Spleen Biopsy Research Articles

Comment on pregnancy-induced hemophagocytic syndrome.

To the Editor, I read with much interest the paper by Shukla et al. that appeared in a recent issue of the Journal (2013;63:203–205). The diagnosis of hemophagocytic syndrome can be considered established in the patient in light of the prolonged fever, pancytopenia, hyperferritinemia, hypertriglyceridemia, and splenomegaly. It needs mention that the microscopic visualization of hemophagocytosis is simply one of the possible diagnostic criteria and does not necessarily need to be present to establish the diagnosis of hemophagocytic lymphohistiocytosis [1]. The performance of liver biopsy in the pregnant woman with thrombocytopenia as described by the authors may have been unnecessary. Liver, spleen, and lymph node biopsies merely for demonstration of hemophagocytosis should be avoided [2]. Could the patient have had an undiagnosed infection by an obligate intracellular microbe e.g., Salmonella typhi or Brucella sp. that could have triggered the hemophagocytic syndrome? Details of antimicrobial therapy and the number of antibiotic days prior to the patient having the spontaneous abortion with resolution of the hemophagocytic syndrome are, thus, of interest.

Follicular lymphoma, a long-term diagnosis

Follicular lymphoma (FL) is the paradigm of all histological subtypes of Non-Hodgkin lymphomas, previously known as indolent lymphomas. This paper describes the extremely slow clinical course of a case FL until its diagnosis. Case: Man, 33 years old, healthy until six years when it arrives to the Emergency Department (ED) with complaints of pain in the right upper quadrant of the abdomen with 1 month of evolution. Abdominal ultrasound with giant splenomegaly and vesicular lithiasis. All body CT-scan revealed mediastinal and retroperitoneal lymphadenopathy. A splenectomy, a liver and a bone marrow biopsies were performed. As histological findings, necrotizing granulomatous disease in the spleen and inconclusive biopsies. Extended infectious serology study was performed with negative results. The patient was sent to outpatient follow-up. During the next six years, several of these studies were repeated with overlapping results except a slight progressive increase of lymphadenopathy. Six years later comes back to the ED with chest pain and chest pressure without cardiorespiratory complaints. Repeat CT-scan that reveals increased of conglomerate mediastinal lymphadenopathy (with 6 cm) and the patient was submitted to a mediastinoscopy for biopsy of lymphadenopathy and histological results were inconclusive but with some features of Castleman's disease. For a strong diagnosis it was decided a thoracotomy to removal of conglomerate mediastinal lymphadenopathy. Now the result of immunohistological staining was LF. With this case the authors pretend to highlight the difficulty of diagnosis and the need of long follow-up in these patients because of possible long and painless evolution of these cases.

Effectiveness and safety of minilaparoscopy-guided spleen biopsy: a retrospective series of 57 cases

Minilaparoscopy is an accepted method for liver biopsy. We report our experience with minilaparoscopy for splenic biopsy.We reviewed the records of all minilaparoscopy procedures performed from 1996 to 2004 at the University of Mainz Medical Center and from 2005 to mid-2011 at the University of Hamburg Medical Center to identify patients who underwent a minilaparoscopy-guided splenic biopsy. All procedures were performed using the previously described method (2.75-mm trocar, 2.3-mm Veress needle, 1.9-mm laparoscope) with the patient under conscious sedation (midazolam/meperidine/propofol). Splenic biopsies were performed using a second trocar with an 18-G Tru-Cut needle. Argon plasma coagulation (APC) and/or fibrin glue (FG) were used to control postbiopsy bleeding.Fifty-seven patients underwent minilaparoscopy-guided biopsy of the spleen (27 females, 30 males; median age = 41 years, range = 16-76). A specimen suitable for histopathologic evaluation was obtained in all patients. Grouped by preprocedure indication, a definitive diagnosis was obtained in 70% (7/10) of patients who had splenic mass lesions in prior imaging (3 B-NHL, 2 hemangioma, 1 tuberculosis, 1 sarcoidosis; p < 0.01) compared to 29% (10/34) in the group with unexplained fever or suspected lymphoma (3 tuberculosis, 2 B-NHL, 1 hepatosplenic T-cell lymphoma, 1 sarcoidosis, 1 Still's disease, 1 EBV, 1 Q-fever) and 0/13 with unexplained splenomegaly. Focal lesions noted at laparoscopy yielded to a histologic diagnosis in 38% (11/29) of 42 patients compared to 21% (6/28) without laparoscopic abnormality (p = 0.25). Bleeding from the biopsy site was noted in 96.5% (55/57) and was classified as brisk in 9. Control of hemorrhage was achieved in all patients (APC: 47, FG: 1, APC/FG: 7). There was no postprocedure bleeding or other complications.Splenic biopsy guided by minilaparoscopy can be performed safely. Postprocedure bleeding is readily controlled with APC with or without fibrin glue. The highest diagnostic yield is in patients with focal splenic lesions.

