Prevalence and distribution of VZV in temporal arteries of patients with giant cell arteritis

OBJECTIVE

Varicella-zoster virus (VZV) infection may trigger the inflammatory cascade that characterizes giant cell arteritis (GCA).

METHODS

Formalin-fixed, paraffin-embedded GCA-positive temporal artery (TA) biopsies (50 sections/TA) including adjacent skeletal muscle and normal TAs obtained postmortem from subjects >50 years of age were examined by immunohistochemistry for presence and distribution of VZV antigen and by ultrastructural examination for virions. Adjacent regions were examined by hematoxylin & eosin staining. VZV antigen-positive slides were analyzed by PCR for VZV DNA.

RESULTS

VZV antigen was found in 61/82 (74%) GCA-positive TAs compared with 1/13 (8%) normal TAs (p < 0.0001, relative risk 9.67, 95% confidence interval 1.46, 63.69). Most GCA-positive TAs contained viral antigen in skip areas. VZV antigen was present mostly in adventitia, followed by media and intima. VZV antigen was found in 12/32 (38%) skeletal muscles adjacent to VZV antigen-positive TAs. Despite formalin fixation, VZV DNA was detected in 18/45 (40%) GCA-positive VZV antigen-positive TAs, in 6/10 (60%) VZV antigen-positive skeletal muscles, and in one VZV antigen-positive normal TA. Varicella-zoster virions were found in a GCA-positive TA. In sections adjacent to those containing VZV, GCA pathology was seen in 89% of GCA-positive TAs but in none of 18 adjacent sections from normal TAs.

CONCLUSIONS

Most GCA-positive TAs contained VZV in skip areas that correlated with adjacent GCA pathology, supporting the hypothesis that VZV triggers GCA immunopathology. Antiviral treatment may confer additional benefit to patients with GCA treated with corticosteroids, although the optimal antiviral regimen remains to be determined.

Analysis of Varicella-Zoster Virus in Temporal Arteries Biopsy Positive and Negative for Giant Cell Arteritis

IMPORTANCE

Giant cell arteritis (GCA) is the most common systemic vasculitis in elderly individuals. Diagnosis is confirmed by temporal artery (TA) biopsy, although biopsy results are often negative. Despite the use of corticosteroids, disease may progress. Identification of causal agents will improve outcomes. Biopsy-positive GCA is associated with TA infection by varicella-zoster virus (VZV).

OBJECTIVE

To analyze VZV infection in TAs of patients with clinically suspected GCA whose TAs were histopathologically negative and in normal TAs removed post mortem from age-matched individuals.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study for VZV antigen was performed from January 2013 to March 2015 using archived, deidentified, formalin-fixed, paraffin-embedded GCA-negative, GCA-positive, and normal TAs (50 sections/TA) collected during the past 30 years. Regions adjacent to those containing VZV were examined by hematoxylin-eosin staining. Immunohistochemistry identified inflammatory cells and cell types around nerve bundles containing VZV. A combination of 17 tertiary referral centers and private practices worldwide contributed archived TAs from individuals older than 50 years.

MAIN OUTCOMES AND MEASURES

Presence and distribution of VZV antigen in TAs and histopathological changes in sections adjacent to those containing VZV were confirmed by 2 independent readers.

RESULTS

Varicella-zoster virus antigen was found in 45 of 70 GCA-negative TAs (64%), compared with 11 of 49 normal TAs (22%) (relative risk [RR] = 2.86; 95% CI, 1.75-5.31; P < .001). Extension of our earlier study revealed VZV antigen in 68 of 93 GCA-positive TAs (73%), compared with 11 of 49 normal TAs (22%) (RR = 3.26; 95% CI, 2.03-5.98; P < .001). Compared with normal TAs, VZV antigen was more likely to be present in the adventitia of both GCA-negative TAs (RR = 2.43; 95% CI, 1.82-3.41; P < .001) and GCA-positive TAs (RR = 2.03; 95% CI, 1.52-2.86; P < .001). Varicella-zoster virus antigen was frequently found in perineurial cells expressing claudin-1 around nerve bundles. Of 45 GCA-negative participants whose TAs contained VZV antigen, 1 had histopathological features characteristic of GCA, and 16 (36%) showed adventitial inflammation adjacent to viral antigen; no inflammation was seen in normal TAs.

