[Mesothelial proliferation of the tunica vaginalis testis]

Proliferative changes seen in reactive mesothelial hyperplasia of a hydrocele sac may mimic malignant mesothelioma. There is no immunohistochemical staining that reliably separates benign from malignant mesothelial proliferations. However, the combined analysis of BAP1 by immunohistochemistry and CDKN2A by FISH has been reported to yield both a high specificity and sensitivity in this differential diagnosis. In addition, the evaluation of risk factors such as asbestos exposure or prior traumata may be helpful for the correct diagnosis. Exclusion of stromal invasion, which is diagnostic for malign mesothelioma, is of utmost importance. Therefore, extended histological workup is essential.

[Partial pericardium defect with a cardiac heart diverticulum and extensive intrauterine hypoxic myocardial lesions]

The autopsy of a fetus at 23 weeks gestational age revealed a partial pericardial defect with subsequent herniation of parts of the left ventricle. The myocard was impinged by the fibrous rim of the residual pericardium. Microscopic examination showed signs of recurrent myocardial infarctions with necrosis, calcification, fibrosis and prominent deposition of iron.Partial pericardial defects result from incomplete fusion of the pleuropericardial membrane and may lead to myocardial infarction via compression of the coronary arteries.

Electroencephalographic study showing that tactile stimulation by fabrics of different qualities elicit graded event-related potentials

BACKGROUND/PURPOSE

Neurophysiologic data on reactions of the human brain towards tactile stimuli evoked by fabrics moved on the skin are scarce. Furthermore, evaluation of fabrics' pleasantness using questionnaires suffers subjective biases. That is why we used a 64-channel electroencephalography (EEG) to objectively evaluate real-time brain reactions to fabric-skin interactions.

METHODS

Tactile stimuli were triggered by selected fabrics of different qualities, i.e. modal/polyamide single jersey, cotton double rib and a jute fabric, applied hidden to either the palm or forearm of 24 subjects via a custom-made fabric-to-skin applicator called SOFIA. One-way anova analysis was carried out to verify the EEG data.

RESULTS

The modal/polyamide fabric applied to the forearm and palm led to slightly stronger emotional valence scores in the brain than the conventional or baseline fabric. Furthermore, the single jersey elicits significant higher event-related potential (ERP) signals in all subjects when applied to the forearm, suggesting less distraction and better cognitive resources during the fabric/skin interaction. The brain thus reacts with instantaneous ERP to tactile stimulation of fabrics and is able to discriminate different qualities via implicit preferences.

CONCLUSION

The test procedure described here may be a tool to evaluate the fabric feel with the exclusion of subjective biases.

[GIP-like findings with a special spectrum of causes]

Giant cell interstitial pneumonia (GIP)-like pulmonary alterations as a special form of condensate pneumopathy may result following inhalation of certain types of tobacco smoke which can cause a pitfall diagnosis of sideropneumoconiosis or hard metal lung disease. Exact information regarding the patient occupation and smoking history and especially regarding the origin of the cigarettes helps to clarify the findings.

[Morphological diagnostics of malignant pleural mesothelioma]

The World Health Organization (WHO) classification differentiates between pleural tumors of mesothelial and mesenchymal origin as well as lymphoproliferative disorders, with malignant mesotheliomas forming the most common pleural primary tumor. Histologically, epithelioid (40-60 %), sarcomatoid (20-40 %), and biphasic mesotheliomas (20-40 %) are distinguished. The certain morphological diagnosis of a malignant pleural mesothelioma requires the establishment of mesothelial differentiation by means of an appropriate panel of antibodies to exclude pleural dissemination of a pulmonary or extrapulmonary epithelial malignancy and also requires the establishment of at least focal invasive growth to distinguish from reactive mesothelial proliferation. The exclusion of a malignant pleural mesothelioma may induce further differential diagnostic considerations, e. g. concerning the assignment to a certain primary tumor after the establishment of carcinomatous pleuritis.