Feasibility and safety of minilaparoscopy-guided spleen biopsy

We read with interest the article by Werner et al. [1]. We appreciate their effort to clarify the usefulness of this technique in practice of establishing the diagnosis of splenic abnormalities. However, we have several concerns about this technique. In the setting of cystic tumors or some inflammatory lesions such as tuberculosis, it is difficult to guarantee that cells will not be disseminated in the peritoneal cavity in the process of spleen biopsy. There was no peritoneal disseminations reported in the series. I hope the authors can share their experience in preventing peritoneal dissemination. During the process of minilaparoscopy-guided spleen biopsy, we wonder how the authors located the lesions that were in the parenchyma of the spleen. We are also concerned with the indications of this procedure. In our opinion, it is not suitable for all patients with focal splenic lesions detected in prior imaging studies to undergo minilaparoscopy-guided spleen biopsy. For many lesions, such as hemangioma and tuberculoma, mere diagnosis of these abnormalities is insufficient. Treatment, such as splenectomy or partial splenectomy, is required. During the last decade, which has seen a strong emphasis on the preservation of the immunologic function of the spleen, there has been an increased interest in performing a partial splenectomy for a number of indications, including nonparasitic cysts, benign tumors, and lymphoma staging [2, 3]. In the setting of these lesions, we prefer splenectomy or partial splenectomy to spleen biopsy for the reason that splenectomy or partial splenectomy not obtain more tissue for histopathologic examination while simultaneously removing the lesions. We agree with Werner et al. that minilaparoscopyguided spleen biopsy is an effective and safe procedure to establish a definitive diagnosis for many patients. However, we think that it is not suitable for all patients with focal splenic lesions found via prior imaging studies. The selection criteria for this technique should be better defined.

Widespread epithelioid angiosarcoma with ventricular wall involvement in a dog.

This paper reports on a canine angiosarcoma, presenting as an "undifferentiated metastasizing tumor". A 14-year-old female Cocker Spaniel was referred to the University of Extremadura Veterinary Clinic for clinical examination after suffering rapid deterioration, with chronic cough, anorexia and cachexia. One week after clinical examination, the dog died of right congestive heart failure and ventricular arrhythmia. Blood counts revealed lymphopenia and platelet depletion. The biochemistry profile was within normal limits, except for a drop in blood urea nitrogen. Cytological evaluation of liver and spleen biopsies revealed clustered anaplastic cells that lacked convincing tissue differentiation. Major findings at necropsy were enlarged spleen and multiple, beige to dark-red nodules ranging from 0.5 to 3 cm in diameter in the heart, lung, liver and spleen. At histological examination, multiple nests of anaplastic epithelioid cells were found in sections from all affected organs. Immunohistochemistry revealed widespread expression of CD31 and Factor VIII-related antigen. The neoplastic cells were negative for CD 18. The diagnosis of epithelioid angiosarcoma, localized in the myocardium, lung, liver and spleen was made. The primary site of the neoplasm could not be determined.

Gamma Heavy-chain Disease

Gamma heavy-chain disease (gHCD) is defined as a lymphoplasmacytic neoplasm that produces an abnormally truncated immunoglobulin gamma heavy-chain protein that lacks associated light chains. There is scant information in the literature regarding the morphologic findings in this rare disorder, but cases have often been reported to resemble lymphoplasmacytic lymphoma (LPL). To clarify the spectrum of lymphoproliferative disorders that may be associated with gHCD, this study reports the clinical, morphologic, and phenotypic findings in 13 cases of gHCD involving lymph nodes (n=7), spleen (n=2), bone marrow (n=8), or other extranodal tissue biopsies (n=3). Clinically, patients showed a female predominance (85%) with frequent occurrence of autoimmune disease (69%). Histologically, 8 cases (61%) contained a morphologically similar neoplasm of small lymphocytes, plasmacytoid lymphocytes, and plasma cells that was difficult to classify with certainty, whereas the remaining 5 cases (39%) showed the typical features of one of several other well-defined entities in the 2008 WHO classification. This report demonstrates that gHCD is associated with a variety of underlying lymphoproliferative disorders but most often shows features that overlap with cases previously reported as "vaguely nodular, polymorphous" LPL. These findings also provide practical guidance for the routine evaluation of small B-cell neoplasms with plasmacytic differentiation that could represent a heavy-chain disease and give suggestions for an improved approach to the WHO classification of gHCD.

