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PlESIDENT JOYCE BENNETT. M.D. IM"'x D. Yt'EIL£R HOSPITAL OF A.LBEJ:T EINSTEli'W COU..ECE OF MEDIO NI! IW EASTCKESTER ROAD IIRONX, N6W YORK 11).161

PATHOLOGISTS' CLUB ' OFNEWYORK

Jl\TE: Thursday, April 7, 1994

l'tiiCE: lol:xxlhull ~caL & Mental Health Genter ~1C£- -PWID6NT W.AliUS P~ VAI..SA.MlS; M.D. D£PAJITMl!NT OF PA THOi..OOY tiEV( YORk MEDICA.L COU..SOR VALHAU..A. NEW YORK 10$9,

7f;O Broadl.lay ( intersection of Bl"(ladd.ay . Graham, an:! Flushing Averues) Brooklyn, NY ll:xl6

Stt:itETARYTReASVREJl ~£o B.SM:fTM., ~.0. N:Pt.Ji~!'MEHT OP P A 'rHOI..OOY $1'. VJKCEm'S HOSPITAL UJ WEST II rn STRE£1' ~lW YORK; NY 10011

tllST: Dr. Will:L:nn L. 'lbllm:l ( 718) 963-8098

lffm'I'Irn AND DINNER: 5:15 - 7:00 EM: Third Floor Conferen:e Cent er, Roan 3<D-17

~ ~ENI'IFIC SESSirn: 7:00 - 9:00 EM: Third Floor Conferen::e· Center . Rocrn 3<D-18

By subway: Take the M or J t rain to the Fl ushing Ave.rue stop; station exit s teps take you to the !Dspital entry gate. Or, take the G train to the Fl~ Averue-Marcy Averue stop an:! walk east O'l

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Flushing Averue to the lmpi tal ·entry gate on Flushing Averue aiXi Broadl.lay. Fouofi Floor

By car, fran IJ!)per Marilattan, Bronx, an:! ()!eens; Take the Met ropolitan Averue exit f ran the SOltthllourrl Brook!~ Express­c.ay, tum left onto Metropol itan Averue ~tbrurrl, right on Graham Averue to the -lmpital .

By car, firan ll:Mer Manhattan. BrooklY!l. am Staten r.Slazd~ Take the Flushing A'l/le!U! exit fran the mrtliJOtni Brooklyn­Q.Jeens Expressc.ay, tum right onto Flushing Averue am proceed ~t to the !Dspital.

Parkin8 Ent1o1nce

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, , 1 Woodhull Hospi tal • ' T 760 Broadway, Brooklyn, N.Y. 11206 • • . " m .I

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- .... -Tompkins Ave.

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f ourth f loo r Par\: tng h. tl

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Secured par\d.n!; Will be available in the lmpi tal 's garage ; entry fran 'Ihroop Averue (see nap. )

flRJHlMll'{; H!E:I'INJ: May 5, 1994: Metropolitan lt:lspi tal Center

.. Case l. Invited discussant: Dr. l,.eUI Gallo, Bellevue Hospital

Host discrsant: Dr. E. ~ ~

A 70 )leal' old black male 1m a gastric rrass for ahrut 5 years.

1 .. .

Case 2. Invited discussant: Dr. COOS~ A. Ax:iotis, ~County Hospital Center, SUNY Host discussant: Dr. s. Mitra

A 52 year old black male 1m pain ani tenletreSs of the ribS for 2 rronths. 'lW:l tTaSSeS ~Jere mted on the e:igh.th right ard on the fifth left ribs. The rrass on the eighth rib was resected.

Case 3. Invited d:iscussant: Dr. Josephine Llena, MJnti!fiore Hospital ard Medical Center Host discussant: Dr. Cesar Del llosario '

