MOC31 Immunostaining in the Diagnosis of Metastatic Adenocarcinoma in Serous Fluid: Special Emphasis on Atypical Cytological Cases

BACKGROUND

The diagnosis of atypical cases in the effusion cytology sample often poses a challenge to the cytologists.

AIMS AND OBJECTIVES

We evaluated the diagnostic role of MOC31 in the metastatic adenocarcinoma in effusion fluid.

MATERIALS AND METHODS

The cytological examination and MOC31 immunostaining in the cell block sections were carried out in 64 cases of serous effusion. A total of 23 cases showed atypical cytology, out of which suspicious for malignancy (SFM) and atypia of undetermined significance (AUS) were 19 and 4 cases, respectively. In these cases, we also performed calretinin immunostaining. The cytological features, results of MOC31 immunostaining, and follow-up data were correlated to find out the sensitivity and specificity of MOC31 immunostaining in the diagnosis of metastatic adenocarcinoma.

RESULT

The sensitivity and specificity of MOC31 were 100%. MOC31 detected all the cases of metastatic adenocarcinoma. MOC31 showed strong positivity in 19 cases of SFM. All these cases had a malignant outcome in histopathology or follow-up data. In AUS cases, MOC31 immunostaining was negative with a benign outcome. In all the atypical but malignant cases calretinin stain showed diffuse cytoplasmic and nuclear positivity. In contrast, MOC31 showed strong membranous positivity and occasionally cytoplasmic positivity.

CONCLUSION

MOC31 is an excellent marker of metastatic adenocarcinoma in the serous effusion. The membranous positivity of MOC31 and negative calretinin immuno-staining are helpful in atypical cytological cases to avoid the diagnostic dilemma. The MOC31 positivity is significantly useful in discrete atypical cells which are more challenging to recognize.

Eosinophilic gastroenteritis with multiple serous membrane effusion as the first sign: a case report and literature review

Multiple serous membrane effusion (MSSE) as the first sign of eosinophilic gastroenteritis is extremely rare, and its clinical features and treatment methods have not been well described. The clinical characteristics, diagnosis, and treatment methods of MSSE in a 44-year-old woman were retrospectively reviewed. Laboratory testing revealed an elevated eosinophil count and serum immunoglobulin E level. The levels of all tumor markers were normal, but the CA125 level in serum and ascitic fluid was significantly increased. Ultrasonography showed a large amount of ascites and a moderate amount of pleural effusion. Echocardiography showed a small amount of pericardial effusion. Chest and abdominal computed tomography showed gastrointestinal wall thickening. Moreover, eosinophilic infiltration was detected in duodenal and rectal biopsy samples that had been collected during endoscopic examination of the upper gastrointestinal system. The patient was treated with 30 mg of prednisolone, and seafood was excluded from her diet for 4 weeks. The prednisolone was tapered over 8 weeks and continued at 5 mg prednisolone daily thereafter. The MSSE and peripheral eosinophilia showed a dramatic response to the steroid treatment. This case indicates that we should be highly aware of MSSE as the first clinical manifestation of eosinophilic gastroenteritis.

Infliximab Induced Cardiac Tamponade

Aim To report the first case of cardiac tamponade related to Infliximab induction therapy in an Ulcerative Colitis patient. Methods Review of published case reports. Results This complication was likely due to a type 3 hypersensitivity immune-complex reaction resulting in a reactive pericardial effusion Discussion Though rare, this case demonstrates how autoimmune reaction to anti-TNF𝛼 therapy can initially mimic infection, as our patient presented with tachycardia, hypotension, raised inflammatory and infective markers and fever.

Utility of T-cell interferon-γ release assays for diagnosing tuberculous serositis: a prospective study in Beijing, China

BACKGROUND

Diagnosis of tuberculous serositis remains a challenge. The aim of this study was to evaluate the diagnostic efficiency of T-SPOT.TB on serous effusion mononuclear cells (SEMC) for diagnosing tuberculous serositis in a high TB burden area.

METHODS

The present prospective study enrolled patients with suspected tuberculous serositis in a tertiary referral hospital in Beijing, China, to investigate the diagnostic sensitivity, specificity, predictive value (PV), and likelihood ratio(LR) of these tests. Clinical assessment, T-SPOT.TB on SEMC, and T-SPOT.TB on PBMC were performed. Test results were compared with the final confirmed diagnosis.

RESULTS

Of the 187 participants, 74 (39.6%) were microbiologically or clinically diagnosed as tuberculous serositis and 93(49.7%) were ruled out. The remaining 20 (10.7%) patients were clinically indeterminate and excluded from the final analysis. Compared to that on PBMC, T-SPOT.TB on SEMC showed higher sensitivity (91.9%vs73.0%, P = 0.002), specificity (87.1%vs.73.1%, P = 0.017), PPV (85.0%vs.68.4%, P = 0.013), NPV (93.1%vs.77.3%, P = 0.003), LR+ (7.12vs.2.72) and LR- (0.09vs.0.37), respectively. The frequencies of spot forming cells (SFCs) for T-SPOT.TB on SEMC were 636 per million SEMC (IQR, 143-3443) in patients with tuberculous serositis, which were 4.6-fold (IQR, 1.3-14.3) higher than those of PBMC. By ROC curve analysis, a cut-off value of 56 SFCs per million SEMC for T-SPOT.TB on SEMC showed a sensitivity of 90.5% and specificity of 89.2% for the diagnosis of tuberculous serositis.

CONCLUSIONS

T-SPOT.TB on SEMC could be an accurate diagnostic method for tuberculous serositis in TB endemic settings. And 56 SFCs per million SEMC might be the optimal cut-off value to diagnose tuberculous serositis.

Importance of flow cytometric analysis of serous effusions in the diagnosis of hematopoietic neoplasms in patients with prior hematopoietic malignancies

OBJECTIVE

To determine the criteria for the use of immunophenotyping by flow cytometry (FCM) in the diagnosis of hematopoietic lesions.

STUDY DESIGN

A retrospective review of 89 consecutive body fluid specimens with concurrent FCM analysis during 2001 to 2006 was performed. The cytopathologic diagnosis was compared with the final diagnosis as modified by subsequent FCM.

RESULTS

The cytopathologic diagnosis was benign in 61 cases (69%), atypical in 20 cases (22%) and malignant in 8 cases (9%). In patients without any prior clinical history, FCM study was positive in 2 cases and negative in 49 cases. In these patients, the working cytopathologic diagnosis was modified from benign/atypical to malignant in 2 (11%) cases and atypical to benign in 11 (33%) cases. In patients with a prior clinical history, FCM was positive in 23 cases and negative in 15 cases.

