Severe thyrotoxicosis as initial presentation of gastric choriocarcinoma: a case report

Background

Extragonadal choriocarcinoma is rare and can be associated with hyperthyroidism when producing very high levels of human chorionic gonadotropin.

Case presentation

A 62-year-old Hispanic female presented with a 3-week history of shortness of breath, palpitations, extreme weakness, new-onset hot flashes, and right flank pain. Her physical examination was remarkable for tachycardia, hepatomegaly, hyperreflexia, and tremor; goiter was absent. Laboratory studies revealed increased lactate dehydrogenase, alkaline phosphatase, suppressed thyroid stimulating hormone, very elevated T4, and absent thyroid stimulating immunoglobulin. ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography exhibited hepatomegaly with multiple large fluorodeoxyglucose-avid liver masses and a focus of fluorodeoxyglucose avidity in the stomach with no structural correlate. A thyroid scan (^99mTcO₄⁻) showed diffusely increased tracer uptake. She was started on propranolol and methimazole. Upon stabilization of severe thyrotoxicosis, upper endoscopy was performed, showing a ~ 5 cm bleeding lesion in the greater stomach curvature body; biopsy was consistent with choriocarcinoma; beta-human chorionic gonadotropin hormone was 2,408,171 mIU/mL. The patient received methotrexate followed by etoposide and cisplatin. Methimazole was titrated down, and upon liver failure the medication was stopped. The thyrotoxicosis was effectively controlled with antithyroid drug and concurrent chemotherapy. At ~ 1.5 months after initial diagnosis, the patient died due to bleeding/acute liver failure with coagulation defects followed by multiple organ failure.

Conclusions

Severe thyrotoxicosis can represent an unusual initial presentation of metastatic choriocarcinoma in the setting of extreme elevation of beta-human chorionic gonadotropin. Primary gastric choriocarcinoma is an aggressive malignancy with very poor outcomes. The co-occurrence of severe thyrotoxicosis with advanced primary gastric choriocarcinoma and imminent liver failure complicates management options.

Immunohistochemical Expression of Nuclear β-Catenin and STAT-6 in a Solitary Fibrous Tumor of the Soft Palate: A Case Report and Review of the Literature

The solitary fibrous tumors (SFT) are rare tumors in the head and neck region and there have been only 5 cases reported in the literature in the soft palate. The current paper presents a unique case of a 62-year-old male with TFS arising in the soft palate. The tumor was highly cellular, composed of bland looking haphazardly arranged spindle cells. The signal transducer and activator of transcription (STAT)-6 and nuclear β-catenin were reactive by immunohistochemistry (IHC). The current case highlights the importance of the STAT-6 and the β-catenin as IHC markers to make a differential diagnosis with other entities. In summary, the paper presents the first reported case of a SFT of the soft palate in a male patient with nuclear expression of STAT-6 and β-catenin.

Solitary Fibrous Tumor of Soft Tissue Clinically Simulating a Chemodectoma

We present a case of a 48-year-old woman with a solitary fibrous tumor localized in the carotid bifurcation clinically simulating a chemodectoma. The tumor was composed of spindle cells with abundant intercellular collagen. These spindle cells were positive for CD34 and negative for chromogranin, S-100 protein, NSE, GFAP, and cytokeratin. This is the first solitary fibrous tumor reported in this location, in the English literature.

S100A8/A9 proteins mediate neutrophilic inflammation and lung pathology during tuberculosis

RATIONALE

A hallmark of pulmonary tuberculosis (TB) is the formation of granulomas. However, the immune factors that drive the formation of a protective granuloma during latent TB, and the factors that drive the formation of inflammatory granulomas during active TB, are not well defined.

OBJECTIVES

The objective of this study was to identify the underlying immune mechanisms involved in formation of inflammatory granulomas seen during active TB.

METHODS

The immune mediators involved in inflammatory granuloma formation during TB were assessed using human samples and experimental models of Mycobacterium tuberculosis infection, using molecular and immunologic techniques.