I .,

A 2::1 year old black male was aamtted to W:xldblll Hospital upon arrival fran Haiti, ~lainiq: of reat~acres, difficultY in gpeech, generalized ilmobility, ani inability to sit, stan!, or ..w.k'. At age 10 re was roted to be-mxh taller' than his peers. At 16 years'he had gynecalastia. His h!:igh.t is 6'9" an:! arm span 7'5"; I~ hiiS a ferale escutcreon ard ab:ophic ' testes. Glu:oSe ti>leran::e test, slcull x-ray, thyroid fm:tion testS~ Ul ani prolactin levels' were all rormal. A~ earlier re ~.as seen at~ General Hospital for a mild <Xlrr::I.FSinn fran a mimr vehicle accident. At that tine re was anbllatocy, able to drive aid: play basl<etball, ' 'IW:l I!DI'lths lat'er re was ·seen at Broal<rla.le Hospital for ~ of the let; ard difficUlty With s~. ntree nooths pribr to admiss:i.OO re ·had p~ive gait difficulty. slowed body l!'ll\lelEnts , ani tlimlrs of' both arm;. After tWl nooths in the ·llosPitai~ re developed fever am pneiJJDilia ani died of rrassive GI bleedirl:. Autojisy was done am a section of the brain is sul:mitted.

Case 4, Invited disorsant: Dr. Gial.l:o Frizzera, New York University Hedica.1 Center Host discussant: Dr. William L. Thel.rrO

A 34 )leal' old wte male 1m a right groin rrass for 2 nooths. lle had experienced fever am dti.lls Cor the last 3 nooths. cr scan of the alxlanen With contrast !tiselosed para!-eortic l~thy. llio!sY of the groin rrass is sul:mitted. · · ~ · ·· r.

- • .,. I. : • I ' ·:.r. . '· ... -Case 5. Invited discussant: Dr. Johl Li, ~ Islanl. College Hospital

Host discussant: Dr. M. Han - . > " c . :

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A 34 year old bladt aale - lldrlitted for CLQ!h, fever, am~ l.as6 for tWl weekS. lle 'hlid a historY of llllltiple -.1 partuers, am crack ani alcdlol ab.Fe. Olest x-ray sllM:d left lower lobe . atelectasis, 'Sputun al!d-bl.ood. culture!! were· negative foi'"AFB, t'l.lrP; · ar¥1. bacteria. Bone 11111l'r0W• st1l:lies were ~t~:r He lllld-di.an:flr!a. ; Stool liOrl<ql was ni%ative for IsoSpOra am cryptospori4i\lll: . rli! was ~'for. ~failure. CSF was ronml. lie died af-ter I t/2 nooths' stayL.in the~mspital. Autopsy·'\olaS darie ard-a sectim of adrem1 is Slbr!itted. • ' · 1 • • :

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Ap!rl.l. 29':;- May·I~ 1994: Synposi\111 on GastrointestinaFDiseases (Drs. R~~ Ridlelf, -H. Rotterdam, l Lefl<OOtcb, Wl Weinstein), Ta.rrytol.n Hilton, ~. NY. Ccntac~ ·NY State Society of

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, Patl:rll.QPsts, c / o Terry l<Juio;en, • 5 ClOIIeotJOd Road, Ri8h Falls, NY 114lt0, (914) 68·7-0955: - • • I 1 1.: - ;)! ~ ~· f .:J:.f1 -' ' ff'k

May· 00; ·1.994: · SchleifStein Patho!Ql:y Conferen::e on Diseases of the l..lh: (Dt. '·A. Katzenstein) / · .. , . 1les:ron:l Inn, ·Alblin)t, NY.- Contaet ms Association of POOiic Health' t.alxiratorieS·, c/o E.H. · ·· lobitt:an, Bax.210, Averill Park, NY 1 2::118, · (518) 674-5874. . ·. ··' ·

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Jf.E.SIOEl'ol tOYC't 8f]ri.,..ETT M D 1-'!CIC 0 wtiUit HOSPnAI. 0'-.4UIU 1 EJ"'STtJI'~ COt..UGIOF MF.Dt(ts~ UlS EAST0tf..S1'tlt l OA 0 !l()!(X "''t"'' YC)aiC IW I

\"'Ct· PUSII>&-"T M"~IU$ P VAU Afo(l$, M 0 OEtAl TMtHTOPPAn.OLOGV NEW Y()ltl( MeDICAL COLLEGE \'ALHA!J.A, N8W VORK IOS9S

$llC'ItETAMV Tlt.li.A$Ukf! .. ~'l£0 8 . SMITH, M,O, DEPAMTMENT Of! PATIIQt.OO\' ST VINClH'rS ttOSPITAI.. ISl WUT lll1Unlf.T tr-1: .. ' '1'011.~ I"Y 1«111