CONCLUSION

FCM studies were helpful in the cytopathologic diagnosis in 35% of body fluid specimens, permitting appropriate cancer staging and management. In the absence of a prior clinical history, immunophenotyping by FCM in body fluid specimens should be ordered after adequacy studies when there is cytologic atypia or a strong suspicion of malignancy on the cytopathologic diagnosis.

Echocardiography in the cardiac transplant recipient

Despite the widespread use of echocardiography in the cardiac allograft recipient, the clinical usefulness of this practice is not well defined. In this article, the authors review the spectrum of echocardiographic findings in the adult heart transplant patient. Appreciation of typical alterations from "normal" allows the transplant physician to identify clinically significant changes and to avoid unnecessary invasive procedures based on misinterpretation of these differences. Though abnormalities of systolic and diastolic function correlate with episodes of acute rejection, the primary diagnostic usefulness of echocardiography in acute rejection is guiding the endomyocardial biopsy. Additionally, echocardiography has found a role as a supplement to invasive angiography in the diagnosis of cardiac allograft vasculopathy.

The management of tuberculous pericardial effusion: experience in 233 consecutive patients

AIM

We report on the 30-day and one-year outcome of consecutive effusive pericarditis patients, including those with tuberculous pericarditis, over a six-year-period.

METHODS AND RESULTS

Patients with large pericardial effusions requiring pericardiocentesis were included in the study after having given written informed consent. Clinical and radiological evaluations were followed by echo-guided pericardiocentesis, and extended daily intermittent drainage via an indwelling pigtail catheter. A standard short-course anti-tuberculous regimen was initiated. A total of 233 patients was included. One hundred and sixty-two patients had pericardial tuberculosis (TB), including 118 (73%) with microbiological and/ or histological evidence of TB and 44 (27%) diagnosed on clinical and supportive laboratory data. Over the six-year period, two patients developed fibrous constrictive pericarditis after receiving adjuvant corticosteroid therapy. The 30-day mortality (8.0%) was statistically higher for HIV-positive patients (corresponding mortality 9.9%) than for HIV-negative patients (6.2%; p = 0.04). The one year all-cause mortality was 17.3%. It was also higher for HIV-positive (22.2%) than for IV-negative patients (12.3%; p = 0.03). Cardiac mortality was equal for HIV-positive and -negative patients.

CONCLUSION

Tuberculous pericardial effusions responded well to closed pericardiocentesis and a six-month treatment of antituberculous chemotherapy. The former was effective and safe irrespective of HIV status.

Idiopathic pericarditis in dogs: no evidence for an immune-mediated aetiology

OBJECTIVE

To ascertain whether specific immunological changes are associated with canine pericardial effusion due to idiopathic pericarditis.

METHODS

In this prospective study, serum antinuclear antibody and serum and pericardial fluid immunoglobulin (Ig) G, Ig M and Ig A concentrations were measured in dogs with pericardial effusion due to idiopathic pericarditis or pericardial neoplasia. The secretory index relative to albumin concentration was calculated in order to distinguish between Ig actively secreted into the pericardial fluid and that derived from the blood accumulating within the pericardial sac. Statistical analysis was performed comparing the results obtained between the two groups of dogs.

RESULTS

Only three dogs were antinuclear antibody positive; two of these dogs had idiopathic pericarditis and one had neoplasia. Mean serum Ig M and Ig A concentrations were lower than the reference values in both groups, and the secretory indices for Ig M and Ig A were greater than 1.0. However, there was no significant difference with respect to any Ig measurement between the two groups of dogs (P>0.1).

CLINICAL SIGNIFICANCE

The results of the present study do not support the hypothesis that canine idiopathic pericarditis has a significant 'immune-mediated' aetiology or immunological features that distinguish it from the pericardial changes associated with local neoplastic disease.

Transient Th1/Th2 disbalance indicates postoperative effusions and edema after cardiopulmonary bypass in children

BACKGROUND

Cardiac surgery with cardiopulmonary bypass (CPB) induces substantial release of IL-10, indicating increased Th2 cell response. Therefore, in this study, we wanted to verify if this response is due to CPB or surgical trauma, and to study its relation to postoperative effusions and edema (POEE) in children.

METHODS

Th1/Th2 reaction was monitored in children undergoing cardiovascular surgery with (n = 75) and without CPB (n = 29).

RESULTS

Surgery with CPB compared to surgery without CPB induced a transient shift towards Th2. Elevated Th2 response was related to increased vascular permeability and POEE.

CONCLUSION

The immune suppression/Th2 response is typical for CPB, and at intermediate level is tolerable but at high level could be adverse for the patients.

Characterization of the immunological features of tuberculous pericardial effusions in HIV positive and HIV negative patients in contrast with non-tuberculous effusions

OBJECTIVE

To investigate the immunopathogenesis of pericardial tuberculosis (TB) and the influence of human immunodeficiency virus (HIV) on the anti-tuberculous immune response.

DESIGN

Consecutive patients presenting with large pericardial effusions were subjected to a full clinical examination and pericardiocentesis. Aspirated fluid was sent for biochemistry, differential leukocyte count, flow cytometric analysis and determination of cytokine levels. Pericardial tissue was sent for TB culture and histopathological evaluation. Diagnoses were made according to pre-determined criteria.

RESULTS

Fifty-six patients were included and divided into HIV positive TB (n = 22), HIV negative TB (n = 21) and non-tuberculous effusions (n = 13). Peripheral blood neutrophil, lymphocyte and monocyte counts were significantly lower in HIV positive TB patients. Lymphocytes were the dominant cell type in tuberculous pericardial effusions. CD4+ cells dominated in HIV negative tuberculous effusions, whereas CD8+ cells dominated in HIV positive TB. The difference in the concentration of IFN-gamma levels in the tuberculous and non-tuberculous pericardial effusions was statistically significant. Despite significant differences in pericardial CD4+ cell counts, IFN-gamma levels were similarly elevated in HIV negative and HIV positive tuberculous effusions. Highest levels of pericardial IL-10 were observed in samples associated with least tissue necrosis, suggesting the possibility of a tissue protective immunoregulatory role for IL-10.

CONCLUSIONS

Tuberculous pericardial effusions result from a T helper1 (Th1)-dominant immune response. IFN-gamma producing CD4+ lymphocytes dominate in HIV negative patients, whereas CD8+ seem to play a more important role in HIV positive patients. Infection with HIV leads to the depletion of immunocompetent cells such as monocytes, NK cells and neutrophils.