Effectiveness and safety of minilaparoscopy-guided spleen biopsy: a retrospective series of 57 cases

Minilaparoscopy is an accepted method for liver biopsy. We report our experience with minilaparoscopy for splenic biopsy. We reviewed the records of all minilaparoscopy procedures performed from 1996 to 2004 at the University of Mainz Medical Center and from 2005 to mid-2011 at the University of Hamburg Medical Center to identify patients who underwent a minilaparoscopy-guided splenic biopsy. All procedures were performed using the previously described method (2.75-mm trocar, 2.3-mm Veress needle, 1.9-mm laparoscope) with the patient under conscious sedation (midazolam/meperidine/propofol). Splenic biopsies were performed using a second trocar with an 18-G Tru-Cut needle. Argon plasma coagulation (APC) and/or fibrin glue (FG) were used to control postbiopsy bleeding. Fifty-seven patients underwent minilaparoscopy-guided biopsy of the spleen (27 females, 30 males; median age = 41 years, range = 16-76). A specimen suitable for histopathologic evaluation was obtained in all patients. Grouped by preprocedure indication, a definitive diagnosis was obtained in 70% (7/10) of patients who had splenic mass lesions in prior imaging (3 B-NHL, 2 hemangioma, 1 tuberculosis, 1 sarcoidosis; p < 0.01) compared to 29% (10/34) in the group with unexplained fever or suspected lymphoma (3 tuberculosis, 2 B-NHL, 1 hepatosplenic T-cell lymphoma, 1 sarcoidosis, 1 Still's disease, 1 EBV, 1 Q-fever) and 0/13 with unexplained splenomegaly. Focal lesions noted at laparoscopy yielded to a histologic diagnosis in 38% (11/29) of 42 patients compared to 21% (6/28) without laparoscopic abnormality (p = 0.25). Bleeding from the biopsy site was noted in 96.5% (55/57) and was classified as brisk in 9. Control of hemorrhage was achieved in all patients (APC: 47, FG: 1, APC/FG: 7). There was no postprocedure bleeding or other complications. Splenic biopsy guided by minilaparoscopy can be performed safely. Postprocedure bleeding is readily controlled with APC with or without fibrin glue. The highest diagnostic yield is in patients with focal splenic lesions.

Effect of trichloroethylene intake via drinking water on Th17 cells in BALB/c mice

This study aimed to investigate the effect of trichloroethylene (TCE) intake via drinking water on Th17 cells in mice. Forty eight six weeks old female BALB/c mice were divided into blank control, vehicle control, 2.5 mg/ml TCE and 5.0 mg/ml TCE groups by random number table (12 mice each group), and exposed to TCE by drinking water. On the 14(th), 28(th), 56(th), 84(th) days, blood were collected and assayed for IL-17, IL-6, and TGF-β concentration in serum through ELISA. Animals were killed and spleen biopsies were taken sterility. The proportion of Th17 cells among CD4(+) T cells and RORγt mRNA expression level in spleen were measured by FCM and real-time PCR. In 2.5 mg/ml TCE and 5.0 mg/ml TCE group mice, Th17 cells/CD4(+) T cells in spleen were (3.46 ± 0.32)% and (5.45 ± 0.45)% on day 14, (3.47 ± 0.33)% and (4.10 ± 0.39)% on day 84, which were significantly higher than those for solvent control group at the same time point ((2.15 ± 0.20)%, (2.16 ± 0.35)%, respectively) (P < 0.01). RORγt mRNA expression levels were (1.870 ± 0.084) and (1.965 ± 0.060) on 14 day, (1.998 ± 0.079) and (2.028 ± 0.073) on day 56, which were also significantly higher than those for solvent control group at the same time point (1.77 ± 0.04 and 1.75 ± 0.09, respectively) (P < 0.05). IL-17 concentrations in serum were (32.28 ± 5.38) and (34.47 ± 5.02) pg/ml on day 14, and (34.87 ± 5.48) and (41.94 ± 6.19) pg/ml on day 28, which were significantly higher than those for solvent control group at the same time point((21.57 ± 5.23), (22.11 ± 5.11) pg/ml). IL-6 concentration in serum were (43.07 ± 6.71) and (47.86 ± 8.52) pg/ml on day14, (41.32 ± 7.04) and (46.74 ± 9.33) pg/ml on day 56, which were significantly higher than solvent control group at the same time point ((7.56 ± 7.71) and (28.26 ± 7.22) pg/ml). TGF-β concentration were (17.48 ± 3.06) and (18.93 ± 3.12) pg/ml on day 14, which did not show significant difference from solvent control group ((15.25 ± 2.95) pg/ml). Correlation analysis showed that IL-6 in serum were significantly positively correlated with the proportion of Th17 cells among CD4(+) T cells and RORγt expression level in spleen (r = 0.741, 0.765, P < 0.01). TCE might promote the differentiation of Th17 cells and increase IL-17 secretion by inducing IL-6 and up-regulating RORγt expression together with TGF-β.

