Changes In Biopsy Specimens Research Articles

Morphological features of skin changes in the undetermined clinical picture of psoriasis and atopic dermatitis in children

Absrtact Introduction The literature describes atypical clinical forms of psoriasis and atopic dermatitis in children that combine features of both diseases. In such cases, dermatologists resort to biopsy of plaque skin elements in the complex diagnosis. However, the histological picture in these biopsy specimens is uncertain and does not allow to make an unequivocal judgment about the correspondence of changes to one or another disease. The purpose of work was to compare pathomorphological changes in biopsy specimens of plaque skin elements in children with undetermined clinical picture of the disease with changes in typical forms of psoriasis and atopic dermatitis. Materials and methods A morphometric study of 10 plaque skin biopsy specimens from children (mean age 9.2±1.11 years) with an indeterminate clinical picture of the disease was performed. The obtained data were compared with two control groups of adult patients with typical clinical pictures of psoriasis (n=20; mean age 34.35±3.58 years) and atopic dermatitis (n=10; mean age 41.33±7.35 years). Results A comparative morphometric analysis of skin biopsy specimens revealed the fewest differences between the analyzed parameters of the squamous epithelium of the patients in the study group and the group with psoriasis. In all three groups, the main mass of the inflammatory infiltrate in the dermis was composed of lymphocytes and macrophages whose numerical density differed in psoriasis and atopic dermatitis at different levels of the dermis, while in the study group it had intermediate values. The number of neutrophils and eosinophils in the study group had minimal values. Discussion Morphological changes in the epidermis of the study group were closest to those in psoriasis, while the cellular composition of the inflammatory infiltrate of the dermis did not correspond to any of the control groups and had either intermediate values (in terms of lymphocytes and macrophages) or minimal values (in terms of eosinophils and neutrophils).

Presence of Color Transition in Biopsy Specimens Predicts Outcome of Liver Lesion Biopsies.

The aim of this study was to evaluate the usefulness of the presence of tissue transition in liver lesion biopsies to predict a successful outcome, as observed by modified macroscopic on-site evaluation (MOSE). This is a retrospective analysis of 264 ultrasound-guided liver lesion biopsies, examining the influence the presence of tissue transition (visible color changes in biopsy specimens as evaluated visually) has on two endpoints (1) material retrieval, (2) attaining a definitive diagnosis) representing successful liver lesion biopsies, compared to previously evaluated variables in this context. Uni- and multivariate analyses were performed using SPSS 21.0. Material retrieval and a definitive diagnosis occurred in 224/264 (84.8%) and 217/264 (82.2%) cases, the latter occurring more often when visual inspection revealed macroscopic tissue transition (92/96 [95.8%]) than when not (124/165 [75.2%]), P < 0.001. Tissue transition in biopsies was more common in secondary (74/162 [45.7%]) than (18/54 [33.3%]) primary liver lesions, though this was not significant (P = 0.112). On multivariate analysis, tissue transition in biopsies was an independent predictor of a definitive diagnosis and material retrieval. In liver lesion biopsies, MOSE of color transition in biopsies can indicate success. This is easily incorporated into clinical practice and can help overcome the lack of an on-site pathologist.