CONCLUSIONS AND RELEVANCE

In patients with clinically suspected GCA, prevalence of VZV in their TAs is similar independent of whether biopsy results are negative or positive pathologically. Antiviral treatment may confer additional benefit to patients with biopsy-negative GCA treated with corticosteroids, although the optimal antiviral regimen remains to be determined.

Malignant glomus tumor. A case report of widespread metastases in a patient with multiple glomus body hamartomas

Glomus tumors are characteristically benign solitary tumors. A few cases of malignant glomus tumors have been reported; however, they are usually only locally invasive, and metastases are exceedingly rare. We report a case of widespread metastases of a malignant glomus tumor involving the skin, lungs, jejunum, liver, spleen, and lymph nodes in a 63-year-old man with end-stage chronic renal failure. At autopsy, multiple glomus body hamartomas were also noted throughout the dermis proximal to the skin tumors. Histologically, the tumor was composed of monotonous round cells in solid sheets and investing numerous capillary-sized vessels. Approximately four to six mitoses were present per high-power field. The tumor cells were strongly immunoreactive for actin and vimentin, and ultrastructurally there were whorls of microfilaments with focal condensations. This case is exceptional because of its aggressive course.

Evaluation of the Triage Micro Parasite Panel for detection of Giardia lamblia, Entamoeba histolytica/Entamoeba dispar, and Cryptosporidium parvum in patient stool specimens

A study comparing the Triage Micro Parasite Panel (Biosite Diagnostics, Inc., San Diego, Calif.) to conventional O&P examination (O&P) was performed using patient fecal specimens. Five hundred twenty-three stool samples were compared. Nineteen specimens were found to be positive by Triage, and 29 were found to be positive by O&P. Seven specimens were positive for Giardia lamblia, four were positive for Entamoeba histolytica/E. dispar, and three were positive for Cryptosporidium parvum as determined by both methods. There was one false positive by Triage (C. parvum) and four false negatives by O&P (two G. lamblia, one E. histolytica/E. dispar, and one C. parvum). The Triage test accurately detected all 18 specimens that contained one of the three organisms that it was designed to detect. The Triage test is a rapid, easy-to-use enzyme immunoassay for the detection of G. lamblia, E. histolytica/E. dispar, and C. parvum in fresh or fresh-frozen fecal specimens. These data suggest that the Triage test can be used as a screen for the immediate testing of stool specimens for these three pathogenic parasites. If Triage test results are negative, O&P can be performed if parasitic infections other than G. lamblia, E. histolytica/E. dispar, or C. parvum are suspected.

Prognostic significance of intratumoral and peritumoral lymphatic density and blood vessel density in invasive breast carcinomas

We studied tumor lymphatic and vascular densities and lymphovascular invasion (LVI) as prognostic markers in 48 cases of invasive breast cancer treated with partial or total mastectomy and lymph node dissection. All cases were immunostained with D2-40 and CD31. Positively stained microvessels were counted in densely vascular/lymphatic foci (hot spots) at x400. The mean+/-SD peritumoral lymphatic microvessel density (LMD) was significantly higher than intratumoral LMD (9+/-7 vs 4+/-6; P< .01). There was a positive correlation of D2-40 LMD (peritumoral and intratumoral) and CD31 microvessel density counts with lymph node metastasis (r=0.35, 0.5, and 0.38), nuclear grade (r=0.36, 0.28, and 0.3), and stage (r=0.42, 0.56, and 0.49), respectively. Peritumoral and intratumoral D2-40 LMD correlated significantly with the presence of angiolymphatic invasion (detected by D2-40; r=0.54 and 0.54, respectively). D2-40 detected more LVI than H&E- and CD31-detectable vascular invasion (18/48, 5/48, 11/48, respectively). Increased D2-40 detected LVI, and high CD31 microvessel counts showed significant adverse effect on survival status.

Pure mucinous carcinoma of the breast: is axillary staging necessary?

BACKGROUND

Mucinous carcinoma of the breast (MCB) may be associated with a low risk of axillary metastases.