MEASUREMENTS AND MAIN RESULTS

We demonstrate that in human patients with active TB and in nonhuman primate models of M. tuberculosis infection, neutrophils producing S100 proteins are dominant within the inflammatory lung granulomas seen during active TB. Using the mouse model of TB, we demonstrate that the exacerbated lung inflammation seen as a result of neutrophilic accumulation is dependent on S100A8/A9 proteins. S100A8/A9 proteins promote neutrophil accumulation by inducing production of proinflammatory chemokines and cytokines, and influencing leukocyte trafficking. Importantly, serum levels of S100A8/A9 proteins along with neutrophil-associated chemokines, such as keratinocyte chemoattractant, can be used as potential surrogate biomarkers to assess lung inflammation and disease severity in human TB.

CONCLUSIONS

Our results thus show a major pathologic role for S100A8/A9 proteins in mediating neutrophil accumulation and inflammation associated with TB. Thus, targeting specific molecules, such as S100A8/A9 proteins, has the potential to decrease lung tissue damage without impacting protective immunity against TB.

[Frequency of visualization of celiac ganglia by endoscopic ultrasound and its potential in assessing neural invasion in patients with pancreatic lesions]

BACKGROUND

Celiac ganglia (CG) can be seen by endoscopic ultrasound; they play an important role in pain management and are a potential site for extrapancreatic tumor neural invasion.

AIMS

To evaluate the frequency of CG visualization during endoscopic ultrasound examination and to evaluate the feasibility of this technique to identify extrapancreatic tumor neural invasion in patients with pancreatic lesions.

METHODS

We retrospectively reviewed all endoscopic ultrasound studies performed between November 2007 and June 2010. Images of the celiac region were presented to an endosonographer, who reported the presence or absence of CG.

RESULTS

We included 31 cases. CG were identified in 14 (45%) cases. Average size was 10mm (range 4-25mm) by±1mm (range 1-7mm). In 2 cases, fine needle aspiration biopsy was performed and reported nerve cell bodies; in one case malignant cells were seen.

CONCLUSIONS

CG were identified in 45% of the cases. Fine needle aspiration biopsy can detect unanticipated extrapancreatic tumor neural invasion in pancreatic malignancies.

CXCR5⁺ T helper cells mediate protective immunity against tuberculosis

One third of the world's population is infected with Mycobacterium tuberculosis (Mtb). Although most infected people remain asymptomatic, they have a 10% lifetime risk of developing active tuberculosis (TB). Thus, the current challenge is to identify immune parameters that distinguish individuals with latent TB from those with active TB. Using human and experimental models of Mtb infection, we demonstrated that organized ectopic lymphoid structures containing CXCR5+ T cells were present in Mtb-infected lungs. In addition, we found that in experimental Mtb infection models, the presence of CXCR5+ T cells within ectopic lymphoid structures was associated with immune control. Furthermore, in a mouse model of Mtb infection, we showed that activated CD4+CXCR5+ T cells accumulated in Mtb-infected lungs and produced proinflammatory cytokines. Mice deficient in Cxcr5 had increased susceptibility to TB due to defective T cell localization within the lung parenchyma. We demonstrated that CXCR5 expression in T cells mediated correct T cell localization within TB granulomas, promoted efficient macrophage activation, protected against Mtb infection, and facilitated lymphoid follicle formation. These data demonstrate that CD4+CXCR5+ T cells play a protective role in the immune response against TB and highlight their potential use for future TB vaccine design and therapy.

[Bilateral tonsillar hypertrophy as the first manifestation of B cell-small lymphocytic lymphoma with interfolicular pattern]

B-cell small lymphocytic lymphoma typically involves nodal or extranodal tissues as a diffuse proliferation with proliferation centers (pseudofollicules) obliterating normal architecture. But there are unusual patterns of involvement including interfollicular pattern that can be difficult to recognize histologically and probably represent partial or early involvement by neoplasm. Tonsillar lymphoma usually presents either as a unilaterally enlarged palatine tonsil or as an ulcerative and fungating lesion over the tonsillar area. Most lymphomas that involve the tonsil are diffuse large B cell lymphomas and primary low-grade lymphomas are exceptional. We present a primary B-cell small lymphocytic lymphoma affecting palatine tonsils with interfollicular pattern in a 54 year-old man that clinically presented with symmetric / bilateral tonsillar enlargement and sleep apnea.

