Morton J. Robinson

Fatal Strongyloidiasis Following Corticosteroid Therapy

Two fatal strongyloides stercoralis infections found at autopsy in patients who had received corticosteroid therapy are presented. A successfully treated case of strongyloidiasis with pulmonary infiltration is also reported. Difficulties in diagnosis, usefulness of upper jejunal intubation, and the importance of ruling out strongyloidiasis prior to administration of corticosteroids to patients with eosinophilia, particularly Vietnam veterans, are discussed.

Ferrugination caused by Monsel's solution. Clinical observations and experimentations

Ferrugination of fibrin, dermal collagen, and striated muscle fibers may result from the application of Monsels solution (20% ferric subsulfate) for hemostasis to wounds caused by excisions of skin. The collagen fibers in the dermis are coated with a slightly refractile, graybrown substance which is strongly positive with Perls reaction for iron. Ferruginated collagen fibers are eliminated through the epidermis as the epidermis regenerates. Some of the ferruginated fibers become calcified. Siderophages are present in these and adjacent areas. Secpage of Monsels solution into deeper tissues at the site of biopsy may result in ferrugination of skeletal muscle, perichondrium, and even eartilage.We applied Monsels solution to biopsy sites caused experimentally in a rabbit and confirmed the capacity of the solution to produce ferrugination of collagen fibers and skeletal muscle. Ferrugination of collagen fibers becomes less pronounced as the wounds heal and as iron pigment is taken up by macrophages. Ferruginated fibers of skeletal muscle act as foreign bodies to elicit a granulomatous reaction. Comparison of biopsy sites to which Monsels solution had been applied with biopsy sites to which the solution had not been applied indicates that the substance does not seem to interfere with the rate of epidermal regeneration. However, when there is injury to skeletal muscle and other deep tissues by Monsels solution, an inflammatory reaction persists at these sites for weeks.

Tetracycline-associated fatty liver in the male: Report of an autopsied case

SummaryDeath associated with hepatic decompensation and fatty liver developing during tetracycline administration is reported in an adult man without predisposing hormonal abnormality. Attention is focused on the dose-related hepatotoxicity of the tetracyclines, and caution in the intravenous administration of this antibiotic, even in the male, is stressed.

Autopsy demonstration of intramyocardial polymer gel emboli associated with a giant-cell reaction following cardiac catheterization: a case report

BACKGROUNDnForeign body type granulomatous vasculitis has been reported in blood vessels of the brain, lungs, and skin of the foot following intravascular instrumentation with devices coated with hydrophilic polymer gel. We report a case of intramyocardial polymer gel emboli associated with granulomatous vasculitis following cardiac catheterization.nnnMETHODnAutopsy observations in a 77-year-old woman are presented. The patient experienced an acute myocardial infarction requiring catheterization and coronary stenting. The patient returned with a pseudoaneurysm at the site of catheterization and shortly after suffered a fatal arrhythmia.nnnRESULTSnMicroscopically, multiple small vessels within the myocardium were noted to contain a basophilic, amorphous, focally lamellated, focally granular material. A granulomatous inflammatory response was noted in the vessels containing the foreign material.nnnCONCLUSIONSnOur case is the first to our knowledge to document intramyocardial vessel gel emboli following a cardiac catheterization with stenting. Although the microscopic finding of emboli within vessels does not seem to be the immediate cause of death in our case, it is highly possible that it contributed to the patients demise.

Pleomorphic liposarcoma of the pterygomandibular space involving the maxilla

Liposarcoma of the head and neck is rare. Because of its rarity, we report this case of pleomorphic liposarcoma of the left pterygomandibular space, involving the maxilla, maxillary sinus, left lateral maxillary wall, left maxillary gingiva with extension into the buccal space, retro-orbital region, left mandibular ramus, and left zygomatic process. To our knowledge, there are only two other reported cases of liposarcoma involving the maxilla, one of which was a pleomorphic liposarcoma. The pertinent literature is reviewed with an emphasis on the importance of histopathologic classification.

Fatal pneumococcal Waterhouse-Friderichsen syndrome in a vaccinated adult with congenital asplenia

