A Case of Herpes Simplex Virus Colitis in an Immunosuppressed Patient

Herpes simplex virus (HSV) can cause severe disseminated infections in immunocompromised patients. Gastrointestinal tract involvement seldom includes the colon. We present a rare case of disseminated cutaneous HSV infection with concomitant colonic involvement in an immunosuppressed patient. The patient's clinical presentation and computerized tomography (CT) findings were concerning for colitis. She failed to improve on antibiotic therapy and subsequently underwent flexible sigmoidoscopy. Gross findings and histopathology were consistent with herpes simplex virus colitis. It is essential to recognize this pathology in immunocompromised patients to evaluate the need to hold immunosuppressive therapy and ensure successful treatment to prevent fatal outcomes.

The Epithelial-Stromal Microenvironment in Early Colonic Neoplasia

Stromal cells play a central role in promoting the progression of colorectal cancer. Here, we analyze molecular changes within the epithelial and stromal compartments of dysplastic aberrant crypt foci (ACF) formed in the ascending colon, where rapidly developing interval cancers occur. We found strong activation of numerous neutrophil/monocyte chemokines, consistent with localized inflammation. The data also indicated a decrease in interferon signaling and cell-based immunity. The immune checkpoint and T-cell exhaustion gene PDCD1 was one of the most significantly upregulated genes, which was accompanied by a decrease in cytotoxic T-cell effector gene expression. In addition, CDKN2A expression was strongly upregulated in the stroma and downregulated in the epithelium, consistent with diverse changes in senescence-associated signaling on the two tissue compartments. IMPLICATIONS: Decreased CD8 T-cell infiltration within proximal colon ACF occurs within the context of a robust inflammatory response and potential stromal cell senescence, thus providing new insight into potential promotional drivers for tumors in the proximal colon.

An aggressive and expanded phenotype in a kindred with a c.57delG SDHD mutation

Familial paraganglioma syndrome type 1 (PGL-1) is maternally imprinted, caused by SDHD mutations on the paternally inherited allele, and presents with paragangliomas and pheochromocytomas that are usually benign. We describe a kindred with a germline c.57delG SDHD mutation that demonstrates an aggressive and possibly expanded phenotype. Eight individuals across four generations were heterozygous for the c.57delG SDHD mutation. The three with known paternal inheritance were clinically affected. The aggressive phenotype was manifested by a neck paraganglioma with distant metastases, and to a lesser degree a neck paraganglioma infiltrating into local connective tissue and a pheochromocytoma presenting at age 8 y. A pulmonary capillary hemangioma may expand the SDHD phenotype. We conclude that the c.57delG SDHD mutation may confer a more aggressive and possibly expanded phenotype than other SDHD mutations.

Rheumatoid pannus presenting as a large epidural mass in the subaxial cervical spine: A case report

Rheumatoid arthritis (RA) is a debilitating inflammatory condition characterised by joint damage that affects the cervical spine most commonly at the atlantoaxial joint resulting in neck pain and myelopathy. The pathogenesis of RA involves the formation of a hyperplastic synovial tissue, termed pannus, which invades the local bone and causes osseous erosion. Here, we describe a case of rapid onset quadriparesis due to spinal cord compression at C5-C6 secondary to vertebral subluxation and mass effect from a large inflammatory pannus in the subaxial spine. Surgical decompression and resection of the subaxial pannus were performed, and the patient regained strength in all extremities. Histopathologic evaluation of the resected tissue confirmed the diagnosis of pannus over other more common epidural masses. Pannus formation commonly occurs in the peri-odontoid region; however, its presentation as a large soft tissue mass in the subaxial spine is not described in the current literature. Therefore, pannus should be considered in the differential diagnosis of epidural masses in the spine of RA patients. We use this case to discuss the pathology and radiological findings relevant to rheumatoid pannus formation in the subaxial cervical spine, as well as emphasise the importance of treatment in the context to severe degenerative disease.

Metastatic cholangiocarcinoma in a patient with undiagnosed Wilson disease

Cholangiocarcinoma (CC) is the second most common primary hepatic malignancy. Although the frequency of malignancy is generally increased in chronic liver disease, CC rarely presents in Wilson disease (WD). The incidence of hepatic malignancy in WD is only 1.2%, with CC accounting for 0.5%. A 66 year old male with history of hypertension, diabetes, and compensated cryptogenic cirrhosis presented with acute onset dyspnea and pleuritic chest pain. He was incidentally found to have a sizeable mass in the right hepatic lobe. Ultimately, a liver biopsy revealed dense demoplasia and increased mucin production, consistent with diagnosis of CC. Biopsy also demonstrated increased copper deposition consistent with WD, explaining the patient's underlying cirrhosis. Unlike other forms of chronic liver disease where incidence of liver cancer is increased, the lower rate of malignancy seen in WD may be explained by a protective effect of copper in WD. Copper acts to both directly stabilize DNA and inhibit angiogenesis. In this case, it is possible that the degree of copper deposition in his liver was mild, causing cirrhosis and the chronic liver inflammation that caused his CC. However, it may not have been sufficient to "protect" against development of CC.

Characterization of Mucosal Dysbiosis of Early Colonic Neoplasia

Aberrant crypt foci (ACF) are the earliest morphologically identifiable lesions in the colon that can be detected by high-definition chromoendoscopy with contrast dye spray. Although frequently associated with synchronous adenomas, their role in colorectal tumor development, particularly in the proximal colon, is still not clear. The goal of this study was to evaluate the profile of colon-adherent bacteria associated with proximal ACF and to investigate their relationship to the presence and subtype of synchronous polyps present throughout the colon. Forty-five subjects undergoing a screening or surveillance colonoscopy were included in this retrospective study. Bacterial cells adherent to the epithelia of ACF and normal mucosal biopsies were visualized by in situ hybridization within confocal tissue sections. ACF showed significantly greater heterogeneity in their bacterial microbiome profiles compared with normal mucosa. One of the bacterial community structures we characterized was strongly correlated with the presence of synchronous polyps. Finally, using DNA mass spectrometry to evaluate a panel of colorectal cancer hotspot mutations present in the ACF, we found that three APC gene mutations were positively associated with the presence of Instestinibacter sp., whereas KRAS mutations were positively correlated with Ruminococcus gnavus. This result indicates a potential relationship between specific colon-associated bacterial species and somatically acquired CRC-related mutations. Overall, our findings suggest that perturbations to the normal adherent mucosal flora may constitute a risk factor for early neoplasia, demonstrating the potential impact of mucosal dysbiosis on the tissue microenvironment and behavior of ACF that may facilitate their progression towards more advanced forms of neoplasia.

