Liron Pantanowitz

Cryoprecipitate. Patterns of use.

The type of coagulation factors and proteins in cryoprecipitate determine the appropriate indications for its use. To determine the pattern of use at a tertiary care medical center, we performed a retrospective audit of cryoprecipitate utilization. A total of 51 patients received 88 pools of cryoprecipitate. In 39 patients, cryoprecipitate was transfused for appropriate indications: hypofibrinogenemia (n = 19), tissue plasminogen activator reversal (n = 1), management of massive transfusion (n = 7), correction of uremic bleeding (n = 2), and for making fibrin sealant (n = 10). Overall, these patients used approximately 80% of the cryoprecipitate transfused. In 12 other patients, cryoprecipitate was transfused inappropriately to attempt reversal of the anticoagulant effects of warfarin therapy (n = 6), to treat impaired surgical hemostasis in the absence of hypofibrinogenemia (n = 4), and to treat hepatic coagulopathy with multiple factor deficiencies (n = 2). The patterns of misuse, involving 24% of all cryoprecipitate orders, suggest a widespread misunderstanding and need for focused education about the coagulation factors and proteins present in cryoprecipitate and appropriate indications for its use.

Pathology of the Breast Associated With HIV/AIDS

Breast pathology that is characteristic of patients infected with human immunodeficiency virus (HIV) has not been addressed in the literature. HIV may directly and indirectly affect the glandular, mesenchymal, and intramammary lymphoid tissue in seropositive patients. Likely infections in this setting include tuberculous mastitis and pyogenic abscesses that may lead to fatal septicemia. Benign stromal changes include gynecomastia, adipose tissue deposition as part of the fat maldistribution syndrome, and pseudoangiomatous stromal hyperplasia. Breast carcinoma in HIV‐infected patients occurs at a relatively early age, with increased bilateral disease, unusual histology, and early metastatic spread with a poor outcome. However, the link between breast cancer and HIV remains controversial. Kaposis sarcoma and non‐Hodgkins lymphoma may also be localized to the breast in patients with acquired immunodeficiency syndrome (AIDS). This article reviews benign and malignant breast diseases that are likely to be encountered in patients with HIV/AIDS.

Evolving spectrum and incidence of non-AIDS-defining malignancies.

Purpose of reviewNon-AIDS defining cancer (NADC) has emerged as an important cause of morbidity and mortality in the HIV-infected population. Insight into the incidence, spectrum, risk factors, management, and outcome of these cancers has continued to emerge. The recent literature on this topic is reviewed. Recent findingsSeveral recent studies have explored the shifting spectrum of NADC in both developed and underdeveloped regions of the world. Investigators have shown only a minor difference in the geographic spectrum of NADC. Although several NADC have continued to occur at rates significantly higher than expected, a noticeable decline was observed in other cancers despite antiretroviral therapy. Factors other than HIV and immunosuppression proved to be important in the risk, treatment response, and outcome of these neoplasms. Studies dealing with the management of several NADC were published, including the role of highly active antiretroviral therapy (HAART). SummaryAn increased overall relative risk of developing NADC continues to be reported in the HIV-infected population worldwide. The development of NADC appears to be multifactorial. Although control of HIV viremia has proven to be beneficial, the impact of HAART on NADC incidence rates and survival is not uniform. Further effort is needed to resolve the direct and indirect effects of HIV on NADC in order to guide effective prevention and treatment strategies of these malignancies.

Breast Enlargement in 13 Men Who Were Seropositive for Human Immunodeficiency Virus

Breast enlargement, a condition that was rarely reported in the era before highly active antiretroviral therapy, is emerging as a problem in the treatment of male human immunodeficiency virus (HIV)-infected patients. Evaluation of this condition must distinguish between gynecomastia (proliferation of ducts and periductal stroma), lipomastia (adipose-tissue deposition), and malignancy. We describe 13 HIV-infected men, all of whom had exposure to antiretroviral therapy, who presented with breast enlargement. Nine of these patients had gynecomastia, only 1 had lipomastia, and 3 had lymphoma (2 had non-Hodgkin lymphoma and 1 had Hodgkin disease). Gynecomastia was unilateral in all but a single case. In addition, all but 1 of our patients with gynecomastia had prolonged exposure to protease inhibitors. Six patients had potential causes of gynecomastia other than antiretroviral therapy, including liver disease (in 2 patients), mild hypogonadism (in 1), long-term marijuana use (in 2), and use of medications that have known associations with gynecomastia (in 3). Although most causes of breast enlargement in HIV-infected men are likely to be benign, malignancies other than carcinoma are of concern.

Significance of the juxtaoral organ (of Chievitz)

Most physicians are unaware of the juxtaoral organ (of Chievitz) and its clinical significance. The aim of this review is to draw attention to the clinical importance of this organ.