[Atypical tumor regression]

A 67-year-old man presented with a poorly differentiated squamous cell carcinoma of the esophagus diagnosed by biopsy. After neoadjuvant radiochemotherapy the gastroesophagectomy specimen showed diffuse polymorphic and anuclear cell residues ranging from 35 µm to 46 µm in size. Immunohistochemically, PanCK and AE1-3 revealed a positive staining while CD68 and MIB1 showed a negative staining. The retrospective anamnesis revealed that the patient had chronic polyarthritis as underlying illness, for which reason he had been taking humira and methotrexate, a cytostatic drug, for many years. Therefore, the development of the tumor might have been enhanced by these drugs. Electron microscopic analysis confirmed that the avital akaryote cell residues represented a special type of tumor regression. Complete tumor regression level IV without vital rest tumor tissue based on Baldus et al. was diagnosed.

Fatal human metapneumovirus infection following allogeneic hematopoietic stem cell transplantation

Respiratory viruses are an important yet underestimated cause of infectious morbidity and mortality in immunocompromised children and adolescents. Here, we report the occurrence of fatal lower respiratory tract disease associated with human metapneumovirus (HMPV) infection in a 10-year-old girl with chronic graft-versus-host disease following allogeneic hematopoietic stem cell transplantation (HSCT) for secondary chronic myeloid leukemia. Symptoms occurred 8 months after HSCT while on immunosuppression with 0.2 mg/kg/day of prednisone, and presented as dry cough, bilateral pneumonitis, and progressive respiratory distress. Non-invasive and invasive microbiological investigations revealed HMPV type B as the sole pathogen. Histopathological findings showed interstitial and intra-alveolar pneumonitis with profound alveolar cell damage. The patient was treated with intravenous and oral ribavirin and polyvalent immunoglobulins, but ultimately died from respiratory failure. The case reflects the potentially fatal impact of infections by respiratory viruses in immunocompromised patients and the need for effective approaches to their prevention and treatment.

[Histopathological evaluation of the meniscus]

Menisci fulfill many functions within the complex biomechanics of the knee joint. In the case of meniscus lesions, sparing arthroscopic resection and surgical refixation are the treatments of choice. In terms of diagnosis, this means in general that histopathologic diagnostics are carried out on detached meniscus fragments of between 5 mm and 2 cm in size. A good knowledge of physiologically possible cellular and fibrous histological meniscus damage, as opposed to nonphysiological change regarded as normal with respect to age, is essential for diagnostic meniscus evaluation. The clinician expects clear statements from the pathologist regarding the severity of previous or secondary degenerative meniscus damage, the age and type of traumatic tears, and an appraisal of the relationship between trauma and meniscus damage from an insurance point of view. Close cooperation between the clinician and the pathologist allows for a fast and unambiguous correlation of anamnesis, the clinical picture, and morphological reporting such that problematic insurance cases can be clarified quickly.

[Lung transplantation and rejection. Basic principles, clinical aspects and histomorphology]

Lung transplantation is the ultimate therapeutical approach for the treatment of both children and adults with terminal congenital or acquired lung disease. In contrast to survival rates during the first year following transplantation, the long-term survival for patients after lung transplantation has not significantly improved in the past. In addition to other complications, acute cellular rejection constitutes a major cause for diminished function of pulmonary grafts, and can, among other factors, be causative for chronic rejection (bronchiolitis obliterans syndrome, BOS). In 2006, the International Society for Heart and Lung Transplantation (ISHLT) provided a revised version of the grading system for acute and chronic rejection of pulmonary grafts.

Neuropsychiatric symptoms and brain structural alterations in Fabry disease

BACKGROUND

Neuropsychiatric symptoms (NPS), mainly cognitive deficits up to dementia and depressive syndromes have been described repeatedly in Fabry disease (FD). However, examinations regarding the pattern, extent, and frequency of the NPS in FD are still lacking. Moreover, the relationship between NPS and brain structural alterations in FD is unknown. The aim of this study was 1) to characterize NPS in a relatively large cohort of adult subjects with FD, and 2) to explore the association of cognitive performance and depressive syndromes with the FD-typical brain structural findings.

METHODS

Twenty-five Fabry patients (age 36.5 ± 11.0) with mild to moderate disease involvement and 20 age, gender-, and education-matched healthy controls were extensively studied by neuropsychiatric assessment, structural magnetic resonance imaging, magnetic resonance angiography, and diffusion-tensor imaging.