Blood lymphocyte subsets in canine idiopathic pericardial effusion

The immunophenotype of peripheral blood lymphocytes was investigated in 23 dogs diagnosed with idiopathic pericardial effusion in order to provide information about a possible role of the immune system in this pathology. Flow cytometric analysis showed a significant reduction in nearly all lymphocyte subsets examined and a strong, significant (P < 0.001) reduction of the CD4 subset, which gave rise to a significantly lower CD4/CD8 ratio. Our data suggest that an imbalance in the immune system is present during the course of the disease, preferentially affecting the T helper cell response.

[Antimycobacterial antibody level in pleural, pericardial and cerebrospinal fluid of patients with tuberculosis]

The goal of the study was to evaluate IgG, IgA and IgM mediated humoral immune response against 38kDa and 16 kDa or 38kDa and LAM mycobacterial antigens in pleural, pericardial or cerebrospinal fluid from patients with tuberculosis (TB) and to compare to non-tuberculous controls (NTB). 30 cerebrospinal fluids (CSF) (16 TB pts and 14 NTB pts), 17 pericardial fluids (6 TB and 11 NTB) and 20 pleural fluids (7 TB and 13 NTB) were examined. Commercially available ELISA-based assays (Pathozyme Tb complex plus, Myco G, A and M--Omega Diagnostic) were used. Tests were performed and cut off established according to manufacturer instruction. Mean IgG level against 38 + 16kDa was significantly higher in neurotuberculosis group compared to control (p<0.05). Sensitivity of the test in detecting neurotuberculosis was of 42% and specificity of 96%. Mean IgG, IgA and IgM against 38kDa + LAM level was higher in TB group compared to NTB in CSF. No difference was observed between TB and NTB group in pleural effusion. Antimycobacterial antibody levels were non-significantly increased in pericardial fluid in TB. The findings of the study indicate that TB is associated with the presence of detectable levels of antibodies in the CSF and pericardial effusion. Anti 38kDa + 16kDa IgG test can be used in combination with other diagnostic methods to increase diagnostic accuracy of neurotuberculosis.

[Clinical evaluation of mediastinal hematologic malignancies (lymphoma and granulocytic sarcoma)]

In a retrospective review of all patients who visited our hospital between January 1997 and December 2001, we identified 22 with mediastinal lymphoma or mediastina granulocytic sarcoma. They represented 24.2% of the 91 patients with mediastinal tumors. Histology revealed 6 cases of diffuse large B-cell lymphoma, 6 of lymphoblastic lymphoma, 6 of Hodgkin's disease, 2 of granulocytic sarcoma, and 1 of lymphoplasmacytic lymphoma. More than 1/3 of the tumors had highly aggressive histological pictures. Immunocytochemical analysis of cell surface markers by flow cytometry was very useful for reaching a definitive diagnosis of these tumors. In two cases, definitive diagnosis could be obtained only by flow cytometric examination of pleural or pericardial effusion. Careful attention should be paid to the relatively high incidence of hematologic malignancies in mediastinal tumors. Early and accurate diagnosis of these tumors is essential because some of these patients require immediate treatment by hematology specialists.

Prevention of inclusion body hepatitis/hydropericardium syndrome in progeny chickens by vaccination of breeders with fowl adenovirus and chicken anemia virus

The hypothesis that an effective protection of progeny chickens against inclusion body hepatitis/hydropericardium syndrome (IBH/HP) can be achieved by dual vaccination of breeders with fowl adenovirus (FAV) serotype 4 and chicken anemia virus (CAV) was tested. Thus, 17-wk-old brown leghorn pullet groups were vaccinated by different schemes including single FAV (inactivated), single CAV (attenuated), FAV and CAV dually, or were not vaccinated (controls). Subsequent progenies of these breeders were challenged with the virulent strains FAV-341 and CAV-10343 following three strategies: 1) FAV-341 intramuscularly (i.m.) at day 10 of age (only FAV-vaccinated and control progenies); 2) FAV + CAV i.m. simultaneously at day 10 of age (all progenies); 3) CAV i.m. at day 1 and FAV orally at day 10 of age (all progenies). The induction of IBH/HP in these progenies was evaluated throughout a 10-day period. Both breeder groups vaccinated against FAV and those vaccinated against CAV increased virus neutralizing specific antibodies. Challenge strategy 1 showed 26.6% mortality in control progeny chickens and 13.3% in the progeny of FAV-vaccinated breeders. Presence of lesions in the liver of these groups showed no significant differences (P > 0.05), suggesting a discreet protective effect of the vaccine. Challenge strategy 2 showed 29.4% mortality in controls and 94% of chickens showed hepatic inclusion bodies (HIB). Single CAV vaccination of breeders did not demonstrate a beneficial effect, with both mortality and liver lesions resembling the nonvaccinated controls. FAV vaccination of breeders significantly reduced both mortality (7.4%) and liver lesions (26% HIB) (P < 0.05), providing protection against this challenge strategy. Dual vaccination of breeders with FAV and CAV proved to be necessary to achieve maximum protection of the progeny (no mortality and 7% HIB). Challenge strategy 3 produced no mortality but consistent liver damage in controls (96% HIB). In this case, both CAV and FAV + CAV-vaccinated breeders showed best protection results in terms of liver histopathology (8% and 0% HIB, respectively). FAV vaccination alone produced 24% HIB, similar to challenge strategy 2, demonstrating a lower protective effect.

Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone; the way to avoid side effects of systemic corticosteroid therapy

AIMS

To evaluate efficacy and safety of intrapericardial treatment with the crystalloid corticosteroid triamcinolone in autoreactive pericardial effusion.

METHODS AND RESULTS

Two hundred and sixty consecutive patients with pericarditis/myopericarditis underwent pericardiocentesis, pericardioscopy (Storz-AF1101B1), and epicardial biopsy with pericardial fluid and tissue analyses. By polymerase chain reaction for cardiotropic viruses/bacteria in pericardial effusion and epicardial biopsies as well as by immunohistochemistry and immunocytochemistry of epicardial and endomyocardial biopsies, 84/260 patients were classified as autoreactive pericarditis and underwent intrapericardial instillation of triamcinolone (group 1: 54 patients, 50% males, mean age 48.9 +/- 14.3 years, triamcinolone 600 mg x m(-2) x 24 h(-1); group 2: 30 patients, 46.7% males, mean age 52.5 +/- 12.7 years, triamcinolone 300 mg x m(-2) x 24 h(-1)). Intrapericardial administration of triamcinolone resulted in symptomatic improvement and prevented effusion recurrence in 92.6% vs 86.7% of the patients after 3 months and in 86.0% vs 82.1% after 1 year in groups 1 and 2, respectively (P>0.05). There were no treatment-related acute complications. During the follow-up, 29.6% of the patients developed transitory iatrogenic Cushing syndrome in group 1 in contrast to 13.3% in group 2 (P<0.05). Conclusion Intrapericardial treatment of autoreactive pericarditis with 300 mg x m(-2) x 24 h(-1) of triamcinolone prevented recurrence of symptoms and relapse of effusion as effectively as the 600 mg x m(-2) x 24 h(-1) regimen, but with significantly fewer side effects.

