammation. These results indicate that MCMV can produce a necrotizing retinopathy in mice and that immunosuppression facilitates infection. Although ocular MCMV infection in immunosuppressed adult mice is a potential model for study of human CMV retinopathy, many differences exist between human CMV and MCMV and between the ocular diseases they produce.

HMB-45 antibody reactivity in pigmented lesions of the conjunctiva

Conjunctival pigmented lesions, including ten compound nevi, three subepithelial nevi, two acquired melanoses, and six melanomas, were examined histologically and immunohistochemically to determine the specificity of mouse monoclonal HMB-45 antibody for these lesions. Eleven of 13 nevi, two of two acquired melanoses, and six of six melanomas stained with this antibody. Conjunctival melanomas showed intense and diffuse cytoplasmic staining; compound nevi and subepithelial nevi showed less intense but diffuse reaction. There was strong staining in melanocytic cells at the junction of the epithelium and substantia propria in compound nevi and acquired melanoses. Unlike skin nevi, conjunctival nevi show HMB-45 reactivity in their stromal components. Immunoreactivity to HMB-45 does not distinguish benign from atypical or malignant melanocytic lesions of the conjunctiva.

Keratinizing corneal intraepithelial neoplasia

Corneal intraepithelial neoplasia (CIN) is the term applied by some authors to the spectrum of disease ranging from mild dysplasia to carcinoma in situ. Such lesions usually are associated with dysplastic or neoplastic processes at the limbus or adjacent conjunctiva; isolated corneal dysplasia is rare. Clinically, CIN appears as a geographic, gray, translucent thickening of the epithelium with fimbriated or scalloped borders and lesions often contain scattered white dots. We report a case of intraepithelial neoplasia limited to the cornea that had the unusual clinical appearance of a white plaque, which prompted the misdiagnosis of a calcific scar. Histopathologic examination of the debrided tissue revealed intraepithelial neoplasia and marked hyperkeratosis as the cause of the opacification.

Revascularization studies of an opposing eyelid pedicle flap

Opposing eyelid pedicle flaps are used extensively in ophthalmic plastic surgery. Controversy exists over the timing of pedicle severance. Additionally, the functional and morphologic status of eyelid pedicle flaps at the time of severance has not been fully assessed. We attempt to investigate these questions by measuring the functional and morphologic changes that occur in an animal model of an opposing eyelid pedicle flap. These results were correlated with clinical case studies. Experimental results revealed vascularization of the animal model flap at 5 days. Clinical case studies revealed successful flap division by 3 weeks or less. We discuss factors that may delay flap revascularization.

Traumatic dehiscence of incisions seven years after radial keratotomy

We studied the clinical and pathologic features of a traumatically ruptured eye seven years after radial keratotomy. The radial keratotomy incisions were identified and topographically related to perforation sites. Three radial keratotomy incisions were perforated. Seven additional incisions were partially separated. Radial keratotomy incision depths ranged from 50% to 90% in the remaining incisions. All incisions showed disruption of Bowman's membrane, 15 of 16 showed malapposition of Bowman's membrane, and 14 of 16 showed epithelial plugging. In this case the healing and strength of radial keratotomy incisions were suboptimal seven years after the procedure.

Ocular toxoplasmosis in patients with the acquired immunodeficiency syndrome

In seven of eight cases of presumed ocular toxoplasmosis in patients with AIDS, the diagnosis was supported by a reduction or resolution of intraocular inflammation and healing of necrotic retinal lesions after initiation of antiparasitic drug therapy including one or more of the following medications: pyrimethamine, sulfadiazine, clindamycin, tetracycline, or spiramycin. In two cases the diagnosis was confirmed histologically. The cases differed clinically and histopathologically from those in immunocompetent patients. There was no evidence that disease originated in preexisting retinochoroidal scars. Lesions frequently were bilateral and multifocal. Vitreous inflammatory reaction was a common clinical finding, but histopathologic examination demonstrated scant retinal inflammation in areas of necrosis. Ocular toxoplasmosis in these patients with AIDS probably resulted from newly acquired infection or dissemination of organisms from nonocular sites of disease. Infections became clinically inactive with drug therapy in all treated patients, but reactivation and progression of disease occurred when therapy was stopped in two of three patients. Severe retinal necrosis led to retinal tears or detachment in three cases. Ocular lesions were the first manifestation of Toxoplasma gondii infection in four of five patients with evidence of multisystem infection.