RESULTS

Patients with FD showed deficits only in the attention domain. Clinically relevant depressive syndromes were noted in 60% of the patients. The subgroup of patients with markedly elevated volumes of white matter lesions (not associated with actual stroke; n=7) showed slightly more learning and memory deficits, but no higher depression rate compared to less affected patients.

CONCLUSIONS

Against the prevailing assumption, Fabry patients, even those with marked brain structural alterations, showed only mild cognitive deficits. The high frequency of depression in FD is likely to be related to the burden of this chronic multiorganic hereditary disease, but not to the FD-typical brain structural alterations. Longitudinal studies are necessary to clear, if the mild cognitive deficits in FD might precede clinically relevant cognitive decline.

Visual adaptation to convexity in macaque area V4

Aftereffects are perceptual illusions caused by visual adaptation to one or more stimulus attribute, such as orientation, motion, or shape. Neurophysiological studies seeking to understand the basis of visual adaptation have observed firing rate reduction and changes in tuning of stimulus-selective neurons following periods of prolonged visual stimulation. In the domain of shape, recent psychophysical work has shown that adaptation to a convex pattern induces a subsequently seen rectangle to appear slightly concave. In the present study, we investigate the possible contribution of V4 neurons of rhesus monkeys, which are thought to be involved in the coding of convexity, to shape-specific adaptation. Visually responsive neurons were monitored during the brief presentation of simple shapes varying in their convexity level. Each test presentation was preceded by either a blank period or several seconds of adaptation to a convex or concave stimulus, presented in two different sizes. Adaptation consistently shifted the tuning of neurons away from the convex or concave adapter, including shifting response to the neutral rectangle in the direction of the opposite convexity. This repulsive shift resembled the known perceptual distortion associated with adaptation to such stimuli. In addition, adaptation caused a nonspecific response decrease, as well as a specific decrease for repeated stimuli. The latter effects were observed whether or not the adapting and test stimuli matched closely in their size. Taken together, these results provide evidence for shape-specific adaptation of neurons in area V4, which may contribute to the perception of the convexity aftereffect.

[Extraskeletal mesenchymal chondrosarcoma: rare differential diagnosis of pleural calcifications]

We report on a 78-year-old male patient with unilateral pleural effusion who underwent multiple diagnostic tests including thoracoscopy without establishing a final diagnosis. In the course of time, the patient developed multiple pleural tumors with calcifications. A CT-guided transthoracic biopsy was performed; the specimen revealed histopathological and immunohistochemical evidence for an extraosseous mesenchymal chondrosarcoma. Besides a short review of the literature, the case is discussed as an extremely rare differential diagnosis of pleural calcifications. To the best of our knowledge, this is the first patient in whom the diagnosis of an extraosseous chondrosarcoma, most likely of the pleura, could be established by CT-guided transthoracic biopsy.

[Sarcoidosis as a mimicry of haemangiotic carcinomatosis]

The radiologic work-up of a 67-year-old female patient for dyspnea revealed micronodular infiltrates in both lungs, which in combination with enlarged mediastinal and abdominal lymph-nodes were highly suspicious of sarcoidosis stage II. A bronchoscopic examination including transbronchial biopsy in another hospital was not diagnostic, so the patient was referred to us for surgical lung biopsy. A specimen from the right middle lobe showed massive haemangiotic carcinomatosis of a clear-cell carcinoma. The pathologist--without knowing the history of the patient--discussed a renal-cell carcinoma as potential primary malignancy, which could easily be confirmed as the patient had a tumor-nephrectomy two years ago.

[Diverticulum of the ductus arteriosus. Cause of traumatic aortic ruptures?]

INTRODUCTION

According to angiographic studies 9-26% of all adult aortae show a ductus arteriosus diverticulum (DAD), i.e. an indention of the aortic wall at the insertion of the obliterated ductus arteriosus. This region is predisposed for traumatic aortic rupture. Up to now fixation at the transition from aorta transversa to fixed aorta descendens is regarded as cause. It is unclear whether ductus diverticulum favours traumatic aortic rupture.

MATERIAL AND METHODS

A total of 143 thoracic aortas (female symbol:37; male symbol:106, 17-91 years) were scanned histomorphologically for DAD. Calcification was quantified by CT multislice volume scan.

