Serological Assessment of Rubella During Pregnancy

In 45 patients with rubella-like illnesses during pregnancy serological tests showed that the clinical diagnosis had been accurate in only 20. Since only 16 of these patients had presented for laboratory investigations within a week of the onset of symptoms, the value of haemagglutination-inhibition tests was considerably reduced; the diagnosis in these cases was confirmed by complement-fixation and rubella-specific IgM tests.Of 172 patients exposed to a rubella-like illness, only 17 were seronegative; 105 sought advice within two weeks of exposure, and therefore the haemagglutination-inhibition antibody tests were useful in determining immunity. Since the clinical diagnosis of rubella was proved incorrect in a number of cases, these pregnancies were saved. Hence both doctors and patients should report both exposure to and rubella-like illnesses as early as possible, so that laboratory investigations may be carried out without delay.     

DNA flow cytometry of pleural effusions. Comparison with pathology for the diagnosis of malignancy

A study was undertaken to determine the potential value of DNA flow cytometry (FCM) for the diagnosis of malignancy in pleural effusions and to compare its results with those of traditional cytomorphology. Forty-one pleural fluids from 37 patients were evaluated by DNA FCM and routine cytologic techniques. Of the 41 pleural fluids, 29 (70.7%) demonstrated an abnormal DNA content by FCM. Two of the 29 pleural fluids had been originally diagnosed as benign by cytology. Cytologic review of these two cases showed no abnormal cells; therefore, there were no false-negative cases based on cytology. In 12 (29.3%) of the 41 fluids, DNA FCM and cytologic evaluation both indicated benign processes. Our preliminary observations indicate that FCM is an accurate and reliable technique that may be of aid in the diagnosis of malignant effusions. The technique may prove to be of special value in the differential diagnosis of reactive mesothelial cells versus malignant mesothelioma as well as for following patients who receive chemotherapy for malignant pleural effusions. DNA FCM may also complement cytomorphologic diagnoses in other serous, exfoliative or aspiration material.     

Systemic lupus erythematosus; early cytologic diagnosis

The diagnosis of systemic lupus erythematosus-a relatively common disease-is difficult because of the variable nature of the symptoms, which resemble those of many other conditions. The finding of the characteristic cells is pathognomonic, although failure to find them does not rule out the diagnosis. If the diagnosis is suspected the "L.E." cell test should be performed on two samples of blood from the veins and one from the bone marrow. After separation of a haparinized sample by centrifuge, a drop from the buffy coat is Wright-stained on a slide and examined for rouleaux formation and for a hematoxylinstaining material sometimes seen in intercellular bodies (which may be surrounded by a rosette of leukocytes) and sometimes seen as ingested by a leukocyte. Only the last finding is positively diagnostic of lupus erythematosus.A statistical analysis of 62 cases treated at the Los Angeles County General Hospital is given. Because of the frequency of rheumatoidlike arthritic changes in the disease, all patients with this form of arthritis should be given the test. Spontaneous remission and then relapse after a long asymptomatic interval occurred in many cases. With early diagnosis and vigorous treatment with cortisone and corticotropin, many patients can be relieved of symptoms.     

Outcome of endoscopy and barium radiography for acute upper gastrointestinal bleeding: controlled trial in 1037 patients.

A study was conducted to find whether the higher diagnostic yield of endoscopy compared with barium radiography improves management or survival in patients with acute upper gastrointestinal bleeding. A total of 1037 patients were entered into a randomised study comparing the outcomes after each investigation. The diagnostic yield in patients who underwent endoscopy was 73% (382 of 526 cases) and in those examined by radiography 55% (280 of 511 cases). A fifth of the patients in the radiology group and a tenth of those in the endoscopy group subsequently underwent the alternative investigation; in most cases, however, no additional diagnostic information was obtained. Operation rates were similar in two groups, though patients in the endoscopy group were generally operated on sooner. Mortality rates were also similar in the two groups, though postoperative mortality was higher in the endoscopy group. Endoscopy may be a more accurate means of diagnosis than radiography, but it offers no short-term benefits in management.     

