Bioptic Findings Research Articles

P70 UNEXPLAINED TRANSIENT BIVENTRICULAR DYSFUNCTION IN A PATIENT WITH DISSEMINATED TUBERCULOSIS AND SEVERE EOSINOPHILIA

Abstract Introduction Tuberculosis (TB) is an infectious disease with significant global burden. Pericardial injury is relatively common, while myocardial involvement has only rarely been described. Case presentation A 29-years-old man from Gambia with disseminated TB, treated with isoniazid, rifampin, pyrazinamide and ethambutol, was admitted to our hospital. He denied history of heart disease, cardiovascular risk factors and voluptuary habits. Laboratory exams revealed severe eosinophilia without microbiological evidence of parasitic infection; a lymphocyte proliferation test ruled out allergic reaction to anti-TB therapy. Baseline echocardiographic evaluation showed normal cardiac function with negative troponin. The patient, subsequently, developed worsening dyspnoea and asthenia with progressive biventricular dysfunction. Therefore, he was admitted to our department for further investigations. Cardiac magnetic resonance (CMR) showed a 20% left ventricular ejection fraction and absence of myocardial oedema or fibrosis [Fig.1]. Coronary CT angiography (CCTA) was unremarkable. Endomyocardial biopsy (EMB) showed absence of TB lesions or eosinophilic infiltration. Cardiac troponin and electrocardiogram remained negative throughout. Optimal medical therapy (OMT) for heart failure was promptly initiated. After several months an almost complete recovery of cardiac function was documented [Fig.2]. Discussion In cases of ventricular dysfunction, establishing an etiological diagnosis is imperative, though sometimes challenging. When pre-test probability is low, CAD can be ruled out by CCTA. Myocarditis is a common cause of reversible cardiac dysfunction. In this case, the absence of Lake Louise criteria, negative bioptic findings, persistently negative cardiac troponin and microbiological tests argue against this diagnosis. However, the timing of investigations can affect diagnostic accuracy; furthermore, focal lesions can be missed by EMB, leading to false negative results. Alcoholic cardiomyopathy (CMP) could be an option, but it was not considered due to absence of alcohol consumption. The clinical picture was not compatible with a typical CMP phenotype. Immune-mediated reaction to anti-TB drugs was ruled out by immunological testing. Although not previously described, ethambutol and pyrazinamide direct cardiotoxicity may explain transient impairment of cardiac function. Recovery may be related to withdrawal of these drugs and introduction of guideline-directed OMT.

P4422Myocarditis: a deceitful but not infrequent athletes' enemy

Abstract Introduction Myocarditis represents a not negligible cause of sudden death (SD) in athletes, representing the cause of 4%-14% cardiac arrests and deaths in athletes. Preparticipation screening including 12-leads basal electrocardiogram could drastically reduce SD in athletes and screening programs are therefore now recommended by most medical and sport association. At the moment, no data in literature are available about incidence of concealed myocarditis in athletes but there is general consensus about disqualification from competitive sport in the presence of myocardial fibrosis (MF). Purpose Purpose of our study was to quantify incidence of MF consistent with past myocarditis in athletes that referred to our Sport Cardiology Center for ventricular arrhythmias (VA) +/− repolarization abnormalities (RA) detected at preparticipation screening. Methods In our study we retrospectively evaluated all athletes with VA +/− RA and we quantified how many were found to have MF consistent with myocarditis at cardiac MRI. Furthermore, we evaluated characteristics of presentation in terms of clinical symptoms of myocarditis and frequency and morphology of VA. Finally, we analyzed findings of invasive diagnostic workout when performed. Results In the last two years we evaluated 111 athletes for VA +/− RA and we found MF consistent with myocarditis in 18 (16%) of them. Only 2/18 referred past febrile status probably correlated with myocarditis and 1 had symptoms consistent with acute myocarditis. Number of VA was not correlated with MF fibrosis, while polymorphic VA and exercise-correlated VA were the most frequent finding. 5/18 (28%) had also rest and/or exercise induced RA. 10/18 (55%) athletes underwent electrophysiological study without any induction of arrhythmias. 7/18 (39%) underwent also electroanatomical mapping (EAM) with pathological findings in 5/7 (71%). All of these 5 underwent endomyocardial biopsy guided by EAM and in 2 cases bioptic findings were consistent with arrhythmogenic cardyomyopahty (ACM). All 18 athletes were disqualified from competitive sport as for Italian Sport Medicine protocols. Conclusion MF consistent with past myocarditis is a not infrequent finding in athletes with VA with or without RA. Morphology and exercise behavior of VA are the most important “alarm bell”, while VA number is not correlated with MRI pathological findings. Sometimes MF interpreted as consistent with past myocarditis is actually the manifestation of ACM. Identification of these diseases is of extreme importance for athletes' safety.