The use of bioerodible polymers and 5-fluorouracil in glaucoma filtration surgery

A study was performed to examine the effect of a localized and sustained delivery of 5-fluorouracil (5-FU) on the success of glaucoma filtration surgery in 18 rabbits in a prospective, randomized, double-masked and placebo-controlled fashion. A bioerodible polyanhydride composed of bis (p-carboxyphenoxy) propane and sebacic acid was used as the drug carrier. The polymer and 5-FU (20% by weight) were compressed into 3 mm diameter discs, 1 mm thick. The polymer with the 5-FU was randomized to one eye and the fellow eye received the blank polymer. The results showed that intraocular pressures (IOP) were lower in the experimental eyes during the 5th through 17th postoperative days, but eventually both experimental and control eyes returned to preoperative levels. Filtration blebs lasted longer in experimental eyes when compared to control eyes. Implant disappearance occurred after IOP elevations and bleb failure. Eventually, the filtration surgery failed in both the experimental and control rabbit eyes.

Quantitation of tumor seeding from fine needle aspiration of ocular melanomas

Twenty-two fine needle (30 gauge) aspirations were performed in eyes enucleated for the clinical diagnosis of melanoma. Cytologic preparations were evaluated for adequacy of material, and needle tracts were evaluated for tumor implantation. A scleral marking method was used to identify all needle tracts. The number of tumor cells in tracts of direct transscleral aspirates was compared to those in tracts of indirect aspirates that traversed the anterior chamber or vitreous. Cellular material obtained with 30-gauge needles was sufficient for the diagnosis of malignant melanoma in all but one case. While 14 of 21 (67%) of all fine needle aspiration tracts and eight of 15 (53%) of indirect tracts contained tumor cells, the number of tumor cells was less than that associated with tumor growth in experimental models. Indirect aspirate tracts contained significantly fewer cells than tracts of direct aspirates (P less than .001).

Cytological grading of prostatic aspiration biopsy: a comparison with the Gleason grading system

Cytological grade determined by fine needle aspiration of the prostate was compared to histological grade in 30 patients undergoing subsequent radical prostatectomy. The degree of cytological pleomorphism determined by the consensus grade of 3 observers predicted correctly the Gleason grade sum range in 80 per cent of the cases. The cytological grade was reasonably reproducible with agreement among all 3 observers in 50 per cent of the cases and between 2 of 3 observers in the remainder. The accuracy of predicting the Gleason grade sum of the radical prostatectomy specimen by cytological examination compared favorably with that achieved by histological examination of cutting needle biopsy and transurethral resection specimens reported in the literature.

Ocular pathologic findings in neonatal adrenoleukodystrophy

Ocular pathology in a case of neonatal adrenoleukodystrophy (ALD) showed marked degeneration of photoreceptor cells throughout the retina including the macula. Macroscopically visible white opacities in the cortical vitreous of the posterior fundus were shown immunohistochemically and ultrastructurally to be macrophages containing bileaflet inclusions, a finding previously unreported. Additional findings included extensive loss of the retinal nerve fiber and ganglion cell layers, optic nerve degeneration, and bileaflet inclusions in retinal pigment epithelial cells and macrophages of the retina and optic nerve. Focal retinal pigmentary changes were observed that histologically were different from retinitis pigmentosa.