METHODS

To evaluate the incidence of axillary nodal metastasis in MCB, a review of all cases from January 1990 to July 2000 was performed. Pure MCB was defined as all tumor cells being completely surrounded by mucin. Patient demographics, tumor size, estrogen receptor status, total number of dissected lymph nodes, and incidence of nodal metastasis were studied. Deeper sections on the lymph nodes from the pure tumors were performed and stained with low-molecular cytokeratin.

RESULTS

Nineteen cases of pure MCB and 41 cases of mixed MCB were identified. Patients with pure MCB were older than those with mixed MCB. Tumor size and estrogen receptor status showed no statistically significant differences between the two groups. None of the patients with pure MCB demonstrated lymph node metastases, whereas 12 of 41 cases with mixed MCB demonstrated metastatic lymph node involvement.

CONCLUSIONS

Because pure MCB seems unlikely to metastasize, axillary lymph node staging in these patients may not be necessary. The presence of lymph node metastases strongly indicates the presence of a mixed MCB.

Membranous fat necrosis

We report the case of a 66-year-old man with nodular lesions on the chest that were clinically diagnosed as epidermal cysts. Histologically the lesions consisted of fat necrosis with cystic spaces lined by striking membranous structures, mimicking a parasitic cuticle and exhibiting all the staining reactions of ceroid. Retrospective review of 33 consecutive cases of fat necrosis revealed similar membranous changes in 21% of the cases. The etiology and pathogenesis of this variant of fat necrosis are uncertain.

Clinical assessment of anaerobic isolates from blood cultures

Patients at two tertiary-care medical centers were evaluated to determine the clinical significance of anaerobic isolates from their blood specimens and to identify whether aerobic and/or anaerobic conditions were necessary for the detection of Streptococcus pneumoniae isolates. Significant anaerobes were isolated from only 0.1% and 0.4% of all blood cultures collected. The majority of patients with significant anaerobes had clinical conditions in which anaerobes are known to cause infections. Of the S. pneumoniae organisms, 83% were isolated only from the aerobic bottles of a blood culture set. These data lend support to the recommendations for the selective ordering of anaerobic blood cultures without compromising the isolation of S. pneumoniae.

Infiltrating breast carcinoma smaller than 0.5 centimeters: is lymph node dissection necessary?

BACKGROUND

The incidence of axillary lymph node metastases from infiltrating breast carcinomas measuring 1.0 cm or smaller reported in the literature varies from 0% (for tumors measuring < or =0.5 cm) to 27.1% (for all tumors < or =1 cm).

METHODS

The authors examined all infiltrating breast carcinomas measuring 1.0 cm or smaller with axillary lymph node dissections in patients seen at their institution between January 1990 and March 1997 (117 cases) to determine the incidence of axillary lymph node metastases. All tumors were evaluated for patient age, histologic type of tumor, modified Bloom-Richardson grade, estrogen and progesterone receptor status, ploidy, S-phase fraction, and angiolymphatic vessel invasion, to determine whether there was a relation between the indicators and axillary lymph node metastases. The authors also performed immunohistochemical stains for the basement membrane components laminin and Type IV collagen on the tumors demonstrating metastases and on an equal number of size- and date-matched tumors not demonstrating metastases.

RESULTS

Twelve cases of infiltrating carcinoma with axillary lymph node metastases were identified (a 10.3% overall incidence of metastases). Lymph node metastases were not identified in any of the cases with tumors measuring < or =0.5 cm (24 cases). The incidence of axillary lymph node metastases for carcinomas 0.6-1.0 cm was 12.9% (12 of 93 cases). High nuclear grade was found to correlate with the presence of lymph node metastases (P = 0.007). No statistically significant correlation was found between the other indicators examined and axillary lymph node metastases or between basement membrane staining and axillary lymph node metastases.

CONCLUSIONS

The authors concluded that infiltrating breast carcinomas measuring < or =0.5 cm are unlikely to have demonstrable axillary lymph node metastases. Lymph node dissections in these women may be unnecessary. Nuclear grade may be the best predictor of lymph node metastases in T1b tumors.