Cytodiagnosis of oral pemphigus vulgaris

A study was undertaken to verify the reliability of the Tzanck test, performed both by traditional cytomorphology and by a direct immunofluorescence technique, for the diagnosis of oral pemphigus vulgaris. Cytologic smears were obtained from oral erosions of 129 patients with various bullous diseases of the oral mucosa, clinically suspected of being oral pemphigus, as well as from 30 healthy subjects. The 40 cases with subsequent histologic proof of oral pemphigus were cytologically diagnosed as such, based on the significant cytomorphologic findings of acantholytic cells or on the pericellular deposition of IgG (which persisted after cytocentrifugation) in epithelial cells, as studied by direct immunofluorescence. Cytomorphology gave positive results in 37 patients with pemphigus and in one patient with a final diagnosis of herpetic stomatitis and gave negative results in all other cases. Immunocytology gave positive results in all patients with pemphigus and negative results in all other cases. The findings indicate that cytomorphologic studies may be useful in screening suspected cases of oral pemphigus vulgaris while the immunocytologic test may provide a reliable definitive diagnosis.     

SYSTEMIC LUPUS ERYTHEMATOSUS—Early Cytologic Diagnosis

The diagnosis of systemic lupus erythematosus—a relatively common disease—is difficult because of the variable nature of the symptoms, which resemble those of many other conditions. The finding of the characteristic cells is pathognomonic, although failure to find them does not rule out the diagnosis.If the diagnosis is suspected the “L.E.” cell test should be performed on two samples of blood from the veins and one from the bone marrow. After separation of a haparinized sample by centrifuge, a drop from the buffy coat is Wright-stained on a slide and examined for rouleaux formation and for a hematoxylinstaining material sometimes seen in intercellular bodies (which may be surrounded by a rosette of leukocytes) and sometimes seen as ingested by a leukocyte. Only the last finding is positively diagnostic of lupus erythematosus.A statistical analysis of 62 cases treated at the Los Angeles County General Hospital is given. Because of the frequency of rheumatoidlike arthritic changes in the disease, all patients with this form of arthritis should be given the test. Spontaneous remission and then relapse after a long asymptomatic interval occurred in many cases. With early diagnosis and vigorous treatment with cortisone and corticotropin, many patients can be relieved of symptoms.     

Improving the sensitivity of cervical cytologic screening. A comparison of duplicate smears and colposcopic examination of patients with cytologic inflammatory epithelial changes

During a ten-month period, 264 cervical cytologic specimens were submitted in duplicate to two separate cytology laboratories. An attempt was made to perform colposcopy on all 45 patients reported as having an abnormality by either laboratory. All but one patient with a cytologic diagnosis of cervical intraepithelial neoplasia (CIN) underwent colposcopy, as did 68% of the patients with a diagnosis of nondysplastic atypia (inflammatory epithelial changes [IEC]). Five cases of histologically verified CIN were found by colposcopic study of patients with a cytologic diagnosis of CIN; two additional cases were found by colposcopic study of patients with a cytologic diagnosis of IEC. On the assumption that patients not colposcoped were not systematically different from the others with IEC, the screening sensitivities for both laboratories and for cytology followed by colposcopy of IEC cases were estimated. A statistically significant improvement in screening sensitivity was achieved by colposcopic examination of patients with IEC. This conclusion was tempered by a Bayesian analysis that suggested that some of the apparent improved sensitivity could be due to falsely positive biopsy reports. Despite potential benefits, it is premature to recommend universal colposcopic examination of patients with cytologic reports of inflammatory epithelial changes.     

Endobronchial Metastases in Breast Carcinoma

In a consecutive series of 1,628 patients with breast carcinoma, six cases of endobronchial metastases were diagnosed for an incidence of 0.4 percent. The median latent interval from the diagnosis of the primary carcinoma until the time of diagnosis of endobronchial metastases was 21 months. Endobronchial metastases can be the initial manifestation of recurrent cancer and can present with no abnormalities shown on x-ray films of the chest. Because of similar symptomatology, the diagnosis of endobronchial metastases may be confused with a central bronchogenic carcinoma but the histological appearance could differentiate the two entities. Local treatment with radiation therapy is usually inadequate and patients should also be treated with some form of systemic treatment such as chemotherapy. The median survival after the diagnosis of endobronchial metastases was 13 months.     

