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Infectious Disease Pathology
Monday, March 19, 2012, 7:30 PM
Convention Centre 301-305
Clinical histories are printed below.
Click on the case numbers for text and references of each case.
Click on each slide thumbnail image for an enlarged view
Here, There and Yonder
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Moderator:
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JEANNETTE GUARNER
Emory University
Atlanta, GA
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Disclosure:
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In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose.
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Panelists:
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Amy L. Adams, Emory University, Atlanta, GA
A. Brian West, Yale University, New Haven, CT
Laura W. Lamps, Univ of AR/Medical Sciences, Little Rock, AR
Jose Jessurun, Univ of Minnesota, Minneapolis, MN
Jeannette Guarner, Emory University, Atlanta, GA
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Clinical histories are displayed below.
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for Text and References
Submitted by: Amy L. Adams -
Emory University, Atlanta, GA
The patient is a 63 year old man who underwent deceased donor renal transplant for end-stage renal disease secondary to presumed systemic arterial hypertension. He received anti-thymocyte globulin induction, followed by a maintenance immunosuppressive regimen of tacrolimus, mycophenolate mofetil, and prednisone. On post-operative day (POD) 12 he presented to clinic complaining of poor p.o. intake, dizziness, decreased urine output, dysuria, occasional hematuria, and watery diarrhea since his discharge on POD 3. He reported no history of fever. Upon examination he was found to be hypotensive with a blood pressure of 66/44 mmHg. Initial labs revealed a serum creatinine of 5.7 mg/dl, increased from a nadir of 2.4 mg/dl (normal range 0.7-1.2 mg/dl). Urinalysis showed 100 mg/dl protein, large blood, and trace leukocyte esterase. He was admitted to the Inpatient Transplant Service for treatment and evaluation. With no improvement in his renal function after aggressive IV hydration, the patient underwent renal biopsy which was interpreted as acute cellular rejection, Banff grade I-B. He was started on a 3-day steroid pulse. Urine and blood cultures, as well as stool samples for culture, ova and parasites, and Clostridium difficile toxin, were all negative. His creatinine had improved to 4.41 mg/dl at the time of discharge on POD 15. On POD 20 the patient again presented to clinic with a 2-day history of decreased p.o. intake, chills, diffuse body aches, nausea, and soft stools. He had been unable to tolerate his medications in the 2 days prior to admission. Laboratory analysis showed a persistently elevated creatinine of 4.77 mg/dl and a subtherapeutic tacrolimus level. He was admitted and treated with a 10-day course of anti-thymocyte globulin, given the previous history of rejection and lapse in his immunosuppressive medications. With no significant improvement in creatinine despite this, a second renal biopsy was performed.
Case 1 - Figure 5
Biopsy #2, vaguely granulomatous interstitial inflammation (H&E, 10X) |
Case 1 - Figure 6
Biopsy #2, necrosis of tubular epithelium, (H&E, 20X) |
Case 1 - Figure 7
Biopsy #2, coagulative necrosis of tubular epithelium (H&E, 20X) |
Case 1 - Figure 8
Biopsy #2, necrosis of tubular epithelium with "smudgy" intranuclear inclusions, (H&E, 40X) |
for Text and References
Submitted by: A. Brian West -
Yale University, New Haven, CT
A 24 year-old primagravida presented to her obstetrician at 36 weeks gestation because she had felt no fetal movements for 5 days. She had been a regular attender at prenatal visits, the last at 32 weeks, and her pregnancy up to this had been uneventful. Intrauterine demise was confirmed by ultrasound examination, and the fetus was submitted for autopsy. The patient was a male fetus of 3,560 g weight, with hydrops fetalis and Grade III maceration. The external and internal features were otherwise normal, with the exception of the heart which showed cardiomegaly (35 g; normal range for body weight, 23.1 +/- 3.1 g), and the liver which was severely autolysed. The brain was heavy for gestational age at 390 g, and there were recent foci of subarachnoid hemorrhage. The placenta weighed 480 g and was complete with unremarkable membranes and umbilical cord.
