Malignant and pre-malignant oesophageal pathology in a South African teaching hospital

BACKGROUND

South Africa (SA) has one of the highest global incidences of squamous cell carcinoma of the oesophagus (SCC). A decreasing incidence of oesophageal SCC in SA has been suggested. The study aimed to assess whether the incidence of these malignant histopathological subtypes has changed in this setting.

METHOD

A retrospective review of histopathological reports on pre-malignant and malignant oesophageal lesions over three time periods (TP), namely: 2003-4 (TP1), 2008-9 (TP2) and 2013-14 (TP3) was carried out at Inkosi Albert Luthuli Central Hospital, Durban, South Africa.

RESULTS

A total of 1341 specimen reports were retrieved. TP1-3 consisted of 514 (39.3%), 320 (24.5%) and 474 (36.2%) patients respectively. Six hundred and forty-nine patients were male (48.3%), 642 were female (47.8%) and 50 were not specified. i.e. a sex ratio of 1.01:1. The mean age was 60.8 (± 11.8). There were 1197 Black patients (91.5%), 66 Asian (5.1%), 25 White (1.9%), 9 mixed ancestry (0.7%), and 11 of unknown race (0.8%). SCC was the most common cancer 1098 (89.1%) followed by adenocarcinoma (AC) 69 (5.6%). The ratio of SCC to AC remained fairly consistent over the total time period. Seventy-four oesophageal resections were performed with a yearly average resection rate of only 5.6%.

CONCLUSION

SCC is still the most prevalent oesophageal cancer (OC) without an increase in the ratio of AC to SCC. The diagnosis of squamous cell dysplasia is concordant with previously cited rates. Barrett's oesophagitis remains uncommon. Resection rates for OC are low but similar to other South African referring centers.

Endovascular Therapy for Large Vessel Vasculopathy in HIV-infected Patients

OBJECTIVES

To evaluate outcomes after endovascular treatment of patients with aneurysmal or occlusive vasculopathy in HIV-infected patients.

METHODS

Retrospective analysis of a prospective database of treatment outcomes in patients with HIV related vasculopathies between April 2005 and September 2015.

RESULTS

Sixty HIV patients presented with post-traumatic pseudoaneurysm formation (n = 7), aneurysmal disease (n = 24) or occlusive disease (n = 29 (48%)). The majority were male (42/60 (70%)), with a mean age of 43.9 years (SD ± 12.6). All seven patients with a post-traumatic pseudoaneurysm were treated by insertion of a covered stent (n = 6) or coiling (n = 1). All were successfully treated at 30 days, but only one patient returned for late surveillance. 23/24 patients who underwent insertion of a stent graft/covered stent for aneurysmal disease returned for 30 day review (one asymptomatic stent graft occlusion). Only 11 patients attended for late surveillance; 9/11 were asymptomatic with patent stent grafts. Late stent occlusion occurred in two (no further action (n = 1), major limb amputation (n = 1). In the 29 patients who underwent endovascular treatment for occlusive disease, 9 (31%) had immediate treatment failure (including 8 amputations (28%)). Of the sixteen who returned for serial review, 8 (50%) suffered further complications including 4 amputations. Overall, 12/29 treated patients (41%) ultimately underwent amputation.

CONCLUSIONS

In the immediate short term, an 'endovascular first' strategy was associated with good outcomes in HIV patients with aneurysmal disease. By contrast, outcomes were poor in HIV patients with occlusive disease. Whether this relates to the underlying natural history of HIV occlusive vasculopathies remains unclear. One major problem in trying to formulate meaningful management strategies is a generalised reluctance for HIV patients to return for surveillance.

Intestinal inflammatory myofibroblastic tumour

BACKGROUND

Inflammatory myofibroblastic tumours (IMFTs) are rare tumours characterised by nosologic, histogenetic and aetiopathogenetic controversy and variable clinicopathological features. We report our experience with intestinal-IMFTs (I-IMFTs) that have been reported mainly as single case reports to date.

METHODS

Five patients with I-IMFTs, identified between 2005 and 2008, formed the study cohort. The clinicopathological features were obtained from departmental and hospital records.

RESULTS

The median patient age was 13 years. While 4 patients presented with symptoms and signs of intestinal obstruction, one IMFT was an incidental finding at laparotomy for trauma. Three I-IMFTs were located in the small bowel and 2 in the colon. Complete resection with end-to-end anastomoses was performed. The gross morphology included 1 polypoid myxoid tumour that served as a lead point for an intussusception, 3 multinodular whorled masses and 1 firm circumferential, infiltrative tumour. Microscopically, all tumours had typical features of IMFT with variable expression of ALK-1, a low proliferation index and tumour-free resection margins. All patients had an uneventful recovery. One patient was lost to further follow-up. Four patients were well, without local recurrence or metastases at 6 months to 3 years.

CONCLUSIONS

Surgery with tumour-free resection margins is the gold standard of care of adult and paediatric I-IMFTs. Heightened recognition of I-IMFT, albeit rare, as a cause of intestinal obstruction, including intussusception, is necessary for pre-operative suspicion of I-IMFT.

The gonads of 111 South African patients with ovotesticular disorder of sex differentiation

PURPOSE

The aims of this study were to describe the gonadal tissue found in the Southern African true hermaphrodite and establish if there was a correlation between the clinical and histopathologic findings and if these findings were similar to patients with this condition elsewhere.