Application of molecular genetics to the diagnosis of lymphoid-rich effusions: study of 95 cases with concomitant immunophenotyping

The cytological differentiation between reactive lymphocytosis and malignant lymphoma in serous effusions is often difficult. The present study was designed to evaluate the potential contribution of molecular genetic clonality analysis to a solution to this problem. We examined the cytological specimens of 95 consecutive patients collected during a 4-yr period, including 74 pleural, 20 peritoneal, and one pericardial fluids. Cytological diagnosis in the 95 lymphocyte-rich effusions was positive for lymphoma in 20 cases, suspicious for lymphoma in 26 cases, and negative in 49 cases. The analysis by ICC was not carried out, inconclusive, or noninterpretable in 25 cases. In five cases molecular genetic analysis was hampered by technical problems. By immunocytochemistry, eight additional cases of lymphoma were detected and lineage classification was achieved in 15 of the 20 cytologically positive effusions. PCR and Southern blot analysis were used to assess B- and T-cell clonality. Monoclonality was found in 40 (42%) of the 95 effusions analyzed. One-third of the effusions with a monoclonal B-cell gene rearrangement were detected by Southern blot analysis but not by the PCR performed in parallel. The results of molecular genetic analysis were corroborated by histological findings and/or clinical evolution in 15 cases. Our results indicate that molecular genetic analysis is a useful tool in the analysis of lymphocyte-rich serous effusions.

Cytokine activation in pericardial fluids in different forms of pericarditis

There are many causes of pericardial effusion and it is useful to classify them etiologically, since this disorder is the most common pathologic process involving the pericardium. This report details our experience with pericardioscopy and epicardial biopsy in 101 patients with pericardial effusions in whom pericardioscopy was performed. By means of clinical data and polymerase chain reaction we tried to elucidate the etiology of the pericardial effusion which were classified as follows: we found 41 effusions to be induced by primary malignant tumors or tumors metastatic to the pericardium. Specific diagnosis of viral and bacterial pericarditis was established in 17 patients by examination of the pericardial effusion with PCR, where we found 3 patients positive for adenovirus, 5 patients positive for cytomegalovirus, 2 patients positive for enterovirus-RNA and 5 patients positive for borrelia Burgdorferi-DNA. Additionally, idiopathic effusions (lymphocytic and autoreactive) were seen in 35 patients. In summary immunological and molecular biology investigations seem to provide an additional tool in the diagnostic of pericardial effusion with unknown etiology. If we focus on the ELISA results, there is some evidence, that the demonstration [table: see text] of activation markers and soluble mediators of inflammation such as Il-6, Il-8 and IFN-gamma in pericardial effusion and the simultaneously lack of these mediators in sera of the patients first may be helpful in the discrimination of autoreactive and lymphocytic effusion. Second, this cytokine pattern or distribution indicates a possible local inflammatory process, where these cytokines were all released from activated T lymphocytes present in lymphocytic effusion. In the future, this may have therapeutic implications.

Intrapericardial treatment of autoreactive myocarditis with triamcinolon. Successful administration in patients with minimal pericardial effusion

A major clinical drawback in the treatment of autoreactive pericarditis is its inherent feature to relapse. Intrapericardial treatment with triamcinolone was reported to be efficient in patients with large, symptomatic autoreactive pericardial effusions, avoiding side effects of systemic treatment as well as compliance problems. Intrapericardial treatment with 300 mg/m2 triamcinolone was for the first time performed in patients with autoreactive myopericarditis and minimal pericardial effusions (75 to 110 ml). After 12 months of follow-up both patients are asymptomatic and there were no further recurrences of pericardial effusion. Pericardiocentesis in these patients was performed with the application of the PerDUCER device, guided by pericardioscopy. This device has a hemispherical cavity at the top of the instrument connected with a vacuum-producing syringe. In this cavity the pericardium is captured by vacuum and tangentially punctured by the introducer needle. Pericardium that can be captured, must be up to 2 mm thin to fit into the hemispherical cavity. Pericardioscopy performed from the anterior mediastinum significantly contributed to the success of the procedures enabling visualization of the portions of the pericardium free of adipose tissue or adhesions, suitable for puncture with the PerDUCER. In conclusion, intrapericardial treatment of symptomatic autoreactive myopericarditis with minimal pericardial effusion was safely and efficiently performed in 2 patients. Pericardiocentesis was enabled by means of the PerDUCER device, facilitated by pericardioscopy.

Serial antinuclear antibodies titre in pleural and pericardial fluid

The antinuclear antibodies (ANA) test has been a cornerstone of the evaluation of connective tissue disease. The aim of this study was to investigate the diagnostic value of the ANA test in pleural or pericardial effusions of unknown causes. Over a 3-yr period, a total of 126 pleural fluid and 30 pericardial fluid samples were analysed. ANA tests were performed using a commercially available kit. The ANA kit used an indirect immunofluorescent antibody method with a human epithelial (HEP-2) cell line as substrate. Patients with high fluid ANA titre (>1:160) received a second aspiration 2 weeks after the initial aspiration if diagnosis was not confirmed. ANA results were positive in 39 pleural and 10 pericardial fluid samples. All but one of the effusions with positive ANA testing were exudative. Eleven pleural or pericardial effusions due to active systematic lupus erythematosus were identified and all had high ANA titres (1:160) with various staining patterns. Thirty-eight of 145 patients (26%) with effusions of nonlupus aetiologies had positive ANA testing in pleural or pericardial fluid. Thirteen of these 38 patients had high ANA titre. Malignant or paramalignant effusions constituted 11 of the 13 samples. In conclusion, although a negative antinuclear antibodies test makes a diagnosis of lupus serositis unlikely, high antinuclear antibodies titres in pleural or pericardial fluid are not diagnostic of lupus serositis even when as high as 1:5,120. An unexplained high antinuclear antibodies titre in pleural or pericardial effusion warrants search for malignancy.

A case of rheumatoid pericarditis with high concentrations of interleukin-6 in pericardial fluid

A case of rheumatoid pericarditis that developed into cardiac tamponade without deterioration of rheumatoid arthritis is described. The concentration of interleukin-6 (IL-6) in pericardial fluid was notably increased compared with serum. IL-6 may be associated with progression or maintenance of rheumatoid pericarditis.