An unusual case of pigmented villonodular synovitis after total knee arthroplasty presenting with recurrent hemarthrosis

Pigmented villonodular synovitis (PVNS) is a benign proliferative joint disease, which is a rare finding after total knee arthroplasty (TKA). There is currently no link between PVNS and TKA, and it has been described infrequently in the literature. Its presentation has varied along with the time that it presents postoperatively. We describe a case of a patient who presents with recurrent hemarthrosis 4 years after TKA. The patient had no previous history of PVNS and had an arthroscopy 1 year after the index operation with no evidence of synovitis. We present details of the first case with a review of imaging and pathology and a brief review of the literature on PVNS occurring after TKA.

Hepatitis caused by herpes viruses: A review

Herpes virus hepatitis varies in presentation, ranging from asymptomatic to acute liver failure, in both immunocompetent and immunocompromised individuals. Hepatitis caused by the Herpesviridae family is uncommon and usually results in mild disease. It is also often self-limiting, although in certain populations especially immunosuppressed patients, it can cause severe infections, leading to acute to fulminant hepatic failure. In addition, some isolated cases of fulminant disease in immunocompetent individuals have been reported. As the presentation is frequently non-specific, it is important to maintain a high level of suspicion for these viral etiologies and start empiric therapy with antiviral agents as soon as possible. Liver transplantation is the last resort. Mortality remains high in fulminant hepatic failure caused by Herpesviridae without liver transplantation. Here we review the literatures on hepatitis caused by three members of the Herpesviridae family, cytomegalovirus, Epstein-Barr virus and herpes simplex virus to discuss the epidemiology, diagnostic methods, clinical features and current management, and also to determine which aspects need to be investigated in further detail. Herpesviridae-mediated acute liver failure is rare but is associated with a poor prognosis, even after early treatment.

Endoscopic Features of Mucous Cap Polyps: A Way to Predict Serrated Polyps

Background/Aims

The aims of the study were to identify whether a mucous-cap predicts the presence of serrated polyps, and to determine whether additional endoscopic findings predict the presence of a sessile serrated adenomas/polyp (SSA/P).

Methods

We analyzed 147 mucous-capped polyps with corresponding histology, during 2011–2014. Eight endoscopic features (presence of borders, elevation, rim of debris, location in the colon, size ≥10 mm, varicose vessels, nodularity, and alteration in mucosal folds) of mucous-capped polyps were examined to see if they can predict SSA/Ps.

Results

A total of 86% (n=126) of mucous-capped polyps were from the right sided serrated pathway (right-sided hyperplastic [n=83], SSA/Ps [n=43], traditional serrated adenoma [n=1]), 10% (n=15) were left-sided hyperplastic polyps, and 3% (n=5) were from the adenoma-carcinoma sequence. The presence of a mucous cap combined with varicose vessels was the only significant predictor for SSA/Ps. The other seven characteristics were not found to be statistically significant for SSA/Ps, although location in the colon and the presence of nodularity trended towards significance.

Conclusions

Our study suggests that mucous-capped polyps have high predictability for being a part of the serrated pathway. Gastroenterologists should be alert for a mucous-capped polyp with varicose veins, as these lesions have a higher risk of SSA/P.

Neoplastic Colonic Polyp with Extensive Squamous Metaplasia. Case Report

Extensive squamous metaplasia in neoplastic colonic polyps is rare. This paper describes extensive squamous metaplasia in an adenomatous polyp evolving into adenocarcinoma. The origin of squamous cell carcinoma and adenocanthoma of the colon is not well understood. This case is the only case reported in the literature that demonstrates the development of squamous metaplasia in dysplastic colonic glands, in situ adenocarcinoma, and finally invasive adenocarcinoma of the colon. The pertinent literature is reviewed.

Proximal Aberrant Crypt Foci Associate with Synchronous Neoplasia and Are Primed for Neoplastic Progression

Aberrant crypt foci (ACF) are the earliest morphologically identifiable lesion found within the human colon. Despite their relatively high frequency in the distal colon, few studies have examined the molecular characteristics of ACF within the proximal colon. In the following study, clinical participants (n = 184) were screened for ACF using high-definition chromoendoscopy with contrast dye-spray. Following pathologic confirmation, ACF biopsies were subjected to laser capture microdissection (LCM), and epithelial cells were evaluated for somatic mutations with a customized colorectal cancer mutation panel using DNA-mass spectrometry. Samples were further characterized for microsatellite instability (MSI). Logistic models were used to associate proximal ACF with synchronous (detected during the same procedure) neoplasia. Thirty-nine percent of participants had at least one histologically confirmed proximal ACF. Individuals with a proximal ACF were significantly more likely to present with a synchronous neoplasm (P = 0.001), and specifically, a proximal, tubular, or tubulovillous adenoma (multivariable OR = 2.69; 95% confidence interval, 1.12-6.47; P = 0.027). Proximal ACF were more likely to be dysplastic (52%) compared with distal ACF (13%; P < 0.0001). Somatic mutations to APC, BRAF, KRAS, NRAS, and ERBB2 were detected in 37% of proximal ACF. Hyperplastic ACF were more often MSI-high, but there were no differences in MSI status observed by colonic location. In summary, ACF are identified in the proximal colons of approximately 40% of individuals undergoing chromoendoscopy and more often in patients with synchronous proximal adenomas.Implications: This study provides the most complete set of data, to date, that ACF represent the earliest step in the adenoma-carcinoma sequence but remain below the detection limit of conventional endoscopy.Visual Overview: http//mcr.accrjournals.org/content/molcanres/16/3/486/F1.large.jpg Mol Cancer Res; 16(3); 486-95. ©2017 AACR.