MATERIALS AND METHODS

A retrospective study at the University of KwaZulu-Natal, Durban, South Africa, looked at all patients diagnosed with true hermaphroditism seen between 1984 and 2006. For this 23-year period, 111 consecutive true hermaphrodite patients were diagnosed on clinical findings, internal genital assessments, and the histologic examination of 217 gonadal biopsy specimens. All gonadal tissue taken from these patients was sent for histopathologic evaluation. The results were correlated to the clinical and internal genital evaluations of the patients.

RESULTS

Five patients only had a single gonad. Analysis of the gonadal biopsy specimens showed that there were 118 (54%) ovotestes together with 59 ovaries and 40 testes. The ovotestes were divisible on gross appearance into 11% bipolar and 89% mixed types. Histologically, the mixed-type ovotestes have an outer mantle consisting of ovarian tissue, which encapsulated an inner core of 2 distinct types. The first is an admixed ovotestis (constituting 44% of the mixed ovotestes), the central core consisted of gonadal stroma, with scattered foci of separate ovarian and testicular tissue. The second type was the compartmentalized ovotestis (constituting 56% of the mixed ovotestes); here, the outer mantle was thickened in the upper pole and encapsulated a large core of testicular tissue in the lower pole of the gonad. The bipolar ovotestis had a strictly polar distribution of ovarian and testicular tissue, which had an irregularly interdigitating junction between the 2 types of tissue. Statistical analysis showed that no correlation could be found between the type of gonadal tissue and any of the clinical or genital features.

CONCLUSION

Three distinct ovotesticular types are identified in the Southern African true hermaphrodite, which have not been described previously. The structure of these gonads has bearing on the type of biopsy done and the subsequent management of the ovotestes.

Lymphoepithelial lesions of the parotid gland in the HIV era--a South African experience

OBJECTIVE

Historically, lymphoepithelial lesions (LELs) have been a peripheral indication for surgery on the parotid gland, accounting for less than 1% of all parotidectomies undertaken. In the HIV era the profile of parotidectomy has changed, with LEL becoming a common indication for parotidectomy, prompting a review of our current experience.

DESIGN

A retrospective study was undertaken between January 1998 and December 2005. Setting. Surgical services at King Edward VIII Hospital, Durban.

SUBJECTS

All patients presenting with parotidomegaly.

RESULTS

One hundred and sixty-two patients with parotidomegaly were evaluated; 53 (32.7%) had LEL lesions. A total of 151 parotidectomies (including 42 parotidectomies undertaken for LEL lesions) were performed in 147 patients. Radiotherapy was offered to 11 patients with LEL lesions. Complications following parotidectomy for LEL included facial nerve palsy (N=3), seroma formation (N=5) and facial artery false aneurysm (N=1). Three patients required re-parotidectomy for recurrent LEL parotidomegaly. In the patients who underwent radiotherapy, there was a satisfactory outcome; 2 patients who received 4 Gy radiation per sitting developed mild skin discolouration of the treated area.

CONCLUSION

Although surgical management of LEL parotidomegaly may provide a satisfactory result, this approach is technically challenging and is associated with complications and recurrences. For these reasons, the non-operative approach employing radiotherapy should be considered.

A cross-sectional study of HIV-seropositive patients with varying degrees of proteinuria in South Africa

Human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) is the most common finding on renal biopsy in HIV-infected black patients and is also the commonest cause of end-stage renal disease in these patients. Early detection of HIVAN may be beneficial in evaluating early treatment. This study examined the pattern of renal diseases in HIV-infected South Africans and also attempted to diagnose HIVAN at an early stage. In this single-center cross-sectional study, 615 HIV-infected patients were screened for proteinuria. Thirty patients with varying degrees of proteinuria underwent renal biopsy. Patients with diabetes mellitus, uncontrolled hypertension, known causes of chronic kidney disease, and serum creatinine above 250 mumol/l were excluded. Patients in this study were not on antiretroviral therapy. HIVAN was found in 25 (83%) patients. Six of them (24%) had microalbuminuria. Altogether, seven patients with persistent microalbuminuria were biopsied and six (86%) showed HIVAN. Other biopsy findings included membranoproliferative nephropathy in two (7%) and interstitial nephritis in three (10%). Four patients with HIVAN had associated membranous nephropathy. HIVAN is the commonest biopsy finding among our study patients with HIV infection who present with varying degrees of proteinuria. Microalbuminuria is a manifestation of HIVAN in our study patients. Therefore, microalbuminuria may be an early marker of HIVAN, and screening for its presence may be beneficial. Renal biopsy may be considered in seropositive patients who present with persistent microalbuminuria, especially with low CD4 counts irrespective of good renal function. This will allow diagnosis and treatment of HIVAN at an early stage and may prevent further disease progression.

Isolated splenic tuberculosis

Tuberculosis isolated to the spleen is a rare clinical entity particularly in the non-HIV-positive patient population. In the four patients described, two presented with thrombocytopenia; in two patients the condition was diagnosed serendipitously at laparotomy undertaken for abdominal trauma.