IMMUNOHISTOCHEMICAL INVESTIGATIONS OF P16 INK 4A EXPRESSION IN CARCINOMAS AND HIGH GRADE CERVICAL LESIONS

SUMMARY: During the years the role of viruses as a cause of oncological illness was known. One of them is cervical carcinomas, related to Human papilloma viruses (HPV’s). There are about 450000 new cases of cervical cancer worldwide each year, and 250000 deaths of this diagnosis. By the diagnosis cervical cancer get there with two procedures: after mass scrinning or clinical suspicious for ill. By the availability apparent tumor diagnosis is put with biopsy. By the discreet lesions require utilization modern diagnostic methods. One of them is immunohistochemical method. In situ hybridization (ISH) assays for high-risk human papillomavirus (HR-HPV) and immunohistochemical (IHC) assays for surrogate markers such as p16 INK 4a can be useful in detecting HR-HPV in cervical dysplasia. The aim of the following study was to find difference the level for expression of the tumor specific gene p16 INK 4a in reactive, dysplastic and invasive changes in biopsy specimens from uterine cervix. In the lesions of the uterine cervix, overexpression of p16 INK 4a is induced by HPV and is associated with the process of cancerogenesis in the epithelium. Almost 100% of the high grade lesions and the invasive carcinomas demonstrated high level of expression of p16 INK 4a while non displastic epithelium is always negative.

582P - Predictors of Response to Preoperative Chemoradiotherapy (Crt) for Rectal Adenocarcinoma: Biopsy Specimens Obtained 1 Week After Starting Treatment are a Reliable Prognostic Factor

ABSTRACT Aim: Preoperative CRT is the standard of care for locally advanced rectal cancer. Patients who have pathological complete response (pCR) to CRT have good outcomes with a low risk of distant metastasis. We previously reported that changes in biopsy specimens obtained 1 week after the start of CRT are a reliable predictor of histologic response. We studied the relations between survival and changes in biopsy specimens, pCR, histologic marked regression and tumor shrinkage rate as evaluated by MRI. Methods: The study group comprised 127 patients with clinical Stage II/III rectal adenocarcinoma who received CRT (40 to 45 Gy in 20-25 fractions with concurrent oral UFT or S-1) from 2006 through 2012. Surgery was performed 6 to 8 weeks after the completion of CRT. Biopsy specimens were obtained 1 week after the start of CRT and stained with hematoxylin and eosin (H-E). Patients showing moderate changes were assigned to group A, and those showing mild changes were assigned to group B. Patients with a pCR were classified as group C, and those with no pCR were classified as group D. Patients showing histologic marked regression were assigned to E group, and those without such regression were assigned to group F. Patients with a tumor shrinkage rate of 75% or higher were classified as group G, and those with a lower rate were classified as group H. Results: The proportions of patients in each group were as follows: group A, 46%; group C, 17%; group E, 43%; and group G, 52%. The 5-year recurrence-free survival rate (RFS) and the 5-year overall survival rate (OS) were respectively as follows: 79% and 92% in group A vs. 59% and 79% in group B (p = 0.019, p = 0.127); 93% and 100% in group C vs. 64% and 82% in group D (p = 0.017 and p = 0.080); 78% and 95% in group E vs. 61% and 79% in group F (p = 0.008 and p = 0.022); and 71% and 88% in G group vs. 68% and 84% in group H (p = 0.423 and p = 0.480). Moderate changes on biopsy specimens and pCR were associated with higher rates of RFS, and histologic marked regression was associated with higher rates of RFS and OS. Conclusions: Changes of H-E stained biopsy specimens 1 week after starting CRT were a prognostic factor. A pCR and marked histologic regression in resected specimens were also prognostic factors, but changes of biopsy specimens after 1 week of CRT had the important advantage of early availability. Disclosure: All authors have declared no conflicts of interest.

How do tissue infiltrating B cells and plasma cells correlate with other inflammatory features in muscle tissue from patients with JDM?

The International Juvenile Dermatomyositis (JDM) Biopsy Consensus Group has previously published and validated a scoring tool for assessment of the severity of pathological change in biopsy specimens from patients with suspected or proven JDM. This tool assesses histological features characteristic of JDM, organised into four domains (inflammatory, vascular, muscle fibre and connective tissue). The score tool includes the assessment of CD3+ and CD68+ inflammatory cells. Given that JDM is a disease characterised by production of autoantibodies and some patients respond to anti-B cell therapy we hypothesise that B cells play an important role in the pathogenesis of the disease.