Return to work in heart failure patients with suspected viral myocarditis.

Background:Endomyocardial biopsy is considered as the gold standard in patients with suspected myocarditis. We aimed to evaluate the impact of bioptic findings on prediction of successful return to work.Methods:In 1153 patients (48.9 ± 12.4 years, 66.2% male), who were hospitalized due to symptoms of left heart failure between 2005 and 2012, an endomyocardial biopsy was performed. Routine clinical and laboratory data, sociodemographic parameters, and noninvasive and invasive cardiac variables including endomyocardial biopsy were registered. Data were linked with return to work data from the German statutory pension insurance program and analyzed by Cox regression.Results:A total of 220 patients had a complete data set of hospital and insurance information. Three quarters of patients were virus-positive (54.2% parvovirus B19, other or mixed infection 16.7%). Mean invasive left ventricular ejection fraction was 47.1% ± 18.6% (left ventricular ejection fraction <45% in 46.3%). Return to work was achieved after a mean interval of 168.8 ± 347.7 days in 220 patients (after 6, 12, and 24 months in 61.3%, 72.2%, and 76.4%). In multivariate regression analysis, only age (per 10 years, hazard ratio, 1.27; 95% confidence interval, 1.10–1.46; p = 0.001) and left ventricular ejection fraction (per 5% increase, hazard ratio, 1.07; 95% confidence interval, 1.03–1.12; p = 0.002) were associated with increased, elevated work intensity (heavy vs light, congestive heart failure, 0.58; 95% confidence interval, 0.34–0.99; p < 0.049) with decreased probability of return to work. None of the endomyocardial biopsy–derived parameters was significantly associated with return to work in the total group as well as in the subgroup of patients with biopsy-proven myocarditis.Conclusion:Added to established predictors, bioptic data demonstrated no additional impact for return to work probability. Thus, socio-medical evaluation of patients with suspected myocarditis furthermore remains an individually oriented process based primarily on clinical and functional parameters.

Sekundäre Osteoporosen

Due to increasing knowledge on pathogenetic factors causing osteoporosis and increasingly more detailed investigations, the diagnosis of secondary osteoporosis is being made increasingly more often. A rational search for the underlying disease or the bone-damaging medication is indicated particularly in adolescents, premenopausal women, men and postmenopausal women with rapidly decreasing bone tissue. The early detection of the causative disease in the preclinical stage of osteoporosis and the current therapeutic options allow not only normalization of the bone structure and the risk of fracture but also targeted therapy of the cause of the osteoporosis. The focal point in the diagnostics of secondary osteoporosis is still dual energy X-ray absorptiometry (DXA) measurement together with the manifold imaging procedures in radiology and additional clinical, laboratory chemical and bioptic findings.

Bone Scan with Confusing Appearance: Superscan or Metabolic Disorder

We present a patient with metastatic prostate cancer with known bone involvement and unknown osteomyelofibrosis. It has the general appearance of a superscan, with homogeneously increased tracer uptake and no visualization of the kidneys. However, while a superscan should have greater uptake in the axial skeleton compared to the appendicular skeleton, this scan is reverse, raising the suspicion of an overlying metabolic bone disorder. Subsequent laboratory-, bioptical findings confirmed a myeloproliferative syndrome with osteomyelofibrosis. As such, this scan demonstrates that in a patient with both affiliations, metabolic bone disease can override even severe osseous metastases on a bone scan.

1494: Low Correlation between Bioptical Findings of a Single Microfocus ( < 1 MM non Gradable) of Prostate Adenocarcinoma and Clinical Significant Disease Assessed after Radical Prostatectomy

1494: Low Correlation between Bioptical Findings of a Single Microfocus ( < 1 MM non Gradable) of Prostate Adenocarcinoma and Clinical Significant Disease Assessed after Radical Prostatectomy

829Low correlation between bioptical findings of a single microfocus (< 1 MM non gradable) of prostate adenocarcinoma and clinical significant disease assessed after radical prostatectomy

829Low correlation between bioptical findings of a single microfocus (< 1 MM non gradable) of prostate adenocarcinoma and clinical significant disease assessed after radical prostatectomy

Lactate-stress testing in 54 patients with mitochondriopathy.