PATHOLOGISTS' CLUB OF NEW YORK

loOXJUL lo£DICIIL liND !ofNrAL HE'AL1H CENllR 'Dl.RSOO, APRIL 7. I~

' .,

Me!lbers and their guests ~re greeted by Dr. William L. Thelrro. Director of Laboratories and the rost' for the meet:i.r@. lb:> ,later chaiftld the presentation of cases in the Scientific Sess:lan. Dr. Boyce Bennett, Club President. retiiJxled tl'rJse in atten:laoce that the Clllb 1 s Jreetings :j.n May and June Will be held at Metropolitan lbspital and SUNY Health Science Center ~t 8rooklyn, respectively. He .artnru'l:ed that the next election of officers of the Clllb Will take place at the June mee~. and that 1D11irees for the offices are Dr. ~us Va.l.sa11i.s (current Vice President ) for President, Dr. Fred Smith (current Secretary-treasurer ) for v,tce ~:ident , and Dr. Joan Jones for Secretary-Treasurer. ('lhlse interested can sul:ltlit aQ;litional rauinations for any o~ the offices, provided they do.!!O before .the June .JI'I!et:i.r@,. bY contact:i.r@ one of the current .officers.). The nerbers present then .wte<) .• ~lY. to awrove ~ awticci.tions ior nerbe~ in the club sulmitted by Dr§., Alexamer PodoLsky, Paul Sageman, George 1\Jri, Patricia Wassenren, Roserary Wieczorek. am OUH<1Il Chen.

. .. .. .. case l. Invited~: Dr. ~za f.allo, B.ellevue,ip;pital ~ , ,

lbst disorsmt: Dr. E. ~

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For this case, an exercise :in cytapathol®c cliagpJsis , IIDSt of the Club nedJe.ts, as ~11 as Dr. Gallo, ~re fortlmte to be provided With the actual smear preparatiors of the lesion, obtained fran b~ perfonl)ed a1 the patimt 'a exrisioo specimen, The lesialws a polypoid gastric nass in a , 70 year pld 11B111 laKW1 to, Jl!M been 1\resent for ·s )'elliS. _.

Jlr· Gallo ill~ the ~ularicy of _the preparation, a feature itself S\ll!&e5tive of neoplasln, a¢ the tw:l cell populatimo. lll1ch ~ present. •'·~ interpreted the ,po(!U}ation of CXlbesive, larger ~ -.. cells with prtlllinent, w:leoli as reactive gastric surface epi thel.ill;, ;mi the smller, dispersed cells . 'with scant cytoplasln ani ·coarse 'chnJmat:in as neoplastic. 1 AltlnWl ~ tumr lo1l6 a plausible . . ,, · rtifferential COUiideiat:icn :in the dias~Dsis, she felt the lack of cohesion and cytolaP,c appearal'D! fawred l)m'C)Ium. The ronsistent association of the Sllllll neoplastic cells with the reactive gastric epitheliun, .~ ~11. as .the lcq clinical h:istoty,: St.gi!Sted a low grade i)o'Qium aris~ :in gastric 1IIICOS'M'5 SOCiated 1)'!11lhlid tissue (!oW..T l)m'C)Ium. )

Dr. ~~jie!tcnsttated ~polypoid l~Jn the bocly regim arrl.diffuse ou::nsaHhicken:il¥;;. present :in the antral ~ of the 1!'066 ~ of the p;trectlJI!Y specimen. ltlstologi,.c> examination ~ed a ~!-differentiated SI!Bll l)qlbxytic l)o'Qium,o~ ecpressed 8-cell.IIBikers and widely :inYOlved the m.r.osa am SlD!uxFa of the stl:mlch, and a ~icially sp~ pdmuy gastric aderocarcinr::a, ..mch 1o116, Cllllf:ined to the antND. ~ed vwth of the tw:l JIB.ljgnalxies a:AIJ.d be d~trated,j.n sectiorll·of the mtrun. Peri&astric l)l(l'(lh mdes 1oere difcfusely i.l'l\lolved by the 1~ and contained a s:i.r@le ml.crane~tasis of the carc:imra. 'She 'discussed the small liter­ature 14'rlch exists on coexistent gastric 1~ and carc:l.ncml.