Elevated serum CA-125 levels in hemodialysis patients with peritoneal, pleural, or pericardial fluids

OBJECTIVE

Serum CA-125, an ovarian tumor marker, is used especially in the follow-up of ovarian cancer for monitoring the efficacy of therapy and for early detection of recurrence. A number of benign gynecologic as well as benign and malignant nongynecologic conditions are associated with elevated serum CA-125 levels. Malignant and nonmalignant serosal fluids were also found to be associated with high serum levels of CA-125, suggesting that the presence of fluid in the serosal cavities may stimulate its release.

METHODS

We performed a clinical study in 39 patients (21 females, 18 males) on chronic hemodialysis who were divided into two groups based on the presence of fluid in the serosal cavities (peritoneum, pleura, or pericardium) without clinical and radiologic evidence of neoplasia. There were 26 patients (16 females, 10 males) aged 50.11 +/- 13.86 years (range, 20-76 years) in the serosal fluid-negative group (group 1) and 13 patients (8 females, 5 males) aged 45.30 +/- 18.84 years (range, 17-73 years) in the serosal fluid-positive group (group 2). The control group consisted of 52 healthy volunteers (30 females, 22 males) aged 44.19 +/- 12.59 years (range, 19-68 years).

RESULTS

Significantly elevated serum CA-125 levels were found in hemodialysis patients with serosal fluid (P < 0.05) when compared with both the hemodialysis patients without serosal fluid and the control group. There was no statistically significant difference between the control group and the patients without serosal fluids (P > 0.05).

CONCLUSION

Although CA-125 can be considered a reliable tumor marker in patients undergoing hemodialysis, it should be interpreted with caution in patients with serosal fluids.

Proteus syndrome and immunodeficiency

A 10 year old boy with Proteus syndrome presented with a pericardial effusion of unknown aetiology. Immunological investigation revealed low serum IgG and IgA, accompanied by low levels of specific antibodies to pneumococcal and haemophilus type B polysaccharides. Circulating lymphocyte surface marker profile revealed T and B cell lymphopenia. This is the first report of hypogammaglobulinaemia occurring in the Proteus syndrome.

Human herpesvirus-8 in lymphomatous and nonlymphomatous body cavity effusions developing in Kaposi's sarcoma and multicentric Castleman's disease

Human herpesvirus-8 (HHV-8) has been associated with Kaposi's sarcoma, multicentric Castleman's disease and primary effusion lymphoma. Kaposi's sarcoma and multicentric Castleman's disease patients may develop body cavity effusions that, unlike primary effusion lymphoma, are poorly characterized. To better define these effusions, pleural and peritoneal fluids derived from 12 human immunodeficiency virus-seropositive and one seronegative patients affected by Kaposi's sarcoma or multicentric Castleman's disease were analyzed by a combination of morphologic, immunophenotypic, and DNA analyses, including polymerase chain reaction amplification of HHV-8, Epstein-Barr virus, and immunoglobulin heavy-chain (IgH) gene sequences. In addition, HHV-8 serologic status was assessed by using an immunofluorescence assay. All patients were adult men with high antibody titers to HHV-8; 11 of the 13 patients were homosexual/bisexual. Effusions revealed monocyte/macrophage-rich infiltration (10 patients) or large-cell lymphoma with CD45(+)/non-T/non-B phenotype (three of 13 patients); polymerase chain reaction analysis showed the presence of HHV-8 sequences (nine of 13 patients), germline IgH (seven of 12 patients) or clonal IgH rearrangements (four of 12 patients), and rarely Epstein-Barr virus sequences (two of 12 patients). In the setting of HHV-8 infection, two effusion types may occur. One fulfills the criteria for HHV-8-positive PEL (lymphoma-morphology, HHV-8-DNA(+), IgH rearrangement). The other seems more reminiscent of an HHV-8-associated nonneoplastic process (monocyte-macrophage morphology, HHV-8-DNA(+/-), germline IgH). Interestingly, a single case of the latter effusion type harbored a B-cell monoclonal proliferation, which suggests the hypothesis that a prelymphomatous effusion may precede overt body cavity lymphoma.

Efficacy of an inactivated oil emulsion vaccine against hydropericardium syndrome in broilers

Two inactivated vaccines were prepared against hydropericardium syndrome. The vaccine prepared from liver homogenate extracted with chloroform, inactivated with formalin and adjuvanted with liquid paraffin was highly effective against challenge in chickens aged three, five and seven weeks. Seroconversion following vaccination and challenge was assessed by the agar gel immunodiffusion test. The inactivated oil emulsion vaccine was highly effective against the syndrome in both experimental trials and field trials.

Immunohistochemical detection of cytotoxic lymphocytes in malignant serous effusions

The use of ancillary techniques to aid in the diagnosis of metastatic carcinoma in serous effusions has been the subject of numerous studies. In this article, we study 35 cases of malignant effusions (metastatic adenocarcinoma) and 20 benign effusions using a panel of immunohistochemical markers to determine whether changes in the subpopulations of accompanying lymphoid cells can be detected with this technique and whether such changes are associated with the presence of malignancy. We noted a significant increase in cytotoxic lymphocytes, defined as the percentage of all lymphoid cells staining with an antibody to TIA-1 (an antigen localized to the cytotoxic granule membranes of cytotoxic T cells and natural killer cells) in malignant compared with benign effusions (23% vs. 12%; P < 0.05). In addition, nearly all cases in which cytotoxic lymphocytes composed > 20% of the lymphoid cell population contained metastatic tumor. Thus, immunohistochemical staining for TIA-1 can reliably detect cytotoxic lymphocytes in cell blocks of serous effusions; in addition, a relative increase in their number is associated with the presence of malignancy.

[The evaluation of carcinoembryonic antigen determination in the pericardial fluid in the diagnosis of the cause of pericarditis]

Pericardial fluid CEA level was measured with radioimmunoassay in 19 patients with large pericardial effusion of unknown origin. In 11 patients malignancy was diagnosed. In all of these patients pericardial fluid CEA levels were above 7 ng/ml (mean value 52.6 +/- 42.6 ng/ml). In 8 patients the etiology of pericarditis was non-malignant. In all of them pericardial fluid CEA levels were below 7 ng/ml (mean value 2.2 +/- 1.6 ng/ml). In 9 patients with malignant pericarditis serum CEA levels were also determined: they were found to be lower than pericardial fluid CEA values in 6 patients. It was concluded that pericardial fluid CEA elevation is a reliable criteria of neoplastic pericardial involvement.