Since there are only few data available about the lactate stress test in a group of patients with mitochondrial myopathy, we investigated the sensitivity of this test in a larger cohort of such patients. Serum lactate was determined before, during and after a 15 minute, constant 30 W workload on a bicycle ergometer in 47 controls, aged 15 to 72 years and 54 patients with mitochondrial myopathy, aged 15 to 74 years. Lactate's upper reference limits at rest, 5, 10, 15 minutes after starting, and 15 minutes after finishing the exercise were 2.0, 2.1, 2.1, 2.1 and 1.8 mmol/l respectively. The sensitivity of the lactate-stress test was 69%. The lactate-stress test complements electrophysiological and bioptical findings and proved to be helpful in diagnosing mitochondrial myopathy.

An unusual case of myocarditis

A 25-year-old woman was admitted to our center for left heart failure. The clinical, electrocardiographic and bioptic findings suggested an acute lymphocytic myocarditis. One month later, paroxysmal hypertension and high urinary excretion of noradrenaline revealed the presence of a pheochromocytoma.

Endoscopic and bioptic findings in the upper gastrointestinal tract in patients with Crohn's disease.

A prospective study was carried out on 41 patients diagnosed as having Crohn's disease (CD) to evaluate the degree of upper gastrointestinal tract involvement. In 23 patients (56%), endoscopic alterations were found most frequently affecting the antrum and duodenum. Lesions encountered were: Aphthoid erosions, ulcers, thickening of folds, nodules, erythema and stenosis. Granulomas were found in biopsies in 19.5% of the patients: They were more frequent in those demonstrating endoscopic alterations (26%) than in those with normal endoscopic findings (11%). Clinical evolution was favorable with conventional treatment for CD and ranitidine, although the endoscopic lesions did not totally disappear in any cases. We conclude that upper gastrointestinal endoscopy with biopsies is useful in evaluating the extension of disease and can be of diagnostic value in cases of indeterminate colitis.

Right ventricular dysplasia: angiographic study

At the moment, the most reliable method for diagnosing right ventricular dysplasia is considered to be angiography. Morphological alterations such as the presence of akinetic/dyskinetic areas, aneurysmatic dilatations and deep anteroapical fissuring, not necessarily associated with an increase in ventricular volume, are understood to be angiographic criteria indicating dysplasia. To verify their diagnostic value, these abnormalities have been evaluated in: (1) 33 patients suspected of having dysplasia because of PVBs with LBBB morphology and with 'borderline' involvement of the right ventricle or without instrumental evidence of cardiac disease (Group A); (2) 16 subjects with no arrhythmia and normal left ventricular angiography, coronary and bioptic findings (Group B); (3) 36 patients with a clinical, angiographic and bioptic diagnosis of dilated idiopathic cardiomyopathy (Group C). In 48.5% of the patients in Group A, angiography showed localized akinesia/dyskinesia (12 patients), small conical outpouchings persisting during systole (10 patients) and apical deep fissuring (two patients). In 81% of these patients, endomyocardial biopsy showed the presence of fibrous and/or adipose tissue in at least 20% of the examined sample. Angiographic abnormalities suggesting dysplasia were found in none of the normal subjects and only in two of the 36 patients with dilated cardiomyopathy (5.5%).

Programmed stimulation in patients with minor forms of right ventricular dysplasia

Programmed electrical stimulation (PES) was performed in 17 patients, mean age 31 +/- 8 years, with minor forms of right ventricular dysplasia diagnosed because of (1) premature ventricular beats (PVBs) of left bundle branch block (LBBB) morphology; (2) no clinical or non-invasive evidence of cardiac abnormalities; (3) angiographic evidence of right ventricular wall motion abnormalities and bioptic findings of fibro-adipose infiltration. Fifteen patients had frequent and complex PVBs while two had sustained ventricular tachycardia (VT). During PES, sustained VT was induced in 2/2 patients with spontaneous sustained VT; ventricular repetitive responses were induced in 2/15 cases (13%) with complex and frequent PVBs. In conclusion, in minor forms of right ventricular dysplasia, PES induces VT only in patients with clinical VT; on the contrary, in patients with PVBs it is only possible to induce repetitive ventricular responses in a small proportion of cases; it is therefore not possible to select patients at high risk of developing severe ventricular arrhythmias.

Myocardial bioptic findings in correlation with TL-201 imaging and hemodynamic parameters in patients with latent cardiomyopathies suspected of having myocarditis.