The natural history of cervical intraepithelial neoplasia as determined by cytology and colposcopic biopsy

The smears preceding the histologic diagnosis of cervical intraepithelial neoplasia (CIN 3) were examined in 100 consecutive cases from an intensively screened population. In 60 patients, negative cytology has been recorded prior to the development of dysplasia; in 27 this had occurred within two years of the histologic diagnosis. These findings suggest that the transition time from epithelial normality to CIN 3 may be shorter than has been generally assumed; therefore, the intensity and frequency of screening should be reviewed.     

Gastric tuberculosis. Endoscopic cytology as a diagnostic tool

OBJECTIVE: To highlight the utility of endoscopic brush smears in the diagnosis of gastric tuberculosis in clinically unsuspected cases. STUDY DESIGN: A retrospective analysis of endoscopic brush smears from 210 patients with gastric symptoms. In seven of these patients (3.3%) the possibility of gastric tuberculosis was suggested in Giemsa-stained smears. Biopsy was available in all cases. Ziehl-Neelsen stain to demonstrate tubercle bacilli was used in brush smears and biopsies in seven and three cases, respectively. RESULTS: Endoscopically the sites involved were antrum (two), pylorus (two), pylorus and duodenum (three). One patient had an ulcerative lesion, and six had growths. Granulomas and/or epithelioid cells were seen in brush smears in all cases. Tubercle bacilli could be demonstrated in cytologic smears in four cases. Endoscopic biopsy showed granulomas in five cases and non-specific gastritis in two. Tubercle bacilli could not be demonstrated in any of the biopsy sections. On further clinicoradiologic investigation, two patients were found to be follow-up cases of pulmonary and nodal tuberculosis. Enzyme-linked immunosorbent assay for HIV, done in three cases, was negative. A final diagnosis of primary gastric tuberculosis in five patients and secondary in two was considered. Six patients responded to antituberculosis treatment and showed healing of the lesions on repeat endoscopy after six months of therapy, while one was a recent case with four weeks' follow-up. CONCLUSION: Endoscopic brush cytology is a reliable modality for the diagnosis of gastric tuberculosis.     

A morphometric filter improves the diagnostic value of morphometric analyses of frozen histopathological sections from mammary tumours.

Frozen sections of 202 consecutive breast tumour cases were analyzed by morphometric quantitation of nuclear features. Nuclei were selected at random. Conventional light microscope examination of the paraffin-embedded specimens revealed 144 cases of cancer and 56 benign tumours. Using multivariate discriminant analysis of morphometric features, all but two of the benign cases and 79% of the malignant tumours were correctly classified. When a morphometrically based dynamic filter set to exclude 'non-diagnostic' nuclei was used, the correctly classified malignant cases rose to 86% Morphometry is a fast, reproducible and efficient method that can be used in conjunction with the histomorphological diagnosis of mammary frozen sections. The combination of systematic sampling and an objective dynamic filter may be a powerful approach to quantitative analyses of tumours from other sites. However, it is also likely that efficiency can be improved by combining nuclear morphometric features with structural, histochemical and molecular biological data. The combination of traditional histomorphological examination with quantitative information may well increase the diagnostic accuracy in individual patients.     

Scrape cell-block technique for fine needle aspiration cytology smears

An inconclusive diagnosis on fine needle aspiration cytology (FNAC) may be due to poor spreading and presence of thick tissue fragments despite aspiration of adequate material. Repeat aspiration may not be possible especially when aspirates of deep seated organs have been obtained by image guided techniques. We have resorted to a 'scrape cell-block' (SCB) technique in such cases. In this technique the cellular material on the slides which had already been fixed and stained, was carefully removed by scraping following destaining and then processed as a cell block. SCB interpretation was then compared with the smear diagnosis and histological diagnosis, wherever available. A total of 27 cases were studied. In 12 cases SCB slides added information to the FNAC smears. In 14 cases SCB did not offer any additional information. SCB was inconclusive in one case. Final histological correlation was available in eight cases and the SCB diagnosis was confirmed in six cases, whereas in two cases SCB failed to identify the tumour. Immunocytochemistry (ICC) was done in one case. SCB is a useful technique to make the best use of the available material when reaspiration is difficult.     

