Abnormal cervicovaginal cytology in women with lupus: a retrospective cohort study

OBJECTIVE

The aim of this study was to review Pap smear reports in women with systemic lupus erythematosus and compare them to a large control population.

METHODS

Pap smear results of 29 women with a diagnosis of lupus seen consecutively were compared to those of a control population of 747 women attending the gynecology clinic at the same medical center during the same year. Records of lupus patients were reviewed to obtain clinical data. Fisher's exact test and chi(2) analysis were used to determine statistical significance, as appropriate.

RESULTS

Of 29 women with lupus, 1/29 had high-grade squamous intraepithelial lesions (HGSIL) and 6/29 had low-grade squamous intraepithelial lesions (LGSIL). The control population of 747 women had 9/747 with HGSIL and 63/747 with LGSIL. chi(2) and Fisher's exact tests showed that the lupus population had a statistically significant increase in Pap smear reports of dysplasia compared to the control group (P < 0.021 for HGSIL/LGSIL combined, P < 0.036 for LGSIL alone). Examination of serial Pap smear results revealed that 45% of the lupus patients had cervical dysplasia at some time.

CONCLUSION

Women with lupus have an increased prevalence of cervical dysplasia. Serial observation revealed dysplastic cytologies in nearly half of the patients, suggesting that this may be a more common problem than previously reported. Serial prospective studies are needed to assess better the risk of premalignant cervical lesions in lupus.

Cytological, histological, and clinical correlations in intravesical Bacillus Calmette-Guerin immunotherapy

Bacillus Calmette-Guerin (BCG), an attenuated form of mycobacterium, has been used extensively for the immunotherapy of bladder carcinoma. BCG induces a granulomatous response in the bladder wall. The cytological features induced by BCG-immunotherapy in urines and bladder washes have been described in only rare articles. We evaluated cytologic specimens from 50 patients who received intravesical BCG for bladder carcinoma. Forty-three patients received BCG therapy in a single course, averaging to 6.3 weeks per patient, whereas seven patients received an average of 9 weeks therapy with 2 to 3 interruptions. A total of 93 voided urines (avg, 1.9/patient), 57 bladder washes (avg, 1.1/patient) and 64 biopsies (avg, 1.3/patient) were obtained in the 2-year and 8-month retrospective review from these 50 patients. There were 30 responders and 20 nonresponders to BCG therapy. Positive cytology was predictive of recurrence: (cytologic-histologic correlation, 85%). Nine of 64 (14%) tissue biopsies revealed granulomatous inflammation, whereas only 2 of 150 cytological specimens (1.3%) exhibited specific inflammatory cells and epithelioid cells diagnostic of granulomas. Decoy cells appeared on the surface of the urothelium in four biopsies and in two cytological specimens. Based on this study, cytology appears to be adequate for the follow-up of BCG-treated patients for assessment of recurrence of carcinoma. Diagnostic features of granulomas were detected only in a smaller percentage of urine specimens, compared with biopsies. The presence of decoy cells in the urine and biopsies is an intriguing phenomenon that requires further investigation, especially in regard to the source of these cells and whether they are apoptotic in nature or whether they result from necrosis.

Amiodarone pulmonary toxicity: cytopathology, ultrastructure, and immunocytochemistry

One hundred ninety cardiac patients were prospectively enrolled in an amiodarone protocol. Over a 10-year period, 16 patients developed new or progressive respiratory symptoms while taking amiodarone. These symptoms included dyspnea associated with abnormal chest radiographs or new or worsening abnormalities on pulmonary function testing. Specimens for microscopic examination were obtained by fiberoptic bronchoscopy with transbronchial lung biopsy (TBB), bronchoalveolar lavage (BAL), open lung biopsy (OLB), or autopsy. Large foamy macrophages with characteristic lamellated cytoplasmic inclusions were noted in all specimens, regardless of other evidence of pulmonary toxicity, suggesting that foamy macrophages represent a routine drug effect. Foamy macrophages were not present in BAL specimens from 53 normal controls and were rarely seen in specimens from 27 patients who had other interstitial lung diseases. When present, the foamy macrophages were less prominent than those seen in specimens from patients receiving amiodarone. Fibrosis was noted in 11 of 16 histological specimens, whereas type II-cell-hyperplasia was observed in 7 of the 16 specimens. Four of the 16 patients with respiratory symptoms died, and their autopsy revealed a combination of foamy macrophages with fibrosis and type II cell hyperplasia reflective of amiodarone pulmonary toxicity. Hyperplastic type II cells were not found in the absence of fibrosis. Immunocytochemistry allowed differentiation between foamy macrophages and type II cells and represents a useful tool for future investigations of the pathogenesis of amiodarone-induced pulmonary disease.