Case 2 - Slide 1
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Case 2 - Figure 8
Immunoreactive nucleated red cells in placental villus capillaries |
Case 2 - Figure 9
B19-infected cells in area of hematopoiesis in fetal spleen |
Case 2 - Figure 10
B19 in erythropoietic cells in hepatic parenchyma, with lack of staining in portal tract |
Case 2 - Figure 11
Giant proerythroblasts in bone marrow biopsy from a renal transplant patient with chronic anemia. Naked nucleus in panel on bottom right. |
Case 2 - Figure 12
Giant proerythroblasts in bone marrow biopsy (top left) and aspirate from an AIDS patient with chronic anemia. Naked nucleus on bottom right. |
Case 2 - Figure 13
B19 immunostaining of giant proerythroblasts in the biopsy illustrated in Fig k. |
for Text and References
Submitted by: Laura W. Lamps -
Univ of AR/Medical Sciences, Little Rock, AR
The patient is a 12 year old boy with a several month history of vomiting and abdominal pain. He did not complain of diarrhea. Upper GI series showed an ileal stricture. Upper endoscopy was normal. Colonoscopy showed a normal colon; the ileum could not be intubated due to the stricture. The patient underwent a segmental resection of the ileum and right colon.
No pertinent laboratory findings.
for Text and References
Submitted by: Jose Jessurun -
Univ of Minnesota, Minneapolis, MN
A 32-year-old man presented to the clinic complaining of high-grade intermittent fevers, night sweats, severe joint pain, and an erythematous maculopapular rash that had persisted for 1 month. His primary care physician obtained a skin biopsy that was suggestive of erythema nodosum and referred him to the University of Minnesota Medical Center for further assessment for a possible immune complex disorder. The physician had seen the patient a month earlier at the onset of his illness and prescribed a 7-day course of levofloxacin for a presumed upper respiratory infection. The patient was originally from Matamoros, Mexico but had lived in McLeod County, Minnesota for the past 10 years. He had not returned to Mexico during that time. On examination, the man was febrile with a temperature of 103.4 degrees F. He demonstrated alopecia areata and supercilliary madarosis. Numerous erythematous macules and papules were distributed over his body, mostly on his chest, back, thighs, and the volar surfaces of his forearms. Few lesions were found on the shins, a site classically involved with lesions of erythema nodosum. The lesions were painful, tender, and nonpruritic. The patient stated that the lesions would come in crops and subside within a few days, followed by residual pigmentation and lichenification. A tender left axillary lymph node, along with a right inguinal node, could be palpated. There was no ocular involvement. The patient complained of paraesthesias and dysesthesias in both forearms, with no evident neurological deficit. A clinical diagnosis of erythema nodosum was made which was thought to be secondary to an immune disorder such as sarcoidosis. To confirm this diagnostic impression before starting anti-inflammatory treatment an inguinal lymph node biopsy was performed.
WBC: 15.1 109/L 89% neutrophils. Microcytic hypochromic anemia with increased rouleaux formation CRP: 17.6 mg/dL ( normal 0-0.80 mg/dL) ANA: weakly positive. Serum ACE: 62 IU/L (normal 9-67 IU/L) Mycoplasma serology: negative. Blood bacterial and fungal cultures: negative Chest Xray: normal, no evidence of mediastinal or hilar lymph nodes. Skin biopsy: subcutaneous panniculitis consistent with erythema nodosum. PET scan: abnormal hypermetabolic activity in bilateral inguinal and iliac nodes. Increased activity in the nodules in the medial thigh supporting a presumptive diagnosis of sarcoidosis. HIV: negative Hepatitis B and C: negative
Case 4 - Slide 1
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Case 4 - Figure 1
Fite stain shows numerous acid fast organisms within the vacuolated histiocytes. |
for Text and References
Submitted by: Jeannette Guarner -
Emory University, Atlanta, GA
54 year old woman that is being worked up for a lung mass that was seen in a chest X-Ray.
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