Antibody to S-100 protein aids the separation of pagetoid melanoma from mammary and extramammary Paget's disease

We evaluated the usefulness of immunohistological staining for S-100 protein in differentiating mammary and extramammary Paget's disease from primary malignant melanoma of superficial spreading (pagetoid) type. This technique was compared to both the mucicarmine and periodic acid-Schiff (PAS) methods. The tumor cells of 10 melanomas contained abundant cytoplasmic S-100 protein. In tissues from mammary and extramammary Paget's disease, S-100 protein was detected in myoepithelial cells, Langerhans cells, and Schwann cells of cutaneous nerves, but was not present in tumor cells. The mucicarmine stain was most useful for vulvar Paget's disease, mucicarminophilic material being present in 9/10 cases. In mammary Paget's disease, only 2/8 cases stained by the mucicarmine technique. Cytoplasmic PAS-positive material was present in the tumor cells of 9/10 cases of vulvar Paget's disease, but was noted in only 1/9 cases of mammary Paget's disease. Melanoma cells from two cases stained weakly with both mucicarmine and PAS indicating that these stains are not specific for Paget's disease in this comparison. The PAS and mucicarmine stains are helpful in differentiating anogenital Paget's disease from pagetoid melanoma, but are less useful in mammary Paget's disease. Immunohistological demonstration of S-100 protein provides an additional diagnostic tool to aid the separation of Paget's disease from pagetoid melanoma.

Miliary retinitis in coccidioidomycosis

We studied the pathologic features of a rare case of coccidioidomycosis retinitis in a 12-year-old girl. At autopsy there were multiple small lesions throughout the vital organs. Ocular lesions were restricted to the posterior part of the fundus. Step-level serial sectioning including the optic axes of both eyes showed 29 discrete retinal and 22 choroidal granulomas. Topographic analysis demonstrated random distribution of lesions throughout the fundus. Retinal granulomas were centered within layers served by the retinal circulation. Choroidal lesions most often involved the middle vascular layer and in only two areas focally disrupted Bruch's membrane. The pigment epithelium was intact. Retinal granulomas were not topographically associated with choroidal lesions.

Fine-needle aspiration cytology of juvenile hemangioma of the parotid gland: a case report

A 4-mo-old child presented with a 20-day history of swelling of the left cheek. Fine-needle aspiration (FNA) biopsy revealed a spindle-cell neoplasm with a bloody background. Subsequent surgical excision confirmed the presence of a juvenile hemangioma (juvenile hemangioendothelioma). The FNA biopsy and surgical pathology findings are presented along with a discussion of the differential diagnosis of this relatively rare neoplasm.

Fine-needle aspiration of salivary gland lesions. Comparison with frozen sections and histologic findings

The results of 171 salivary gland fine-needle aspirates, with subsequent histologic correlation, were compared with those from previous head and neck series and analyzed for diagnostic accuracy. Cytologically, 118 cases were diagnosed as benign; 51, malignant; and two, insufficient for diagnosis. The false-negative rate was 4.7%, and the false-positive rate was 3.5%. Pleomorphic adenoma, mucoepidermoid carcinoma, chronic sialadenitis, and malignant lymphoma were the lesions most frequently misdiagnosed. Corresponding frozen sections (available in 38 cases) showed an exact correlation with the final surgical pathologic diagnosis in 58% of the cases, with no false-positive diagnoses but an 11% false-negative rate.

Fine needle aspiration cytology of primary bone lesions

Fine needle aspiration (FNA) cytologic findings were compared with the results of conventional histology in a series of primary bone lesions to determine the diagnostic accuracy of FNA cytology. The series included 12 osteogenic sarcomas, 4 Ewing's sarcomas, 3 chordomas, 3 myelomas, 2 chondrosarcomas, 2 undifferentiated sarcomas and 1 case each of normal bone and marrow elements, lymphoma and giant-cell tumor. All aspirates yielded adequate material for smear diagnosis, and all 29 cases were correctly identified as benign or malignant by cytology. In 19 cases (66%), specific cytologic diagnoses were rendered and histologically confirmed. This series is compared with other published series of bone aspirations in terms of technique, accuracy and ability to obtain diagnostic material. The importance of technique, radiographic investigations and experience in performing the aspirations in achieving a high diagnostic yield is emphasized.