Isolated amoebic appendicitis

Amoebiasis, a disease of worldwide distribution, is endemic in tropical countries with suboptimal sanitation facilities. Isolated amoebic appendicitis (IAA) is regarded as a rare manifestation of the disease globally. Because there are no defined clinical features that distinguish IAA from bacterial appendicitis, diagnosis is usually dependent on histopathological examination. A 9-year retrospective study was undertaken to investigate the clinicopathological aspects of IAA. The main complaints were fever and abdominal pain. None of the patients had dysentery. The pre-operative clinical diagnosis was acute appendicitis and acute abdomen in 13 and 8 patients, respectively. In all cases the intra-operative diagnosis was acute appendicitis. Gross pathological appraisal revealed peritonitis and perforation in 19 and 17 cases, respectively. Histopathological examination of these appendices demonstrated appendiceal ulceration, transmural mixed inflammation, haematophagous amoebic trophozoites and necrosis in all cases. Vascular pathology comprised venous and capillary luminal plugging (11 cases), necrotising small vessel vasculitis (11 cases), thrombophlebitis of medium sized veins (9 cases) and arteritis with associated thrombosis (1 case). Organising fibrinopurulent peritonitis was present in 19 cases. Two appendices that appeared normal macroscopically demonstrated ulceration and inflammation that were confined to the mucosa and submucosa. All of 18 patients who were treated with metronidazole survived without further surgery, while three patients who were untreated succumbed to the disease. Appendicectomy, accurate histopathological appraisal thereof and optimal, timely management of IAA were critical to the favourable outcome in the present study.

Pitfalls in thoracoscopic sympathectomy: mechanisms for failure

The technical ease of thoracoscopic sympathectomy has established this as the procedure of choice for upper-limb sympathectomy. Notwithstanding the invariable success of this procedure, those rare instances of unsuccessful sympathectomy are disconcerting to the surgeon. Unsuccessful sympathectomy manifests as persistent or recurrent sympathetic activity after a seemingly successful procedure. The causes of this phenomenon include misinterpretation of the sympathetic chain at thoracoscopy, regeneration of the sympathetic chain, and alternate neural pathways via the nerve of Kuntz. With the large numbers of sympathectomies being undertaken, the few instances of unsuccessful sympathectomy have prompted a review of this subject. Although alternate neural pathways may have little significance when a T2 ganglionectomy is undertaken, anatomic misinterpretation of the sympathetic chain is an important yet under-recognized cause of an unsuccessful sympathectomy. Sympathetic nerve regeneration remains extremely uncommon. Persistent and recurrent sympathetic activity may be successfully managed by resympathectomy performed thoracoscopically.

Aggressive CD34-positive fibrous scalp lesion of childhood: extrapulmonary solitary fibrous tumor

Although solitary fibrous tumor (SFT) was originally described as a pleural tumor, an increasing number of extrapleural sites of SFTs have been documented. This has been attributed not only to the heightened awareness of the spectrum of histopathological features that characterizes SFTs but also to the recognition of the role of CD34 immunostaining in soft tissue tumors in general, and in SFTs in particular. Despite the large number of documented extrapleural SFTs in adults, cranial SFTs are rare, having been documented in the meninges, scalp, and infratemporal fossa. Extrapleural SFTs are, to date, an unrecognized entity in children. We document an aggressive fibrous scalp lesion in a 30-month-old female child that demonstrated features common to benign cranial fasciitis and SFT. However, based on bright, diffuse CD34 antigen immunopositivity, a diagnosis of SFT was made. The need to include the CD34 antigen stain in a panel of immunohistochemical markers used to assess spindle cell lesions of childhood is emphasized.

Thyroid carcinoma at King Edward VIII Hospital, Durban, South Africa

BACKGROUND

Western literature depicts papillary carcinoma as the most common thyroid malignancy followed by follicular carcinoma.

OBJECTIVE

To assess the clinical pattern of thyroid carcinoma among African and Indian patients.

SETTING

King Edward VIII Hospital, Durban, South Africa.

DESIGN

A retrospective study.

SUBJECTS

One hundred patients with thyroid carcinoma treated at a tertiary teaching hospital between 1990 and 1997.

RESULTS

Seventy seven patients were Africans and 23 were Indians. The male to female ratio was 1:6. Ninety eight patients presented with goitre with or without regional lymph node involvement or distant disease. The duration of symptoms ranged from one to 360 months. The mean age at presentation was 48.6 +/- 16.0 years. Follicular carcinoma was the most common malignancy among African patients (68%), followed by papillary carcinoma (16%), anaplastic carcinoma (13%) and medullary carcinoma (2.6%). Papillary carcinoma was the most common malignancy among Indian patients (57%) followed by follicular carcinoma and medullary carcinoma. There was no anaplastic carcinoma among Indian patients. Fifty five patients underwent lobectomy with 32 undergoing subsequent completion thyroidectomy. Nine patients had near total thyroidectomy, 27 were offered total thyroidectomy as primary surgery and eight had biopsy only. The in-hospital mortality was 8%. Recurrence rate was 8%.

CONCLUSION

Most patients present long after the development of symptoms. Follicular carcinoma is the most common thyroid malignancy among Africans. Further studies are required to explain this phenomenon.