Primary Follicular Lymphoma of the Gastrointestinal Tract: Case Report and Review

PURPOSE

Primary gastrointestinal follicular lymphoma (GI-FL) is considered a rare disease with fewer than 400 cases reported in the literature. It accounts for roughly 1-3 % of GI non-Hodgkins lymphomas (NHL). It originates in the GI tract and typically affects small bowel. The disease has an indolent course, and a prolonged survival can be expected in most cases. Due to its rarity, an optimal diagnostic work up and treatment plan has not been well established.

METHODS

Endoscopic evaluation of the entire gastrointestinal (GI) tract using esophagogastroduodenoscopy (EGD), wireless capsule endoscopy, double-balloon enteroscopy, colonoscopy, and whole body examination with fluorodeoxyglucose-positron emission tomography (FDG-PET) has been suggested to more accurately stage the disease and guide the treatment plan.

RESULTS

Treatment options for GI follicular lymphoma include watch and wait strategy, surgery, chemotherapy, radiation, immuno-radiotherapy, or a combination of these modalities.

CONCLUSION

In this article, we have summarized the existing information regarding clinical presentation, diagnostic evaluation, and treatment options for this rare entity after presenting a case of GI-FL who was diagnosed during an EGD for evaluation of belching, heartburn, and weight loss.

Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis: a Review Featuring a Women's Health Perspective

Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) are two major types of chronic cholestatic liver disease. Each disorder has distinguishing features and variable progression, but both may ultimately result in cirrhosis and hepatic failure. The following offers a review of PBC and PSC, beginning with a general overview of disease etiology, pathogenesis, diagnosis, clinical features, natural course, and treatment. In addition to commonly associated manifestations of fatigue, pruritus, and fat-soluble vitamin deficiency, select disease-related topics pertaining to women's health are discussed including metabolic bone disease, hyperlipidemia and cardiovascular risk, and pregnancy-related issues influencing maternal disease course and birth outcomes. This comprehensive review of PBC and PSC highlights some unique clinical considerations in the care of female patients with cholestatic liver disease.

Second harmonic generation imaging distinguishes both high-grade dysplasia and cancer from normal colonic mucosa

BACKGROUND AND AIM

Second harmonic generation (SHG) is a novel imaging technology that could provide optical biopsy during endoscopy with advantages over current technology. SHG has the unique ability to evaluate the amount of extracellular matrix collagen protein and its alignment.

METHODS

Hematoxylin- and eosin-stained slides from colon biopsies (normal, low-grade dysplasia (LGD), high-grade dysplasia (HGD), and cancer) were examined with SHG imaging. Both signal intensity and collagen fiber alignment were measured. Average intensity per pixel (AIPP) was obtained, and an analyzing polarizer was used to calculate β, an alignment parameter.

RESULTS

The mean AIPP for normal mucosa was 48, LGD was 38, HGD was 42, and malignancy was 123 (p < 0.01). The AIPP ROC curve between malignant versus non-malignant tissue was 0.96 (0.93-0.99). An AIPP value of 60 can differentiate malignancy with 87 % sensitivity and 90 % specificity. The mean β for normal tissue was 0.490, LGD was 0.379, HGD was 0.345, and cancer was 0.453 (p = 0.013), with a normal tissue mean rank of 6.5 compared to 2.5 for HGD (p = 0.029).

CONCLUSIONS

SHG signal intensity can differentiate malignant from non-malignant colonic polyp tissue with high sensitivity and specificity. Anisotropic polarization can discern HGD from normal colonic polyp tissue. SHG can thus distinguish both HGD and malignant lesions in an objective numeric fashion, without contrast agents or interpretation skills. SHG could be incorporated into endoscopy equipment to enhance white light endoscopy.

Hepatic Sarcoidosis

Sarcoidosis is a multisystem disease characterized by the presence of non-caseating granulomas in affected organs. Pulmonary involvement is the most common site of disease activity. However, hepatic involvement is also common in sarcoidosis, occurring in up to 70% of patients. Most patients with liver involvement are asymptomatic. Therefore, the majority of cases are discovered incidentally, frequently by the finding of elevated liver enzymes. Pain in the right upper quadrant of the abdomen, fatigue, pruritus, and jaundice may be associated with liver involvement. Portal hypertension and cirrhosis are complications linked to long-standing hepatic sarcoidosis. Liver biopsy is usually required to confirm the diagnosis. It is important to differentiate hepatic sarcoidosis from other autoimmune and granulomatous liver diseases. Not all cases of hepatic sarcoidosis require treatment. For symptomatic patients, the first line treatment includes corticosteroids or ursodeoxycholic acid. Various immunosuppressant agents can be used as second line agents. Rarely, severe cases require liver transplantation.

An ironic case of liver infections: Yersinia enterocolitis in the setting of thalassemia

A 49 years old Vietnamese male with a history of thalassemia, presented with gastrointestinal symptoms and signs of hemolysis. He was diagnosed with yersinia enterocolitis. Yersinia is a gram-negative rod that most frequently occurs in children especially during the winter months. In the current case, the bone marrow biopsy showed hemophagocytosis along with positive cultures for Yersinia. The microorganism likely triggered hemophagocytosis. This syndrome, also known as, hemophagocytic lymphohistiocytosis, is defined by fever for more than 7 d, cytopenia of two or more cell lines, hemophagocytosis, hepatitis, serum ferritin greater than 500, jaundice, lymphadenopathy, and hepatosplenomegaly. This disorder can be either familial or secondary to a strong immunologic activation. Both have an overwhelming activation of T-cells and macrophages.

Case report and review of esophageal lichen planus treated with fluticasone

Lichen planus is a fairly common chronic idiopathic disorder of the skin, nails and mucosal surfaces. Esophageal involvement of this disease on the other hand is rare and only about 50 cases have been reported in literature. Given its rarity, it can be difficult to diagnose and may be easily misdiagnosed as reflux esophagitis. Currently, there are no clear recommendations on the optimal management of this disease and little is known about the best treatment approach. Systemic steroids are usually the first line treatment and offer a favorable response. In this report, we would like to present a novel approach in the management of esophageal lichen planus in a middle-aged woman treated successfully with swallowed fluticasone propionate 220 mcg twice a day for 6 wk, as evidenced by objective clinical findings. Based on our review of related literature and experience in this patient, we feel that a trial of swallowed fluticasone may be a prudent approach in the management of these patients since it has a more favorable side effect profile than systemic treatment.