: . ( , f J ~~4SS'lon that io llor.oed. both Or. Gallo am Or. SU!lgcad agre€<1 that ca.rcl./'O'M cells ~1'1!

probaiJ~ rot present th the s lides that had been Pl'l!pared am dJstriruted to etub rte'!'IJers . The bru;lur@.s had been done on the polyp01d a.I\'11 of the lxxly nu:osa Ul the specll!ell , ...tueh \oiM rot tmolved by the c:art:J.rara 111 sections.

References: Kasahara Y, et al: Coexistn aderocarcimra am nalignant-l~.nf the stamch ... A'Il- J Gastroenterol 83: 19J0988l •

Pl.ariter M: Syrr;:luon:m dooble prinury l!8.)jgnant l )ll!fll'ara of low grade nalignarcy ani early ~er (coll:ision ruror l of the s tamch. Heparo-gastroenterol 31: 144(1984)

Nri< L, et a1: S)llrllrooJu; diffuse welHI.i.fferent:i.ated 1)'!11ltDcytic 1~ am gastnc ad.eoocarcimra present:ill; as splemrecaly am irorH!eficierry anemia. Nr1 J

' Gas'troenterol 85: 1635(199JJ Burl<e J: Histologic criteria for dist~ between•benjgn am nalil;nant· 1\lll'l)l'rlid

inl'iltrates. Sem Di.agrostic Pathol 2:152(1985l Isaacson P. et al: PriJrary lkeH gastn0"' 1>1!1ltma. flun•Patrol IH7-2 (19861

case 2. liiVlted dlscussai1t :: Or: Constantine ·A •• Ax:l.OtlS, Kir@;s Co.mty HospJ.tal Center <. ltlst dl.scussane Or. s-. Mit.ra ~

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Both discussants txlllCI.1lTed that the specimen' sulJ!ti.t ted for review in this case, an exr::isiona.l , biopsy of one of t:Wi lytic les:i.offi of the rtbs in a 52 year old rren,. had histologic features d:iagmstic of ~erhans cell graru!CIIatosis. Usir« piDtographs of the !U-sta:ined sect:i.offi, •Dr. Axiot:is . detomtrated the destru::tive,>"expailsile character of the lesion, the abscess-Uke 'ni!Crosis in the. • center con~ ~ropliiles .aril eas:imphiles, am the I18I1Y ~pale bistiocytoid •cellsl He exclllled the possibility of a JCanthJgrarulaoo.tous Variant of infectious osteanyelitiS by conf:l.xntil1l that the pale cell population consisted a.l!mst entirely•of ~erhans cells: they· had reniform or gl'lXJIIW ru:lei. the cytoplasm WlS stained positively for 5-100 protein. am many had. a denlritic confornation (best appreciated on ~·the sect:i.offi stained for•S'-IOO.tl' • He presented a bnef · ·, review df the history . fln:t:lbn, am patrol~ af • the' ~rhans cell.

Dr. Mit ra reviewed radiologic am 'IJJclear rredicine ilrag:i.m stu:lies wuch· had confirmed the ' presen::e •o! TUTerous bore les:ioffi >in·t!Us patient , and discussed his Sl.lbsequent crurse. Unfortunately, the n:wmeded steroid t reaorent presented difficulties because the patient had caiOODiitant tuber- • culosis and WlS tiOIII:XJJ~liant. lie WlS treated briefly for a spinal ami ·CXJ!llression s)l!ll.rare. ani died 2 years afte'r thiS' idrrissiai with evidence of an IJ'J:Iefined infiltrati\'e pl'bcess in 'the l~Q:S. (No aut.CJ!l6Y WlS performed. l 'w . . . _

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case 3. lnvl.t ed c:lisC:us6ant: · Or. _Jo&epb:ine Llena, MJntefiore ltlspital anilMed:ical Cente r '· •· .• • • ,, tr"t Host discussants: Dr .. jf~ Del· Posar:i.d , ' ... ! v~ ., d ·"" '1!,

~.. • .~., .. ;"'I ·~ I' .1..-.. r-' :--.... "":<t I'- ' .· • ;; CMS MANIFfSTATI<NS Of WlLSOI'S DISI?ASEJ 1 ·: -~ c.· . '