Fulminant amoebic colitis: a favorable outcome

Fulminant amoebic colitis (FAC) is often associated with a poor outcome (reported mortality between 55% and 87.5%). We present the outcome of a conservative surgical approach to the management of this condition. Over an 8-year period (January 1992 to December 1999), 23 patients with FAC were managed and prospectively evaluated by a surgical unit at King Edward VIII Hospital, Durban. There were 19 males and 4 females with a mean age of 36 years (range, 18-57 years). Unrelenting abdominal signs was the indication for surgery in all patients. A preoperative diagnosis of FAC was made in 20 patients; in 1 patient the diagnosis was made intraoperatively. FAC was not recognized in 2 patients. The 21 patients diagnosed with FAC were managed by perileal antegrade colonic lavage; 2 patients underwent total colectomy and ileostomy. Following colonic lavage and ileostomy, there was a 95% survival rate (N = 20). Both patients who underwent total colectomy and ileostomy died postoperatively. Patients underwent restorative surgery at a mean period of 7.2 weeks (range, 6-10 weeks) following the initial surgery. The extent of colonic stricturing invariably warranted colonic resection. This included total colectomy (N = 12), right hemicolectomy (N = 5), left hemicolectomy (N = 2), and right and transverse colectomy (N = 1). The overall survival rate of the 23 patients presenting with FAC was 82.6% (N = 19). Early recognition of FAC and a conservative surgical approach are associated with a favorable outcome. Resectional surgery in FAC has a potentially fatal outcome and should be avoided.

Transepithelial elimination of late cutaneous vulvar schistosomiasis

Late cutaneous vulvar schistosomiasis (LCVS), which represents the cutaneous response to the deposition of schistosomal ova, is characterized by a range of clinical manifestations. Histopathological descriptions of LCVS have highlighted the hyperplastic epithelial reaction, and a few reports have alluded to the presence of intraepidermal bilharzial ova. Although transepithelial elimination (TEE), a well-known phenomenon whereby the skin rids itself of foreign, potentially dangerous substances, has been documented in a range of infectious processes, it has not been recognized as a distinct process in LCVS. This study not only documents TEE in 23 biopsies of LCVS but also correlates the role of the histopathological inflammatory reaction pattern, density of ova, and pseudoepitheliomatous hyperplasia in the pathogenesis of TEE. The importance of TEE as an additional, hitherto unrecognized mechanism of release and spread of schistosomal ova to the exterior is also highlighted.

Pemphigus in South Africa

BACKGROUND

Pemphigus is an autoimmune disease characterized by intraepidermal blistering. We describe the demography, prevalence, clinical features, response to treatment, and human leukocyte antigen (HLA) characteristics of pemphigus in Kwa-Zulu Natal, South Africa.

METHODS

All patients with pemphigus were prospectively recruited over 12 years from January 1987 to December 1999. The demography, clinical features, histology, and immunofluorescence (IF) were recorded. In a subset of patients, HLA tests were performed.

RESULTS

One hundred and twelve patients had pemphigus. Pemphigus foliaceus (PF) was the commonest variant seen (62 patients) and 80% of these patients were black. The mean age was 43 years (12-93 years) and the male to female ratio was 1 : 1.4. Fifty patients had pemphigus vulgaris (PV), of whom 82% were Indian. The mean age of presentation of PV was 48 years (21-82 years). The male to female ratio was 1 : 1.7. There was no mucosal involvement in PF. PV patients had painful oral lesions. The mortality rate was 14% in the total sample (six in PV and two in PF). HLA-B8 was positive in 41% of patients with PF (P < 0.001).

CONCLUSIONS

PF occurs more commonly in black people, while most cases in Indians present with the PV subtype. Pemphigus patients present with severe and extensive disease, and PV patients share features in common with patients from their land of origin (India), suggesting a genetic link.

Transepithelial elimination of cutaneous vulval granuloma inguinale

BACKGROUND

Transepithelial elimination (TEE), a distinct and well-known entity, is a process during which the skin eradicates undesirable or irritative dermal substances through intact epidermis or follicular epithelium by passive or active means. Although TEE is being described in an increasing number and range of pathological processes, to date, TEE of granuloma inguinale (GI) remains unrecorded in the English-language literature. The aims of this study were: 1) To appraise the light microscopic and ultrastructural morphological epidermal changes that are associated with TEE of cutaneous vulval GI; and 2) To determine the role of intra-epidermal leucocytes and histiocytes in the pathogenesis of TEE of vulval GI.

METHODS

This is a retrospective 9-year histopathological review of all cases diagnosed and coded as vulval granuloma inguinale in the Department of Anatomical Pathology, Nelson R. Mandela School of Medicine, University of Natal, Durban, South Africa. Ultrastructural evaluation was performed on selected cases using a Jeol transmission electron microscope.

RESULTS

Of 53 skin biopsies from 47 patients with vulval GI, 43 were suitable for the study. The age range of patients was 15-40 years (mean age=22 years). There were eleven papular, twelve nodular, seven verrucous and thirteen ulcerative lesions. Donovan bodies within macrophages, free-lying Donovan bodies and dense aggregates of neutrophils and plasma cells were seen in the dermis of all biopsies. There was consistent overlying pseudoepitheliomatous hyperplasia. The dermal inflammatory infiltrate hugged the dermo-epidermal junction and appeared entrapped between elongated and acanthotic epidermal rete ridges and pegs. Transepidermal neutrophil microabscesses, histiocytes containing Donovan bodies and neutrophilic and histiocytic fragmentation were present. A variable number of free-lying and intra-histiocytic Donovan bodies and neutrophils were present on the surface of the epidermis. On ultrastructural investigation epidermal spongiosis, intracellular oedema, free-lying, intra-neutrophilic and intra-histiocytic Donovan bodies, and intact and degenerating neutrophils and histiocytes were evident between keratinocytes. The degenerative histiocytes demonstrated marked vacuolation, mitochondrial swelling and bacilli within phagolysosomal vacuoles, bound by intact or disrupted limiting membranes.