Gangliocytic paraganglioma associated with duodenal adenocarcinoma. Case report with immunohistochemical evaluation

We present the first reported case (to our knowledge) of duodenal gangliocytic paraganglioma (GPG) to be associated with an underlying invasive adenocarcinoma. The patient, a 71-year-old man, presented with epigastric tenderness and was found to have metastatic adenocarcinoma in two regional lymph nodes. Immunohistochemical evaluation of the GPG demonstrated positive staining for gastrin, glial-fibrillary acidic protein, glucagon, neuron-specific enolase, pancreatic polypeptide, S100 protein, somatostatin, and substance P. The clinical, pathologic, and immunohistochemical features of GPG are discussed, with a review of the literature.

Aspiration cytology and immunohistochemistry of a pheochromocytoma-ganglioneuroma of the adrenal gland

The results of fine needle aspiration (FNA) cytology, immunohistochemical staining and electron microscopy of combined pheochromocytoma-ganglioneuroma are presented. The cytologic findings included clusters of neoplastic cells with features of a neuroendocrine tumor and aggregates of spindle-shaped cells with interspersed ganglionlike cells. Aspirated material was tested for a panel of hormones by the peroxidase-antiperoxidase method. The neoplastic cells showed positive staining for neuron-specific enolase (NSE) and vasoactive intestinal polypeptide (VIP). Electron microscopy demonstrated granules similar to those of a pancreatic VIPoma in the nerve processes of the ganglioneuroma component. This appears to be the first description of the FNA cytology of a combined pheochromocytoma-ganglioneuroma. The value of immunohistochemical staining in the study of FNA material for making a specific diagnosis and the clinical implications of a preoperative diagnosis in the management of this lesion are discussed.

Fine-needle aspiration of primary soft-tissue lesions

This study presents the cytologic findings of fine-needle aspiration (FNA) in a series of 136 primary soft-tissue tumors. The cytologic appearances of some rare mesenchymal lesions are presented, including the first (to our knowledge) published descriptions of fibrous hamartoma of infancy and myositis ossificans. Fine-needle aspiration showed high diagnostic sensitivity (95%) and specificity (95%) for the determination of malignancy, approaching that obtained with frozen-section interpretation. Problems encountered with the diagnosis of mesenchymal lesions, including nodular fasciitis, Kaposi's sarcoma, and spindle cell lipoma, are discussed. Based on these findings, recommendations for aspiration cytology of soft-tissue tumors are presented.

Adult testicular torsion

A case of testicular torsion is described in a sixty-four-year-old man. Although unusual in this age group, the diagnosis of testicular torsion should be considered in older patients presenting with unilateral testicular pain. Early recognition and surgical intervention may reverse testicular ischemia and avert unnecessary orchiectomy.

Neuropathologic findings in the acquired immunodeficiency syndrome (AIDS)

The acquired immunodeficiency syndrome (AIDS) is characterized by a severe idiopathic deficiency in T-cell mediated immunity. Homosexuals, intravenous drug abusers and Haitians are predominantly affected, predisposing them to opportunistic infections and neoplasms. In this study, the central nervous system (CNS) was examined at autopsy in 29 AIDS patients. Significant CNS complications occurred in 55%, mainly related to opportunistic infections similar to those seen in patients with other causes of immunosuppression. Progressive multifocal leukoencephalopathy (three cases), cytomegalovirus (CMV) encephalitis (five cases), cryptococcal meningitis (four cases), Mycobacterium avium-intracellulare (three cases), and toxoplasmosis (one case) were found. Widespread microglial nodules were observed in 20 patients, 80% of whom had CMV inclusions elsewhere at autopsy. Primary cerebral lymphoma (one case) and lymphomatoid granulomatosis (one case) were present. Subarachnoid (five cases) and intraparenchymal (three cases) hemorrhage was seen although these were not usually clinically significant. A single case of embolic arterial obstruction with cortical infarction was due to non-bacterial thrombotic endocarditis.