A histo~ sect:ibn of the basaF~l:il!. 'rE&ion of an autopSy bnrlb speciJrei prtmdl!d the • ' l!l1.teiial for d:isc\li6:1lln' 'in·'th!.S c:aser.~: The patient, an IDII!RBI.ly tall ai~ old lllin, had a history of l!Dtor ml speech distutbalas, lleada:les, tlli'IXlrs, ml evil:bu of tAmrifMtim1' mille IBI died of 118S6ive gastrointestinal ~. Cb l"I!Vlewirc the clinical history, Dr. Uena pointed rut that th! patient' s feminization mi8ht be due to either a prinury enlocr1ne disonler (Web mllht aJ.so l!lqllain the almrnal stature) or chrali.c liver wsease (the termiml gastrointEStiml lelllrrlase llli&ht have been caused by varices. ) st.! felt that the clinical reurol~ sign; indicated il disease inuolvill: the basal ~lia.- azxrcorrelat8i With the histol.aPc daces seen in the•sli&e, l oss of Tll!lll'llm, gliosis, ani Alzreirrer type u astrocyt.es. Her interpretation WlS an acquire:~ hepatocerebral desen­eration, ani she ruggested that the autopsy ~tion of the liver would srow cirrllosis. She also entertained the possibility of Wilson's llisease. rut was relu::tant to !rake this cl:iagroeis in the al:Eerr:e of· the characteristic·~ cells. ·• . "' · .1 "' ·

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• ' < Dr. De l Rosano~ &e gross ani l!l1CrosqllllC features of &e liver. ~.tucn ~CJ.rrtoLlc \u'l:l.

=tallll!d large 8I!OUI'lts of lustochemicallv dem:lllStrable. COpper. ()-) gross sl1ces oG- &e br'all). ll)e ~tamen appeared ~ar am rusty broo-n. He corcurred <.ith Or. Llena's lustolopc obsflr:-atwns. ~t in addition feuli \otlat he considered to be acceptable e.xanples of Opalski cells. 1he diagmsis of WiLSon's Disease was fur:.ther;,supported.l:>Y biochemical analysis of t~ copper leve~g-~.1\13)5 ~/!I ,dry: ~jght in liver.) Other autop;y f:iJ'Id.jJllS :in::l u::led 00 ~es consistent <.'ith hypoxia ard bleedlr@ fran varices. '·- . ~~ ·~ ... ~ ..... ;. ' . ··.( , \ -~

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Case 4. Invited d.lscussant : Dr. Glau::o Fnzzera, New York University Scl'()ol,.of ~ire

lbst discussant: Dr. William·1hebro ~·· ··" -' .. DIFfUSE I...A!a: CELL MAI..IGNA.VI' L\l'IR(W. (MICKIIIIU.Cl.5 VS. • ?'IFllE HISTIOCYTIC~,._

An enlarged U'E;\.IlJlal. 1)111l)h rode fmn a 34 year old llBil with ~ dulls and f~ver contaJ.ned a populauon of large cytologically nal:lgnant cells lolhich predcll!inantly infiltrated &e Sl11l.ISOids of the rode. The possibility•·of rretastatic carcirora or rrelan:J!I'l- was ~lu::led bY,..abseJl:e of a< an:l S-100 expression by &e cells. and &e d:i.s<:u;sions were centered on classification of ~t l)lT(llmas tl'at have this histol®c appeararx:e 0

Or. Frizzera elaborated ~.tte three najor dimnstic poss:ibihties. all large cell l~t4)1otas IMch nay preck:minantly grow in simsol.ds: mi.crovillrus l)IIT4ll'oTas , anaplastic large cell (l<i.-1+) 1~;.: am rrail3nant histiocytOSis. He. pointed rut· that :l.t is ~ :in::;easin!;ly\d:iff~t to f:in:l<acceptable ex<ll1)les of iiB.lignant thistioc)ltOSis, as i1'llllY turors ~ IOQUJ.d·.P.rev:iouslY have1.been .•. diagrosed as btl ar.e JlCW. recognized ·•to be ex<ll1)les ·of·n:xla,h lcute l!l)'!!l~ytic· 1~ o~~ mi.crQ­'illrus or l<i-1+- l)mlJtom. Mi.crovillrus l~ubd6 are cbaract~:rizecL:bll the. presence.of ¢.c:r!lvilU 1 - .:

Clohich li'IIY -also be present .on cells•of l<i-1+ 1)1114)1Dti!S), absea:e of typical, Ki-1• s~. tes:dem:Y tQ infiltrate rodes -diffusely-as well as w:i.thin simsoids,. pranine:nf. IU)!eo4, pau::ity of neoplastio,.giant cells, and llliversal. &-cell phen:itype. Ki-1+ -anaplastic l)oll4llotas slnlld deTORStrate st~ s~ for Ki-1 antigen (ment>rane am Golgi pattern) :in all the neoplastic cel ls; distrirution ot. phen:itypes has varied widely ·:in differentXr:ePOI'tli t't-.:ell 37~%. B-cell o-m,. lllll cell 18-41%, B an:l T-<ell to-m:. t rue histiocytic rarely.) _'l}le K:i::cJ+ i)lli\AOJas s:an--~ ful;t,rer sulxl:i,vided :into ~,cat~ries. anaplasuc lane.J:ell l)mlJtom of..adul.ts ..{nay be roclal .pr !!l(tra-rodal. _IQCahU!i or, t e:.ner:¥.J,Z!ld •. clm'act~rizec;l by fl'ell\ll!t!t relapses 3ll1 overall ~val ro%) , ''!IJI.lignan~~e~t,:i.oqyt~~ 9{ -ch1..1dl'llod:; aR:l c:'l.ltaQeCJUS:.:I<:i.-1+.1~, t • -4. · _ '"!1 ~~.., ' ) JB: .; .. , "' r·.""' . ~~!:r ... i ':.1 ~·· r

,, .• In, th:\5 ·ease1 ,.or. Ft;iZZ!ffil'~ ~tocllel!iJ1,al. ~tp:q,e,s;..(cr<-.,,Bel:t!2-•. .JX:lt-~'f.ul46+•kwe-~ ro.t .., .• cors:istent l¥ith Kirl.+ anaplastic J.ynVom, ani, by ·l!XCliJIS:i.o!), ~.fe.l.t., ~~this .~ .. probtlbl)( !111 exaq>le of microvillrus l)lll{ltxml. .~ r.c . . •. ;... .:

Or. 'Dlelm:l had obtained ilmm:lloc:ical results s:imi.lar to tbose deronstrated by Dr. Fnzzera, and he COi'1CUI'Ted with his histol®c ol:l!ervati.ons. He provided, :in addition, &e f:il'llil&s on electron llli.croscopic exani.nation: the lli!OPlastic cells did inleed have microvilli, rut also CCJI'Ita:ined rurerrus proninent l)ISOS!J1I!$ ani ~~ :inte~~.1inte~eu~. -~ ~1~ •. j eatures,· )olh1ch SOJ'!! auth:lrs have cons:1dered ev:idenoe of true histiocytic different1.at,iorh_".t('~re· ~.,ro.:~r- _!l!iscussion on the tlxlrQY issue of loh!ther true histiocytic neopl.as:ia eldsts. J

1he further cnaae of tbe dill 11se ~ ~ ~. as 'the pa~ IBs been lost to fo~.

Reference:· :Neze.lat: c,.-et,a.l,~ ~ hisqocyt.OSis in ,c:h:ildtxlqd;,!l d,ist:in::q.ve, _<;n:lQt):-p . =' ••. : , 1 .• 1, • ,. · ;.: ,r,eUniNJ(l!!tl'lll!',llic entiW .. as!!QCiated with a .~. ~~l()\ij\~,,:i.rMJly:il1! ,?q~i.~

• . to f:o;: •,·( ~ ~~j.I; ·Pa~l 9:75(1!:192) .~ _,,, ... ... :cu:.' l'l;.:t !L-- · .·:.. . " oc-r: t.JJ ··~ • ~ · ;·'"'• .... '15 _. ··.L J ·' ··

., ..l. • ; ":J.rl- J ·.nt 1·. ._ .:r.tl:• ..• l . . ! . " ... . :,..

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case 5. Invi~~-~t: .~. Joh'l 1.1, l..or1: Isla!~~. ,eoUege lbspi;al ~· £< • :n ._. · ·" o-<: · " ~ •. ,., ·ltlsJ;,Ail!P!i5'11t: Dto, ·Min W, Han, Albert Eins~eii), College Qf ~ (~tly,k ,.,., , ;.:r..d ;-;.

