Bullous Edema Research Articles

Bullous periorbital oedema in anti-p155/140-positive dermatomyositis: a case series.

Dear Editor, Dermatomyositis (DM) is an idiopathic inflammatory myopathy characterized by immune-mediated skin and muscle injury. There is a diverse spectrum of clinical phenotypes within DM, and this clinical heterogeneity can challenge timely recognition and diagnosis [1]. Myositis-specific antibodies are increasingly utilized to facilitate recognition of DM subgroups, and provide important insights into clinical phenotypes, prognosis and treatment response [1–3]. Anti-p155/140 (TIF-1γ) antibody is associated with increased malignancy risk, refractory disease and distinct cutaneous lesions [e.g. verruca-like palmar papules, hypopigmented and telangiectatic (‘red on white’) patches, and an erythematous ovoid palatal patch] [3, 4]. Herein, we describe five cases of DM with bullous periorbital oedema identified at the Johns Hopkins Myositis Center, all of whom were positive for anti-p155/140, suggesting that this may represent a novel clinical manifestation of this subgroup. A 76-year-old white female presented with a 6-month history of periorbital oedema, proximal muscle weakness and dysphagia (Supplementary Table S1, available at Rheumatology online). Bullous periorbital oedema with heliotrope rash (Fig. 1A), non-scarring alopecia and proximal muscle weakness were noted. Creatinine kinase (CK) was mildly elevated (303 U/l: upper limit of normal 182 U/l). Aldolase was normal (7.9 U/l: upper limit of normal 8.1 U/l). Anti-p155/140 was positive. EMG showed non-irritable myopathy, while MRI noted extensive intramuscular and fascial oedema involving the pelvic and thigh muscles. Bullous oedema and weakness resolved with glucocorticoids, MTX and IVIG (Fig. 1B).

Bladder lesions as incidental findings during transurethral resection of the prostate: prevalence, diagnosis, and pathological findings.

The purpose of this study was to determine the prevalence of bladder lesions diagnosed during transurethral resection of the prostate (TURP), to identify the associated risk factors, and to correlate the macroscopic descriptions with the pathological findings. This was a single-center retrospective case series conducted at a hospital in the city of São Paulo, Brazil. We reviewed the medical and surgical records of patients who underwent TURP between January 2012 and December 2017. The final sample comprised 513 patients, with a mean age of 70.8years. Bladder lesions were identified during TURP in 109 (21.2%) of the patients, and 90 of those lesions were submitted for pathological examination. The most common macroscopic finding was bullous edema, which was seen in 57 (63.3%) of the 90 lesions examined. The pathological analysis revealed chronic cystitis in 61 lesions (67.8%) and malignant lesions in 16 (17.8%). Of the 57 lesions described as bullous edema, 5 (8.8%) were found to be malignant. Alterations in the bladder mucosa appear to be more common among elderly patients who use an indwelling urinary catheter for a prolonged period and among patients with recurrent urinary tract infections. In addition, the risk of a bladder lesion being malignant is apparently higher in current and former smokers than in never smokers. Our findings suggest that at-risk patients should undergo biopsy or resection of incidental bladder lesions even if those lesions seem to be benign, due to the low level of agreement between the visual analysis and the pathological examination.

Development of a photographic handbook to improve cystoscopy findings during resident’s training: A randomised prospective study

ABSTRACTObjectives: To evaluate if the use of a photographic handbook (PH) can be a useful tool to improve the detection of disorders during cystoscopy training, as several hands-on tools have been proposed to improve technical skills but very few aim to improve specificity and sensitivity.Subjects and methods: Eight junior residents (JRs) were divided into two groups: Group A, comprised four JRs with previous limited experience of performing cystoscopies; and Group B, including four inexperienced JRs who were asked to study a specific PH before performing cystoscopies. The findings of the two groups were compared using the chi-squared test.Results: A total of 401 consecutive cystoscopies, of which 214 (53.4%) were performed by Group A and 187 (46.6%) by Group B, were considered. Group B showed superior ability in detecting uncommon findings (i.e., carcinoma in situ, bullous oedema, interstitial cystitis, etc.) with 24/46 (52.2%) detected vs eight of 32 (25%) in Group A (P = 0.016).Conclusions: The PH was a useful tool for improving identification of pathological conditions, which could be used to enhance hands-on simulator and practical tutored training.Abbreviations: CIS: carcinoma in situ; JR: junior resident; PH: photographic handbook; VR: virtual reality Classification: Stones/Endourology