CONCLUSION

The inflammatory infiltrate at the epitheliomesenchymal interface, pseudoepitheliomatous hyperplasia, intra-epidermal accumulation and disintegration of neutrophils and histiocytes, and the associated release of lytic enzymes, play important contributory roles in TEE of GI. TEE of infectious agents is a poorly recognised mechanism of spread of infectious diseases and represents a public health hazard. In cutaneous vulval GI, TEE is highlighted as a hitherto unrecognised, potential method of spread of Calymmatobacterium granulomatis.

Subpectoral post-traumatic lipoma

Although post-traumatic lipomas have been reported in various sites, a subpectoral location has, to the best of our knowledge, not previously been described. We report on the clinicopathological, radiological, intraoperative and postoperative details of a post-traumatic subpectoral lipoma in a 35-year-old black African female.

Solid and cystic papillary epithelial neoplasm of the pancreas. A report of 3 cases

This is a report of 3 female patients presenting with solid and cystic papillary epithelial neoplasms of the pancreas (SCPEN). All 3 lesions were incidental findings. SCPEN is an uncommon low-grade malignant tumour that is histologically distinct from ductal adenocarcinoma and islet cell tumour, occurs chiefly in young women, and is amenable to surgery. The cell of origin is the subject of some debate.

bcl-2 protein expression in aggressive and non-aggressive basal cell carcinomas

bcl-2, the well known anti-apoptotic gene, cloned more than a decade ago, promotes cell viability without promoting cell proliferation. With few exceptions, high bcl-2 protein expression is associated with a favourable outcome in epithelial tumours. bcl-2 immunoreactivity in basal cell carcinomas (BCCs) is contradictory, with 67-100% immunopositivity being reported. Although BCCs are traditionally regarded as low-grade, indolent tumours, aggressive BCCs (A-BCCs) are mutilative, locally destructive tumours that often recur. bcl-2 protein expression as a predictor of BCC aggressiveness is poorly documented in the English-language literature. The bcl-2 protein immunoprofile of 50 clinically non-aggressive (NA-BCCs) and 25 clinically A-BCCs was investigated. Of the latter, 17 manifested with one, two or three recurrences. bcl-2 protein expression in each of the recurrences was also evaluated. bcl-2 expression was scored as follows: 0-5% positive cells=negative, 6-25%=1+, 26-50%=2+, 51-75%=3+, >75%=4+. "High" labeling encompassed 3+ or 4+ labeling while "low" labeling referred to 1 + or 2 + labeling. Although bcl-2 positivity was noted in all BCCs, low bcl-2 labeling was a statistically significant feature of A-BCCs (p < 0.01). High bcl-2 labeling of NA-BCCs was a reflection of the bcl-2 labeling of the dominant constituent nodular or superficial subtypes. Micronodular BCCs revealed 2+ or 3+ labeling. Initial and recurrent A-BCCs with a pure or predominantly infiltrative component, demonstrated 1+ or 2+ bcl-2 labeling. The differential bcl-2 expression in the various clinicopathological subtypes of BCCs suggests that, despite the common derivation of these tumours from a primitive basaloid stem cell and a limited potential for metastasis, they form a heterogeneous group of tumours that differ markedly in histologic and biological behaviour. While the superficial and nodular BCCs are indolent slow-growing tumours with high bcl-2 labeling, the aggressive BCCs are infiltrative, desmoplastic tumours with low bcl-2 labeling. In mixed tumours, heterogeneity of labeling is a distinctive feature and is contributed to in part by the labeling trends of the different histological subtypes. The micronodular BCC shows varied bcl-2 labeling but in combined tumours occupies a niche intermediate between the non-aggressive nodular and superficial and the aggressive infiltrative subtypes. The initial and subsequent biopsies of recurrent, adequately excised BCCs share a pure or mixed, predominantly infiltrative, stroma-rich histomorphology with low bcl-2 labeling, reflecting the immunoprofile of a more aggressive growth pattern.

Childhood Lichen scrofulosorum revisited

Lichen scrofulosorum (LS), an uncommon cutaneous tuberculous reaction, has been described in children and young adults. In the last three decades, there has been a dearth of literature on the entity in children, despite a global increase in tuberculosis. It is usually associated with localized cervical, hilar, or mediastinal lymphadenopathy or with osseous tuberculosis. The occurrence of LS in association with pulmonary tuberculosis is rare and its occurrence with generalized lymphadenopathy is unrecognized. We report LS in two children and highlight its occurrence with pulmonary tuberculosis and generalized lymphadenopathy.

Erythroderma: a comparison between HIV positive and negative patients

Background Erythroderma has protean underlying causes. There have been isolated case reports suggesting an association between erythroderma and the human immunodeficiency virus (HIV).

OBJECTIVE

To describe and characterize further the prevalence, etiology, and metabolic sequelae of erythroderma in HIV positive and negative patients. In a subset of patients, clinicopathologic correlation was performed.

METHOD

One hundred and thirty-eight consecutive patients were prospectively recruited over a one and a half year period at the skin clinic of King Edward VIII Hospital. Demographic, clinical, biochemical, and histologic data were recorded.