Inflammation associated with neoplastic colonic polyps

Little is known about the significance of inflammation in neoplastic colon polyps: tubular, tubulovillous, and villous polyps/adenomas (TVPs) and hyperplastic/serrated polyps (HSPs). We undertake this study to ascertain the significance of acute and chronic inflammation in neoplastic polyps. Eighty-one consecutive, randomized TVPs and fifty-four randomized HSPs accessioned in the UCHC surgical pathology laboratory were selected for final analysis. The TVPs display increased acute and chronic inflammation compared to normal and adjacent non-dysplastic colonic mucosa. Adenoma size correlates with degree of acute and chronic inflammation. TVPs show increased overall acute and chronic inflammation compared to HSPs of the same size. This difference was statistically highly significant (p<.001). The number of adenomas exhibiting high grade dysplasia was insufficient to evaluate the relationship between polyp inflammation, polyp size, and degree of dysplasia. The HSPs showed significantly lower incidence and severity of acute and chronic inflammation compared to the TVPs. No correlation was seen in the HSP group between polyp size and acute or chronic inflammation. The prevalence of IBD was higher in patients with HSP showing acute inflammation than in the general population, but this statistic may be skewed by the low overall incidence of acute inflammation in the HSP group.

Eosinophilic venulitis of colon presenting as ileocecal mass

Reports of eosinophilic infiltration of the colon causing obstruction are few. It is even less common to find associated extensive intestinal venulitis, which is similar to and lumped together with so called Mesenteric Inflammatory Veno-Occlusive Disease (MIVOD) or Self-Limited Intestinal Venulitis. Eosinophilic necrotizing lymphadenitis, such as what we report here, has never been reported in association with this disease. A 41-year-old female presented with cramping lower abdominal pain, hematochezia, nausea, and vomiting. Computed tomography revealed the presence of the mass and thickening of the illeocecal wall. Endoscopy confirmed a cecal mass with surface ulceration suggestive of cecal adenocarcinoma. Patient underwent right hemicolectomy with the clinical and radiologic diagnosis of adenocarcinoma. Microscopic examination of the resected bowel showed an ulcerated mass in the cecum composed of markedly edematous tissue showing transmural eosinophilic infiltration and extensive eosinophilic and lymphocytic venulitis with and without thrombosis. This was associated with a necrotizing lymphadenitis.

Intra-abdominal complications of sarcoidosis

Sarcoidosis is an inflammatory disease characterized by non-caseating granulomas in the absence of other autoimmune processes, infectious diseases, or foreign agents. The etiology of sarcoidosis is not completely understood. Several organ systems can be affected, of which the most frequently involved include the lungs and lymph nodes. Intra-abdominal sarcoidosis is less common, but can be found in the absence of pulmonary or lymphatic disease. Intra-abdominal sarcoidosis is most often asymptomatic. However, long-standing unrecognized disease can result in life-threatening complications. The identification, monitoring and prevention of these complications will be discussed, with emphasis on both clinical and histological presentations of intra-abdominal sarcoidosis.

Eosinophilic digestive diseases: eosinophilic esophagitis, gastroenteritis, and colitis

Eosinophilic digestive diseases (EDD) are relatively rare disorders associated with increased gastrointestinal eosinophilic infiltrates without any underlying primary etiology. The pathophysiology of EDD is unclear, but is suspected to be related to a hypersensitivity reaction given its correlation with other atopic disorders and clinical response to corticosteroid therapy. Given the overall relative increase of various atopic conditions, it is important for clinicians to understand the presentation and diagnosis and treatment options available. We present here a review of EDD, including the proposed pathophysiology, diagnosis and current treatment options for these disorders.

Cytoplasmic phospholipase A2 levels correlate with apoptosis in human colon tumorigenesis

Colon cancers often display perturbations in arachidonic acid metabolism, with elevated levels of cyclooxygenase (COX)-2 expression and prostaglandin E(2) (PGE(2)) production frequently observed. Whereas COX-2 and PGE(2) are associated with cancer cell survival and tumor angiogenesis, arachidonic acid itself is a strong apoptotic signal that may facilitate cancer cell death. To further explore how cancer cells exploit the progrowth actions of prostaglandins while suppressing the proapoptotic actions of intracellular arachidonic acid, we determined the cytoplasmic phospholipase A(2) (cPLA(2)) and COX-2 expression levels in a panel of human colon tumors by immunohistochemistry. Although high levels of cPLA(2) and COX-2 expression are predicted to facilitate maximal prostaglandin production, tumors frequently displayed a high-COX-2/low-cPLA(2) phenotype. The least represented phenotype was the high expression of cPLA(2), a characteristic predicted to generate the highest levels of intracellular arachidonic acid. The potential proapoptotic role of cPLA(2) was supported by a higher frequency of terminal deoxynucleotidyl transferase-mediated nick end labeling staining in cPLA(2)-positive tumors. Moreover, analysis of preneoplastic aberrant crypt foci from high-risk patients suggests that acquisition of the high-COX-2/low-cPLA(2) phenotype may arise at an early stage of colon carcinogenesis. We additionally inhibited cPLA(2) in HT-29 cells using antisense oligonucleotides. Our results indicate that cPLA(2) plays an important role in tumor necrosis factor alpha-induced apoptosis in human colon cancer cells. Our data further support the model in which colon cancer growth is favored when intracellular arachidonic acid levels are suppressed by inhibition of cPLA(2) or by a high-COX-2/low-cPLA(2) phenotype.