Medulloblastoma cancer stem cells: molecular signatures and therapeutic targets

Medulloblastoma (MB) is the most common malignant primary intracranial neoplasm diagnosed in childhood. Although numerous efforts have been made during the past few years to exploit novel targeted therapies for this aggressive neoplasm, there still exist substantial hitches hindering successful management of MB. Lately, progress in cancer biology has shown evidence that a subpopulation of cells within the tumour, namely cancer stem cells (CSCs), are thought to be responsible for the resistance to most chemotherapeutic agents and radiation therapy, accounting for cancer recurrence. Hence, it is crucial to identify the molecular signatures and genetic aberrations that characterise those CSCs and develop therapies that specifically target them. In this review, we aim to give an overview of the main genetic and molecular cues that depict MB-CSCs and provide a synopsis of the novel therapeutic approaches that specifically target this population of cells to attain enhanced antitumorous effects and therefore overcome resistance to therapy.

Granulomatous inflammation of the breast in a pregnant woman: report of a case with fine needle aspiration diagnosis

BACKGROUND

Granulomatous inflammation of the breast is an inflammatory process with multiple etiologies. It can accompany breast carcinoma or be idiopathic. It often presents clinically in a fashion mimicking carcinoma. Idiopathic granulomatous mastitis is strongly associated with lactation and is reported to occur in postpartum patients. This is the second fine needle aspiration (FNA) report of idiopathic granulomatous inflammation in the breast of a pregnant woman.

CASE

A 27-year-old, 7-month-pregnant woman presented with a hard nodule in her right breast; on ultrasound examination it showed mixed echogenicity, suspicious for carcinoma. FNA showed granulomatous inflammation. The smears were highly cellular, with many clusters of and single epithelioid cells displaying moderate pleomorphism and prominent nucleoli in a background composed of neutrophils, plasma cells, lymphocytes and multinucleated cells. Core needle biopsy revealed a nonnecrotizing, granulomatous lesion.

CONCLUSION

The diagnosis of granulomatous inflammation can be challenging, and the cytologic features can be difficult to separate from those of carcinoma. The relatively rare occurrence of this lesion and its cytologic features make it a potentially difficult diagnosis and diagnostic pitfall.

Löwenstein-Jensen media. No longer necessary for mycobacterial isolation

Isolation of mycobacteria on Löwenstein-Jensen media (LJ) and in the BACTEC MB9000 (MB) system was compared. Of 2,271 specimens, 317 were positive for 331 mycobacteria isolated in 1 or both media. The MB was positive in 238 isolates, and LJ was positive for 239 isolates; 92 isolates were detected by MB only and 93 by LJ only. Of the 331 isolates, 146 were recovered by both media. MB recovered 38 of 38 Mycobacterium tuberculosis complex isolates, while LJ recovered 23. MB recovered 94.1% (96/102) of Mycobacterium avium complex isolates and LJ 69.6% (71/102). The MB recovered 81% (65/80) Mycobacterium fortuitum-chelonae isolates and LJ 68% (54/80). Of the remaining species, MB isolated 39, while LJ isolated 91. Only 1 organism that was isolated on LJ alone was medically significant based on medical record review. The addition of LJ media to the MB9000 system is not warranted, as it causes clinically irrelevant workload, increased expenditures for the laboratory, and could cause the inappropriate treatment of patients.

Osseous metaplasia of the breast: diagnosis with stereotactic core biopsy

There are approximately 200 reported cases of breast tumors containing areas of bone. The majority of the neoplasms are sarcomas, phylloides tumors, or fibroadenomata. We present a case of osseous metaplasia mammographically detected by clustered heterogeneous calcifications. Stereotactic core biopsy revealed the presence of well-formed bone tissue without associated neolplasia. The case represents the first reported case of mammographically detected osseous metaplasia confirmed by core biopsy.

Eosinophilic pleural effusion in cutaneous myiasis

We have reported the case of a 54-year-old man with recurrent painful migratory subcutaneous nodules associated with marked blood eosinophilia and an eosinophilic pleural effusion. The entire syndrome was subsequently determined to be due to cutaneous myiasis caused by the larvae of Hypoderma lineatum, the cattle botfly. Infestation by this or other dipterous fly larvae should be among the parasitic diseases considered in the differential diagnosis of any patient with similar symptoms.

Congenital self-healing reticulohistiocytosis. Report of a case with 7-year follow-up and a review of the literature

A case of congenital self-healing reticulohistiocytosis in an otherwise healthy newborn boy is presented. Histological, immunohistochemical, and ultrastructural findings are described and the nosologic position of this entity is discussed.