Inflammatory pseudotumor of the liver and spleen diagnosed by percutaneous needle biopsy

An inflammatory pseudotumor (IPT) is a relatively rare lesion characterized by chronic infiltration of inflammatory cells and areas of fibrosis. IPTs are difficult to diagnose because of the absence of specific symptoms or of characteristic hematological or radiological findings. In this study, a case of a woman aged over 70 years was reported, who presented with a general malaise lasting more than two months. A computed tomography scan demonstrated a diffusely spread lesion of the liver with a portal vein occlusion and a splenic lesion surrounded by a soft density layer. Since the percutaneous liver biopsy showed findings that suggested an IPT, although the radiological findings did not exclude the possibility of a malignancy, we performed a percutaneous spleen biopsy to enable a more definitive diagnosis. The microscopic findings from the spleen specimen lead us to a diagnosis of IPT involving the liver and spleen. Subsequent steroid pulse therapy was effective, and rapid resolution of the disease was observed.

Favorable outcome of chronic disseminated candidiasis in four pediatric patients with hematological malignancies

Four children were diagnosed with chronic disseminated candidiasis (CDC) during treatment for hematological malignancies. All presented with persistent fever, not responsive to broad-spectrum antibiotics, abdominal distension and hepatosplenomegaly. Two children needed artificial ventilation because of respiratory insufficiency. The time between onset of neutropenic fever and diagnosis of CDC ranged from 20-49 days. Ultrasound and computed tomography failed to demonstrate CDC during the neutropenic phase. All children needed a liver or spleen biopsy to establish the diagnosis of CDC. Three of four patients continued chemotherapy during treatment for the fungal infection. All patients had a favorable outcome, both in terms of the invasive Candida infections, as well as their underlying malignancies.

Utility of Percutaneous Image-Guided Biopsy to Diagnose Intraabdominal Lymphoma with Coaxial Core Needles,

Abstract 4214 Introduction:Although pathological diagnosis is an essential component of managing malignant lymphoma and other malignancies, intraabdominal lesions are generally difficult to approach due to the invasiveness of abdominal surgery. We report here the use of percutaneous image-guided coaxial core needle biopsy to obtain intraabdominal specimens. The coaxial method is associated with a lower risk of tumor cell dissemination and allows for repeated biopsies and thus improves the accuracy of pathological or immunohistological diagnosis. To the best of our knowledge, there have been no reports on the feasibility of this technique for diagnosing intraabdominal malignant lymphomas, which typically requires flow cytometry analysis as well as histopathological evaluation. Methods:We retrospectively reviewed consecutive cases involving percutaneous image-guided biopsy to obtain pathological specimens for intraabdominal mass lesions from April 1999 to March 2011 at Nagano Red Cross Hospital, Nagano, Japan. Liver, spleen, kidney, and inguinal node biopsies were excluded. Following local anesthesia, a certified interventional radiologist performed the procedures using a 16 coaxial guide needle (Cook) parallel to the anesthetic needle under computed tomography (CT) or ultrasonography (US). An 18 gauge core needle was inserted to obtain a pathological specimen, following aspiration with a 20 gauge needle for flow cytometry and cytological evaluation. Occlusion materials of the biopsy track were not used. Since laparotomic biopsy was performed for intraabdominal lesions when percutaneous needle biopsy was not indicated due to anatomical difficulties, we compared needle biopsies with simultaneously performed laparotomic biopsies, which led to a diagnosis of lymphoma. Results:During the 12-year period, we performed 66 procedures for 60 patients (32 males, 28 females; median age, 63.5; age range, 16–85). Six patients underwent second or third repeat procedures due to prior inappropriate samplings (5) or relapse (1). The overall diagnostic rate was 86.4% (57/66); there were 56 true positives, 1 true negative, 9 false negatives, and no false positives (sensitivity, 85.9%; specificity, 100%). No patients required additional surgical biopsies. CT and US were used in 51(76%) and 16 (24%) procedures, respectively. There was no statistically significant difference in accuracy between CT and US as an imaging modality. Notably, median interval between recognition of intraabdominal mass and biopsy was only one day (0–24). As for hematological malignancies, 39 patients had malignant lymphoma (diffuse large B cell lymphoma, 16; follicular lymphoma, 12; Hodgkin lymphoma, 3; peripheral T cell lymphoma, 3; small lymphocytic lymphoma, 3; Burkitt lymphoma, 1; extranodal NK/T cell lymphoma, nasal type, 1) including one case with relapse; 45 procedures were performed for these patients. Biopsies were submitted in 43 procedures, and adequate specimens were obtained for histopathological evaluation and diagnosis in 37 (86%). Flow cytometry was used in 39 procedures and detected lymphoma cells in 31 (79.5%). No major adverse events were observed. Twelve patients (9 males and 3 females; median age, 60; age range, 42–72) were eligible for laparotomic biopsy. While every postoperative course was satisfactory, median duration from lesion recognition to therapy initiation for lymphoma cases excluding those who chose watchful wait or refused therapy was significantly shorter for needle biopsies than laparotomy (14 versus 35 days, p<0.001). Conclusions:This is the first report to show the clinical effectiveness of percutaneous image-guided intraabdominal needle biopsy with coaxial core needles for diagnosis of intraabdominal lymphomas. Although no difference was previously reported between coaxial and noncoaxial methods for liver or kidney biopsies (Hatfield et al. AJR 2008), they experienced seven (0.9%) major complications including one death. We identified no major complications using the Cook core needle system in the present study. This method significantly improves the collection of adequate specimens from intraabdominal lymphoma lesions and potentially helps attain immunohistological distinction, allowing for more timely therapy initiation. Disclosures:No relevant conflicts of interest to declare.