Hemolytic Transfusion Reactions

After receiving apparently compatible blood three patients suffered hemolytic reactions. The compatibility tests were by saline and indirect Coombs technique including a screening tube of group 0 cells. The antibodies responsible for these reactions were not clearly demonstrable for several days following the transfusion. In two instances the antibody was anti-E.These case reports point up the following. (a) Currently used cross-matching procedures will occasionally fail to demonstrate an incompatibility. (b) In two of the cases the direct Coombs test was negative on an immediate post-transfusion specimen, when it could have been of great aid in diagnosis. (c) When a transfusion reaction of hemolytic type is suspected, a follow-up study several days after the reaction may clarify the diagnosis; when possible, transfusions should be avoided in the interim.     

18F-Fluorodeoxyglucose Positron Emission Tomography in Elderly Patients with an Elevated Erythrocyte Sedimentation Rate of Unknown Origin

Patients with an elevated erythrocyte sedimentation rate (ESR) and non-specific symptoms often pose a diagnostic dilemma. PET/CT visualises infection, inflammation and malignancy, all of which may cause elevated ESR. The objective of this study was to determine the contribution of 18F-fluorodeoxglucose positron emission tomography (PET/CT) in the diagnostic work-up of referred patients with an elevated ESR, in whom initial routine evaluation did not reveal a diagnosis. We conducted a combined retrospective (A) and prospective (B) study in elderly (>50 years) patients with a significantly elevated ESR of≥50 mm/h and non-specific complaints. In study A, 30 patients were included. Malignancy (8 patients), auto-inflammatory disease (8 patients, including 5 with large-vessel vasculitis) and infection (3 patients) were suggested by PET/CT. Two scans showed non-specific abnormalities and 9 scans were normal. Of the 21 abnormal PET/CT results, 12 diagnoses were independently confirmed and two alternative diagnosis were made. Two diagnoses were established in patients with a normal scan. In study B, 58 patients in whom a prior protocolised work-up was non-diagnostic, were included. Of these, 25 PET/CT-scans showed suspected auto-inflammatory disease, particularly large-vessel vasculitis (14 cases). Infection and malignancy was suspected in 5 and 3 cases, respectively. Seven scans demonstrated non-specific abnormalities, 20 were normal. Of the 40 abnormal PET/CT results, 22 diagnoses were confirmed, 3 alternative diagnoses were established. Only one diagnosis was established in the 20 patients with a normal scan. In both studies, the final diagnosis was based on histology, clinical follow-up, response to therapy or additional imaging. In conclusion, PET/CT may be of potential value in the diagnostic work-up of patients with elevated ESR if routine evaluation reveals no diagnosis. In particular, large-vessel vasculitis appears to be a common finding. A normal PET/CT scan in these patients suggests that it is safe to follow a wait-and-see policy.     

Ventricular Tachycardia Precipitated by Short-long-short Sequence in a Patient with Implantable-cardioverter Defibrillator

Abrupt changes in heart rate, particularly short-long-short sequences in the ventricular cycle length (CL), might precede initiation of ventricular tachycardia/fibrillation (VT/VF). These changes may be facilitated or caused by pacing activity in patients with pacemakers or implantable-cardioverter defibrillators (ICDs). We describe a patient with two episodes of acquired VT precipitated by short-long-short sequences and diagnosed from the ICD recordings. In such cases, the knowledge of the device parameters is extremely important for a correct diagnosis and management.     

Aspiration biopsy cytology, mammography and clinical exploration: a modern set up in diagnosis of tumors of the breast.