Kinetics of purified protein derivative (PPD) proliferation reflects underlying suppressor mechanisms revealed by limiting dilution analysis (LDA) in patients with extrapulmonary tuberculosis (TB)

Mononuclear leucocytes from the blood (PBML) and effusion (EML) of patients undergoing pericardiocentesis were assayed for proliferative response to purified protein derivative of Mycobacterium tuberculosis (PPD). Of the 23 patients tested, 10 had culture-positive tuberculous effusions, while 13 had non-tuberculous aetiologies. Three different kinetic responses were identified: (i) accelerated responses (found in 70% of EML from patients with culture-positive tuberculous effusions); (ii) 'flat' responses (found in 10% of EML from patients with culture-positive tuberculous effusions); and (iii) normal kinetic responses. These differences in kinetic response may reflect underlying immune mechanisms important in the immunopathogenesis of TB. In order to address this possibility we performed LDA on a selection of patients with culture-positive extrapulmonary TB: three patients with accelerated responses, two with normal responses, and one with a 'flat' response. The results confirm the previously reported accumulation of PPD-specific responder cells in the effusion of patients with TB. Cell-mediated suppressor mechanisms (as shown by 'V'-shaped LDA curves) were found in the blood of one patient and the effusion of another. In both cases 'flat' PPD-proliferative responses were observed. However, the LDA data also suggested the presence of in vivo mechanisms limiting the clonal burst size. Thus it appears that immune responses in extrapulmonary TB are influenced by an array of inhibitory mechanisms, modulation of which may influence the outcome of infection.

Utility of HBME-1 immunostaining in serous effusions

HBME-1 is an anti-mesothelial cell monoclonal antibody derived from human mesothelioma cells. We investigated 227 body cavity effusions to test its utility in differentiating mesothelioma from adenocarcinoma. HBME-1 outlined cell membranes in non-neoplastic mesothelial cells. Thick surface staining was observed on all mesotheliomas. HBME-1 reactivity was also detected in 24% of metastatic carcinomatous effusions. Most ovarian carcinomas (83%) reacted with this antibody, showing surface staining. Cytoplasmic HBME-1 immunoreactivity was observed in a small proportion of non-ovarian adenocarcinomas (14%). Despite its limited specificity, HBME-1 might be added to the battery of other markers of epithelial and/or mesothelial differentiation to be used in cases of suspected mesothelioma. Evaluation of suspicious cells should include careful study of the pattern of immunostaining.

Combined cytomorphologic and immunophenotypic approach to evaluation of effusions for lymphomatous involvement

Combining cytomorphology and immunophenotypic data in evaluation of effusions for lymphomatous involvement is reliable, non-invasive, and expeditious. In this study, 30 effusion specimens from 30 patients with clinically suspected or previously diagnosed non-Hodgkin's lymphoma (NHL) were evaluated cytomorphologically and by flow cytometric immunophenotyping with a large panel of monoclonal antibodies. Of 11 patients with a previous diagnosis of NHL, 50% had cytomorphologic and immunophenotypic evidence of lymphomatous involvement of effusion specimens; therefore, flow cytometric immunophenotyping is recommended in these cases since there may be substantial therapeutic impact. In addition, 69% of the effusions positive for lymphomatous involvement represented newly diagnosed NHL; in 36% of these cases, tissue biopsy was not necessary since they were either high-grade (lymphoblastic or small, non-cleaved cell type) or of the small lymphocytic lymphoma cell type.

Total and specific anti-Trypanosoma cruzi immunoglobulin E in pericardial fluid samples from patients with chronic Chagas disease

Levels of total and specific anti-Trypanosoma cruzi immunoglobulin E (IgE) were determined by immunoenzymatic assay among 101 samples of pericardial fluid from patients who had died in one trypanosomiasis endemic area in central Brazil. These samples were divided into 6 groups. Group I, 17 samples from patients with the cardiac form of Chagas disease; group II, 11 samples from patients with the digestive form of Chagas disease, presenting megaoesophagus and/or megacolon; group III, 41 samples from patients with the indeterminate form of Chagas disease; group IV, 4 samples from patients with both cardiac and digestive forms of Chagas disease; group V, 5 samples from patients who suddenly died and were seropositive for T. cruzi antibodies; group VI, 23 samples, used as a control group, which came from patients seronegative for T. cruzi antibodies. Significantly high levels of total IgE were observed in groups I, II, III, IV and V when compared with group VI (mean concentrations 708-1157 iu/mL compared with 394 iu/mL). In groups I-V, 32 samples (41%) had specific anti-T. cruzi IgE antibodies. The individual percentage positivity rates in these groups were 64.7% (group I), 45.4% (group II), 34.1% (group III), nil (group IV), and 40.0% (group V). A significant correlation between total IgE and specific anti-T. cruzi IgE was observed only in the samples from patients with the cardiac form of Chagas disease (group I).

Postpericardiotomy syndrome: a complication of cardiac surgery

Postpericardiotomy syndrome is a frequent complication of cardiac surgery and is characterized by fever, chest pain, and a pericardial friction rub. Based on current evidence, there may be an immunologic basis to this syndrome. Treatment is aimed at reducing inflammation and promoting comfort. Although this syndrome is usually benign and self-limiting, it can recur and has been complicated by cardiac tamponade and early bypass graft closure.

Massive pericardial effusion in scleroderma: a review of five cases

Medical records of five patients with scleroderma (SSc), each of whom had pericardial effusion with an estimated volume of more than 200 ml, were reviewed to study the clinical and immunological significance of massive pericardial effusion in SSc. Diffuse SSc (4/5), with a wide area of pigmentation (4/5), flexion contracture (4/5), oesophageal hypomotility (5/5), pulmonary fibrosis (4/5) and autoantibodies to topoisomerase I (3/5) were the common features in this group. High protein, lactate dehydrogenase and low white blood cell count were the characteristics of pericardial fluid. None of the patients had signs of acute pericarditis. Four of the five cases died within 9 months of the diagnosis of pericarditis; two with renal failure, one with cardiac tamponade and another with sudden death. The pericarditis in diffuse SSc, especially in cases with anti-topoisomerase I, may be characterized by a chronic form of pericarditis with poor prognosis, often complicated by renal failure.