Role of Lipid Infiltration of Hepatocytes in the Morphogenesis of Chronic Hepatitis C

Immunohistochemical and PCR analysis of the structure of lipid-containing hepatocytes and replication of chronic hepatitis C viral particles revealed no positive correlation between the presence of HCV RNA in blood specimens, number of infected hepatocytes (by expression of HCV NS3Ag) with clinical biochemical parameters and intensity of structural changes in biopsy specimens. Small-vesicular subcytolemmal lipid infiltration of hepatocytes was detected, presumably associated with hepatitis C virus replication phase. Characteristic subcytolemmal location of the lipid droplets can reflect their involvement in virus transport from the cell and indicate a virus-induced nature of lipid metabolism disorders.

Original Paper Inflammatory changes in biopsy specimens from patients with suspected prostate cancer

IntroductionProstate cancer (PCa) is one of the most commonly diagnosed cancers in elderly men, and accounts for 30% of all newly diagnosed cases of cancer. The development of the ‘clinically insignificant’ prostate cancer into its invasive form is still unclear, and it is believed that chronic inflammation may play its role, as proposed by De Marzo in 1999. However, there is no clear opinion on the subject of existence of dependencies between changes of the inflammatory type and PCa.Material and methodsThe study involved 1,010 men, suspected of prostate cancer development by positive digital rectal examination (DRE) and/or elevated PSA value. The 10 cores, TRUS guided biopsy was performed. In those with ASAP, HG–PIN or inflammation the second biopsy was proposed.ResultsIn the first biopsy PCa was diagnosed in 336 patients (33.27%). ASAP was found in 58 (5.74%), HG–PIN in 82 (8.11%), and the coexistence of both was found in 19 (1.88%). Chronic prostatitis was diagnosed in 101 (10%) men. Of those who underwent second biopsy, PCa was diagnosed in six of 19 patients (31.57%) who were diagnosed with HG–PIN in the first biopsy, in four of 40 (10%) with BPH in the first biopsy, in four of 18 (22.22%) with ASAP or LG–PIN together with ASAP, and in two out of five (40%) with the coexistence of ASAP and HG–PIN. Malignancy was not confirmed in any of the patients in whom the diagnosis of BPH, HG–PIN, or ASAP was accompanied by chronic prostatitis.ConclusionsChronic prostatitis does not significantly increase the value of PSA in patients with benign changes (BPH). The presence of prostatitis in the first biopsy did not predict cancer in subsequent biopsy, because the second biopsy did not reveal prostate cancer in any of the patients in whom prostatitis was diagnosed in the first biopsy.

Colonoscopic and histologic features of colonic Crohn's disease in Chinese patients

An attempt was made to provide a better insight into endoscopic and histological features and to enhance the understanding of the diagnostic value of colonoscopy combined with biopsy for colonic Crohn's disease. As presented in our 27 cases of colonic Crohn's disease (Crohn's colitis), the endoscopic findings and histological changes of biopsy specimens were analyzed. As collated with correspondent results of biopsy and surgical specimens, the diagnostic accuracy of endoscopy was evaluated. Of these patients, 26 involvements of the colon (often combined with other sites of the bowel) were observed (96.3%). However, involvements limited to the colon alone were seen in only four cases (14.8%). Endoscopically, diverse patterns of multi-staged-segmental distributed and multi-sited inflammatory lesions, both destructive and proliferative/regenerative changes were observed in the bowel of the same patient. The diagnostic accuracy of colonoscopy, as confirmed by the histological examination of biopsy and resected specimens, was 66.7%. The major characteristic features of mucosal biopsy were the focal distribution of inflammatory infiltration and lymphoid aggregate. Otherwise, it may include edematous and widened submucosa, deep fissuring ulcers and hyperplasia, fibrosis and granulomas (detected in 30% of the group), among others. The colonic involvement of Crohn's disease was common. Colonoscopy may be valuable in establishing a diagnosis and in assessing the extent and severity of such colonic involvement. Biopsy is helpful to confirm a diagnosis conducted by colonoscopy. Colonoscopy combined with biopsy may replace radiology as the initial test of choice in many clinical situations.

