Richard Siderits

Cutaneous anthrax: conservative or surgical treatment?

This article summarizes the diagnostic features and treatment recommendations for cutaneous anthrax, exemplified by a case report of nontypical cutaneous anthrax. The treatment of choice is medical, with ciprofloxacin or doxycycline the preferred antibiotics. However, surgical biopsy may be used if the clinical setting and microbiologic examination of swabs are not diagnostically conclusive. Histopathologic findings explain the clinical observation that most cutaneous anthrax lesions heal without scar formation.

Three‐dimensional reconstruction of the human renal glomerulus

The capillary bed of the human renal glomerulus is one of the more complex capillary structures in the human body. This paper illustrates three‐dimensional reconstruction of the capillary bed from serial sections. It shows that, although traditional methods of three‐dimensional rendering by computer fail to handle the complexities of the capillary structure, new methods based on filtering using three‐dimensional mathematical morphology are capable of revealing previously unseen details. This is done at the expense of eliminating fine structure (small capillaries). An error analysis allows the degree to which fine details are lost to be estimated.

Endoscopically identified pseudomelanosis duodeni: striking yet harmless

Melanosis and pseudomelanosis duodeni are benign processes that appear endoscopically as black tiger stripes. Histologically, aggregates of pigment-laden macrophages are observed in the lamina propria of the duodenal villi, most commonly within the apical tips. These pigments may include lipomelanin, ceroid, and iron sulfide. Results of iron staining with Prussian blue is characteristically variable. Pseudomelanosis duodeni may be associated clinically with hypertension, end stage renal disease, diabetes mellitus, and certain medications; for example, pigment deposition has been associated with absorption of cyclic compounds in antihypertensive medications. We report a case of an 80-year-old woman presenting with a brief history of vague abdominal pain. Endoscopic evaluation documented nonerosive gastritis and a darkly pigmented duodenal mucosa. Biopsy of the duodenum revealed subepithelial black pigment that was negative for stainable iron. These findings are consistent with pseudomelanosis duodeni, a benign duodenal mucosal pigmentation with variable iron staining results and specific clinical associations. Pseudomelanosis duodeni is relatively uncommon and is considered to be a benign condition, first described in 1976 by Bisordi and Kleinman. It usually is identified

Angiosarcoma of Small Bowel Presenting with Obstruction: Novel Observations on a Rare Diagnostic Entity with Unique Clinical Presentation

We present a case of angiosarcoma in small bowel, presenting with partial small bowel obstruction in a 79-year-old man with no history of radiation, chemotherapy, toxin exposure, or previous operative intervention. Angiosarcoma of small bowel is a rare entity which may present with nausea, abdominal pain, recurrent bleeding, and usually a history of prior radiation or exposure to specific toxins (polyvinyl chloride). Angiosarcoma of small bowel tends to spread rapidly and has a poor prognosis. We review the surgical and oncologic challenges. We report unique macroscopic findings of raised hyperemic margins, which are suggestive of a vasogenic lesion and the histologic feature of a partially retiform pattern with dense basement membrane material in an otherwise poorly differentiated lesion.

Schistosoma mansoni in Colon and Liver

Schistosoma mansoni is the species of the superfamily Schistosomatoidea that is pathogenic to humans. It is found in many countries in Africa and the Arabian Peninsula, as well as in the Western Hemisphere, including the islands of the West Indies and parts of Brazil. Its life cycle alternates between asexual multiplication in aquatic snails and sexual reproduction in humans. The life cycle of the major Schistosoma species has been described previously. 1 Cercariae infect humans through skin penetration in snail-infected waters. The parasites then migrate to the lungs and liver as schistosomula. They mature (female size, 1.6 cm) and mate in approximately 6 weeks. The adult worms are free of host reaction. Their habitat is portal venous, primarily of the large intestine, and egg deposition is hepatic and colonic. The eggs are elongated, with a prominent lateral spine near the more rounded posterior end, and measure up to 180 3 70 mm. They have a propensity to invade the venous walls and to penetrate the adjacent stroma. The eggs elicit the host reaction, which consists of suppurative inflammation and all stages of granulomas. Some eggs are excreted and are capable of hatching in water and infecting the snail intermediate host. Other eggs are trapped in the host tissue, where they die and disintegrate. Dead eggs usually are surrounded by resolving or scarred foci. Schistosoma mansoni eggs do not calcify. Inflammatory reaction can cause symptoms related to impairment of any organ in which the eggs are deposited, producing significant scarring. Therefore, an early diagnosis and prompt treatment are important. The diagnosis is based on the presence of eggs in feces (possibly using concentration methods to detect them) and in colonic biopsy specimens. 2 The images of eggs surrounded by inflammatory reaction in the colonic mucosa and the liver illustrate our case and correlate with clinical symptoms. A 25-year-old woman presented with a multiyear history of diarrhea. On examination, anemia, elevated liver enzymes, and gastrointestinal bleeding were found. She underwent elective colonoscopy, which revealed friable, erosive, and granular mucosa of the distal colon. Microscopic examination showed colonic mucosa with generally preserved crypt architecture, moderate inflammatory infiltrate of mucosal stroma, and multiple viable and nonviable parasitic eggs scattered in the mucosal stroma. Some areas with distorted crypt architecture and intraluminal leukocytes were noted, usually next to disintegrating eggs; however, no significant increase of intraepithelial leukocytes was seen

Retroperitoneal cystic abdominal lymphangiomatosis diagnosed by fine needle aspiration: a case report.