Immunofluorescent staining of metastatic carcinoma cells in serious fluid with carcinoembryonic antibody, epithelial membrane antibody, AUA-1 and Ber-EP4

Using an indirect immunofluorescence technique, we assessed the accuracy and clinical usefulness of a panel of monoclonal and polyclonal antibodies. The panel consisted of carcinoembryonic antibody (CEA) and epithelial membrane antibody (EMA), AUA-1, and Ber-EP4 conjugated with fluorescein isothiocyanate. Twenty-six specimens from pleural, peritoneal or pericardial effusions known to contain carcinoma cells (adenocarcinoma or large cell anaplastic carcinoma) and 16 specimens without carcinoma were first examined. The sensitivity and specificity for each of the antibodies were as follows: CEA, 71% and 75%; EMA, 96% and 81%; AUA-1, 80% and 100%; and Ber-EP4, 85% and 100%, respectively. The panel of antibodies was then applied to a group of 14 'problematic' fluids. These had been identified as causing dilemmas in interpretation, either because the cells in the fluids were of equivocal appearance on light microscopy, or the cytological diagnosis was different from that expected in the light of the clinical condition of the patient. Insufficient cellular material was present in one specimen. In five (39%) of the cases the immunochemical staining supported the light microscopic diagnosis. In four (30%) cases, however, the results indicated that the original light microscopic report was incorrect. Two of these were examples of large cell carcinoma of the lung, in which false negative reports had been issued on pleural fluids. The other two were cases of benign ovarian tumours in which a false positive report had been issued. The immunostaining also clarified the final diagnosis in the three patients (23%) on whom 'suspicious' cytological reports had previously been issued. The remaining case, fluid from a patient with a high grade mixed Mullerian tumour of the ovary, was unresolved. We conclude that immunofluorescent staining by AUA-1, EMA and Ber-EP4 is an aid in the cytological interpretation of serous fluids. CEA is much less helpful.

Pericardioscopy and epicardial biopsy--new diagnostic tools in pericardial and perimyocardial disease

Pericardioscopy is a new diagnostic tool for macroscopic visualization of alterations in both the epicardium and pericardium. We report on 35 patients with pericardial effusion due to inflammatory perimyocardial disease. After puncture of the pericardial effusion, an 8F sheath was introduced over a guidewire under X-ray control. The pericardial pressures were measured; the fluid was removed by aspiration and exchanged with 100 ml of body-warm saline until the pericardial fluid was clear. To visualize the peri- and epicardium, for video- and photo documentation, two sorts of 8F endoscope were used, either a flexible fibreglass version or a rigid 110 degree one--both made by Storz. Cytology of the fluid and optically guided and controlled epicardial and pericardial biopsies were performed to classify the form of pericarditis. A specific diagnosis of viral pericarditis could thus be established in seven cases--by in situ hybridization for cytomegalovirus (n = 3) and by microneutralization test for enteroviruses and/or coxsackievirus B4 isolation (n = 4); of lymphocytic perimyocarditis in 16; of bacterial pericarditis in seven and antibody-mediated autoreactive pericarditis in five cases.

Immunophenotype of lymphocytes in pericardial fluid from patients with different forms of heart disease

Cytofluorometric analysis was performed to characterize the immunophenotype of lymphocytes of the pericardial fluid (PF) from 127 patients undergoing open cardiac operation (heart valve disease, congenital heart defects, chronic ischemic heart disease). Macrophages and T cells represented the dominant cell types. Similar to T cells of body fluids other than peripheral blood, a high percentage of PF T cells expressed CD45RO and activation-associated molecules such as HLA-DR, CD69, CD54 and CD26. Surprisingly, we could demonstrate a very high proportion of CD11b+ T cells in PF. Furthermore, a significant proportion of PFT cells expressed aminopeptidase N/CD13. PF was further analyzed for the presence of IL-6, TGF-beta as well as TNF-alpha. IL-6 levels were low (undetectable to 4,500 U/ml), TGF-beta levels ranged from < 3 ng/ml up to 80 ng/ml, and TNF-alpha levels from < 3 pg/ml to 233 pg/ml. These findings show evidence of the presence of activated lymphocytes with a special immunophenotype as well as multiple cytokines in PF of patients with different forms of heart disease.

Characterization of T cells infiltrating the heart in rats with experimental autoimmune myocarditis. Their similarity to extrathymic T cells in mice and the site of proliferation

A model of experimental autoimmune myocarditis, which resembles fatal giant cell myocarditis in humans, was previously established in rats immunized by s.c. injection of human cardiac myosin. We characterized herein the surface phenotype of lymphocytes infiltrating the heart and pericardial cavity as well as of mononuclear cells in various organs by using mAb in conjunction with immunofluorescence tests. Since profound thymic atrophy always accompanied the diseased states, attention was focused on characterization of T cells with properties similar to those of extrathymic T cells. In mice, extrathymic T cells were activated in association with thymic atrophy, expressed high levels of LFA-1 and IL-2R beta-chains, and contained a significant proportion of double negative CD4-CD8- T cells. In diseased rats, a large proportion of activated T cells that expressed high levels of LFA-1 and IL-2R was demonstrated in the pericardial effusion and heart tissue. Such T cells were rare in the other organs. Light scatter and microscopic observation revealed that activated lymphoblasts were most abundant in the pericardial effusion. Moreover, one-fourth of such T cells in the pericardial effusion displayed double negative phenotype. These cells in rats might correspond to the extrathymic T cells in mice. However, only a limited population of such activated T cells infiltrated the heart tissue. Concerning the location of such T cells mainly in the outer layer of the heart, it raised the possibility that extrathymic T cell differentiation in these autoimmune rats might occur in the pericardial cavity, and the differentiated cells then migrated to the sites of the cardiac lesion.

Usefulness of serum CA125 measurement for monitoring pericardial effusion

To investigate the clinical significance of carbohydrate antigen 125 (CA125), an antigen related to ovarian cancer, in patients with pericardial effusion, we examined the relationship between serum levels of CA125 and the presence or severity of pericardial effusion. Fifty-seven patients (25 with heart failure, 22 with pericardial metastasis, 4 with hypothyroidism, 4 with renal failure, and 2 with other diseases) in whom pericardial effusion was confirmed by echocardiography or autopsy, were used as subjects. Thirty-seven of these patients (65%) tested positive for CA125 in the serum. Of these, no significant differences in serum levels of CA125 were found between patients with benign and those with malignant underlying diseases or between those with, or without, pericarditis. However, CA125 values were higher in the patients with larger pericardial effusions and the serum level decreased when the pericardial effusion reduced. In some cases, the serum level normalized before the effusion resolved. Pericardial drainage was performed on 6 patients with cardiac tamponade. Four of these 6 patients had high serum CA125 levels and recurrent pericardial effusion. The other 2 patients had normal serum CA125 levels and no recurrence of effusion. An immunohistological study showed that a positive stain of pericardial tissues reacting to CA125 antibodies correlated to higher serum and pericardial fluid levels of CA125 than the levels of groups staining negative to the antibody. These results suggest that CA125 can be useful in assessing the status and clinical course of this disease.