Six hundred and two mammary tumors were examined clinically, by mammography and cytology, with a histologic checkup following surgical biopsy. There were 247 cases of malignoma and 355 benign cases. The limited reliability of the individual methods is demonstrated, and it is shown that their combined use can improve the diagnosis. More malignomas are detected, and preoperative diagnosis is made more safely. If all three methods yield identical results, as was the case in 50.2% of the malignant and 32.7% of the benign lesions, the probability of diagnostic error is less than one per cent. With a malignoma thus established, surgical treatment may follow immediately, or irradiation can be started. In benign cases a surgical biopsy may be foregone and further developments may be awaited with due provision for regular control. If the three methods yield conflicting or doubtful results, elucidation by surgical biopsy and histology is indicated.     

Stereotactic biopsy and cytological diagnosis of solid and cystic intracranial lesions

Cytological smears from 115 consecutive cases of stereotactic biopsies of intracranial lesions were reviewed. Ninety-five lesions were solid and 20 cystic. Material from 90 solid and 13 cystic lesions was sent both for cytological and histological examination. In 66 of the solid lesions, the cytological diagnosis was confirmed by histology (five were benign lesions and 61 malignant tumours: 56 primary brain tumours, three metastases and two lymphomas). In 24 cases with discrepant cytology and histology, the histology was inconclusive or insufficient in 14 cases, while cytology established the diagnosis of astrocytoma grade II (seven cases), metastases (two cases), gliosis (one case) and benign (four cases). Necrosis of tumour type was observed cytologically in six patients representing glioblastoma (two cases), anaplastic astrocytoma (one case), lymphoma (one case) and normal brain (two cases) histologically. Three cases reported cytologically as benign were primary brain tumour (two cases) and gliosis (one case). One smear of a glioblastoma was insufficient for cytological diagnosis. Cystic lesions were cytologically benign in 17 cases and malignant in three cases. Histology from the cyst wall confirmed the malignant diagnosis in three cases and showed tumour in six more cases, a benign process (two cases), changes induced by radiotherapy for arteriovenous malformation (one case) and insufficient material (one case). In conclusion, cytology from solid brain lesion allows an accurate diagnosis and subtyping of tumours in a majority of cases, and can thus be used to choose type of therapy. In cystic brain tumours, however, examination of the cystic fluid, is often inconclusive and a biopsy from the cyst wall should be performed if there is clinical or radiological suspicion of tumour.     

Mastocytosis in children: clinicopathological study based on 35 cases

Immunohistochemical staining is useful in the diagnosis of bone marrow infiltration in systemic mastocytosis. However, it is not clear if antibody staining may be helpful in the diagnosis of cutaneous mastocytosis (CM). We studied the histological appearance of CM in 35 pediatric patients. Cases were assigned to three basic clinical groups: I--Urticaria pigmentosa (UP, n=29); II--Mastocytomas (n=4); and III--Diffuse Cutaneous Mastocytosis (DCM, n=2). The analysis of clinical information revealed an association between the presence of diarrhea and a higher number of cells/field. Nine doubtful cases, all of them macules, were selected based on the scarcity of mast cells (MC) and the absence or rarity of other inflammatory cells. We compared the number of cells identified in Giemsa and immunohistochemical stains in definite and doubtful cases. The intraclass correlation statistic tested the concordance between each staining method. All 9 dubious cases according to the Giemsa stain had their CM diagnosis confirmed by the immunohistochemistry analysis. The intraclass correlation between Giemsa and c-kit was good (0.7) when the number of MC was high. However, there was no correlation between the mast cells counts in the two different stains in the dubious cases. The immunohistochemistry with c-kit might make CM diagnosis easier, especially in the macular cases, when there is a lower number of MC.     

Acute Brucellosis Treated with Trimethoprim and Sulphamethoxazole

Four patients with acute brucellosis are described, none of whom had any connexion with farming or milk industry, the source of infection being different in each case. The diagnosis was made by serological tests, and in three of the four cases was confirmed by positive cultures from bone marrow (one case) and liver biopsy (two cases). Treatment with the combination of trimethoprim/sulphamethoxazole was successful in three out of four cases, and in the fourth case failure may have been due to the development of trimethoprim resistance.