|
Infectious Disease Pathology
Tuesday, February 14, 2006 - 7:30 PM
Regency V Room
|
Moderator:
Gary W. Procop
Cleveland Clinic Foundation
Cleveland, OH
Disclosure: The speakers have indicated they have nothing to disclose.
|
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
Submitted by:
Mary Klassen-Fischer
Armed Forces Institute of Pathology
Washington DC
The patient was a 15 year-old Samoan girl who had moved to Hawaii at age 13. At that time she had a febrile illness with cough and bloody sputum. She was found to have trichuriasis and hookworm infection. She was treated with vermox, and her symptoms slowly resolved. She continued to have intermittent cough, productive of a small amount of phlegm, but was otherwise asymptomatic. She moved from Hawaii to California and then to Georgia at age 14. Nine months prior to the most recent admission she was seen at a local university hospital with bilateral pneumonia and a right pleural effusion. Her temperature was 101.7°F, and white count was 16,300. After 2 weeks of oral penicillin, her cough and pleural effusion resolved, but general malaise continued. Six weeks later, she presented again with fever, chills and cough. Chest x-ray showed resolving pneumonia with residual scarring of the bases bilaterally. Two weeks prior to the most recent admission, she presented again with mild cough and no chest pain. Chest x-ray showed bilateral fluffy infiltrates consistent with severe chronic lung disease and bronchiectasis with superimposed pneumonia. Four days prior to admission, she developed left chest pain which became worse on inspiration. On admission her temperature ranged to 104°F. Her white count was 13,300 (86 segs, 2 bands, 9 lymphs, 3 monocytes), hematocrit 37 and hemoglobin 12.4. She was anergic. Subsequently the white count increased to 49,100 (84 segs, 7 bands, 4 lymphs, 4 monos). Chest x-ray showed white out of the left lung field. She was treated with oxacillin because of a single blood culture that was positive for coagulase-positive Staphylococcus species. Bronchoscopy showed that the bronchial mucosa was inflamed and erythematous throughout her bronchial tree bilaterally and pus was draining from both lungs. Left thoracotomy was performed for decortication and drainage of pleural effusion. Approximately 800cc of thick gelatinous yellow green fluid with fragments of tissue and pleura were removed. The lung was not biopsied because of severe bleeding. Representative sections of the fragments of tissue and pleura removed during thoracentesis were submitted for histology.
Case 1 - Figure 1 -
Fragment of pleural tissue removed during left thoracotomy for decortication and drainage of pleural effusion showing necrosis and inflammation. (Hematoxylin and eosin, X10.)
|
Case 1 - Figure 2 -
Area of necrosis in a fragment of pleural tissue removed during thoracotomy. (Brown-Hopps tissue gram stain, X100.)
|
Submitted by:
Randall T. Hayden
St. Jude Children's Research Hospital
Memphis, TN
The patient was a 74 year old man living in Louisiana with a history of diffuse actininc skin disease, severe arsenic related hyperkeratosis of palms and soles and tobacco related chronic pulmonary disease. He presented with new plaque-like excrescences on the left forearm. He had no lymphadenopathy. A punch biopsy and an excisional biopsy were performed on the forearm lesions. The punch biopsy was submitted for cultures which grew Staphylococcus on most plates and another species on one plate, both interpreted to be contaminants. On gross examination, the excisional biopsy consisted of a 3.7 x 2 cm ellipse of white skin. The surface displayed geographic thickening, pitting and grooving. There were areas of vascular congestion which extended into the cut surface. Representative sections were submitted for histology.
Case 2 - Figure 1 -
Skin excision specimen showing epidermal hyperplasia, hyperkeratosis, intraepidermal abscess and acute and chronic granulomatous dermatitis. (Hematoxylin and eosin, X4.)
|
Case 2 - Figure 2 -
Acid-fast branching filamentous microorganism in an area of necrosis in the dermis. (Fite-Faraco, X100.)
|
Submitted by:
Nancy Cornish
Nebraska Methodist Health System
Omaha, NE
A 73 year old woman presented with chronic left maxillary sinus pain. A CT scan of the sinuses showed complete opacification of the left maxillary sinus with bony erosion in a portion of the medial wall of the sinus. The findings were felt to be due to either chronic infection or an underlying malignancy. She was admitted to the ENT service for a surgical exploration of the left maxillary sinus. At surgery "obvious green and black fungal debris oozed from the maxillary ostium. The surgeon sent the specimen for "culture" on a swab and the tissue for histological exam (Figures 1-3). A fungal culture was not felt to be necessary as it was obviously fungus. A routine bacterial culture was set up and grew 2 colony types of coagulase-negative staph as well as rare Enterobacter cloacae. The accompanying gram stain showed some cellular debris, a few gram positive cocci and no white cells. On microbiology rounds, the technologist questioned the need to do susceptibilies on this specimen.
Submitted by:
Carol Farver
Cleveland Clinic Foundation
Cleveland, OH
The patient is a 57 year-old white female, 4 months status post single lung transplantation (donor/recepient CMV+) for emphysema secondary to smoking, who presented with increasing shortness of breath which progressed to complete opacification and diffuse infiltration of the transplanted lung by chest X-ray. The patient was taken to open biopsy due to a rapidly declining respiratory status.
Case 4 - Figure 1 -
Low power of lung biopsy with hyaline membranes (Hematoxylin and eosin stain)
|
Case 4 - Figure 2 -
Hyaline membrane and type 2 pneumocyte hyperplasia (Hematoxylin and eosin stain)
|
Case 4 - Figure 3 -
High power view of type 2 pneumocyte atypia and inclusions (Hematoxylin and eosin stain)
|
Case 4 - Figure 4 -
Immunohistochemical study in area of Figure 3. (Hematoxylin counter stain).
|
|
|
|
|