Hyperphosphatasemia in Scottish Terriers: 7 Cases

Increased serum alkaline phosphatase (ALKP) activity in dogs is commonly encountered. In the study reported here, 7 Scottish Terriers were identified with hyperphosphatasemia, for which a cause could not be determined. The clinicopathologic findings of the syndrome are described and correlated with hepatic pathologic changes in biopsy specimens and in specimens obtained at postmortem examination. Five of the 7 dogs were related. The ALKP activity ranged from 1.7 to 17 times the reference value at the time of biopsy. Increased ALKP activity was present for >6 months in 2 dogs and >12 months in 5 dogs; activity was > 1,000 U/L for at least 1 measurement in 5 dogs. Results of liver function testing, adrenocortical function testing, and hepatic ultrasonography were reviewed. Results of histological examination were normal in 6 dogs. One dog had regional, chronic cholangitis without evidence of cholestasis. The lesion was judged unlikely to account for the degree of hyperphosphatasemia. This study provides evidence of possible benign hyperphosphatasemia in Scottish Terriers or of another familial disorder causing asymptomatical hyperphosphatasemia without corresponding histopathological abnormalities in the liver. Prospective studies of ALKP isoenzyme characterization, investigation of skeletal integrity, evaluation of additional related dogs to determine prevalence, and longer follow-up evaluation are necessary to better characterize this finding.

Importance of colonoscopy combined with biopsy in the diagnosis of colonic Crohn's disease

An attempt was made to provide a better insight into endoscopic and histological features and/or problems encountered when establishing a diagnosis of colonic Crohn's disease (Crohn's colitis). As presented in our 27 cases with Crohn's colitis, the endoscopic findings and histological changes of biopsy specimens were summarized. As collated with correspondent results of biopsy and surgical specimens, the diagnostic accuracy of endoscopy was evaluated. twenty-six involvements of the large intestine (combined with other sites of the intestine) was found (96.3%). However, involvement limited to the colon alone was seen in only 4 cases (14.8%). Endoscopically, overlapped lesions with multistaged-segmental distributed and multi-sited diverse patterns (destructive and proliferative/regenerative) of inflammatory changes were observed. Endoscopic accuracy was 66.7%. The characteristic features of mucosal biopsy include focal distribution of the lesions, a thickened and edematous submucosa, deep fissuring ulcers, lymphoid aggregate, and hyperplasia, fibrosis and granulomas (detected in 30% of the group), etc. Colonic involvement of Crohn's disease is common. Colonoscopy may be valuable in establishing the diagnosis and in assessing the extent and severity of colonic involvement, and CDEIS was value in the follow up of patients. Colonoscopic biopsies are helpful for verification of the diagnosis in difficult cases. Colonoscopy has replaced radiology as the initial test of choice in many clinical situations.

Evaluation of tubulointerstitial injury by Doppler ultrasonography in glomerular diseases.

While Doppler ultrasonography is used commonly in various renal diseases, its clinical value in diagnosis of renal parenchymal diseases, especially glomerular diseases, remains controversial. We investigated whether Doppler ultrasonography in glomerular diseases could discriminate tubulointerstitial lesions, which correlated closely with long-term prognosis for renal function. Sixty patients with primary or secondary glomerular diseases were examined by Doppler ultrasonography immediately before renal biopsy. The resistive index was calculated, as was the atrophic index (a newly proposed parameter defined as renal sinus length/renal length). These were compared with histologic changes in biopsy specimens. Receiver operator characteristic analysis showed a resistive index of 0.65 to be the optimal for discriminating tubulointerstitial changes with specificity of 100% and sensitivity of 57.1%. Tubulointerstitial injury scores were significantly higher in patients with resistive indices exceeding 0.65 than in patients with a lower value. An atrophic index of 0.70 was also shown to be optimal with specificity 100% and sensitivity 61.9%. In combination, the 2 indices showed improved sensitivity; when the patients were divided into groups where both resistive and atrophic indices were normal (respectively < or = 0.65 and < or = 0.70) or where either or both were high, sensitivity rose to 85.7%, while specificity remained 94.4%. In combination, the resistive and atrophic indices discriminated tubulointerstitial injury in glomerular diseases with high specificity and sensitivity.