Immunohistochemical characterization of Renaut bodies in superficial digital nerves: further evidence supporting their perineurial cell origin

Renaut bodies are well-demarcated cylindrical (circular in cross section) hyaline structures attached to the inner layer of the perineurium that can be found in normal and pathological nerves of various animals and humans. They are composed of spidery fibroblasts and perineurial cells immersed in an extracellular matrix that contains randomly oriented collagen fibers and elastin precursors but not axons or Schwann cells. Frequently, they are associated with thickened subperineurial capillaries. As Renaut bodies are mainly located at sites of nerve compression, it is hypothesized they may act as 'protective cushions' for endoneurial components, and that they may be formed as a secondary reaction to trauma. Herein, we report the presence of Renaut bodies within numerous small dermal nerve trunks in an amputated finger. By immunohistochemistry, Renaut bodies expressed markers identical to those of perineurial cells (epithelial membrane antigen, Glut-1, and claudin-1), supporting the concept of a closely associated perineurial but not endoneurial origin. In addition, expression of hypoxia-inducible factor 1 alpha (which has been shown to increase Glut-1 transcription), neurofibromatosis 1 gene related product and NF-2, were also detected in these peripheral nerve structures.

[Pure mucinous (colloid) carcinoma of the male breast. An uncommon subtype]

Pure mucinous (colloid, mucous) carcinoma of the male breast is an extremely rare neoplasm. We report the case of a 74-year-old male who displayed a rapidly growing retroareolar tumor of the left breast. The patient underwent modified radical mastectomy. The tumor was well demarcated, had a soft consistency with a glistening gelatinous appearance. Histologically, the neoplasm corresponded to a pure mucinous carcinoma which is one of the most unusual subtYpes, accounting for less than 2% of male breast carcinomas.

[Kikuchi-Fujimoto disease (histiocytic necrotizing lymphadenopathy) clinicopathologic and immunohistochemical study of 14 cases and its differential diagnosis with other reactive and neoplastic necrotizing lymphadenopathies]

Kikuchi-Fujimoto disease also known as histiocytic necrotizing lymphadenopaty (HNL) is a rare entity, originally described in Japanese population, although currently it has been described all over the world. It is more frequent in young women and it is usually located in cervical lymph nodes. We report 14 cases of HNL in Mexican population, their clinicopathological and immunohistochemical study as well as a comparative study with other necrotizing lymphadenopaties due to B or T-cell lymphomas, tuberculosis, Epstein Barr virus infection, and non-specific necrosis. In our study we found that there was more expression of the immunomarkers CD68, MPO, CD123 and antikerat in OSCAR in the cases of HNL in contrast with the lesser or even null expression of the same markers in the necrotized lymph nodes of the comparative study group.

[Expression of p53 and BCI-2 as prognostic markers and for anatomical location in gastrointestinal stromal tumors (GIST). Clinico-pathological and immunohistochemistry study of 19 cases]

OBJECTIVE

To correlate the expression of p53 and BCl-2 with the clinical outcome and anatomic location of the gastrointestinal stromal tumours (GIST).

BACKGROUND DATA

The GIST are the most common nonepithelial neoplasm of the gastrointestinal tract. In spite of the existence of a wide range of predictive factors, their clinical outcome is unpredictable. There are several studies that correlate the expression of p53 and Bcl-2 with the clinical outcome and anatomic location of the GIST.

METHODS

We obtained 19 cases from the archives of the Department of Pathology of the ABC Medical Center, in Mexico City. GIST were classified into risk groups according to the Fletcher et al. classification. We performed an immunohistochemestry panel including CD117, CD34, actin, desmin, P-S100, p53 and BCl-2 and correlated their expression to the risk group and anatomical site of the tumors.

RESULTS

There was less expression of p53 in the gastric tumors (27%) than in small bowel tumors (100%). There was greater expression of p53 in the high-risk tumors than in the very low-risk ones, regardless of the anatomical site. Bcl-2 expression was more expressed in the small intestine tumors (100%) than in those located in the duodenum (50%) The high risk tumors showed slightly more expression of Bcl-2 than the low risk ones (89% vs. 100%), despite the anatomical location.

