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Surgical PathologyUnknown Case Conference

3/26/07Case 1:

Congenital Toxoplasmosis

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Transmission: 1 infection during gestation maternal parasitemia placental invasion ?fetal circulation Exceptions: reactivation (AIDS) and infection within 3

months of conception Rate of transmission = Timing of maternal infection

Severity of disease = 1/Age of fetus at time of infection

Asymptomatic (90% infected pregnant womenand 85% newborn infants)

Severe disease in antenatal/neonatal period Asymptomatic at birth manifestations later in life

Infant with subclinical infection gestational alterations

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Maternal diagnosis by serologic testing

Serial specimens to detect seroconversion orsignificant rise in IgG titer + detectable IgM

Prenatal (fetal) diagnosis by PCR ofamniotic fluid and ultrasound

PCR: S=64%, NPV=88%, Sp/PPV=100%

US: ascites, hydrops, intracranial/intrahepatic

calcifications, hepatosplenomegaly, hepatitis,encephalitis

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Placental Pathology

Chronic placentitis - villitis, fibrosis, edema

TORCH: USA > 90% = CMV, T. pallidum

Large pale placenta

mild villous inflammation (histiocytes)

foci of necrotizing chronic villitis

pseudocysts in cord stroma chronic deciduitis (nonspecific)

Granulomatous villitis

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Surgical Pathology

Unknown Case Conference3/26/07

Case 2

Congenital Tuberculosis

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RARE

Results from maternal tuberculousendometritis (infected AF) or miliarytuberculosis (hematogenous)

Transmitted to fetus through theplacenta and umbilical vein

AFB recovered from decidua, amnionand chorionic villi

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Criteria for Diagnosis: Proven tuberculosis lesions in infant plus:

Lesions in the 1stweek of life, or Primary hepatic complex, or

Maternal genital tract or placental tuberculosis, or Exclusion of postnatal transmission

Placenta: granulomatous deciduitis,intervillous abscesses with AFB

High neonatal mortality due to delayeddiagnosis and treatment

Active pulmonary TB during pregnancy adverse fetomaternal outcome

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Tuberculous Peritonitis and

Gastrointestinal Tuberculosis

Peritonitis - spread from adjacentdisease (fallopian tube, intestine,mesenteric lymph node) or miliary

disease Diagnosis: fluid-culture, PCR, ADA; bx

Gastroenteritis

Ileocecal area most typical site ofenteritis presents as mass or acute abdomen

diagnosis: biopsy/surgical resection-culture

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Surgical Pathology

Unknown Case Conference

3/26/07

Case 3:

Candida Pneumonia in Patient with

Immune Compromise

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Candida Pneumonia

Low prevalence ICU 1992-97(N=4389): 7.8% all fungi

(mainly Candida), bacteremic patients

1986-93 = 4% Immunosuppression neutropenic,

DM, steroids, cirrhosis, HIV

Prior lung infection/disease Mainly a colonizer and not the cause

of disease

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Candida pneumonia

Two main forms

Primary: local or diffuse BN fromendobronchial inoculation of lung-rare

Secondary: hematogenous seeding withfinely nodular diffuse lung infiltrate

Other forms

Necrotizing pneumonia mycetoma,transient infiltrates, URI, empyemathoracis

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Candida Pneumonia

Diagnosis

X-ray and CT scan nonspecific

Sputum, ET aspirate, BAL culture indefinite

Biopsy demonstrating lung tissueinvasion by fungi + positive culture*

= definitive diagnosis*Culture: C. albicans= 40-70% 1

candida pneumonia

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Candida Pneumonia

Histopathology

Primary

Evidence of aspiration

Evidence of Candida invasion into bronchialwall with or without destruction of resp.ep.

Secondary

Microabscesses with pseudohyphaepenetrating vessels, and

Evidence of pseudohyphae invading lunginterstitium and airways

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Candida Pneumonia

Gross and microscopic pathology

Hematogenous: miliary nodules withcentral necrotizing inflammation and

hemorrhagic rim Aspiration: bronchopneumonia with

fungi in airways or bronchocentric

granulomatous inflammation Candida glabrata in tissue: yeast only

w/o pseudohyphae

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Surgical Pathology


Case 4:

Disseminated Aspergillosis s/p XRT

for Clear Cell Sarcoma in AIDS Patient

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Aspergillosis

Patterns of Pulmonary Aspergillosis Colonization (fungus ball)

Hypersensitivity (ABA, eosinophilic

pneumonia, bronchocentricgranulomatosis, hypersensitivitypneumonitis)

Invasive (acute, necrotizing

pseudomembranous tracheobronchitis,chronic necrotizing PNA, BP fistula,empyema)

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Aspergillosis

Invasive disease = angiocentric hemorrhagic infarction withcharacteristic hyphae

Dichotomous branching at 45 Septation

3-6 um wide

+/- characteristic fruiting head

Differentiate from: *Fusariumspp,Zygomycete, Candidaspp, P. boydii

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Clear Cell Sarcoma

Rare sarcoma of young adults withmelanocytic/uncertain differentiation

Initially in the extremities, oftenrecurrent and/or metastatic

t(12;22)(q13;q12) = EWS/ATF1fusion

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Surgical Pathology


Case 5

Intestinal Mycobacterial Infection

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Intestinal Mycobacterial Infection

Endoscopy +/- biopsy = enteritiswith unusual clinical features

Similar infectious agents affect thesmall bowel and colon with someexceptions

Attempt specific diagnosis ofinfectious agent using special stainsor molecular techniques

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Enteric Mycobacterial Infection

M. tuberculosis

Re-emerging

Primary GI or miliary with lung disease

Ileocecal/jejunoileal/appendix/asc.colon

Nontuberculous mycobacteria (MAI)

HIV/AIDS

Disseminated with GI involvement

Small bowel/colon/mesenteric nodes

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Enteric Mycobacterial Infection

M. tuberculosis

Multiple ulcers/strictures with skip areas

Caseating (transmural) granulomas with

hyalinization/calcification and aphthousulcers with rare or no AFB

MAI

HIV: diffuse histiocyte infiltration, rarelygranulomas (with or without necrosis)

Abundant AFB

Documents

03-26-07