Abstract A65: Improved immunological responses against melanoma in vivo with T lymphocyte adoptive cell therapy coupled with targeted inhibition of mutated and activated BRAF

Abstract Vemurafenib blocks activated BRAF with V600E driver mutation and induces unprecedented high response rates in patients with metastatic melanoma. However, most patients have response durations limited to only several months. Conversely, immunotherapy based on adoptive transfer of T cells has induced low frequency, but highly durable tumor responses. We previously reported (Clin Cancer Res. 16(24), 2010) that T lymphocytes exposed to high concentrations of vemurafenib had preserved viability and function, providing a compelling rationale for a combined targeted drug/immunotherapy approach. We first established an implantable murine melanoma cell line driven by the V600E BRAF oncogene (SM1) from a spontaneously arising melanoma in transgenic mice harboring the V600E BRAF mutation under the control of tyrosinase promoter. SM1 cells exposed to vemurafenib had partial in vitro sensitivity (IC50 of 14 uM) resulting from inhibition of MAPK pathway signaling (as demonstrated by Immunoblotting), while murine lymphocytes were spared. In vitro assays indicated that SM1 cells undergo apoptosis and cell cycle arrest at G1 phase in the presence of vemurafenib. Mice implanted with SM1 tumors responded significantly with daily i.p. injection of vemurafenib, confirming its efficacy in vivo. We then tested the combination of vemurafenib and immunotherapy in vivo using two models of adoptive cell transfer (ACT) therapy. OT-1 T cell receptor-expressing lymphocytes targeting ovalbumin (OVA) present in SM1-OVA tumors or pmel-1 lymphocytes targeting the melanoma-associated-antigen gp100 (endogenously expressed by SM1) combined with daily i.p. injections of vemurafenib resulted in superior antitumor responses compared to either therapy alone. We then quantified the adoptively transferred T cells in spleen and tumor biopsies by tissue immunostaining. There were no significant differences in numbers of T cells infiltrating the tumors with or without vemurafenib. Further analysis with two different molecular imaging-based in vivo T cell tracking (1-Luciferin bioluminescence and 2-Positron Emission Tomography with dFAC tracer) confirmed that vemurafenib did not significantly alter the expansion, distribution or tumor accumulation of the adoptively transferred T cells. Also, vemurafenib did not alter SM1 antigen presentation as demonstrated by lack of significant differences in gp100 expression and MHC-I levels in SM1, as well as, in vivo cytotoxic activity of adoptively transferred cells against their cognate antigen. We then performed immunophenotypic analysis of transferred T cells. Vemurafenib skewed these cells towards a phenotype resembling central memory T cells, a favorable characteristic for superior and prolonged tumor control. Further functional analysis of tumor infiltrating lymphocytes indicated increased interferon-gamma secretion as assayed by intracellular staining and FACS. In conclusion, our data derived from two independent models combining BRAF targeted therapy and immunotherapy indicated favorable changes in T cell function/immunophenotype and support the testing of such combination in patients with BRAFV600 mutant metastatic melanoma. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the Second AACR International Conference on Frontiers in Basic Cancer Research; 2011 Sep 14-18; San Francisco, CA. Philadelphia (PA): AACR; Cancer Res 2011;71(18 Suppl):Abstract nr A65.