Eosinophilic Cystitis Mimicking Bladder

A 16-year-old male presented with urinary urgency, a frequency of 4 months duration and intermittent gross haematuria which were there since one month. Eosinophilia was noted in complete blood count and CT KUB with contrast showed a filling defect in the right lateral wall, over the vesicoureteric junction. Cystoscopy revealed a sessile mass lesion over right vesico-ureteric junction, with bullous oedema . Rest of the mucosa was normal. Transurethral resection of lesion was performed and histological examination showed features of eosinophilic cystitis. Patient was treated with corticosteroids, antimicrobial agents and antihistaminics and he is recovering well. We are presenting this case for its rare presentation and its possibility of mimicking a bladder tumour. Biopsy of the lesion was diagnostic and an early treatment showed good results.

Pseudocarcinomatous Urothelial Hyperplasia of the Bladder: Clinical Findings and Followup of 70 Patients

Pseudocarcinomatous urothelial hyperplasia is rare and almost exclusively described in the pathology literature. We reviewed 70 cases during a 9.5-year period. Two specimens were taken from biopsies done at our institution and 68 were from cases referred for consultation. Samples were obtained from a total of 60 men and 10 women with a mean age of 67 years (range 33 to 85). Of 68 patients with information available 52 (76.5%) underwent prior pelvic irradiation, 2 received systemic chemotherapy only, 3 had an indwelling bladder catheter, 2 received intravesical chemotherapy, 1 had been treated with radical prostatectomy, 4 had severe peripheral vascular disease, 1 had an arteriovenous malformation, 1 had sickle cell disease and only 2 (2.9%) had no identifiable contributing factors. Pseudocarcinomatous urothelial hyperplasia developed an average of 54.6 months (range 9 months to 13 years) after prior irradiation. Hematuria was the most common clinical presentation, noted in 45 of 51 patients with data available. Of 48 patients with data endoscopy revealed erythema in 20, a papillary/polypoid lesion in 12, broad-based elevated erythematous lesions in 6, erythematous bullous edema in 5, shallow bleeding ulcers in 4 and prominent trabeculation in 1. Additional findings in the bladder were carcinoma in situ in 3 cases, and dysplasia, low grade papillary urothelial carcinoma and papillary urothelial hyperplasia in 1 each. Three of the 40 patients with an average followup of 27 months (range 1 to 94) subsequently had urothelial carcinoma, including 1 who had prior positive cytology and fluorescence in situ hybridization, 1 with prior high grade papillary urothelial carcinoma and 1 with an unknown history. Although pseudocarcinomatous urothelial hyperplasia mimics invasive urothelial carcinoma clinically and histologically, it is not related to urothelial neoplasms. Almost all patients have causes of bladder ischemia, most commonly a history of remote prior pelvic irradiation.

Emphysematous cystitis as complication in chronic rejection of renal transplant

This 43-year-old Caucasian female presented in a septic condition in the emergency room. At the time of admission her temperature was 38.5 Celsius, white blood cells (WBC) 12800, red blood cells 3.8 mill, hemoglobin 10.8, hematocrit 36, urea 28 mg/dl, serum creatinine 3.2 mg/dl, K 5.8 meq/l, Na 128 meq/ l, alk ptsa 142 U/l. Urine analysis 50 WBC/hpf, innumerable bacteria/hpf, cellular debries, gas bubbles. Both urine and later blood cultures revealed E. coli. The lower abdomen and pelvis were exquisitely tender to palpation. Patient had been hemodialyzed 2 days earlier. Patient had received a cadavertransplant 3 years ago, which functioned well until 4 months ago. At this time chronic rejection was diagnosed. An antegrade pyelogram revealed a stricture at the implant site of the cadaver ureter, dilatation and possible ulcerations of the mid – and upper ureter. Bullous edema of the native bladder was seen, most prominent near the implant site. Immunosuppressive therapy was instituted and despite these efforts, function of the transplant kidney continued to deteriorate and the patient was finally put on hemodialysis 1 month ago. It was contemplated to perform a ureteroneo-calicostomy with the still present native ureter to hopefully salvage the kidney A non-contrast multi-detector computed tomography demonstrated gas in the submucosa and bladder, and also extravesical anterior to the bladder (Figure-1). Strands of debries and sloughed tissue surrounded by air are seen in the bladder lumen (arrow). Gas has dissected along the anterior abdominal wall (Figure-2). A coronal reconstruction shows relatively little striation in the perirenal space. There is edema in the peripelvic area and around the upper ureter (Figure-3). To control the fulminating gas forming infection, bladder, transplant kidney and ureter were removed, the space of Retzius drained. Depending on the severity of the infection and underlying conditions such as diabetes mere control of the diabetes and appropriate antibiotic therapy may suffice while severe forms may mandate surgical intervention to remove the necrotic debries (1-3). After prolonged antibiotic