An unusual presentation of hepatocellular carcinoma: case report and review

Hepatocellular carcinoma (HCC) is a common cancer presenting in adults with an increasing incidence in the United States. The many etiologies of cirrhosis place patients at increased risk for developing hepatocellular carcinoma but not all patients who develop this cancer have underlying cirrhosis. Presented is a case of a man without cirrhosis or any known risk factors for liver disease who was admitted in fulminant hepatic failure. He was found to have hepatocellular carcinoma complicated by an extensive tumor thrombus. At autopsy, underlying hemochromatosis was discovered. The etiologies, clinical manifestations, diagnostic modalities and treatment options are discussed patients with hepatocellular carcinoma.

Hepatitis B virus infection of transplanted human hepatocytes causes a biochemical and histological hepatitis in immunocompetent rats

AIM: To characterize the host response to hepatitis B virus (HBV) infection in human hepatocytes transplanted into immunocompetent rodent rats tolerized by, and transplanted with primary human hepatocytes.

METHODS: One week after the transplantation, rats were inoculated with HBV, and viral gene expression, replication, and host response was monitored.

RESULTS: HBV DNA was detectable in serum for at least 60 days. HBsAg levels rose steadily for 3 weeks post-inoculation and then plateaued at a level of about 0.6 pg/ml. HBV RNA was also found in liver at levels that remained constant through the time course. Immunofluorescence revealed clusters of hepatocytes that stained positive for HBcAg. The presence of HBV covalently closed circular DNA (cccDNA) in liver was demonstrated using nuclease digestion of single-stranded DNA followed by PCR. Serum ALT levels rose and reached a peak level of 180 IU/L on day 18, but remained elevated for 60 days. Histology revealed a progressive predominantly mononuclear lobular hepatitis.

CONCLUSION: These data indicate that human hepatocytes transplanted into rats rendered tolerant to these cells, when infected by HBV, results in biochemical as well as histological evidence of hepatitis that accompanies viral gene expression, and DNA replication.

The crystal structure of the influenza matrix protein M1 at neutral pH: M1-M1 protein interfaces can rotate in the oligomeric structures of M1

The influenza matrix protein (M1) forms a protein layer under the viral membrane and is essential for viral stability and integrity. M1 mediates the encapsidation of the viral RNPs into the viral membrane by its membrane and RNP-binding activities. In order to understand the roles of M1-M1 protein interactions in forming the M1 layer, X-ray crystallographic studies of a M1 fragment (1-162) were carried out at neutral pH and compared with an acidic pH structure. At neutral pH the asymmetric unit was a stacked dimer of M1. A long molecular ribbon of neutral stacked dimers was formed by translation as dictated by the P1 space group. The elongated ribbon had a positively charged stripe on one side of the ribbon. A similar M1-M1 stacking interface was also found in the acidic asymmetric unit. However, within the acidic stacked dimer the molecules were not straight, but rotated in relation to each other by slightly changing the M1-M1 stacking interface. The acidic structure possessed an additional M1-M1 twofold interface. Protein docking confirmed that the M1-M1 stacking and M1-M1 twofold interfaces could be used to form a double ribbon of M1 molecules. By iterative repetition of the rotated relationship among the M1 molecules, a helix of M1 was generated. These studies suggest that M1 has the ability to form straight or bent elongated ribbons and helices. These oligomers are consistent with previous electron microscopic studies of M1, which demonstrated that isolated M1 formed elongated and flexible ribbons when isolated from what appeared to be a helical shell of M1 in the influenza virus.

Papillary thyroid carcinoma associated with papillary renal neoplasia: genetic linkage analysis of a distinct heritable tumor syndrome

Papillary thyroid carcinoma usually is sporadic, but may occur in a familial form. The complete clinical and pathological phenotype of familial papillary thyroid carcinoma (fPTC) has not been determined, and the susceptibility gene(s) is unknown. We investigated the clinical and pathological characteristics of an unusually large three-generation fPTC kindred to characterize more fully the clinical phenotype. We performed linkage analysis to determine the chromosomal location of a fPTC susceptibility gene. In addition to the known association of fPTC with nodular thyroid disease, we observed the otherwise rare entity of papillary renal neoplasia (PRN) in two kindred members, one affected with PTC and the other an obligate carrier. The multifocality of PRN in one subject adds weight to the likelihood of a true genetic predisposition to PRN. Both genetic linkage and sequence analysis excluded MET, the protooncogene of isolated familial PRN, as the cause of the fPTC/PRN phenotype. A genome-wide screening and an investigation of specific candidate genes demonstrated that the fPTC/PRN phenotype was linked to 1q21. A maximum three-point log of likelihood ratio score of 3.58 was observed for markers D1S2343 and D1S2345 and for markers D1S2343 and D1S305. Critical recombination events limited the region of linkage to approximately 20 cM. A distinct inherited tumor syndrome has been characterized as the familial association of papillary thyroid cancer, nodular thyroid disease, and papillary renal neoplasia. The predisposing gene in a large kindred with this syndrome has been mapped to 1q21.

Familial papillary thyroid carcinoma is genetically distinct from familial adenomatous polyposis coli

Familial papillary thyroid carcinoma (fPTC) is an inherited tumor syndrome characterized by isolated papillary thyroid carcinoma (PTC) in affected subjects. Its etiology is unknown. Large multigeneration families with PTC are very rare, and therefore, modern genetic linkage studies have not been applied extensively to this disorder. Familial adenomatous polyposis coli (FAP) is an inherited tumor syndrome enriched in PTC. FAP is caused by germline mutations of the adenomatous polyposis coli (APC) gene that is located in the 5q21 region. It is not known if fPTC is a phenotypic variant of FAP, or if it is a genetically distinct disorder. We report a large 3-generation fPTC kindred and use linkage analysis to test the hypothesis that fPTC and FAP are genetically distinct. In this kindred there are 25 living informative subjects; 5 have PTC, and 1 is an obligate carrier. Inheritance is autosomal dominant with incomplete penetrance. There is vertical transmission, multifocal disease, an average age of onset of 36 years, and 1 subject has colon cancer. The probability is approximately 1 in 2 billion against the clustering of 5 sporadic PTC cases in this kindred. To test for linkage to the APC gene we used 2 highly polymorphic markers, D5S656 and D5S421, which are located within a maximum distance of 1.7 megabase (Mb) of the APC gene and within an estimated genetic region of less than 1 centimorgan (cM) from each other. After polymerase chain reaction (PCR) amplification 18 family members were genotyped. Construction and inspection of haplotypes showed that the affected subjects do not share the same allelic composition. Using a penetrance ratio of 75%, linkage was excluded at 2 cM and 3 cM on both sides of D5S656 and D5S421, respectively. The combined haplotype of these 2 markers provided an exclusion region of 4 cM. We conclude that fPTC is genetically distinct from FAP.