Proliferative index and expression of CD38, Zap-70, and CD25 in different lymphoid compartments of chronic lymphocytic leukemia patients

Proliferative index and expression of CD38, Zap-70, and CD25 in different lymphoid compartments of chronic lymphocytic leukemia patients Olga Khoudoleeva1 Eugeny Gretsov1 Natasha Barteneva2,3 Ivan Vorobjev11Hematology Scientific Center, Russian Academy of Medical Sciences, Moscow, Russia; 2Immune Disease Institute and Program in Cellular and Molecular Biology, Children Hospital of Boston, Boston, MA, USA; 3Department of Pathology, Harvard Medical School, Boston, MA, USAAbstract: Recent studies of chronic lymphocytic leukemia (CLL) show that malignant B cells proliferate at a rate similar to normal B lymphocytes. This is in apparent contradiction to the very low proliferation rate found in blood specimens from CLL patients. To address this problem, we studied the expression of Ki-67, CD38, CD25, and Zap-70 in different compartments of CLL patients. Using triple-color flow cytometry, we examined the expression of CD38, CD25, Zap-70, and Ki-67 antigens in the peripheral blood, bone marrow, spleen, and lymph nodes biopsies of patients with CLL, splenic marginal zone lymphoma (SMZL), and nonmalignant diseases. In parallel probes of lymph node/spleen biopsies and blood taken from one and the same patient, Ki-67 expression was 17 times higher. Among the whole cohort, we also found significantly higher Ki-67 expression in biopsies from lymph nodes and spleen (4.95% &plusmn; 0.55%), compared with bone marrow (1.88% &plusmn; 0.32%) and peripheral blood (0.45% &plusmn; 0.03%, P &lt; 0.01). In CLL patients, there are statistically significant correlations between the expression of CD38 and Ki-67 in bone marrow (P &le; 0.01), Zap-70 and Ki-67 in blood (P &le; 0.01), and Zap-70 and CD38 in blood (P &le; 0.01). Patients with SMZL also showed a significant correlation between Ki-67 and CD38 expression (P &le; 0.01) and between Ki-67 and Zap-70 expression (P &le; 0.01). We show for the first time that proliferation of B lymphocytes in CLL patients is associated primarily with lymph nodes/spleen. Malignant cells in the blood represent only a subpopulation of nonproliferating and less-activated B cells in this disease.Keywords: chronic lymphoid leukemia, CD38, Zap-70, Ki-67, bone marrow, lymph node

The Prevalence and Drug Sensitivity of Tuberculosis among Patients Dying in Hospital in KwaZulu-Natal, South Africa: A Postmortem Study

Tuberculosis is the leading cause of death in South Africa by death notification, but accurate diagnosis of tuberculosis is challenging in this setting of high HIV prevalence. We conducted limited autopsies on young adults dying in a single public hospital in the province of KwaZulu-Natal between October 2008 and August 2009 in order to estimate the magnitude of deaths attributable to tuberculosis. We studied a representative sample of 240 adult inpatients (aged 20-45 years) dying after admission to Edendale Hospital. Limited autopsies included collection of respiratory tract secretions and tissue by needle core biopsies of lung, liver, and spleen. Specimens were examined by fluorescent microscopy for acid-fast bacilli and cultured in liquid media; cultures positive for M. tuberculosis were tested for drug susceptibility to first- and second-line antibiotics. Ninety-four percent of our study cohort was HIV seropositive and 50% of decedents had culture-positive tuberculosis at the time of death. Fifty percent of the participants were on treatment for tuberculosis at the time of death and 58% of these treated individuals remained culture positive at the time of death. Of the 50% not receiving tuberculosis treatment, 42% were culture positive. Seventeen percent of all positive cultures were resistant to both isoniazid and rifampin (i.e., multidrug resistant); 16% of patients dying during the initiation phase of their first ever course of tuberculosis treatment were infected with multidrug-resistant bacilli. Our findings reveal the immense toll of tuberculosis among HIV-positive individuals in KwaZulu-Natal. The majority of decedents who remained culture positive despite receiving tuberculosis treatment were infected with pan-susceptible M. tuberculosis, suggesting that the diagnosis of tuberculosis was made too late to alter the fatal course of the infection. There is also a significant burden of undetected multidrug-resistant tuberculosis among HIV-coinfected individuals dying in this setting. New public health approaches that improve early diagnosis of tuberculosis and accelerate the initiation of treatment are urgently needed in this setting. Please see later in the article for the Editors' Summary.

Evaluation of Blood Agar Microtiter Plates for Culturing Leishmania Parasites To Titrate Parasite Burden in Spleen and Peripheral Blood of Patients with Visceral Leishmaniasis

Serial dilution of blood and spleen biopsy specimens, plated on Novy-MacNeal-Nicolle (NNN) blood agar using microtiter culture plates, is a sensitive and reproducible method for detection and growth of Leishmania parasites. Plates could be easily monitored, and growth could be rapidly detected. Moreover, parasite number may be estimated using this technique.