··il ,.'t ·. :;;:' '"· 1. ,, :· ..r.: .: · 4 -~ - • • .. .·r ;. :,.,, ·.t.. 1. ~ • ~~--... ~-' ... - ~· :":~ JJ:. . ~· .~ <.."r ' . · ~' · DISSOONA11!D )'II~~CIS~·pi A!Wc• _ ,;n, ~, : < ~ ·;· • ,, .:n . ~

-- ... . -· •:.;; .. 1-- .,.:l! r~ .;_ J.~.-r :.., ._ "'1 -:.-o ·.- :.''1. t:!,L'" J,'-1he slide for discussion :in this case CXIltained a section of t,l:le_adrl!tl¥ glard obtaine9 at the ......

autopSy of a 34 year old iiB.le drug user lb:lse ill.ness lo8S characterized by chronic d.i.anhea. p..Wronary

Wllc."ates . dl"rl tema.nal resp1ratory fa1lure . IHis HIV serolOI:J.c starus was rot trade av<Ulabl~ to tl'e nerilers or to Or. l.J.: 1t was later revealed that the panent had refused HIV test u-.;. 1

Or. l.J. felt that the lustorv StiU!l&lY StUested HIV lllfect100 ani probable AII:5 . The adrenal gland secuon siD;ed occasional cells m the nalulla \o'lth cyt~m<'UUS effect. a i~ rJJW so famhar to th:lse <.h:l eX> autopSies on lxldies of patlents Wlth Alll5. Of oore interest was the presence of l~e areas of necrosis , involvir& the cortex. lredulla. ani capsule; arcuxl these areas, lot!ich had meager associated inflamatory reaction. \iere cells-1rost appeariil; to be cortical epithelial cells­lot\i.ch 10ere filled with 1 u c)ltoplasnic "dots" sUI'Ytllnied by clear halos. Or. Li interpreted these as mtracellular microorganisns, ani focussed rrost of h:ls discussion on the histologic distin::tion of the wu"ious agents presen~ this plCtW'e of intracellular parasitization of the cells of the llml.l!1lCOTl­

pranised luran rost. Histoplasrosis ani micro variant of BlastanyeoslS ~re of the proper size. rut all f\JrsJ. could be exclu:ied, sin::e they parasitize only histiocytes ani never paren:h...-1 or surface epl.thehun. Pneurocystis could be exr::lu:ied sin::e mtracellular parasitizanon lS rot l<!n.n to occur. The l'e1Ulilll't. possibill.tles, all protozoan lllfections. 10ere tOlQJPlasroslS. trypan:l5QlllaSlS 10laga's D1sease has been tramrnJ.tted by tramfusion m this CQ.IItryl. cryptospOrid.iosis (this patient's stools 1.1ere examined ani reported as negatlve for this o~) . ani microsporidloslS. Aft er revJ.e~o<ill; the appeal"SR:e of the o~ Wlth vanous stalnir«: r ethlds (Giersa. <M>. PAS. c:hrarotrope 2Rl. as 1.11!11 as the clinical settm;, Dr. Li 's preferred diagrnsis was microsporidiosis.

Dr . Han reviel.led the f:ln:lircs fran the autopsy he had perfol1!Ed m this case. am slllWed row he had originally realized that the patient had systemic microsporidiosis by~ Giersa-stained irr(lrints of the ltQ; lot!ich denonstrated respiratory columar epithelw cells loaded with the tiny organisns. Virtually all organs 1.1ere infected, lotlich Dr. Han interpreted as resultil:¥ fran hem­to&ero.JS d:issemi.nation fran a prinary acquired infection of the respiratory tract. He illustrated the electron l!II.CrosaJPic appeal'lii'K:e of the orgauisn, .mch lolll5 CORSistent with ~~itozc_ll}n omculi.

References: Scl1oarU 01\. et al: Pathol~ of s~taratic mic.rosporidial (E. hellem) bron::ttiolitis in Alll5 ... lb'n Patlnl 24:937(1993) - - -

Zel'ller ID, et al: A case of E. Cl.Kliculi peritonitis in a patient with AIII5. Am J Clin Pathol 92:352(1989)

Scl'Wlrtz lltl, et al: O:isseminated microsporid.iosis (B,_~J.!~) ani Alll5, Al.ltor6Y evidence for respiratory acquisition. Arch Patlnl lab l'i!<i 116:660(1992l

Respectfully &tmi.t ted.

~ Fred B. ~th. M.D. Secretary-Treasurer