Exanthème à type de « syndrome babouin » au cours d’une primo-infection par le parvovirus B19 : deux cas

Primary parvovirus B19 infection may present a wide variety of dermatological features. We report two cases of parvovirus infection presenting as flexural erythema of baboon syndrome induced by various drugs, but associated with purpuric or oedematous features. A pregnant 23-year-old woman at 39 weeks of amenorrhoea and a 49-year-old woman consulted for flexural eruption in a setting of fever. In both cases, clinical examination revealed erythematosus rash in the major skin folds, with vesicles and elements of purpura in the former patient and bullous oedema in the latter. In both cases, the diagnosis of primary parvovirus B19 infection was confirmed by positive PCR screening of viral genome and by seroconversion after two weeks. The skin lesions regressed spontaneously within several days. Although initially linked solely with systemic drug toxicity, baboon syndrome has since been reported in connection with other allergens (drug reactions, contact dermatitis, viral and streptococcal infection). Among these causes, parvovirus B19 infection merits particular interest.

Tuberculous osteomyelitis of the foot in a haemodialysis patient.

A 64-year-old woman with end-stage renal disease secondary to hypertension undergoing haemodialysis for 2 years was admitted with a history of fever, pain and swollen left foot lasting for 1 year. Clinical examination demonstrated localized erythema, warmness and swelling (Figure ​(Figure1).1). The erythrocyte sedimentation rate was 122 mm/h and C-reactive protein was 12.6 mg/dL (normal <0.5 mg/dL). The tuberculin skin test revealed 26 mm enduration with bullous oedema. Thoracic computed tomography indicated only calcified lymph nodes in the left hilar region. Magnetic resonance imaging showed destruction in the navicular bone and widespread oedema in the adjacent bones and fluid collection (Figure ​(Figure2).2). After surgical intervention, a diagnosis of tuberculosis (TB) was established with the histopathological examination of the tissue. Growth of mycobacterium tuberculosis complex was found in the culture obtained at the time of bone debridement. However, she was lost to follow-up without anti-TB treatment. After 10 months, she presented with fever, swelling and drainage in the left inguinal region. Ultrasonographic examination revealed enlarged inguinal lymph nodes. The diagnosis of TB lymphadenitis was made by demonstrating positive acid-fast bacilli in the drainage fluid. She was cured with standard anti-TB drugs for 9 months. Fig. 1 Swollen left foot in the lateral position. Fig. 2 The MRI of the patient showed a diffuse low-intensity signal on T1-weighted sagittal image in the left navicular bone. TB osteomyelitis is one of the unusual manifestations of osteoarticular TB and comprises 2–3% of all cases [1]. Due to nonspecific presentation, symptoms together with frequent extrapulmonary localization, this rare condition is often misdiagnosed or the true nature of the lesion is identified late in the diagnostic process as in our case.

Endosonographic diagnosis in uterine tumors

Endosonography offers two major advantages in the pretherapeutic examinations of a histologically verified carcinoma of the uterus. Endosonography allows (1) an overview of the size and location of the tumour and (2) an evaluation of the spreading and/or involvement of adjacent organs. Both add up to a more objective staging of the tumour and, therefore, may cause a more effective therapeutic approach. Especially in cases with endometrial carcinoma the uterine walls can be visualized either by the well-tolerated method of vaginosonography or by hysterosonography which can be performed only in general anaesthesia. Applying either endosonographical method, the infiltration depth of the myometrium and/or involvement of the cervix can be determined, which seems to be very valuable, particularly when differentiating between stages I and II. Rectosonography, with its transversal scanning probes, offers the advantage of demonstrating the infiltration of a cervical tumour into the parametrium. Here again, the benefit is seen in a more objective evaluation of tumour size and extension. However, tumour growth into the urinary bladder is best shown by cystosongraphy. With this method one cannot only have a view of the epithelium (as in cystoscopy) but one is also able to evaluate the underlying layers of the bladder wall. This seems to be an advantage in findings of a bullous oedema. Once again, rectosonography is advantageous in enhancing the diagnosis of recurrences of malignant tumours in the pelvic region. Like a prolongation of the palpating finger rectosonography is able to depict less echogenic areas located high up on the pelvic wall as local recurrences or tumours.(ABSTRACT TRUNCATED AT 250 WORDS)