Hepatosplenic αβ T cell lymphoma

A 32-year-old male with chronic hepatitis B was admitted to a hospital with cellulitis in the right leg in September 2006. Pancytopenia, hepatosplenomegaly, and systemic superficial lymph node swelling were noted, and he was referred to our hospital. He developed fever and liver dysfunction in June 2007 and underwent a splenectomy. His pancytopenia subsequently improved. A pathologic diagnosis of hepatosplenic alphabeta T cell lymphoma was made by examining spleen tissue and biopsy specimens of the liver and mesenteric lymph node. He had stage IVB disease because neoplastic T cells were noted in the bone marrow. The response of the lymphoma to conventional chemotherapy including the CHOP (cyclophosphamide, adriamycin, vincristine, prednisolone) and DeVIC (dexamethasone, etoposide, ifoshamide, carboplatin) regimens was poor and transient. A partial remission was obtained with an ESHAP (etoposide, cisplatin, cytarabine, methylprednisolone) regimen. Therefore, we planned a bone marrow transplantation (BMT) from an HLA-haploidentical sibling donor. He was moved to the Department of Hematology, Hyogo Medical College, to receive this BMT as part of a clinical trial. During the conditioning procedure for the transplantation, however, he died of septicemia. Since hepatosplenic alphabeta T cell lymphoma is very rare with only 23 reported cases to date, herein we report this case and discuss the therapeutic strategy.

Increased Immunohistochemical CD138 Expression in Waldenström's Macroglobulinemia (WM) in Comparison with Splenic Marginal Zone Lymphoma (SMZL).

Abstract 5008 IntroductionDifferentiating Waldenström's Macroglobulinemia (WM) from other lymphomas and especially Splenic Marginal Zone lymphoma (SMZL), which presents common features with WM, consists a challenge. There is no characteristic molecular abnormality neither for WM nor for SMZL, while in addition, serum IgM cut off is no longer used for the diagnosis of WM. Moreover, while paratrabecular and intrasinusoidal pattern of bone marrow infiltration are described as typical of WM and SMZL respectively, there is often overlap between them. B-lymphocytes' immunophenotype is usually CD5 and CD23 negative in both entities, although deviations from this pattern may be observed; CD38, a marker of lymphocyte activation, theoretically related to lymphoplasmacytic differentiation and adverse prognosis in Chronic Lymphocytic Leukemia, may be expressed. Both WM and SMZL are included among the least reproducible diagnoses of the WHO classification when the diagnosis is based only on clinical grounds, routine laboratory tests and bone marrow biopsy (absence of lymph node or spleen biopsy or typical leukemic picture). CD138 (Syndecan) is expressed in immature as well as in terminally differentiated B-lymphocytes, especially in plasma cells. A strong CD138 expression is observed in myeloma plasma cells. AimTo evaluate firstly whether CD138 is expressed in WM and SMZL and secondly if its expression may help in the differential diagnosis of these entities. Patients and methods61 patients were studied at presentation, 40 with WM and 21 with SMZL. Among WM patients, 16 were females and 24 males with a median age of 64 years. 57% presented anemia with hemoglobin<12gr/lt, 12% lymphathenopathy and 5% splenomegaly. Among SMZL patients, there were 8 females and 13 males (median age 61 years). 70% presented anemia and 9% lymphathenopathy. In all 61 patients bone marrow was infiltrated by neoplastic cells. By definition, all WM patients had a monoclonal serum IgM paraprotein while 19% of SMZL patients secreted a serum monoclonal paraprotein, either IgM or IgG. Paraffin embedded sections of bone marrow biopsies performed at diagnosis, were stained with anti-CD138 monoclonal antibody, CD138 expression was evaluated in the bone marrow of all patients and comparison between the two patient groups was made. 10% CD 138 expression in bone marrow neoplastic cells was used as cut-off for the evaluation of positivity or negativity. Results62% of WM patients presented CD138 expression in contrast with 14% of SMZL patients. Median percentage of total CD138 expression in neoplastic cells in WM was 26.5% (range 2-100%) while in SMZL it was 8% (range 0-30%). These differences were statistically significant (p<0.01). It is interesting to note that, 3 out of 4 SMZL patients who secreted IgM at low levels did not express CD138. Otherwise in WM patients CD138 expression correlated only with serum IgM levels. In addition it was observed that 68% of WM patients expressed CD38 by bone marrow lymphocyte flow cytometry compared to 5% of SMZL (p<0.01); however this finding was not related to CD138 immunohistochemical expression. ConclusionsPatients with WM presented increased CD138 expression when compared to SMZL patients. If confirmed in larger series, CD138 expression could help differentiating the two entities. DisclosuresNo relevant conflicts of interest to declare.