Granulomatous hepatitis as a complication of intravesical Bacillus Calmette-Guerin therapy for bladder carcinoma

Bacillus Calmette-Guerin (BCG) therapy has been proven to be effective treatment for superficial bladder carcinoma with complications that are usually minor and self limited. Although rare, granulomatous hepatitis can develop, and it is important to recognize it and treat it promptly. The hepatitis which occurs appears to be the result of a hypersensitivity reaction to antigens present in the BCG vaccine. Pathological findings include hepatocellular necrosis and pleomorphism, microgranulomas and non-caseous epitheliod granulomas with giant cells. A case of BCG-hepatitis, which developed in a 74-year-old white male following immunotherapy for superficial bladder carcinoma, is described.

Bronchogenic carcinoma presenting as a pseudopregnancy

A young woman with an occult bronchogenic carcinoma presented with secondary amenorrhea and an elevated beta subunit of human chorionic gonadotropin that was mistakenly attributed to pregnancy. Physicians should be aware that this carcinoma may present solely with an elevated beta human chorionic gonadotropin value, and the potential exists for confusion with a pregnancy state in women of childbearing age.

Cyclocreatine inhibits neutrophil accumulation in the myocardium of a canine model of coronary artery occlusion and reperfusion

This study tests the hypothesis that the administration of cyclocreatine before ischemia inhibits the release of neutrophil chemotactic factors from myocardial tissues and subsequently reduces neutrophil accumulation into ischemic areas. Adult mongrel dogs underwent left anterior descending coronary artery occlusion for 1 h, followed by a 2-h reperfusion. Cyclocreatine-treated dogs (n = 6) were injected intravenously with cyclocreatine solution (600 mg/kg) 1 h before the experiment and during ligation of the coronary artery. Control dogs (n = 6) were injected with saline. Neutrophil chemotactic activity was measured in plasma samples using standard modified Boyden chambers. In controls dogs, significantly elevated levels of chemotactic activity were recovered in blood samples taken during reperfusion (i.e., 2.8-3.5-fold; P < .0001) as compared to base-line activity recovered before occlusion. Preliminary biochemical characterizations revealed that the recovered chemotactic factors (via checkerboard analysis) are proteins of high molecular weight (greater than 100 kDa). Biopsy samples of control hearts showed an accumulation of a large number of neutrophils in the ischemic portions. Cyclocreatine-treated dogs, on the contrary, showed low levels of chemotactic activity during reperfusion, which correlated with the absence of neutrophils in ischemic areas. These results indicate the capability of cyclocreatine to inhibit the release of neutrophil chemotactic factors from ischemic myocardium, which subsequently prevented neutrophil accumulation.

Cyclocreatine inhibits the production of neutrophil chemotactic factors from isolated hearts

This study was designed to determine the effect of cyclocreatine on the release of neutrophil chemotactic factors (NCF) from isolated rabbit hearts. We tested the hypothesis that if ischemia is important for the formation of NCF from the myocardium, then blocking (or delaying) ischemic changes with cyclocreatine should inhibit the release of NCF. Two models were used, including (1) perfusion of rabbit hearts (Langendorff apparatus) with oxygenated (95% oxygen) Krebs-Henseleit buffer (K-H buffer) containing 5% cyclocreatine for 120 minutes, and (2) incubating hearts with phosphate-buffered saline (PBS) containing 5% cyclocreatine for 120 minutes. For both models, rabbits were injected intravenously with 10 ml of 5% cyclocreatine solution 30 minutes before the animals were killed and the hearts removed. Control rabbits were injected with 5% creatine solution or saline for 30 minutes before perfusing hearts with K-H buffer or incubating with PBS. Chemotactic activity was assayed in the perfusates and supernatants using modified Boyden chambers and rabbit peritoneal neutrophils as indicator cells. The chemoattractant f-Met-Leu-Phe (f-MLP) was the positive control for a 100% response rate. Isolated hearts perfused with cyclocreatine showed significantly lower chemotactic activity (ie, 1.24 +/- 1% f-MLP; P less than 0.0001) compared to hearts perfused with K-H buffer (129 +/- 18%) or creatine (227 +/- 42%) (mean +/- standard error). Similar results were obtained using incubated hearts. Next the effect of cyclocreatine on neutrophils in the Boyden chamber was determined and it was found that it did not alter neutrophil migration, which excludes a direct inhibitory effect on the cells. Furthermore supernatant from cyclocreatine-treated hearts did not inhibit neutrophil chemotaxis to C5a, indicating absence of a chemotaxis inhibitor in this preparation. Results of these studies suggest that the observed low activity recovered in perfusate and supernatant of cyclocreatine-treated hearts is a result of reduction in the synthesis and/or release of the factors from myocardial tissues. Similar to previously established data, cyclocreatine treatment significantly preserved myocardial nucleotide levels (ie, adenosine triphosphate and creatine phosphate), which supports our hypothesis that the formation of NCF is ischemia dependent and that maintaining elevated levels of myocardial energy nucleotides reduced chemotactic factor release.

Identification of human immunodeficiency virus in the heart of a patient with acquired immunodeficiency syndrome

A 35-year-old homosexual white male diagnosed as having human immunodeficiency virus (HIV) infection presented with recurrent pericardial effusion, and HIV was isolated from the pericardial fluid. Autopsy revealed an extensive gross infiltrative lesion in the left ventricle of the heart. Microscopic examination of the myocardium demonstrated multifocal atypical lymphoid cell infiltrations associated with scattered foci of myocardial necrosis. The atypical lymphoid cells were immunoreactive to UCHL-1, a T cell antigen antibody. HIV was immunocytochemically identified in the cardiac lymphocytic infiltrate with anti-p24 monoclonal antibodies. This finding was supported by ultrastructural examination and in situ hybridization study.