Topical Dual VEGF Receptor/Src Kinase Inhibitors as Potential Therapies for Ischemic Retinal Vascular Disorders

Purpose: Ischemic retinal vein occlusion (RVO) is a common retinal vascular disorder and carries a high risk of visual loss with few therapeutic options. We evaluated whether dual inhibition of VEGFR and down‐stream Src family tyrosine kinases using small molecules is a potential therapeutic intervention for ischemic retinal vascular disorders.Methods: We examined two distinct chemical classes of dual VEGFR/Src kinase inhibitors (represented by compounds TG100801 and TG100948) in a rat model of RVO for their ability to impact retinal edema. Ischemic retinal vein occlusion was induced in rat retina by thrombosis of a single retinal vein using argon laser photocoagulation following injection of a photo‐sensitizer dye. Edema was quantified either using scanning optical fluorophotometry, measuring fluorescein leakage in to the retina, or by optical coherence tomography (OCT), measuring retinal thickness.Results: Following topical administration, both the compounds achieved substantial levels in the retina and intraocular tissues with little to no systemic exposure. At 48 hrs post‐vein occlusion, both TG100801 and TG100948 successfully reduced edema compared to vehicle (by 47% with 0.3% TG100801, P= 0.002, and by 38% with 0.03% TG100948, P= 0.039). OCT scans also showed reduced retinal thickening as well as resolution of pockets of bullous edema.Conclusions: As VEGF plays a key role in the edema and neovascularization which develop in the ischemic retina, we propose that multi‐targeted inhibitors of the VEGF signaling cascade represent promising therapies for these vascular disorders. Moreover, as current forms of therapy require invasive delivery techniques (intravitreal injections), compounds such as TG100801 and TG100948, which can be topically delivered, offer additional therapeutic advantages.

Progressive Herpetic Linear Endotheliitis

To report the clinical course of a rare case of bilateral herpetic linear endotheliitis. A 70-year-old man presented with bilateral circumferential bullous edema with stromal edema progressing centrally in the left cornea and bilateral sensorineural hearing impairment simultaneously. Serum immunoglobulin G (IgG) and IgM antibodies against herpes simplex virus type 1 (HSV1) were tested for, and aqueous humor from both eyes was examined separately using polymerase chain reaction for the presence of HSV1 DNA. Serum antibody titers against HSV1 were positive. In the polymerase chain reaction, the aqueous humor showed HSV1 DNA in both eyes. Forty milligrams of prednisolone was given per day and 200 mg of oral acyclovir was given 4 times daily, but corneal edema progressed. After penetrating keratoplasty surgery in the left eye, recurrent herpetic endotheliitis also seemed to occur. HSV-1 may cause bilateral corneal linear endotheliitis and hearing impairment simultaneously. Linear endotheliitis should be regarded as a manifestation of HSV1 corneal infection. There is a poor prognosis, and severe corneal edema can result if aggressive treatment is not used.

Updated recommendations on ultrasonography in urogynecology

Ultrasound is a supplementary, indispensable diagnostic procedure in urogynecology; perineal, introital, and endoanal ultrasound are the most recommended techniques. The position and mobility of the bladder neck can be demonstrated. In patients undergoing diagnostic work-up for urge symptoms, ultrasound occasionally demonstrates urethral diverticula, leiomyomas, and cysts in the vaginal wall. These findings will lead to further diagnostic assessment. The same applies to the demonstration of bladder diverticula, foreign bodies in the bladder, and bullous edema. With endoanal ultrasound, different parts of the sphincter ani muscle can be evaluated. Recommendations for the standardized use of urogenital ultrasound are given.