Pathological manifestations of feline immunodeficiency virus (FIV) infection in wild African lions

Feline immunodeficiency virus (FIV) causes AIDS in the domestic cat (Felis catus) but has not been explicitly associated with AIDS pathology in any of the eight free-ranging species of Felidae that are endemic with circulating FIV strains. African lion (Panthera leo) populations are infected with lion-specific FIV strains (FIVple), yet there remains uncertainty about the degree to which FIV infection impacts their health. Reported CD4+ T-lymphocyte depletion in FIVple-infected lions and anecdotal reports of lion morbidity associated with FIV seroprevalence emphasize the concern as to whether FIVple is innocuous or pathogenic. Here we monitored clinical, biochemical, histological and serological parameters among FIVple-positive (N = 47) as compared to FIVple-negative (N = 17) lions anesthetized and sampled on multiple occasions between 1999 and 2006 in Botswana. Relative to uninfected lions, FIVple-infected lions displayed a significant elevation in the prevalence of AIDS-defining conditions: lymphadenopathy, gingivitis, tongue papillomas, dehydration, and poor coat condition, as well as displaying abnormal red blood cell parameters, depressed serum albumin, and elevated liver enzymes and gamma globulin. Spleen and lymph node biopsies from free-ranging FIVple-infected lions (N = 9) revealed evidence of lymphoid depletion, the hallmark pathology documented in immunodeficiency virus infections of humans (HIV-1), macaques, and domestic cats. We conclude that over time FIVple infections in free-ranging lions can lead to adverse clinical, immunological, and pathological outcomes in some individuals that parallel sequelae caused by lentivirus infection in humans (HIV), Asian macaques (SIV) and domestic cats (FIVfca).

Splenic metastasis from endometrial carcinoma: report of a case and review of literature

Splenic metastasis from endometrial carcinoma is a rare clinical event, with only 11 cases documented previously in the literature. A 58-year-old woman had surgery and radiotherapy for stage IIB endometrial carcinoma. Eighteen months later, PET scan discovered a hypermetabolic splenic mass and two hypermetabolic lung nodules. Spleen biopsy showed metastasis from endometrial carcinoma. Chemotherapy with six cycles of cyclophosphamide, adriamycin and cisplatin effected a partial response of the splenic and lung metastasis. After few months, however, splenectomy was performed because of substantial growth of the spelnic metastasis and it confirmed that the splenic metastasis was of endometrial origin and solitary in the peritoneal cavity. After splenectomy, the patient received chemotherapy with six cycles of paclitaxel. To date, 6 months after splenectomy, she is alive with no intraperitoneal disease and with few stable lung metastases. This is the 12th reported case of splenic metastasis from endometrial carcinoma. Splenic metastasis from endometrial carcinoma is usually solitary splenic metastasis limited to the splenic parenchyma. Splenectomy is an appropriate treatment to avoid splenic rupture, splenic vein thrombosis and painful splenomegaly, to circumvent the splenic metastasis being a source of secondary metastatic disease, and to provide the potential for cure or extended survival. Since patients with splenic metastasis may be asymptomatic and the interval between the diagnoses of endometrial carcinoma and splenic metastasis may be prolonged, careful and extended follow-up after primary treatment of endometrial carcinoma is warranted.

A Case of Sarcoidosis That Was Initially Misdiagnosed as Nontuberculous Mycobacteria Pulmonary Disease

There are several respiratory diseases that show chronic granulomatous inflammation for the histologic finding. Among them, sarcoidosis and tuberculosis are not easy to differentiate when the clinical and radiological features present similar patterns. The increasing incidence of nontuberculous mycobacteria pulmonary disease is making it more difficult for clinicians to arrive at a proper diagnosis. A 69 year old male patient visited our hospital with chronic cough as his chief compliant. His radiologic findings w ere multiple enlarged mediastinal lymphadenpathies with innumerable micronodules and multiple patch infiltrations. The spleen biopsy finding showed chronic granulomatous inflammation, and Mycobacterium avium was identified on the bronchoscopic culture. Because of these findings, we treated him with drugs for nontuberculous my cobacteria disease other than sarcoidosis. However, during the treatment, his symptoms and radiological features became aggravated. Thus, we reviewed the radiologic and pathologic findings and decided to treat him with steroid, which relieved his symptoms and improved the radiologic findings. We report here on a case of sarcoidosis that was initially misdiagnosed as nontuberculous mycobacteria pulmonary disease.Key Words: Sarcoidosis, Nontuberculous mycobacteria pulmonary disease, Chronic granulomatous inflammation