RESULTS

A DAD was detected in 44% of macroscopically non-calcified and slightly calcified aortic specimens. Histologically, autochthonal elastic and collagenous fibres of the media were disrupted. CT in macroscopically non-calcified aortas proved isolated calcification in 78%.

DISCUSSION

The incidence of 44% DAD-higher than in angiographic studies-can be explained by the method (histopathology), allowing diagnosis of diverticula down to microm. These morphological alterations are to be seen, at least in part, as a causative factor for the predilection to traumatic aortic ruptures.

Vergleich der Metastasierungsmuster maligner Pleuramesotheliome und pulmonaler Karzinome

Starting with the question whether there is a principal difference in the metastatic behaviour of pleural mesothelioma and pulmonary tumors, a detailed retrospective study of the findings of 210 post-mortem examinations between the years of 1992 to 1999 was conducted. The spectrum of metastatic sites is very large in malignant pulmonary carcinomas (n = 148) as well as in malignant pleural mesotheliomas (n = 62). There is no significant difference in the TMN-staging between both tumor groups at the time of death. One exception was the brain: there were significantly more metastases from the pulmonary tumors. Carcinomas metastasized more frequently into the skeleton, the kidneys and the adrenal glands, while metastases of mesotheliomas were more often found in the peritoneum. As of the moment there is no significant difference in the pattern of metastasis between both tumor groups discernible.

Mediastinale Metastase eines tubaren Chorionkarzinoms nach ektoper Schwangerschaft als seltene Ursache thorakaler Schmerzen

We report on a 26-year old female patient with thoracic pain and dyspnea, in whom a large tumorous mass in the anterior mediastinum with a pleural effusion was diagnosed by computed tomography and magnetic resonance imaging. After rapid progression of tumor growth and detection of malignant cells within the pleural effusion operative intervention including resection of the tumor was performed. Histologic examination of the tumor revealed the typical morphology of a large mediastinal choriocarcinoma. The excessively high hCG-levels returned to normal values post-operatively. A thorough history making revealed an ectopic pregnancy which had made unilateral salpingectomy necessary. Although primary histologic examination of the tubarian tissue had shown no malignancy, a secondary look revealed a choriocarcinoma with identical histological features compared to the mediastinal tumor. Thus, final diagnosis of a mediastinal metastasis of a tubarian choriocarcinoma in ectopic pregnancy was made. We discuss this extremely rare disease and provide a short overview of the literature.

[Diffuse smooth muscle proliferation of the lung and severe pulmonary hypertension]

A 50-year old female forest worker presented with the complaints of progressive exercise induced dyspnea and the history of a recent syncope. Right heart catheterisation revealed the diagnosis of severe precapillary pulmonary hypertension. Ventilation perfusion lung scan indicated the existence of multiple pulmonary emboli with high probability. However, pulmonary angiography did not confirm this finding. Computed tomography of the lung demonstrated a slight mosaic pattern of diffuse ground glass opacities. After video assisted thoracoscopy, the histological diagnosis of diffuse smooth muscle proliferation of the lung could be concluded from the removed lung tissue. Diffuse smooth muscle proliferation of the lung is a rarely diagnosed disease, however it should be considered in patients with suspected pulmonary embolism by ventilation perfusion scan but a normal finding in pulmonary angiography, who are suffering from otherwise not explained pulmonary hypertension.

[Bronchocentric granulomatosis]

Bronchocentric granulomatosis is a rare disease, which has to be taken into consideration in the differential diagnostic of pulmonary nodules and tumors. Two cases are presented, in which only open lung biopsy made it possible to get the diagnosis of bronchocentric granulomatosis. A 78-year-old woman presented with multiple small pulmonary nodules with aspergillus colonization, whereas an 83-year-old man presented with a large mass in the left upper lobe. Corticosteroid therapy led to sustained remission in both patients. The case reports will underline that bronchocentric granulomatosis is not a uniform clinical entity, but has variable clinical and radiological appearances. Its former subdivision into two forms differing by the occurrence of asthma with the coexistence of an aspergillus colonization, does not represent the many different manifestations. Until now the etiology of bronchocentric granulomatosis is uncertain. But there are hints, that the granulomatous inflammation might be the uniform response to different causes. The definite diagnosis of bronchocentric granulomatosis can only be made histologically. This mostly requires surgical lung biopsy. With therapy -- either surgery or corticosteroid therapy or the combination of both -- the prognosis is good.