Constitutive Notch Signaling Causes Abnormal Development of the Oviducts, Abnormal Angiogenesis, and Cyst Formation in Mouse Female Reproductive Tract

The Notch signaling pathway is critical for the differentiation of many tissues and organs in the embryo. To study the consequences of Notch1 gain-of-function signaling on female reproductive tract development, we used a cre-loxP strategy and Amhr2-cre transgene to generate mice with conditionally activated Notch1 (Rosa(Notch1)). The Amhr2-cre transgene is expressed in the mesenchyme of developing female reproductive tract and in granulosa cells in the ovary. Double transgenic Amhr2-cre, Rosa(Notch1) females were infertile, whereas control Rosa(Notch1) mice had normal fertility. All female reproductive organs in mutants showed hemorrhaging of blood vessels progressing with age. The mutant oviducts did not develop coiling, and were instead looped around the ovary. There were multiple blockages in the lumen along the oviduct length, creating a barrier for sperm or oocyte passage. Mutant females demonstrated inflamed uteri with increased vascularization and an influx of inflammatory cells. Additionally, older females developed ovarian, oviductal, and uterine cysts. The significant change in gene expression was detected in the mutant oviduct expression of Wnt4, essential for female reproductive tract development. Similar oviductal phenotypes have been detected previously in mice with activated Smo and in beta-catenin, Wnt4, Wnt7a, and Dicer conditional knockouts, indicating a common regulatory pathway disrupted by these genetic abnormalities.

Liver Fibrosis Helps to Distinguish Autoimmune Hepatitis from DILI with Autoimmune Features: A Review of Twenty Cases

Background and Aims: Drug-induced liver injury with autoimmune features (AI-DILI) mimics the clinical presentation, and laboratory and pathologic features of idiopathic autoimmune hepatitis (AIH). We aimed to identify histopathologic hallmarks to differentiate these entities. Methods: All liver biopsies archived for the past 10 years were reviewed retrospectively to identify cases of recently detected liver injury associated with predominantly lymphoplasmacytic interphase hepatitis, positive markers for liver autoimmunity, and negative tests for viral hepatitis. Twenty cases were divided into AIH (n = 12) or AI-DILI (n = 8) groups. Blind qualitative evaluation of necroinflammatory changes and liver fibrosis were performed according to the Scheuer scoring system. Cellular densities were determined using ImageJ (V1.51t, National Institutes of Health, Bethesda, MD, USA). Fibrosis was assessed on Masson trichrome-stained slides, and collagen deposition was estimated following a protocol of color deconvolution. Results: Necroinflammatory changes as well as densities (portal and lobular) of neutrophils and eosinophils, intracellular cholestasis, and regenerative changes did not differ between the two groups (P ≥ 0.05). Neutrophil densities but not eosinophils showed a positive correlation with the severity of hepatocellular damage (r = 0.6 and 0.58, vs. alanine aminotransferase, P < 0.05). Ceroid-laden macrophages but not histiocytic aggregates appeared to be more common in AI-DILI (P < 0.05). AIH patients presented more often with evidence of chronic damage, including higher scores of fibrosis and collagen deposition, in comparison to AI-DILI (P < 0.05). Conclusions: Although there is no histologic feature pathognomonic for AI-DILI or AIH, advanced stages of liver fibrosis can be used to support the diagnosis of AIH in some cases. Definitive diagnosis of AI-DILI requires follow-up and demonstration of complete remission after drug withdrawal with no need for immunosuppression.

Evaluation of the mycobacteria growth indicator tube compared to Septi-Chek AFB for the detection of mycobacteria

The Mycobacteria Growth Indicator Tube (MGIT) and the AFB Septi-Check (SC) systems were compared for the ability to detect myobacterial isolates, time to detection, and rate of bacterial contamination. Fifty-eight mycobacterial culture positive specimens were studied. MGIT and SC were both positive in 30 of the 58 specimens (52%); SC alone was positive in 22 (38%), and MGIT alone was positive in 6 (10%) of the 58 specimens. Among the 30 isolates identified in both systems, there were 7 Mycobacterium tuberculosis, 14 M. avium, 6 M. fortuitum-chelonae complex, and 3 other mycobacterial species. MGIT detected Mycobacterium tuberculosis faster; SC detected M. avium complex faster and more often; and M. fortuitum-chelonae isolates were detected at the same rate. MGIT showed more contamination (12.6%) than did the SC (7.8%). MGIT is comparable to SC for the detection of MTB, but MAC isolates were detected more often and faster in the SC system.