Adrenal pathology in the acquired immune deficiency syndrome

Adrenal pathology was examined in 41 autopsied patients with the acquired immune deficiency syndrome. This represents the largest series and the first study with quantitation of adrenal cortical necrosis. In 32 cases clinical data were analyzed for features of adrenal insufficiency. Common clinical findings included vomiting, diarrhea, fever, hypotension, and hyponatremia. None of the 32 patients showed characteristic skin hyperpigmentation. Two patients were suspected premortem to have adrenal insufficiency. In one of these patients, adrenocorticotrophic hormone (ACTH) stimulation resulted in an adequate rise in plasma cortisol values. In the other patient, the baseline plasma cortisol value was elevated and failed to rise significantly after ACTH stimulation. Pathologic findings included widespread lipid depletion, infection by cryptococcus, and acid-fast organisms consistent with Mycobacterium avium-intracellulare, involvement by Kaposi's sarcoma, and necrotizing adrenalitis due to cytomegalovirus (CMV). A point-counting method was used to quantitate adrenal cortical and medullary necrosis. Necrosis due to CMV was greater in the medulla than the cortex. The maximum amount of adrenal cortical necrosis in any case was 70%. The degree of cortical necrosis was less than that usually associated with adrenal insufficiency.

Fine-needle aspiration of lymphadenopathy of suspected infectious etiology

We present a protocol for culture of lymph node find-needle aspirations in a series of 44 patients. Clinical indications for inclusion in the protocol included fever, localized erythema, pain or heat, an independent clinical diagnosis of infection by the referring physician, or a grossly purulent appearance of the initial aspirate material. Organisms (fungi, bacteria, or mycobacteria) were isolated in 13 (30%) of the aspirates. The probable contamination rate was 9%. These figures approached the culture yields obtained from open biopsy specimens as reported in the literature. A notable discrepancy existed between the cytologic appearance of the aspirates and culture results in three cases of mycobacteria. Six unsuspected malignancies were diagnosed. There were no complications from the procedure in this series. Based on this study, we present recommendations for culture of fine-needle aspirates from lymph nodes.

Clinical and pathologic findings of the liver in the acquired immune deficiency syndrome (AIDS)

Clinical data and histologic sections of the liver, including immunohistochemical studies for hepatitis B surface and core antigens, were reviewed in 42 autopsy cases of the acquired immune deficiency syndrome (AIDS). Hepatomegaly, elevation of serum transaminases, and mild elevation of alkaline phosphatase were commonly observed clinical and biochemical abnormalities. Mildly elevated alkaline phosphatase and normal bilirubin levels were present in patients with Mycobacterium avium-intracellulare (MAI) infection, cytomegalovirus (CMV) infection, and Kaposi's sarcoma (KS). Histologic sections demonstrated liver involvement by MAI in eight cases; KS in six cases; cryptococcus in three cases; and CMV in two cases. One case of MAI infection was associated with marked central vein sclerosis, a finding previously unreported. Thirty-two (76%) of 42 cases had serologic or pathologic evidence of hepatitis exposure. Two patients had histologic evidence of chronic active hepatitis. The pathologic processes involving the liver appeared to be secondary to the infections and neoplasms for which this population is susceptible and did not significantly contribute to morbidity or mortality. No findings specific or pathognomic for AIDS were identified in the liver.

Spontaneous primary dissecting coronary artery aneurysm. Report of two cases

Two cases of dissecting aneurysm of the left main stem and left anterior descending coronary arteries are presented. Both cases were discovered during routine medicolegal death investigations. Unusual aspects of one of our cases include the history of antecedent trauma and the precise identification of an intimal tear.