RESULTS

Seventy-five per cent of the patients were black, 22.5% Indian, and 2.5% white. The men to women ratio was 1.9 : 1. The mean age was 34. 7 years (range, 1 month to 85 years). Forty-three per cent of patients were HIV positive, of whom 90% were black. The commonest causes of erythroderma in the total sample were atopic dermatitis (23.9%), psoriasis (23.9%), and drug reactions (22.5%). The commonest cause in the HIV positive group was drug reactions (40.6%), the commonest being ethambutol (30.8%). HIV positive patients had a significantly lower (P < 0.05) white cell count (7.6 vs. 10.5 x 109 /L), hemoglobin (11.1 vs. 12.6 g/dL), platelets (278.3 vs. 378.0 x 109 /L), and albumin (25.4 vs. 28.7 g/L) and significantly higher serum urates (0.6 vs. 0.4 mM/L) than HIV negative patients. HIV positive patients did not have a significant increase in the number of episodes of erythroderma. Clinicopathologic correlation was greatest with psoriasis in the HIV negative group and with psoriasis and drug reactions in the HIV positive group.

CONCLUSIONS

A large proportion of erythrodermic patients in this study were HIV positive. Inflammatory dermatoses were the commonest cause of erythroderma in all the patients studied. Drug reactions were the commonest cause in HIV positive patients. In the young black patient, erythroderma may be a marker for HIV infection.

Membranous fat necrosis due to subcutaneous elemental mercury injections

Membranous fat necrosis (MFN) is a distinct abnormality in systemic and subcutaneous fatty tissue. Although ischemia and trauma have been implicated in its causation, the exact pathogenesis of MFN remains unknown. The deposition of metallic mercury in subcutaneous tissue due to accidental penetration or deliberate injection of mercury is unusual. Depending on the duration of the deposition, localized necrosis, suppuration, and granuloma formation have been described at mercury injection sites. We report subcutaneous MFN, a hitherto unrecognized histopathologic phenomenon at sites of mercury deposition, in a 21-year-old soccer player who had deliberate subcutaneous and intramuscular elemental mercury injections to improve his sporting performance.

Vasculitis-induced membranous fat necrosis

Membranous fat necrosis (MFN) a distinct degenerative process of adipose tissue, is characterised by the presence of membranocystic lesions (MCLs) superimposed on a background of typical traumatic-type fat necrosis. MCLs are cysts, of varying size and shape, that are lined by an eosinophilic, crenulated membrane, having the staining properties of ceroid. Although MFN has been documented in varying systemic adipose tissue sites and in tumours, the pathogenesis of this pathological curiosity is unknown. To date, an ischemic basis for MFN has been the most proximate, and atherosclerosis and venous insufficiency, due to large and medium vessel disease, have been the most popular underlying clinical disorders. Although systemic vasculitis has been quoted as the underlying ischemic disorder in some patients, vasculitis has not been commented on nor demonstrated in tissue sections in association with MFN. In,reporting vasculitis-induced MFN, we document the occurrence of MFN in association with uncommon causes of vasculitis, namely: 1) Granulomatous vasculitis in a post-herpetic zosteriform scar; 2) Cytomegalovirus-induced vasculitis in the clinical setting of systemic lupus erythematosus; and 3) Lymphocytic vasculitis in a tetanus toxoid immunization site reaction.

Histological evidence of hypertrophy and ischaemia in sigmoid volvulus among Africans

OBJECTIVE

To document histological evidence of hypertrophy and ischaemia in sigmoid volvulus among Africans.

DESIGN

Retrospective case series study of the histology of sigmoid volvulus over seven years with cadaveric controls.

SETTING

King Edward VIII Teaching Hospital, University of Natal, Durban, South Africa.

SUBJECTS

Fifty African patients with sigmoid volvulus and nine cadavers with normal sigmoid colon.

RESULTS

There was hypertrophy of the submucosa, muscularis propria and nerve plexuses with features of ischaemia in the patients' specimens. Their veins were thrombosed and recanalized while mesentery and submucosa had fibrosis and vascular hyalinization. There was also hypertrophy and hyperplasia of Meissner's nerve plexus. In the autopsy study, normal African sigmoid specimen showed similar ischaemic features but specimens from the four Indian patients in the study did not have such abnormalities.

CONCLUSION

We postulate that chronic ischaemia may account for postoperative anastomosis dehiscence in some cases where the resection margins involved the hypertrophic segment. The benefit of an extended resection with anastomosis being effected on the bowel with apparent normal thickness to avoid this possibility should be investigated.

HIV-associated eosinophilic folliculitis in an infant

HIV-associated eosinophilic folliculitis (HIV-EF), which is a well-known entity in adults, has not been described in children. Although Ofuji's disease (OD) or eosinophilic pustular folliculitis (EPF) has been described in children and shares histopathologic features with HIV-EF, it is a distinct entity with characteristic clinical features. We report the occurrence of eosinophilic folliculitis in an 8-month-old HIV-positive patient and discuss the clinical, pathologic and possible pathogenetic aspects thereof. In addition, differences in the clinical manifestations of the present case and that of I-EPF are addressed. Because of clinicopathologic similarities between the present case and HIV-associated eosinophilic folliculitis (HIV-EF) in adults, we believe that eosinophilic folliculitis in this patient represents a cutaneous manifestation of HIV infection, rather than co-incidental occurrence of the infantile form of Ofuji's disease in an HIV-positive patient.