The Overlap Between Respiratory Bronchiolitis and Desquamative Interstitial Pneumonia in Pulmonary Langerhans Cell Histiocytosis: High-Resolution CT, Histologic, and Functional Correlations

To characterize the histologic, high-resolution CT (HRCT), and functional correlates of respiratory bronchiolitis (RB)/desquamative interstitial pneumonia (DIP)-like changes in biopsy specimens of adults with pulmonary Langerhans cell histiocytosis (PLCH). We retrospectively identified 14 adult patients with histologically proven PLCH (all smokers) in whom both biopsy specimens and HRCT were available for review. The presence and extent of RB/DIP-like changes on lung biopsy specimens of patients with PLCH were correlated with total pack-years of smoking, lung function variables, and the presence of ground-glass attenuation on HRCT. Varying degrees of RB/DIP-like changes were identified in all biopsy specimens. The extent of involvement with RB/DIP-like changes correlated with the cumulative exposure to cigarettes smoked at the time of biopsy (r = 0.61, p = 0.03). Ground-glass attenuation was detected in three HRCTs, two of which had extensive RB/DIP-like changes (> or = 70% involvement) on histology, suggesting that substantial smoking-induced RB/DIP-like changes may be the cause of ground-glass attenuation on the HRCT of patients with PLCH. No correlation was found between the extent of RB/DIP-like changes and total lung capacity, FEV(1), or diffusion capacity of the lung for carbon monoxide. RB/DIP-like changes are exceedingly common in PLCH, may be sufficiently severe to cause the appearance of ground-glass attenuation on HRCT, and correlate with the cumulative exposure to cigarettes smoked. This study provides additional evidence that PLCH, RB, and DIP form a spectrum of interstitial patterns of lung injury to cigarette smoke.

Various scoring systems evaluating histologic features of chronic hepatitis C treated with interferon

Various scoring systems for chronic hepatitis have been proposed; however, there is no standard scoring system for studies of interferon (IFN) therapy in patients with chronic hepatitis C. The aims of this study were to determine the most useful system reflecting histologic changes in biopsy specimens from complete responders and predicting the efficacy of IFN therapy. Patients with chronic hepatitis C were administered IFN-α for 6 months. Forty-six patients were included in this study and categorized as complete responders (n = 15), partial responders (n = 24), and nonresponders (n = 7) according to viral and biochemical responses to the therapy. Biopsy specimens obtained from each patient before and after treatment were evaluated under 3 different systems: Histological Activity Index (HAI), modified HAI, and Scheuer classification. Complete responders showed considerable improvement in both grade and stage on the modified HAI and Scheuer classifications. On the HAI, a considerable improvement was observed in grade but not in stage. No significant change was observed in partial responders or nonresponders on any system. Prediction of complete response was not possible under any system, but the pretreatment score reflecting piecemeal necrosis on any 1 of the 3 classifications and the fibrosis score on Scheuer classification were predictors of nonresponse. The modified HAI system and Scheuer classification were amply useful in evaluating histologic changes in complete responders. Scores higher than 4 of the categories reflecting piecemeal necrosis on any system and fibrosis scores of 3 or 4 on Scheuer classification predicted nonresponse to IFN therapy. HUM PATHOL 32:910-917. Copyright © 2001 by W.B. Saunders Company