Molecular characterization of a DNA probe, U6.2, located close to the fragile X locus

A new DNA probe, U6.2, defining locus DXS304, was recently shown to be closely linked to the fragile X locus (FRAXA). It is polymorphic with a number of different enzymes, all of which are in complete linkage disequilibrium, which suggests an insertion/deletion type of polymorphism. Using the method of Sanger, we have sequenced 1,102 bp of the cloned U6.2 fragment. Analysis of the sequence showed there was a long direct repeat of 121 bp and two long inverted repeats. The first was 19 bp long, and the second was a palindromic invert of 20 bp. Such repeats could promote recombination in this region and could have been involved in the suggested insertion/deletion event that created the polymorphism detected at locus DXS304. Long fragments were observed using pulsed field gel electrophoresis (PFGE), but no length variations were seen. The sequence of U6.2 will be useful in developing a polymerase chain reaction (PCR) based assay for the restriction fragment length polymorphism (RFLP) detected at locus DXS304 which should assist with carrier detection and prenatal diagnosis of the fragile X syndrome.

Hypertensive diabetic cardiomyopathy in the rat: ultrastructural features

We previously described a cohort of diabetic patients with typical congestive cardiomyopathy, in whom myocardial lesions were related to concomitant high blood pressure. To evaluate the association of diabetes mellitus and hypertension in more detail, we studied 4 groups of rats with either no disease, streptozotocin-induced diabetes mellitus, renovascular hypertension, or a combination of hypertension and diabetes. Analysis revealed significant myocardial fibrosis and degeneration in the hypertensive-diabetic group when compared to controls, without an obvious relationship to small vessel lesions. The myocardial alterations appeared similar to those observed in patients with hypertension and diabetes mellitus. Of note, although hypertensive animals had focal moderate lesions, diabetic animals had no pathological changes. To further characterize these histological changes, we performed electron microscopy on the 4 animal groups, which we are reporting in this study. Our analysis of the ultrastructural alterations confirms the previous histological observations. Diabetic animals only had increased cellular lipid, and mild, focal areas of myofibrillolysis, with no significant increases in perivascular and perisarcolemmal basal lamina. Consistent with our light microscopic finding that PAS positive material was associated with interstitial or replacement fibrosis, we noted basal lamina proliferation in the hypertensive and hypertensive-diabetic groups, particularly in areas of scarring. Pericapillary basal lamina was increased to the greatest extent in the hypertensive-diabetics. Qualitative alterations of myocardial cells and muscular blood vessels were similar in both the hypertensive and hypertensive-diabetic animals; however, there were more extensive changes in the latter group. This study provides further evidence that the combination of diabetes mellitus and hypertension produces significantly greater myocardial lesions than with either disease alone, not only at the light microscopic level, but ultrastructurally as well. Although the pathogenesis of this cardiomyopathy is unknown it may be related to abnormalities of the cardiac microcirculation. The prevalence of hypertension in the diabetic population suggests that greater attention should be paid to the combination of these 2 conditions and their effects on the heart.

Hypertensive-diabetic cardiomyopathy in the rat: an experimental model of human disease

The authors recently described a group of diabetic patients with severe congestive heart failure, hypertension, and minimal coronary artery disease, who had significant myocardial degeneration apparently secondary to the combined effects of high blood pressure and diabetes on the heart. To evaluate the effects of hypertension and diabetes mellitus more fully, the authors studied four groups of rats with either no disease, streptozotocin-induced diabetes mellitus, renovascular hypertension, or a combination of hypertension and diabetes. They employed semiquantitative light microscopy, which revealed significantly greater replacement fibrosis in the hypertensive-diabetic rats when compared with the other three groups. Interstitial fibrosis was increased in the hypertensive-diabetic animals, though it was just below the 5% level of significance when compared with the hypertensives. Further analysis, however, revealed that those hypertensive-diabetic animals with the greatest relative cardiac hypertrophy, as measured by the heart weight/body weight ratio, had significantly increased interstitial fibrosis. Surprisingly, diabetes mellitus alone produced no morphologic light-microscopic alterations; yet 8 weeks of combined hypertension and diabetes mellitus led to myocardial degeneration similar to the human disease. These changes do not appear to be secondary to abnormalities of intramyocardial muscular vessels. Measurement of 3 parameters of vascular disease revealed that hypertensive animals with less myocardial damage had greater vascular changes than the more severely affected hypertensive-diabetics. This study provides evidence that the combination of diabetes mellitus and hypertension produces significantly greater myocardial lesions than either disease alone. The similarity of the lesions with those observed in human patients suggests that the hypertensive-diabetic rat is a useful model for elucidating the pathogenesis of clinical myocardial disease in patients with hypertension and diabetes mellitus.