Transient peduncular hallucinations secondary to brain stem compression by a cerebellar pilocytic astrocytoma

Almost all peduncular hallucinations have been described in patients with intrinsic lesions of the midbrain. An, as yet, unreported case of peduncular hallucinosis caused by posterior compression of the midbrain by a cerebellar pilocytic astrocytoma is described. The hallucinations and associated symptoms only ceased after removal of the tumour.

Cervical spine dysraphism with teratoma exhibiting pulmonary differentiation: case report and review of the literature

Spinal dysraphism and teratomas are well-recognized spinal cord lesions, but both entities are rare in the cervical spinal cord. Rarely, teratomas have been described within dysraphic lesions in the thoracic and lumbosacral regions. To date, teratomas contained within cervical spine dysraphic lesions have not been described. Although mature cystic teratomas are renowned for the array of organoid tissue differentiation they display, mature lung differentiation is a rarity. While pulmonary differentiation has been described in six female genital tract teratomas, it has not been reported in spinal teratomas. The clinicopathologic features of a complex cervical lesion, comprising a combination of cervical spine dysraphism with a mature cystic teratoma that exhibited pulmonary differentiation, is presented, and the literature on teratomas exhibiting pulmonary differentiation is reviewed.

Papulonecrotic tuberculid in a 2-year-old girl: with emphasis on extent of disease and presence of leucocytoclastic vasculitis

The clinicopathologic features of childhood papular necrotic tuberculid (PNT) have been detailed in 10 patients. PNT is characterized by symmetric, acral papular lesions that undergo necrosis. Despite widespread cutaneous involvement, the number of lesions is usually sparse. The extensor aspects of the limbs are usually involved and trunk involvement is uncommon. Vasculitis, an integral component of PNT, has been documented only once in childhood PNT. We describe PNT in a 2-year-old girl in whom a multitude of lesions were present all over the body, including unusual involvement of flexor surfaces of the limbs, trunk, perineum, and vulva. Biopsied tissue revealed the characteristic features of PNT, including leucocytoclastic vasculitis. There was prompt response to antituberculous therapy. Based on the findings in this patient, we believe that the clinical spectrum of this eminently treatable disease in children must be expanded in terms of distribution and number of lesions to include extensive limb and trunk, perineal, and vulval involvement; the histopathologic spectrum of childhood PNT must include leucocytoclastic vasculitis; and adult and childhood PNT share common histopathologic features, including a common cellular immunohistochemical profile, thereby suggesting a common pathogenesis.

Intracranial tuberculous subdural empyema: case report

OBJECTIVE AND IMPORTANCE

Many types of neurotuberculosis have been described; the most common intracranial forms are tuberculous meningitis and tuberculomas. We report a unique and as yet unreported form of neurotuberculosis, which is an intracranial tuberculous subdural empyema.

CLINICAL PRESENTATION

A 59-year-old man who had been previously treated for pulmonary tuberculosis (TB) presented at our institution with a long-standing history of headaches. General and neurological examinations revealed no abnormalities. Radiography of the chest confirmed fibrotic lung changes caused by healed pulmonary TB. A cranial computed tomographic scan revealed a hypodense extra-axial collection with mass effect as well as adjacent osteitis and scalp swelling.

INTERVENTION

The patient underwent craniectomy of the osteitic bone and drainage of 50 ml of fluid pus located subdurally. Microscopic examination of the bone and pus revealed tuberculous granulation tissue with numerous acid-fast bacilli identified using Ziehl-Neelsen stain. Mycobacterium TB bacillus was cultured from the pus at 42 days. The patient required two further operative procedures as well as a protracted course of anti-TB therapy.

CONCLUSION

The patient eventually achieved a good recovery. We recommend surgical drainage of tuberculous subdural empyema to relieve mass effect and to obtain microbiological confirmation. Furthermore, surgical treatment should be combined with an 18-month course of anti-TB chemotherapy, during which period patient compliance should be closely monitored.

Resympathectomy for sympathetic regeneration

Explanations for recurrent sympathetic activity after an apparently successful sympathectomy are varied and often tenuous. Among the theories given for recurrent sympathetic activity are the development of alternate neuroanatomic pathways, the possibility of an incomplete operation (failure to appreciate an alternative anatomic pathway at the time of surgery, i.e., nerve of Kuntz), and sympathetic regeneration. The latter, although long suspected, has never been conclusively demonstrated in humans. In this report, a case of recurrent sympathetic activity with conclusive evidence of sympathetic regeneration is described.

Pigmentary abnormalities in trisomy of chromosome 13

This paper documents an unusual pigmentary mosaicism in a patient with translocation trisomy of chromosome 13. The dermatological lesions include: (1) broad hypopigmented bands following the typical description of Blaschko's lines on the dorsal aspect of both lower limbs; (2) horizontal linear streaks over the spine without the typical central V-shaped dip of Blaschko; and (3) a 'patchwork' hypopigmentation over the face, neck, chest, upper limbs and ventral surface of lower limbs. The lesions in (3) resemble the rare 'phylloid' or leaf-like pigmentary mosaicism type 3 of Happle, but differ in that the pattern shows no midline separation. A translocation trisomy 13 was uniformly detected on peripheral lymphocyte and skin fibroblast cultures from the hypopigmented and normal skin and there was no evidence of cytogenetic mosaicism or chimerism. These lesions resemble those of hypomelanosis of Ito on histopathological assessment.