Analysis of Prognostic Predictors in Idiopathic Membranous Nephropathy

We studied clinical and histologic parameters at the time of renal biopsy of 19 patients with idiopathic membranous nephropathy (IMN) to investigate the predictors for prognosis of IMN. Nineteen patients diagnosed by open renal biopsy between 1988 and 1993 and followed for at least 5 years were divided into two groups according to the latest follow-up renal function. Group I included 16 patients with normal renal function at the last follow-up point. Group II included three patients with end-stage renal failure at the last follow-up point. Antibodies to CD68, CD45RO, α-SMA, collagen IV, and collagen VI were used to investigate glomerular and interstitial changes in biopsy specimens by the indirect enzyme-labeled antibody method. Degree of global glomerulosclerosis, segmental glomerulosclerosis, adhesion to Bowman's capsule, and crescent formation were evaluated by light microscopy (periodic acid–Schiff, periodic acid-metheramine [PAM] staining). The difference between the two groups was analyzed by Mann-Whitney U test. The number of interstitial cells, the number of interstitial CD45RO-positive cells, and increases of interstitial collagen IV and VI were found to be the most important factors for prognosis of IMN. These findings suggest that the extent of tubulointerstitial changes (cellular infiltration and fibrosis) determines the prognosis of renal function in IMN.

Oral lesions and symptoms related to metals used in dental restorations: A clinical, allergological, and histologic study

Background: Allergy to mercury as a cause of oral lichenoid lesions (OLL) remains controversial. Some authors reported high frequency of sensitization to mercury and beneficial effect from removal of amalgam fillings in such patients, whereas others state that this procedure affects favorably all OLL, whether patients are sensitized to inorganic mercury or not. Objective: Our purpose was to determine the frequency of sensitization to metal salts in 194 patients (patients with OLL partly adjacent to amalgam fillings: 19, oral lichen planus (OLP) without close contact to amalgam: 42, other oral diseases: 28, oral complaints: 46, control group: 59). We further studied the histologic changes of biopsy specimens from positive patch tests to metal salts, and investigated the effect of removal of amalgam in OLL, to clarify whether it is possible to identify patients who will benefit from this procedure. Methods: Patch testing was performed with the German standard series, a dental prosthesis series, and a metal salt series including gold, mercury, and palladium salts as well as other salts of metals used in dental restorations. Late readings (10 and 17 days after application of the patch tests) were performed in all patients. Results: Of 19 patients with OLL adjacent to amalgam fillings, 15 (78.9%) were sensitized to inorganic mercury (INM), significantly more than those with OLL not adjacent to amalgam, other oral diseases or complaints, and the control group. In 5 of 15 (33.3%) of the patients with OLL, a positive patch test to INM was observed only at D10 or D17. Amalgam was removed in 18 patients with OLL (sensitization to INM: 15), and in 11 patients with OLP (sensitization to INM: 2). After removal, the lesions of 13 of 15 of the INM-sensitized patients with OLL (86.7%) and 2 with OLP healed or improved significantly, but this was not observed with the INM negative patients. Frequency of sensitization to gold sodium thiosulfate (GST) and palladium chloride 1% pet (PDC) was high in all groups. This was partly because readings were performed late. Lesions of 2 patients with allergic contact stomatitis caused by gold and 1 caused by palladium healed completely after removal of these restorations. Histologically, lichenoid changes were observed in 14 of 36 biopsy specimens of positive patch tests from INM (9/21), GST (2/10), and PDC (3/5) in all patient groups, mainly in persistent patch tests at D10 or D17. This was not observed in 12 biopsy specimens taken from persistent patch tests from other substances, including nickel sulfate. Conclusion: Our results suggest that sensitization to mercury is an important cause of OLL, whether all lesions or only a part of them are adjacent to amalgam fillings. Sensitization to GST may reflect true gold allergy and should be considered as a cause of oral diseases in some patients. Sensitization to PDC is frequent but has yet only little clinical relevance. Patch tests may be positive only at D10 or D17. This suggests the importance of additional readings of GST, PDC, and mercury salts at this time. (J Am Acad Dermatol 1999;41:422-30.)