Pelvic actinomycosis: urologic perspective

Actinomycosis is a chronic granulomatous infection caused by the gram-positive anaerobic bacteria, Actinomyces israelli. This paper reviews the etiology and clinical presentation associated with Actinomycosis that often presents as a pelvic mass that mimics a pelvic malignancy. A combination of patients treated by the authors in the recent past and a literature review of patients with pelvic Actinomycosis were assessed for demographic, clinical and predisposing co-factors. An analysis is made of age distribution, gender, diagnostic methods and treatment concepts. Thirty-three patients were included in the study that included 2 current patients and 31 obtained from literature review. There were 27 females (age range 16 - 69 years, mean 38 years) and 6 males (16 - 55 years, mean 36 years). Presenting signs and symptoms were lower abdominal mass in 28 (85%); lower abdominal pain in 21 (63%); vaginal discharge or hematuria in 7 (22%). Two patients developed fistulae (entero-vesico 1; vesico-cutaneous 1). Nineteen (70%) of the 27 female patients had intra-uterine contraceptive devices (IUD). Four patients (12.5%) (3 males and 1 female) had urachus or urachal remnants. Cystoscopy in 12 patients noted an extrinsic mass effect, bullous edema and in one patient " vegetative proliferation " proven to be a chronic inflammatory change. Exploratory laparotomy was performed in 32 of the 33 patients who had excision of mass and involved organs. Diagnosis was established by histologic examination of removed tissue. Penicillin (6 weeks) therapy was utilized to control infections. Pelvic actinomycosis mimics pelvic malignancy and may be associated with the long-term use of intra-uterine contraceptive devices, and persistent urachal remnants. Removal of infected mass and antibiotic therapy will eradicate the inflammatory process.

Aktualisierte Empfehlungen zur Sonographie im Rahmen der urogynäkologischen Diagnostik

Ultrasound is an indispensable diagnostic procedure in urogynecology; perineal, introital and endoanal ultrasound are the most recommended techniques. The position and mobility of the bladder neck can be assessed. In patients undergoing diagnostic workup for urge symptoms, ultrasound occasionally demonstrates urethral diverticula, leiomyomas, and cysts in the vaginal wall. These findings lead to further diagnostic assessment. The same applies to the demonstration of bladder diverticula, foreign bodies in the bladder, and bullous edema. With endoanal ultrasound different parts of the sphincter can be evaluated. Recommendations for the standardized use of urogenital ultrasound are given.

URINARY FISTULA BETWEEN THE BLADDER AND LOWER EXTREMITY FOLLOWING BURCH URETHROPEXY

No AccessJournal of UrologyCLINICAL UROLOGY: Case Reports1 Feb 2001URINARY FISTULA BETWEEN THE BLADDER AND LOWER EXTREMITY FOLLOWING BURCH URETHROPEXY RICARDO F. SÁNCHEZ-ORTIZ, THOMAS F. LANCHONEY, and ERIC S. ROVNER RICARDO F. SÁNCHEZ-ORTIZRICARDO F. SÁNCHEZ-ORTIZ More articles by this author , THOMAS F. LANCHONEYTHOMAS F. LANCHONEY More articles by this author , and ERIC S. ROVNERERIC S. ROVNER Financial interest and/or other relationship with Pharmacia Upjohn and Yamanouchi. More articles by this author View All Author Informationhttps://doi.org/10.1097/00005392-200102000-00048AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "URINARY FISTULA BETWEEN THE BLADDER AND LOWER EXTREMITY FOLLOWING BURCH URETHROPEXY." The Journal of Urology, 165(2), pp. 525–526 References 1 : Treatment of radiation-induced cystitis with hyperbaric oxygen. J Urol1985; 134: 352. Link, Google Scholar 2 : Urethrovaginal fixation to Cooper’s ligament for correction of stress incontinence by simple vesicourethral suspension. Am J Obstet Gynecol1961; 81: 281. Google Scholar 3 : Colpocystourethropexy: the way we do it. J Urol1976; 116: 751. Link, Google Scholar From the Division of Urology, Department of Surgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania© 2001 by American Urological Association, Inc.FiguresReferencesRelatedDetails Volume 165Issue 2February 2001Page: 525-526 Advertisement Copyright & Permissions© 2001 by American Urological Association, Inc.Keywordspostoperative complicationsfistulaurethraurinary incontinenceMetricsAuthor Information RICARDO F. SÁNCHEZ-ORTIZ More articles by this author THOMAS F. LANCHONEY More articles by this author ERIC S. ROVNER Financial interest and/or other relationship with Pharmacia Upjohn and Yamanouchi. More articles by this author Expand All Advertisement PDF downloadLoading ...