Cardiac derived neutrophil chemotactic factors; preliminary biochemical characterization

The purpose of this study is to investigate whether isolated hearts perfused with cardioplegic solution release inflammatory mediators such as neutrophil chemotactic factors (NCF). Three conditions were tested, including: (1) perfusion of rabbit hearts with crystalloid cardioplegic solution (4 degree C) saturated with air (95% oxygen) and containing dextrose (i.e. complete system), (2) perfusion of rabbit hearts with non-oxygenated cardioplegic solution, containing dextrose (i.e. minus oxygen system), and (3) perfusion of hearts with cold cardioplegic solution saturated with air in the absence of dextrose (i.e. minus dextrose system). At various time intervals (5 min, 1, 2, 3 and 4 h) samples of circulated perfusate were removed and assayed for the presence of NCF using modified Boyden chambers. Rabbit peritoneal neutrophils were the indicator cells. The standard chemoattractant, f-Met-Leu-Phe (f-MLP) was the positive control. High levels of neutrophil chemotactic activity were detected in perfusate of all above described hearts perfused for 4 h (i.e. 194 +/- 22% of f-MLP control--complete system, 126 +/- 13%--minus oxygen and 136 +/- 10%-minus dextrose). Histological evaluation of these hearts showed evidence of global ischemia. We also detected significant levels of NCF in effluent of hearts perfused for 5 min, 1, 2 and 3 h. Similar to perfused hearts, isolated rabbit hearts incubated for 4 h with non-oxygenated cardioplegic solution (in presence and absence of dextrose) released high levels of NCF (132 +/- 18%-intact heart; and 100 +/- 6% myocardial segments). Standard checkerboard analysis revealed that the observed activity released from these hearts is chemotactic.(ABSTRACT TRUNCATED AT 250 WORDS)

Tc-99m diphosphonate uptake in malignant fibrous histiocytoma: a possible iron-related effect

A man with malignant fibrous histiocytoma of the thigh had avid uptake of Tc-99m MDP in the lesion. Review of tissue sections showed considerable accumulation of iron in the tumor. Iron is known to be a potential nidus for deposition of the Tc-99m diphosphonates. A review was made of tissue sections from two other reported cases of malignant fibrous histiocytoma which also had significant accumulation of Tc-99m diphosphonates. Both revealed iron within the tumor. The origin of the iron is unknown (perhaps from necrosis and hemorrhage, from trauma, or from innate phagocytic activity of the histiocytes). However, this observation may serve as a stimulus to studies attempting to discern the underlying mechanisms of extraosseous deposition of the Tc-99m diphosphonates.

Inflammatory mediators in alkali-burned corneas: preliminary characterization

Leukocyte chemotactic factors (LCF) are important inflammatory mediators which activate and recruit leukocytes from the circulation into sites of tissue damage. These factors were recently detected in the tear fluid of inflamed eyes induced by alkali burn. It remains unclear, however, whether the detected LCF are released from injured corneal tissues or leaked from the circulation. Using a corneal cup model developed in our laboratory, we began examining the capability of corneal tissues to produce LCF in response to alkali injury. We also evaluated the influence of citric acid on the production of LCF from corneas preinjured by the alkali sodium hydroxide (NaOH). For these studies, the epithelial surfaces of corneas isolated from bovine and human eyes were exposed to 1N NaOH for 35 seconds at room temperature. The NaOH was then removed and the epithelial surfaces washed once with buffer and incubated with culture medium for 1, 2, 4, and 6 hours at 37 degrees C/5% CO2 atmosphere. Our results showed that (1) NaOH2 induced corneal epithelial cell injury ranging from cell discoloration and moderate damage of the upper half of the epithelium (1-4 hrs) to total destruction of the epithelium (6 hrs); (2) NaOH-injured corneas (2 hr incubation post injury) produced significant levels of chemotactic activity (via checkerboard analysis) specific for neutrophils (115% maximum chemotactic response [MCR]) and mononuclear cells (94% MCR); (3) preliminary characterization of these factors revealed that they are protease and heat sensitive, extractable by organic solvents, and possess molecular weight values greater than 100,000 daltons; and (4) incubation of NaOH-pretreated corneas with 0.01% citric acid for 2 hours markedly inhibited the production of LCF for both neutrophils (98% inhibition) and mononuclear cells (91% inhibition). Results of these studies indicate that alkali-burned bovine and human corneas generate leukocyte chemoattractants which differ in their biochemical characteristics from previously known low molecular weight chemotactic factors such as C5a, interleukin-1, or leukotriene B4.

Management of endoscopically removed malignant colon polyps

The medical records of 87 patients with 89 malignant colorectal polyps removed endoscopically between 1971 and 1983 were reviewed retrospectively. Fifty-five polyps contained carcinoma-in-situ. Four polyps had "pseudo-invasion" by displaced mucosal glands. Thirty polyps contained invasive carcinoma. No patients with carcinoma-in-situ or "pseudo-invasion" had either local residual disease or metastatic disease at the time of colectomy or which was detected during subsequent follow-up. Four patients (14%) with invasive cancer would have been inadequately treated by polypectomy alone, since one had residual disease at the polypectomy site, one had nodal metastases, one had liver metastases at the time of colectomy, and one subsequently developed liver metastases. Three histologic criteria correctly predicted all four cases where residual or recurrent disease was present: involvement of the polypectomy resection margin, lymphatic invasion within the polyp, and poorly differentiated histology. Polyp size, histology (villous adenoma, adenomatous polyp, or villo-adenomatous polyp), or anatomic location did not identify those patients who warranted further therapy. We conclude that polypectomy alone is adequate treatment for polyps containing carcinoma-in-situ. Polypectomy alone is also adequate treatment for most polyps containing invasive carcinoma. However, patients with lymphatic involvement within the polyp, poorly differentiated cancer, or resection margin involvement should probably undergo colectomy.