[Drug-induced pulmonary damage]

The frequency of drug-induced damage to the lung in inpatients is estimated to be about 10%. Pathoanatomically, varying damage patterns result, ranging from acute pulmonary edema via inflammatory reactions to pulmonary fibrosis. The ATS/ERS 2001 classification, which is based on the suggestions made by Liebow 1969, is an accepted system for classifying findings according to recurring patterns. Generally, there are no specific morphological findings which allow safe conclusions on possible administered drugs. Clinical information is mandatory. Differentiation from pulmonary alterations due to the underlying disease is often difficult. In daily routine diagnostics, it is important to consider iatrogenic causal factors in cases of "undetermined pulmonary disease".

[Cell reactions to amber: amber lung in experimental animals]

Workers in the amber-processing industry are heavily exposed to amber dust during the cutting and grinding. Nothing is known about the effect on the lung of inhalation of amber dust. We studied the histological changes after subcutaneous injection of amber dust in man and the rat and after inhalation of amber dust in the rat.

RESULTS

1. The subcutaneous injection of amber dust led to acute inflammation and later to inflammation with large numbers of macrophages and giant cells, forming giant cell granulomas. 2. There was brisk phagocytosis of the amber dust by macrophages. Digestion of amber could not be identified with certainty. 3. Moderate inhalation of amber led to intraalveolar and intrabronchial phagocytosis, predominantly by macrophages. 4. After intense, repeated inhalation (4 and 6 1/2 months post-inhalation) peribronchiolar foreign body granulomas and fibroblasts were seen. In contrast to the findings in the skin (probably related to grinding paste), no epithelioid cell granulomas were found in the lung. The tissue reactions in man are similar to those in the rat. The inflammatory and fibrotic interstitial reactions observed in the rat lung after prolonged intense exposure to amber dust suggest that chronic pulmonary damage ("chronic amber lung") could occur as a result of occupational exposure to amber dust during cutting/polishing.

Psychiatrische und neuropsychologische Auffälligkeiten bei Patienten mit Morbus Fabry: Literaturübersicht

Fabry Disease (FD) is an X-linked lysosomal storage disorder (prevalence about 1 : 100 000) caused by a genetic defect associated with a lack of alpha-galactosidase A (alpha-GAL) enzyme activity. As a consequence, neutral glycosphingolipides can not be cleaved and metabolized, and accumulate in lysosomes of several tissues, particularly in vascular endothelium and smooth muscle cells. The most prominent symptoms comprise pain attacks and acroparesthesia, angiokeratoma, corneal opacity, renal and cardiac dysfunction, hypo- and anhidrosis, gastrointestinal symptoms, and cerebrovascular dysfunction with vertigo, headache, and cerebral ischemia. Characteristic symptoms of FD can occur in male and female patients with the same prevalence, while females with FD seem to be less severely affected. The course of untreated illness is progressive with considerable interindividual variability. Since 2001 two enzyme replacement therapies are approved which can possibly stop the disease progress and alleviate symptoms. The very few reports and clinical observations have shown that a very high proportion of FD patients develop neuropsychiatric symptoms. However, accurate data are lacking. Although the pathophysiologic mechanisms are quite unknown, it is surmised that sphingolipid deposits in the endothelium of small cerebral vessels lead to regional cerebral ischemia accompanied by neuropsychiatric symptoms and deficits. Furthermore, patients with FD are chronically distressed by pain attacks and additional somatic and psychological impairment. Frequently, pain attacks are triggered by psychosocial stress. The high interindividual variability can, thus, also be interpreted on the basis of existing stress and coping models. The present paper will review the presently available psychiatric and neuropsychological findings in FD and will discuss difficulties associated with classification and differential diagnosis of psychiatric disorders occurring in patients with FD.

[Leiomyosarcoma of the inferior vena cava. Review of a rare disease]

Primary sarcomas of the great vessels are rare. Their most common site is the inferior vena cava. We report a primary leiomyosarcoma of a 41 year old female patient localised just below the right renal vein. The resected tumour showed the histological signs of a well differentiated, progesterone positive leiomyosarcoma. The case is discussed on the data of the reviewed literature.