Sixty-eight patients (24 males, 44 females, mean age 37.2 years) belonging to NYHA classes I and II were investigated. All patients had a nondilated ventricle as well as hemodynamic criteria of "latent cardiomyopathy." In 78% of the patients, a high susceptibility to infection, frequent angina, or possible myocarditis were found. In 75.5%, the mean pulmonary artery pressure was abnormal. T1-201 scintigraphy revealed perfusion defects in 78%. Dyskinesia or hypokinesia were found in 52%. The left ventricular ejection fraction was normal in 74%. On biopsy, pathologic findings were detected in 60.9% of patients with a high frequency of hypertrophy and fibrosis (50%). In two patients, lymphocytic infiltrates were found. Immunohistologically, deposits of complement, IgG, IgM, and gammaglobulin, mainly in the sarcolemma, could be identified in 19.1% of cases. The myocardium was normal in 39.1%; insufficient material was found in 5.9% of patients. Morphologic, scintigraphic, and hemodynamic findings could not be correlated but the combination of two pathologic parameters permitted diagnosis. Biopsy was the most effective diagnostic method in myocarditis.

Morphology of the urinary bladder following long-term experimental irritation of the urothelium.

10 female beagle whelps received an artificial urinary calculus (1.5 ml of a rapidly polymerizing methyl-methacrylate) by means of a transurethral procedure. The X-ray, cytological, endoscopic and bioptic findings were followed in a long-term experiment. After a period of 61 months, precancerous urothelial changes (n = 1) and invasive urothelial microcarcinomas were found (n = 2). Typical changes from earlier controls were pseudopapillary follicular cystites. Chronic irritation of the urothelium is shown to be an important factor in the pathogenesis of urinary bladder carcinoma. Decisive is the length of the period of irritation rather than the actual material used in making the pellet.

Followup of Irradiated Prostatic Carcinoma by Aspiration Biopsy

Of 66 patients with irradiated prostatic carcinoma 53 were controlled regularly by repeat aspiration biopsy every 6 months. Local sterilization was achieved in 43 per cent but the results of combined radiotherapy (endocrine therapy plus irradiation) were only 8 per cent more favorable than those in patients treated by radiotherapy alone. Thus, endocrine therapy is not warranted before the radiation effect is evaluated. Post-radiation treatment should be determined by the clinical and bioptic findings.

Gastritis of the pyloric gland area and gastric acid secretion.

In a total of 117 subjects with a normal histological picture of the fundic mucosa and different bioptic findings of the antral mucosa, quantitative analyses of gastric basal and maximally stimulated secretion were carried out. The statistical analysis showed that basal and maximal secretion are significantly decreased in isolated atrophic gastritis of the antrum compared to normal mucosa and various degrees of superficial gastritis of the antrum. The clinical importance of the isolated antral gastritis is emphasized. A ‘blind’ biopsy of the mucosa of the gastric fundus is inadequate when the diagnosis of gastritis is to be confirmed.

A Study of Visible Malignant Bronchial Tumors

During 16 years (1951-1966), bronchoscopy was performed on 280 cases with malignant bronchopulumonary growths, which were diagnosed clinically by cytologic and bioptic findings or confirmed pathologically on resected or necropsied bronchopulmonary specimens.In 101 out of these 280 cases examined, the malignant growths were found bronchoscopically and these visible tumors were classifted in following four types from the bronchologic, roentgenologic and pathologic point of view:I) Localized primary bronchogenic cancer and sarcoma (Localized Type) .. 20 casesII) Invasive primary bronchogenic cancer (Invasive Type) … 58 casesIII) Bronchial tumorous invasion caused by parabronchial lymphnode metastasis of the primary bronchogenic cancer (Lymphnode Metastatic Type) … 21 casesIV) Bronchial tumorous invasion caused by pulmonary or parabronchial lymphnode metastasis of the primary extrathoracic malignant growths (Extrathoracic Type) … 2 casesIn the majority of the cases with the bronchial tumors of each type, their roentgenologic findings of the chest were characterized by the unilateral, lobar or segmental opacity. However, in some cases, bipolar or cavitary shadow was found, and three cases showed apparently normal x-ray finding of the chest.The bronchial tumors of each type showed no characteristic appearances. However, as to the localization, the tumors of the third type were most frequently located at the carina, the orifice of the right upper lobe bronchus and the median wall of the right main bronchus and the intermedial bronchus.Therapeutecally, it should be most significant to distinguish each type of the bronchial tumors. In the early stage, the bronchial tumors of the first type not only were resectable, but also mostly diappeared or could be replaced with cicatricial tissue by the suitable irradiation therapy, while in the majority of the cases with the tumors of the othere types, their prognoses were less good than those in the former.In our series, 11 cases (52%) of the first type, 3 cases (5.1%) of the second and 4 cases (20%) of the third were treated by lung resection, but only one case of the first type survived for more than five years.