Preoperative Risk Factors for Surface Disease After Penetrating Keratoplasty

We sought to identify the types of, prevalence of, and predisposing factors for the development of surface keratopathy after penetrating keratoplasty. We reviewed the records of 120 corneal grafts performed over a 15-month period. Twenty patients were excluded from the study. Fifty-three men and 47 women composed the group studied. All transplants were performed by the same surgeon. Retrospective data from patients' records were gathered preoperatively and from postoperative visits at 1 week and at 1, 2, 3, and 4 months. Data included preoperative medical and demographic data, operative time, postoperative medication regimens, assessment of the presence and degree, if present, of punctate epithelial keratopathy (PEK), hurricane keratopathy, macroepithelial defects, microcystic edema, bullous edema, and filamentary keratitis. In addition, information on the donor material was recorded. Surface disease and normal groups were compared to identify risk factors for the occurrence of surface abnormalities. Thirty-three of the patients demonstrated persistent surface abnormalities. Coarse PEK was the most common surface abnormality in the sample studied and was most prominent in the first week after surgery. Postoperative surface keratopathy was not statistically associated with preoperative diagnosis, donor age, death-to-preservation time, preservation-to-surgery time, or donor epithelial status. However, corneal recipients in the group with surface keratopathy were significantly older (mean, 68.7 years) than patients in the group with no surface abnormalities (mean, 52.6 years; Mann-Whitney U test, p < 0.001). Although many factors may contribute to the normal integrity of the corneal surface after keratoplasty, recipient age is of key importance in the development of surface disease.

Stage III carcinoma of cervix. The importance of increasing age and extent of parametrial infiltration

The relative importance of a number of potential prognostic factors was analysed for a sequential group of 296 patients with stage III carcinoma of the cervix who had been treated in a mature prospective clinical trial. Using a log-rank analysis of survival curves generated by the life-table method increasing age (p = 0.05) and extent of parametrial infiltration (p = 0.001) were found to be significantly related to prognosis. These two factors were further demonstrated to be independent variables and, of the two, parametrial extension (p = 0.002) was more significant than increased age (p = 0.035). Involvement of the lower third of the vagina, the presence of bullous oedema and the histological differentiation of the disease were not prognostically significant in this study. It is suggested that tumour volume as defined by extent of parametrial infiltration is a sufficiently good prognostic factor to be incorporated into a revised staging system.

“Cobblestone” renal pelvis Radiographic finding in acute renal vein thrombosis

The cobblestoned appearance of the infundibuli, pelvis, and ureter are diagnostic retrograde urographic findings in acute renal vein thrombosis. This radiographic change is believed to be due to acute bullous edema.

Pelvic lipomatosis causing urinary obstruction.

A case of severe pelvic lipomatosis is presented where the pathological process caused marked bullous oedema of the bladder, cystitis glandularis and bilateral hydronephrosis. An ileal conduit was necessary to relieve urinary obstruction. The spectrum of clinical manifestations and the radiological features of this condition are briefly reviewed.

III. Pathological Changes in the Bladder Following Irradiation

The gross and microscopic changes found in the bladder after irradiation have been described by a number of workers and have been investigated by experiments on animals. Shields Warren (1942) has stated that the vesical epithelium is moderately resistant to ionizing radiation and is able to with-stand up to 8,400 r in divided doses. He recognises three stages in the radiation reaction: (1) primary erythema, appearing in 24 hours or less, (2) secondary erythema, appearing in three to four weeks, and (3) a late reaction, rarely becoming manifest in less than one year. The early stages are characterised histologically by oedema, hyperaemia and epithelial desquamation. In the late stages there may be ulcers encrusted with urinary salts. The connective-tissue undergoes hyalinisation, the blood-vessel walls are thickened and fibrosis may spread into the muscle layers. Giant and bizarre fibroblasts may be seen. According to Hueper, Fisher, Carvajel-Forero and Thompson (1942) the late reactions may make their appearance at any time between three months and ten years. They described induration of the bladder wall, reduction of luminal capacity and encrustation of the mucosa with salts (the “Panzerblase” of German authors). The ulcers were sharply out-lined; they were often surrounded by bullous oedema and radiating, tortuous, ectatic blood vessels. On healing they left greyish-white avascular scars. In other cases, these authors found raspberry-like granulations, situated in an extremely hyperaemic mucosa. They stressed the resemblance that such ulcers may bear to cancerous or tuberculous lesions.