Overwhelming postsplenectomy infection (OPSI) is a low-incidence entity with a high mortality rate despite aggressive therapy. Although initial symptoms may be mild and nonspecific, it can progress rapidly to WaterhouseFriderichsen syndrome with full blown septic shock and disseminated intravascular coagulation (DIC). Overwhelming postsplenectomy infection is known to occur at any time after splenectomy, even in patients who have received pneumococcal immunization and/or chemoprophylaxis. Although the term OPSI gives the impression of a “postsurgical” complication, it has been seen in association with conditions predisposing to functional hyposplenism and in children with congenital asplenia. To our knowledge, there has been no previously reported case of OPSI in a pneumococcal vaccinated adult with congenital asplenia. We report a 67-year-old woman with congenital asplenia and current pneumococcal immunization who presented to our emergency department with low-grade fever and nonspecific symptoms that evolved to DIC, refractory hypotension, shock, and death in less than 24 hours. The diagnosis of Waterhouse-Friderichsen syndrome was made at autopsy. The causative organism was Streptococcus pneumoniae. A 67-year-old woman with congenital asplenia presented to our emergency department complaining of chills, fever, severe low back pain, and vomiting of 24 hours of duration. She had a recent history of a treated urinary tract infection and a remote history of sepsis and pneumonia, for which she was hospitalized and treated in other institutions. The patient also had a diagnosis of lung fibrosis of uncertain etiology and was a chronic alcohol user. The patient had received pneumococcal vaccination 1 year prior. On physical examination, she was found to be alert and in no acute distress. Her temperature was 38°C orally; blood pressure, 100/42 mm Hg; heart rate, 113/min; respiratory rate, 26/min; and oxygen saturation, 95% on room air. She had mild tenderness to palpation in the right lower abdominal quadrant and positive bowel sounds. Her initial blood workup showed an elevated white blood cell count of 15.5 0735-6757/

Aggressive Epithelioid Hemangioendothelioma of the Lower Extremity: A Case Report and Review of the Literature

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Significance of Periductal Lymphatic and Blood Vascular Densities in Intraductal Carcinoma of the Breast

A case of epithelioid hemangioendothelioma (EHE) of the left lower extremity in a 50-year-old male is discussed. The neoplasm presented as a tan-purple, painful mass involving the fourth digit of the left foot. Following an excisional biopsy and partial amputation of the fourth digit, the lesion recurred with a multifocal distribution. A physical exam following the recurrence demonstrated multiple palpable lymph nodes in the left inguinal region. A complete amputation of the fourth digit was performed in conjunction with local excisions of the remaining lesions. Additionally, an inguinal lymphadenectomy was performed for staging purposes. Histologically, the tumor was predominantly composed of epithelioid endothelial cells forming nests, cords, and sheets and occasionally forming irregular, primitive vascular structures. Less commonly, nests of tumor cells assumed a spindled morphology. Patches of necrosis and hemorrhage were apparent throughout the neoplasm. There was minimal atypia and mitoses were not identified. Immunohistochemical stains for CD34, CD31, and Ulex europaeus antigens were positive in tumor cells. This case illustrates the potential aggressive behavior of this rare neoplasm and argues against the designation tumor of low-grade malignancy with which it is commonly attributed.

Postmortem Demonstration of the Source of Pulmonary Thromboembolism: The Importance of the Autopsy

Abstract:u2002 We investigated the significance of periductal lymphatic and blood vascular densities in intraductal carcinomas (IDC) of the breast. Thirty five cases of pure IDC treated by partial or total mastectomy were reviewed. Seven cases with normal breast tissue and 48 cases of invasive breast carcinoma were included as controls. All cases were immunostained with D2‐40 and CD31. Positively stained microvessels were counted in densely vascular/lymphatic foci (hot spots) at 400× (=0.17u2003mm2) in the periductal areas. IDC without comedonecrosis showed a mean periductal D2‐40 lymphatic microvessel density (LMD) of 5.8u2003±u20035 (range 0–18), and a CD31 microvessel density (MD) of 14u2003±u20038.9 (range 1–40). IDC with comedonecrosis showed periductal D2‐40 LMD of 8.4u2003±u20033.8 (range 4–18), and a CD31 MD of 24.3u2003±u20037.6 (range 14–40). There was a significant difference between periductal D2‐40 LMD and CD31 MD counts in IDC with and without comedonecrosis. There was a positive correlation of periductal D2‐40 LMD and CD31 MD counts with high nuclear grade (ru2003=u20030.39 and 0.56) of IDC as well as with the presence of comedonecrosis (ru2003=u20030.49 and 0.59). Both D2‐40 LMD and CD31 MD did not correlate significantly with tumor size, estrogen status, or progesterone status. As IDC with comedonecrosis and/or high nuclear grade has a worse prognosis than IDC without comedonecrosis and/or with low nuclear grade, it appears that lymphatic and blood vascular density evaluated by D2‐40 and CD31, respectively, are independent prognostic indicators for patients with IDC of the breast and may be an indicator of early or unrecognized invasion or “regression.”

THE MODIFIED STEINER STAIN: A NEW USE FOR AN OLD STAIN? STAINING CYTOMEGALOVIRUS-INFECTED CELLS IN GASTROINTESTINAL BIOPSIES

Periprostatic or paravaginal venous thromboses are rarely considered clinically as sites of clot origin in patients with pulmonary thromboembolism. The majority of emboli have been demonstrated to originate in the veins of the legs. This report raises awareness of pelvic vein thrombosis as a potential source of pulmonary embolism that is rarely considered or detected clinically, and which usually requires postmortem examination for recognition. It also reviews the possible routes emboli may take to reach the lungs.