Congenital melanoma with multiple prenatal metastases

A 1.95-kg fetus delivered at 33 weeks' gestational age survived less than 1 hour. Physical examination and autopsy disclosed an enormous, protuberant primary malignant melanoma of the skin, enveloping most of the back. A rim of surrounding hyperpigmented skin proved to be a giant congenital melanocytic nevus (GCMN), from which the cutaneous melanoma had arisen. Autopsy demonstrated metastatic melanoma in the lungs, liver, spinal cord, leptomeninges, and placenta. Radiography and dissection confirmed that the melanoma had minimal connection to spinal or neural structures. The mother was clinically free of tumor 8 months after she was delivered of the infant. Pathologic, radiographic, histologic, immunohistochemical, and ultrastructural investigations of this unique case are presented.

Hepatic toxicity of nickel chloride in rats

Enhanced lipid peroxidation was observed in livers of rats killed 24 hr after sc injection of nickel chloride (NiCl2) (750 mumol per kg), as evidenced by 13-fold increase of conjugated dienes in microsomal lipids and 4-fold increase of thiobarbituric acid (TBA) chromogens in hepatic cytosol. Histologic examination of livers from rats killed one to three days after NiCl2 injection (500 mumol per kg) showed microvesicular fatty metamorphosis, mild hydropic degeneration, and foci of inflammation. Microvesicular steatosis of hepatocytes was confirmed by electron microscopy. Dose-related increases of serum aspartate aminotransferase (ALT) activity (up to 7-fold vs controls) and alanine aminotransferase (ALT) activity (up to 3-fold vs controls) were observed 24 hr after injection of NiCl2 (125 to 750 mumol per kg); diminished serum alkaline phosphatase activity (up to 72 percent reduction vs controls) was seen at NiCl2 dosages from 375 to 750 mumol per kg. Diethyldithiocarbamate did not influence the effects of NiCl2 on TBA-chromogens in liver homogenates or on serum AST and ALT activities but acted synergistically with NiCl2 to diminish serum alkaline phosphatase activity and to increase serum bilirubin concentration. This study demonstrates that parenteral administration of NiCl2 to rats produces acute hepatic toxicity, with enhanced lipid peroxidation, microvesicular steatosis, and increased serum AST and ALT activities.

Monoclonal antibody DF3 correlates with tumor differentiation and hormone receptor status in breast cancer patients

The murine monoclonal antibody (MAb) designated DF3, reacts with a 300-kd human mammary epithelial antigen which is expressed on apical borders of secretory mammary epithelial cells and in the cytosol of less differentiated malignant cells. Human mammary tumors have been evaluated for the level of DF3 antigen as a correlate to clinicopathologic parameters related to degree of tumor differentiation: nuclear grade (NG), histologic grade (HG), and estrogen receptor status (ER). More DF3 antigen was present in breast carcinomas with NG 1 and 2 as compared to tumors with NG 3 (p = .002). Similarly DF3 antigen presence was greater in HG 1 and 2 tumors than in HG 3 (p less than .001). The results also demonstrate that quantitative differences in the presence of the DF3 differentiation antigen correlate with estrogen receptor status. Twenty-two of 23 ER positive tumors were also DF3 positive. Only 6 of 23 ER negative tumors were reactive to MAb DF3 (p less than .001). There was, however, no correlation between DF3 reactivity and absolute levels of estrogen or progesterone receptor. These findings confirm our hypothesis that MAb DF3 reacts to a differentiation antigen present in some human breast carcinomas. The DF3 antigen phenotype can serve as an independent phenotypic marker with correlations to standard indicators of degree of differentiation and estrogen receptor status of infiltrating ductal carcinomas of the breast, and should thus be evaluated as a prognostic indicator in breast cancer patients. The data also suggests that DF3 histochemistry may be a useful alternative in assessing estrogen receptor status of small breast cancers where there is an insufficient amount of tumor present for biochemical assay of hormone receptor levels.

Short term survival following perfusion with fluosol-DA for cardiopulmonary bypass

Seven dogs were perfused on cardiopulmonary bypass for one hour using a perfusate which included one liter of Fluosol in order to investigate tissue oxygenation during perfusion as well as possible biochemical and histopathologic effects of Fluosol on various organs. Tissue oxygenation during cardiopulmonary bypass was evaluated by measuring arterial and venous oxygen tensions as well as oxygen content and arterial pH. Biochemical studies were measured pre and post bypass and were followed up to 48 hours following discontinuation of cardiopulmonary bypass. The animals were observed clinically for evidence of abnormal behavior during 30 days of follow-up and were then sacrificed. Biopsies from the heart, lung, liver, spleen, kidney and brain were examined by light and electron microscopy. Excellent tissue oxygenation and normal acid base status was seen uniformly during cardiopulmonary bypass. Clinical status and biochemical parameters remained normal during followup. Histopathologic examination revealed only a marked increase in phagocytic histiocytes in the reticuloendothelial system of liver and spleen with sinusoidal compression but no functional impairment.

Congenital, spontaneously regressing histiocytosis: case report and review of the literature

A patient had numerous skin lesions at birth and they regressed over the next few weeks. Results of the peripheral blood smear and bone marrow examinations were normal. The diagnosis of self-healing histiocytosis was substantiated by the clinical course and characteristic histology. This was subsequently confirmed by the electron microscopic finding of Langerhans' granules within the histiocytic cells, which were positive for S100 by immunoperoxidase.

Reversal of gamma-radiation-induced leukemogenesis in mice by immunomodulation with thiabendazole and dinitrofluorobenzene

The effect of thiabendazole (TBZ) and dinitrofluorobenzene (DNFB) on radiation-induced leukemogenesis was investigated in the C57BL/6 mouse model. Administration of TBZ-DNFB during, post, or during and post irradiation successfully blocked leukemogenesis, as indicated by the absence of leukemia blast cells in thymus and peripheral blood, as well as prevented thymic lymphoma. TBZ-DNFB treatment prevented the development of leukemia when studies were terminated both after 7 months of last irradiation (disease fully developed) and after 5 months of last irradiation (disease in the process of development). This TBZ-DNFB treatment also resulted in a significant increase in survival.