Use of a Pool of Monoclonal Antibodies in Diagnosing Cells from Serous Cavities

Aims and Background

The usefulness of monoclonal antibodies that recognize markers of neoplastic lesions in complementing conventional cytology was evaluated by the avidin-biotin-peroxidase complex, indirect immunoperoxidase technique.

Methods

In order to enhance the sensitivity of the traditional method, a pool of seven combined monoclonal antibodies (Pool C7), which reacts specifically with cells of epithelial origin and is able to distinguish between mesothelial and malignant cells, was tested on cytologic smears of 262 serous effusions. The effusions were benign or neoplastic, mainly from breast, ovary and lung cancers.

Results

Immunocytochemical method showed an 100 % specificity and 100 % of predictivity whereas the sensitivity was 98 %, 96 % and 95 % for breast ovarian and lung carcinomas, respectively.

Conclusions

The results demonstrated that the pool when used together with conventional methods, is useful in analysis of serous effusions in diagnostic investigations.

Immunology of cardiac tumors

Whereas abundant literature is available on mechanisms imposed by neoplastic diseases on the immune system, only few details are known about immunological parameters of autoreactive mechanisms directed against the heart. This report will focus on cardiac autoreactivity in patients with endomyocardial types of cardiac tumors (e.g. atrial myxomas), Hodgkin's disease, and with neoplastic pericardial effusion. In patients with atrial myxomas antimyolemmal antibodies were significantly increased when compared to non-cardiac controls. Antisarcolemmal antibodies were positive in 100% of trivalent immunoglobulin binding. Antiendothelial antibodies of the IgG type could be found in 86% of patients with atrial myxoma. Circulating immune complexes were present in 6 out of 7 patients. In 107 patients with Hodgkin's disease without pericarditis the presence of antimyolemmal antibodies was lower than in healthy controls. The incidence of antimyolemmal antibodies in 10 patients with pericarditis lymphogranulomatosa was 10%, whereas in postradiation pericarditis 8 of 15 patients demonstrated antimyolemmal antibodies. Antiendothelial antibodies were positive in 7 out of 15 patients. The number of patient lymphocytes available for functional assays is yet too small to permit further conclusions on cellular autoreactive mechanisms in Hodgkin's disease. Antimyocardial antibodies were found both in the serum and in the effusions at least in lower titers in all patients. With regard to in-vitro analysis it can not be excluded that a balance between protective and cytolytic antibodies keeps a normal mean of antibody-mediated cytolysis. Analysing the first line of defense, the natural killer cell activity was found significantly increased in neoplastic pericardial effusions, whereas peripheral blood and pericardial effusion showed no lymphocytotoxicity with isolated myocardial cells.

Antinuclear antibody in pericardial fluid from a patient with primary cardiac lymphoma

Pericarditis may be the initial manifestation of systemic lupus erythematosus. Although it is known that antinuclear antibody can be detected in the serum of patients with a wide variety of diseases, it has been proposed that the detection of antinuclear antibody in serosal fluid is a sensitive and specific test for determining that effusions are due to systemic lupus erythematosus. A case is presented in which antinuclear antibody in high titer was identified in the pericardial fluid of a patient who was found at autopsy to have a primary cardiac lymphoma. The case indicates that antinuclear antibody detected in serosal effusions should not be considered pathognomonic for systemic lupus erythematosus.

[ELISA immunoenzymatic assay in the pericardial fluid: a new method for the post-mortem diagnosis of Chagas disease]

Realizou-se o teste imunoenzimático ELISA, paralelamente à reação de imunofluorescência, para a detecção de anticorpos antí-Trypanosoma cruzi, em 137 amostras de líquidos pericárdicos humanos, colhidos na necropsia. Os resultados foram cotejados com os achados anatomopatológicos. Observou-se que: (1) os dois testes foram positivos em 30 casos e negativos em 105; (2) o teste ELISA foipositivo em 2 casos nos quais a immofluorescència revelou-se negativa; num desses casos, havia sinais morfológicos de doença de Chagas; (3) a média geométrica dos títulos obtidos com o teste ELISA foi significativamente maior que a da imunofluorescência; (4) o índice de concordância entre os dois testes apresentou o valor de 0,985. O presente relato parece-nos inédito quanto ao uso do teste imunoenzimático no líquidoperícárdicopara o diagnóstico post- mortem da doença de Chagas.

Value of immunocytochemistry in the study of malignant effusions

Recognition of malignant effusion relies heavily on cytologic examination despite the difficulty of distinguishing atypical mesothelial hyperplasia from metastatic carcinoma. The combination of CEA, EMA, vimentin, keratin, high-molecular-weight cytokeratin (HMWK), low-molecular-weight cytokeratin (LMWK), and Alcian blue was tested in 51 cytologic specimens of pleural, peritoneal, and pericardial effusions. These showed metastatic carcinoma in 38 cases (ovary, 14; lung, 8; breast, 7; GI, 4; endometrium, 4; bladder, 1) and mesothelial processes in 13 (hyperplasia, 9; mesothelioma, 4). Strong positivity for EMA (92%), CEA (90%), and Alcian blue (71%) was noted in metastatic carcinoma but not in the mesothelial processes. Keratin was positive in all cases of mesothelioma but occurred also in mesothelial hyperplasias (44%) and metastatic carcinomas (47%). In mesothelial cells, HMWK was consistently stronger than LMWK, whereas in adenocarcinoma the reverse was true. There was no difference in the degree or distribution of positivity of any of the markers among the various primary sites of the neoplasms. Our findings are consistent with the view that immunocytochemistry with a battery of antibodies is useful in the recognition of malignant effusions but cannot, as yet, determine the site of origin of metastatic neoplasms.

Pneumococcal pericarditis. Diagnostic usefulness of counterimmunoelectrophoresis and computed tomographic scanning

Although counterimmunoelectrophoresis (CIE) analysis of cerebrospinal fluid has proved useful in the diagnosis of meningitis, there has been little experience with its use in analyzing pericardial fluid. We describe two patients with pneumococcal pneumonia whose hospital course was complicated by purulent pericarditis. In one patient, results of a computed tomographic scan were important in suggesting the diagnosis. Results of a Gram's stain and culture of pericardial fluid failed to yield any organisms, presumably because both patients had received nine days of beta-lactam antibiotic therapy. However, the results from CIE analysis of pericardial fluid in both cases were positive for Streptococcus pneumoniae. In one patient, for whom capsular typing of the organism was performed, the pneumococcus type isolated from pericardial fluid matched the type isolated previously from a blood sample. The results of CIE can allow focused antibiotic therapy by establishing the correct diagnosis.