High‐resolution imaging of the thyroid gland using optical coherence tomography

Current diagnostic imaging modalities of the thyroid gland cannot reliably distinguish benign from malignant lesions, primarily because of their inability to visualize microscopic structure. A high‐resolution imaging technique capable of examining thyroid tissue architectural morphology in real time is needed. Optical coherence tomography (OCT) has been shown to achieve high resolutions approaching the cellular range (1–15 μm). The feasibility of optical coherence tomography for imaging thyroid tissue was explored ex vivo on the human thyroid gland.

Tick-borne diseases in transfusion medicine

Summary Ticks are effective vectors of viral, bacterial, rickettsial and parasitic diseases. Many of the tick‐borne diseases (TBDs) are of significance to transfusion medicine, either because of the risks they pose to the blood supply or the necessity for blood products required in their treatment. The transmission of tick‐borne pathogens via blood transfusion is of global concern. However, among transfusion medicine practitioners, experience with most of these microorganisms is limited. Transfusion transmission of TBDs has been documented largely by means of single case reports. A better understanding of the epidemiology, biology and management of this group of diseases is necessary in order to assess the risks they pose to the blood supply and to help guide effective prevention strategies to reduce this risk. Unique methods are required to focus on donor selection, predonation questioning, mass screening and inactivation or eradication procedures. The role of the transfusion medicine service in their treatment also needs to be better defined. This article reviews the growing body of literature pertaining to this emerging field of transfusion medicine and offers some recommendations for transfusionists in dealing with TBDs.

HHV8 is not limited to Kaposi's sarcoma

To the editor: We read with interest the recent paper by Patel et al in which they report strong immunoreactivity for human herpes virus 8 (HHV8) latent nuclear antigen-1 (LNA-1) in all (21/21 cases) of their Kaposi sarcoma lesions, whereas all of their non-Kaposi’s sarcoma cases (including hemangioma, angiosarcoma, etc) were negative for this antigen. Their finding corroborates those of other similar studies using reverse transcription polymerase chain reaction (RT-PCR) and immunohistochemistry directed against LNA-1. The deduction reached by Patel and colleagues is that LNA-1 is a highly sensitive and specific marker of HHV8 infection in paraffin-embedded tissue sections of Kaposi’s sarcoma, and therefore provides a useful tool for differentiating Kaposi’s sarcoma from its mimics, which do not express HHV8 LNA-1. However, we would like to point out that the prevalence of HHV8 seropositivity far exceeds that of Kaposi’s sarcoma. Moreover, Patel et al conducted their study in Cleveland, Ohio in the United States of America (USA) where the prevalence of HHV8 infection is reported to be very low. By comparison, in sub-Saharan Africa and the Mediterranean region HHV8 seropositivity in the general population is high. Therefore, it is plausible in the correct setting for HHV8 to be detected (by molecular or other means) in nonKaposi’s sarcoma lesions in those individuals who harbor HHV8. Patel et al did not report the HHV8 infectious status of their non-Kaposi’s sarcoma cases. They did, however, correctly point out that other non-Kaposi’s sarcoma vascular lesions (eg reactive angioendotheliomatosis) may stain positive for LNA-1 in lesional cells. Some investigators (from the USA) have detected HHV8-like DNA sequences (by PCR) in several (7/24) angiosarcomas. Another, even more illustrative case, was the demonstration of HHV8 in a dermatofibroma by both PCR and in situ hybridization (ISH) in a patient who was HIV-negative but seropositive for HHV-8 antibodies. These authors further indicated that the presence of HHV8 in the studied dermatofibroma was probably blood-borne due to viremia and not due to viral replication in tumor cells. The purpose of this letter is to reiterate these findings and to emphasize that the differential diagnosis of Kaposi’s sarcoma from its mimics should not rely solely on the presence or absence of HHV8 in lesional tissue.

Human Immunodeficiency Virus—Associated Hemophagocytosis with Iron-Deficiency Anemia and Massive Splenomegaly

We present a case of hemophagocytic syndrome in a human immunodeficiency virus-positive man with iron-deficiency anemia that did not respond to highly active antiretroviral therapy. Clinical resolution occurred only after a splenectomy was performed.

Cytomorphology of verrucous carcinoma of the cervix. A case report.

BACKGROUNDnVerrucous carcinoma of the uterine cervix is rare. Cytology is thought not to be helpful in the diagnosis of this lesion due to its bland morphology. The cytologic features of this lesion remain poorly defined.nnnCASEnThe cytologic findings in a Pap smear facilitated the diagnosis of verrucous carcinoma of the cervix. The features included atypical polygonal and spindle cells with abundant, keratinizing cytoplasm; atypical squamous cells with pearl formation; and frequent, nonkoilocytic cytoplasmic vacuolization.nnnCONCLUSIONnThere are 30 published reports on verrucous carcinoma involving the cervix and vagina that include the cytologic findings. In 70% of these cases, cytology was abnormal. Recognition of the cytologic characteristics may help in identifying this lesion on cytology, prevent delays in diagnosis and ensure that patients receive appropriate therapy.