BACKGROUND Attributed to congenital malformation of lymphatic ducts, diffuse retroperitoneal cystic abdominal lymphangiomatosis has a distribution that often corresponds to the location of primitive fetal lymphatic sacs. Three recognized types are capillary, cavernous and cystic. Multisystem involvement may occur involving spleen, liver, bone, pancreas, soft tissue, limbs and brain. CASE A 55-year-old, healthy male with multiple liver lesions and retroperitoneal lymphadenopathy presented for retroperitoneal fine needle aspiration, producing 20 mL of milky liquid. Immediate cytologic evaluation showed a heterologous population of mature lymphocytes with chylomicrons. Flow cytometry revealed a polyclonal population of mature lymphocytes. Chemical analysis demonstrated a normal serum cholesterol level and an elevated triglyceride level. Serum markers were noncontributory. We review the differential diagnostic considerations leading to obstruction or retention of lymphatic fluids (malignancy, surgical, infective and traumatic), with an emphasis on the importance of onsite cytologic evaluation, correlation with clinical history and review of the etiologic considerations. CONCLUSION The constellation of clinical, radiologic, cytologic and laboratory findings presented in this paper are diagnostic of diffuse retroperitoneal cystic abdominal lynmphangiomatosis. To our knowledge, this entity has not been reported before in the fine needle aspiration literature. To prevent further disruption of lymphatic drainage, no further surgical sampling is planned.

Autopsy Report with Clinical and Pathophysiologic Discussion of Autosomal Dominant Adult Polycystic Kidney Disease

The average weight of a kidney is approximately 135 gm, measuring on average 10 × 6 × 4 cm. In hereditary conditions, autosomal dominant and autosomal recessive polycystic kidney disease, the shape, size, and the weight can be significantly abnormal, causing progressive renal failure, often necessitating dialysis or renal transplant for survival. We report a case of adult polycystic kidney disease in a 50-year-old female without a family history, who died of complications of the disease which included accelerated hypertension, and renal and cardiac failure.

Esophageal Plasmacytoma Diagnosed in a Patient Presenting with Cardiac Symptoms: A Novel Case

Extramedullary plasmacytoma is the uncommon phenomenon of a plasma cell neoplasm occurring outside of the bone marrow. Primary plasmacytoma is a rare occurrence in the gastrointestinal tract and exceptional to originate in the esophagus. We present a novel case of a 62-year-old man who presented to our emergency department with chest pain. A cardiovascular workup was negative, and an endoscopy was subsequently performed. The endoscopy findings showed evidence of Grade IV esophagitis with ulcerations extending from 25 cm to 32 cm. Histopathological examination revealed marked acute and chronic inflammation, granulation tissue, and overlying necroinflammatory exudate. However, sheets of plasma cells, some with prominent nucleoli, were also seen. Immunohistochemically, the plasma cells expressed CD138 and MUM1 and were IgG kappa restricted. A bone marrow biopsy was performed which was negative for involvement. This is a novel case of esophageal plasmacytoma diagnosed on endoscopy in a patient presenting with acute chest pain.

Renal Pelviceal Keratinizing Squamous Metaplasia with Sparing of Pyramidal Zones

Metaplastic changes in the urothelium of the upper urinary tract are relatively infrequent. Metaplasia may present as either squamous or less often glandular differentiation. The process may be associated with chronic inflammation or associated chronic infections. There may be malignant transformation to either squamous cell carcinoma or adenocarcinoma. The demarcation of the metaplastic process in the minor calyces has not been well documented to date. We report the case of a 74-year-old female patient who presented with a history of chronic renal disease and acute pyohydronephrosis. The patient underwent a nephroureterectomy which revealed keratinizing desquamative squamous metaplasia throughout the renal pelvis and upper urinary tract with abrupt termination of metaplasia at the junction of the renal pelvis and the minor calyx (pyramidal zone). Immunohistochemical evaluation documents metaplastic urothelium stained positive for CK5, before converting sharply to simple cuboidal epithelium in the minor calyx (pyramidal zones) which stained positive CK7. At the junction of the metaplastic components and low cuboidal lined minor calyceal surfaces, the underlying stroma showed loss of ureteral muscularis mucosa with transition to renal parenchymal type stroma. We believe that this observation is unique and potentially relevant to the etiology and pathophysiology of pelviceal metaplasia.

Preparation and use of a scabies skin scraping kit.

A scabies outbreak could potentially occur in any health care facility at any time. Health care providers need to understand the proper steps to take in handling a suspected scabies case to keep this highly contagious infection under control. Because determining whether a rash is scabies, transporting the patient to a facility that can perform a skin scraping, or simply locating the appropriate materials for a skin scraping can be time consuming, prepared scabies skin scraping kits have been developed at the authors’ facility; an educational program has been made available as well. This article discusses and illustrates the facility’s method of skin scraping and describes the supplies included in a prepared scabies skin scraping kit. The prepared kits are available to nursing units, emergency departments, outpatient services, clinics, and nursing homes throughout the hospital network. An educational presentation that includes video segments of the procedure is also accessible via the Internet. The combination of these factors has had a positive impact on the practice of skin scraping within the authors’ hospital network.