A comparison of the Bactec 9000MB system and the Septi-Chek AFB system for the detection of mycobacteria

The Bactec MB9000 (MB) continuous monitoring system was compared to the Septic-Chek AFB (SC) for the detection of Mycobacterium species from all patient sources. A total of 1485 specimens were evaluated. Two hundred forty-eight specimens grew mycobacteria in one or both systems. The isolates recovered were 18 Mycobacterium tuberculosis (MTB), 109 M. avium complex (MAC), 59 M. fortuitum-chelonae complex (MFC), 51 pigmented mycobacteria (PGM), and 11 nonpigmented mycobacteria, not MTB/MAC (NP). Of the 248 positive specimens, 157 were positive in both systems; 73 in the SC only; and 18 in the MB only. The mean times to detection for specimens were 11.5 days for MB versus 16.4 days for SC. The false positivity rate in the MB was 5.8%. Contamination rates for the MB and the SC were 12.7% and 19.8%, respectively. These data suggest that the automated MB system has clear advantages over the manual SC system in terms of earlier time to detection of significant mycobacteria, less technical hands-on time, and a lower contamination rate.

Large-needle core biopsy in atypical intraductal epithelial hyperplasia including immunohistochemical expression of high molecular weight cytokeratin: analysis of results of a single institution

The diagnosis of atypical intraductal epithelial hyperplasia (AIDH) constitutes 6.3% of the breast core biopsies performed at our institution. Seventy-nine cases that were diagnosed as AIDH on core biopsy and went through excisional biopsy were included. Sixty-four biopsies were performed by an image-guided 11-gauge vacuum device, 11 under sonographic guidance using 14-gauge needles and 4 by a sonographically guided 11-gauge vacuum device. The histopathology of the core biopsies and the surgical excisions were reviewed. Immunohistochemistry was performed on the consecutive sections of core biopsy specimens using high molecular weight cytokeratin (HMW-CK) (DAKO-Cytokeratin, 34betaE12). At interpretation of the stain, intensity and percentage of positive cells were taken into account. The immunoprofiles of AIDH were categorized into four groups showing negative (i.e., no staining) or low-, moderate-, high-, and very high-intensity staining. Surgical excision of the 79 lesions revealed carcinoma in only 3 cases (4%)-two infiltrating carcinomas and one intraductal carcinoma-residual AIDH in 44 cases (56%), and epithelial hyperplasia or other benign lesions without atypia in 32 cases (40%). The HMW-CK stain was performed retrospectively on all of the core biopsies and 66 of them contained residual areas with AIDH for staining. Forty-nine (74%) were CK negative or stained with low intensity, but 17 cases (26%) had a moderate- to high-intensity stain. Our study showed a lower incidence of carcinoma on surgical excision following core biopsy for AIDH than other studies. The HMW-CK stain helped to characterize the nature of the intraductal proliferation and to confirm the presence of atypia, as has been previously reported, but frequently was inconclusive. The low incidence of carcinoma brings into question the need for surgical excision of all cases of AIDH diagnosed by core biopsy.

Low-Grade Ductal Carcinoma In Situ

OBJECTIVES

We aimed to determine the interobserver reproducibility in diagnosing low-grade ductal carcinoma in situ (DCIS). We also aimed to compare the interobserver variability using a proposed two-tiered grading system as opposed to the current three-tiered system.

METHODS

Three expert breast pathologists and one junior pathologist identified low-grade DCIS from a set of 300 DCIS slides. Months later, participants were asked to grade the 300 cases using the standard three-tiered system.

RESULTS

Using the two-tiered system, interobserver agreement among breast pathologists was considered moderate (κ = 0.575). The agreement was similar (κ = 0.532) with the junior pathologist included. Using the three-tiered system, pathologists' agreement was poor (κ = 0.235).

CONCLUSIONS

Pathologists' reproducibility on diagnosing low-grade DCIS showed moderate agreement. Experience does not seem to influence reproducibility. Our proposed two-tiered system of low vs nonlow grade, where the intermediate grade is grouped in the nonlow category has shown improved concordance.