Gastric mucosal mast cells in atopic subjects

Intragastral allergen provocation under endoscopic control (IPEC) allows direct observation of gastric mucosa reactions after contact with inhalant allergens that reach the stomach. We selected patients with proved atopy to Parietaria but without clinical and endoscopic signs of gastric disease, and we tested them with the specific inhalant allergen during IPEC, recording gastric macroscopic reaction and mucosal mast-cell changes in biopsy specimens. All atopic patients showed visible changes in gastric mucosa quantified as IPEC score. Mast-cell numbers detected in atopic patients (135.4 +/- 102.6/mm2 of stromal area) were significantly higher than in nonatopic subjects (59.8 +/- 25.4/mm2; P < 0.03) and were positively correlated to atopic IPEC score (P < 0.01). In addition, 6/12 atopics who had both higher mast-cell counts and IPEC score showed an intraepithelial distribution of gastric mast cells which displayed ultrastructural features of partial degranulation. It is likely that changes observed in our patients with allergy to Parietaria reflect a subclinical activation of mast cells in the gastric mucosa.

Quantitative electron probe X-ray microanalysis of calcium and phosphorus in human lumbar yellow ligaments

The elemental changes of biopsy specimens obtained from the human lumbar yellow ligaments were studied by quantitative electron probe X-ray microanalysis on both glutaraldehyde-fixed Epon-embedded sections and unfixed freeze-dried cryosections. Much higher soluble amounts of Ca and P in the unmineralized fibrocartilage zone were found in specimens obtained from older patients than in those from younger ones.

Small intestinal disease – is endoscopic biopsy the answer?

ABSTRACTEndoscopic biopsy of the canine and feline small intestine is becoming more widely available and is generally preferred to surgical biopsy. However, it has limitations which must be recognised if the appropriate interpretation of biopsy findings is to be made. Lack of histological changes in biopsy specimens is a frequent and often frustrating finding, until it is understood that it may reflect either the inevitable problem of examining only the proximal intestine or the fact that not all intestinal diseases are associated with morphological changes. Some newer advances in non‐biopsy methods for investigating small intestinal disease are described.

Unusual cutaneous lesions associated with chronic myelomonocytic leukaemia

A 69-year-old man presented with unusual nodular cutaneous lesions of 3 years duration predominantly involving the chest, upper back and scalp. Histopathological changes in biopsy specimens from affected skin resembled those seen with granuloma annulare even though there was a lack of epithelioid cells. Based on the sluggish course of the condition, leukocytosis with monocytosis in peripheral blood and the findings on electron microscopic examination of peripheral blood cells, he was diagnosed as having chronic myelomonocytic leukaemia (CMMoL). At lower magnification under the electron microscope, the nodular skin lesions showed pleomorphic cell features with monocytes and histiocytic cells of abnormal appearance. The skin lesions were thus considered to be an unusual type of leukaemia cutis.

Giardiasis: analysis of histological changes in biopsy specimens of 80 patients.

Histological changes in duodenal biopsy specimens from 80 patients infected with Giardia lamblia were defined and compared with changes in duodenal biopsy specimens from 80 randomly chosen "healthy" patients. Villous architecture, the number of intraepithelial lymphocytes, the occurrence of lymphoid follicles and the density of colonisation by G lamblia trophozoites were examined. Grade 1 villous flattening was observed in 41% of cases positive for Giardia and in 37.5% of the control cases. The mean content of intraepithelial lymphocytes was 24.5 compared with 22.6 intraepithelial lymphocytes/100 epithelial cells in the positive and negative groups, respectively. Lymphoid follicles were more frequently observed in Giardia positive specimens, but their incidence was not significantly higher compared with that of controls. Twenty five per cent of patients positive for Giardia showed light, 41% intermediate, and 34% heavy colonisation by Giardia trophozoites. In 76% the parasites were observed in all specimens obtained. It is concluded that histological changes induced by G lamblia are not specific, and that two duodenal biopsy specimens might suffice to detect the trophozoites.