CONCLUSIONS

Both, p53 and Bcl-2 are important markers to establish the anatomical site of GIST and are also helpful to predict the clinical behavior of these tumors.

Nitrotyrosine localization to dermal nerves in borderline leprosy

BACKGROUND

Nerve damage is a common and disabling feature of leprosy, with unclear aetiology. It has been reported that the peroxidizing agents of myelin lipids-nitric oxide (NO) and peroxynitrite-are produced in leprosy skin lesions.

OBJECTIVES

To investigate the localization of nitrotyrosine (NT)-a local end-product of peroxynitrite-in leprosy lesions where dermal nerves are affected by a granulomatous reaction.

METHODS

We investigated by immunohistochemistry and immunoelectron microscopy the localization of the inducible NO synthase (iNOS) and NT in biopsies exhibiting dermal nerves from patients with untreated leprosy.

RESULTS

There were abundant NT-positive and iNOS-positive macrophages in the borderline leprosy granulomas infiltrating peripheral nerves identified by light microscopy, S-100 and neurofilament immunostaining. Immunoelectron microscopy showed NT reactivity in neurofilament aggregates and in the cell wall of Mycobacterium leprae.

CONCLUSIONS

Our results suggest that NO and peroxynitrite could be involved in the nerve damage following borderline leprosy.

[Neuroendocrine gastric carcinoma. A case report and review of current management]

Neuroendocrine or carcinoid tumors of the gastrointestinal tract considered previously extremely rare, are diagnosed at present with increased frequency due to the better capacity to identify neuroendocrine system cells in normal and pathologic conditions. Occasionally, these tumors secrete a great variety of vasoactive substances, producing the carcinoid syndrome. Gastric carcinoids are classified, according to their degree of differentiation into well differentiated and poorly differentiated tumors, also called neuroendocrine carcinomas. Neuroendocrine gastric carcinomas or poorly differentiated gastric carcinoids are seen in 5-15% of all gastric carcinoids, mainly in older male patients. Generally they are large, very aggressive tumors with extensive local infiltration. Due to poor differentiation, they are not frequently associated with an endocrine syndrome. They can be located in any part of the stomach but are mainly seen in antrum. These tumors have an aggressive behavior and must be treated in a radical manner; recurrences are not uncommon. We report the case of a patient with a neuroendocrine gastric carcinoma treated with an en bloc subtotal gastrectomy and colectomy.

Case report: Ocular gnathostomiasis in northwestern Mexico

A 42-year-old woman from Culiacan in the Sinaloa State of Mexico presented with a four-year history of migratory, pruritic, painful swellings of the face. Palpebral edema with conjunctival erythema developed when lesions developed near the eye. Routine eye examination showed a mobile worm in the anterior chamber. Following surgical removal, the parasite was identified by light and electron microscopy as an advanced third-stage larva of Gnathostoma sp. This prevalence of this helminthiasis may be increasing in areas where eating freshwater raw fish ("cebiche") is customary.

Dieulafoy's disease of the bronchus in association with a paravertebral neurilemoma

Dieulafoy's disease is a vascular anomaly characterized by the presence of a dysplastic artery that is related to an epithelial ulcer. While it is most frequently a GI condition, occurrence in the bronchus has been reported previously in six cases. We present the case of a 51-year-old man with severe hemoptysis and epistaxis. Chest radiographs showed diffuse density in the right base and a mass in the pedicle of T4. The results of bronchoscopy corroborated an active arterial bleeding point in the bronchus of the right middle lobe. A middle and lower lobectomy was performed with resection of the paravertebral mass. The final diagnoses were bronchial Dieulafoy's disease and paravertebral neurilemoma.

Laparoscopic-assisted resection of a bleeding gastrointestinal stromal tumor

The authors report a case of a 29-year-old male patient with a severe lower gastrointestinal hemorrhage in whom a successful laparoscopic diagnosis and resection (assisted) of an ileal gastrointestinal stromal tumor (GIST) was performed. Laparoscopy can be very useful in the diagnosis and treatment of selected cases of lower gastrointestinal bleeding.