Folliculosebaceous cystic hamartoma

Although folliculosebaceous cystic hamartoma (FCH) is an uncommon cutaneous entity with distinct classical and variant histopathologic features, it lacks distinctive typifying clinical features. Since the original description of five cases of FCH by Kimura et al. in 1991, 12 cases have been documented. We report a further case of FCH presenting as facial lesion in a 35 year old African male. FCH comprises prominent epithelial and mesenchymal components. The epithelial component is characterised by folliculosebaceous proliferation with cyst-like infundibular dilatation, and the mesenchymal component exhibits variable fibroplasia, vascular and neural proliferation and adipocyte metaplasia. Awareness of the lesion is important to avoid confusion with other cystic or cyst-like cutaneous lesions that contain prominent epithelial folliculosebaceous and variable mesenchymal components.

Membranous fat necrosis in mature cystic teratomas of the ovary

We identified and documented the occurrence of membranous fat necrosis (MFN) in 217 mature cystic teratomas (MCTs) of the ovary. Cysts lined by an eosinophilic and scalloped membrane with pseudopapillary infoldings, the characteristic histologic features of MFN, were identified in 9 tumors. The membranes had the histochemical staining properties of ceroid, as evidenced by periodic acid-Schiff, sudan black, and long Ziehl Neelsen (ZN) positivity, diastase resistance, and autofluorescence. The causes and pathogenesis of MFN are enigmatic, but trauma, torsion, and ischemia are probable factors. MFN is a distinct entity in ovarian MCTs and heightened awareness will increase its histopathologic recognition.

Membranous fat necrosis in appendices epiploicae. A clinicopathological study

Membranous fat necrosis (MFN) is a degenerative process involving mature systemic adipose tissue. It is characterised by the presence of membranocystic foci surrounded by a lipophagic fibro-inflammatory reaction typical of fat necrosis. Membranocystic foci are cysts lined by an eosinophilic membrane with pseudopapillary infoldings having the histochemical staining profile of ceroid. Although MFN is described in an increasing number of adipose tissue sites, it has not been described as a distinct entity in appendices epiploicae (AE). Macroscopically, MFN in AE mimics nodal tuberculosis or metastatic tumour with necrosis and cystic change. Ischaemia, which can be secondary to physiological or pathologic processes, is crucial in the pathogenesis of MFN in AE. Heightened awareness of MFN as a distinct entity in AE is essential for accurate diagnosis and establishment of the pathogenesis of this enigmatic pathological process.

Chronic orbital hematic cysts: a case for craniofacial correction

Chronic hematic cysts are rare conditions that usually present to the ophthalmic surgeons with displacement of the globe. There is usually no, or minimal, bone involvement. Two patients with unusual presentations of chronic orbital hematic cysts are reported. These cysts resulted in significant expansion and erosion of the bony orbits. The presentation, operative findings, and reconstruction are reported and discussed.

Membranous fat necrosis in lipomas

Membranous fat necrosis (MFN) is an under-recognized variant of fat necrosis (FN) that is characterized by the presence of membranocystic foci in which cysts are lined by an eosinophilic, homogeneous membrane with pseudo-papillary luminal projections. Although MFN has been described in systemic adipose tissue, it has not been described in lipomas. We report the rare occurrence of MFN in four lipomas. The lipomas ranged in size between 9 and 22 cm and occurred in menopausal women in the left shoulder, right upper back, right thigh, and gluteal regions. In two cases the membranocystic foci were identified macroscopically, whereas in the other two cases MFN was only identified on histologic assessment. Apart from the typical histologic appearance of the membranocystic foci, the membranes have a distinct histochemical profile that includes consistent Sudan black positivity and either periodic acid-Schiff or Ziehl-Neelsen positivity. In all cases, there was autofluorescence of the membranes on immunofluorescent examination of unstained sections. These membranocystic foci have the typical staining reactions of ceroid pigment. The exact cause of MFN in lipomas is not known, but in view of their large sizes, traumatic and ischemic etiologies are proposed.

Giant congenital naevus of the scalp and cranium: case report and review of the literature

Congenital pigmented naevi are lesions that are usually confined to skin. We report a giant congenital naevus of the scalp which involved skin, galea, full thickness cranial bone, dura and the intracranial venous sinuses. The literature on giant congenital naevi with direct involvement of underlying bone is reviewed.

Osseous localization of Rosai-Dorfman disease

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) is a disease of bone marrow stem cell origin which primarily affects lymph nodes. Solitary bone lesions are rare and can cause diagnostic difficulties. A primary lesion in the right index finger of a 10-month-old child is reported.

An unusual cause of proptosis: orbital solitary fibrous tumor: case report

Although solitary fibrous tumors are well-recognized tumors, they have only recently been described in the orbit. Although histopathological awareness of the lesion has been heightened recently because of the discovery of CD-34 immunoreactivity in solitary fibrous tumors, including orbital lesions, it remains unrecognized clinically as a cause of unilateral proptosis. Clinical awareness of the lesion is important, because benign and malignant forms of the tumor occur. The malignant forms pursue an aggressive course manifested by local invasion, recurrent growth, or metastases. The benign lesions are histologically banal and are cured by surgical excision. This case report describes unilateral proptosis caused by an orbital solitary fibrous tumor, which occurred in a 43-year-old woman. The tumor had a benign histomorphology and clinical course, with surgical excision being curative. In reviewing the literature on orbital solitary fibrous tumors, clinical awareness of the tumor as a cause of unilateral proptosis is emphasized.