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Surgical Pathology Unknown Conference

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					Surgical Pathology Unknown
         Conference
         11 June 2007
     Michael L. Wilson, M.D.
                      Case 1

A 26-Year-Old Female With Good Prenatal Care Presents
  With Severe Pre-Eclampsia. The Delivery is
  Unremarkable With a Viable Fetus and High Apgar
  Scores.
                        Case 1

• What Lesions in the Placenta Should the Pathologist
  Look for in Cases Described as Pregnancy-Induced
  Hypertension, Pre-Eclampsia, or Eclampsia?
• What are the Diagnostic Criteria for These Lesions?
• How do the Lesions Evolve Over Time?
• Are There Any Mimics?
• Can Those Lesions be Associated with Any Other
  Processes?
                    Case 1

Diagnosis: Atherosis (Decidual Vasculopathy)
                          Case 1

Atherosis (Decidual Vasculopathy)
  – Clinical Importance
     • Associated With Hypertension
     • Also Seen With Intra-Uterine Growth Retardation
                            Case 1

Atherosis (Decidual Vasculopathy)
  – Histopathology
     •   Fibrinoid Necrosis of Decidual Vessels
     •   Mononuclear Infiltrate
     •   Subendothelial Foamy Macrophages
     •   Subendothelial Fat Deposition
                        Case 2

A 37-Year-Old Female Presents Develops Pulmonary
  Tuberculosis and is Treated Until Both Sputum Smears
  and Cultures Become Negative. She Now Presents With
  a Febrile Illness: Sputum Smears are Positive for Acid-
  Fast Bacilli but Cultures are Negative. The Patient
  Subsequently Dies of Acute Bronchopneumonia.
                         Case 2

• What Information can be Derived From the
  Histopathologic Sections of Lung Regarding the Clinical
  Status of the Patient (i.e., is this Active or Successfully
  Treated Tuberculosis)?
• What is the Role, if Any, of Nucleic Acid Amplification
  Tests in the Diagnosis of this Disease?
• What is the Risk of Performing an Autopsy or Processing
  a Lung Resection From this Patient? How can That Risk
  be Minimized?
• What is the Risk of Cutting and Processing the Tissues
  in a Histology Laboratory?
                    Case 2

Diagnosis: Pulmonary Tuberculosis
                         Case 2

Pulmonary Tuberculosis
  – Mycobacterium tuberculosis Complex
     • M. tuberculosis
     • M. bovis
     • M. africanum
  – > 2 Billion Persons Infected Globally
  – ~ 2 Million Deaths Annually
                          Case 2

Pulmonary Tuberculosis
  – Treatment Requires Multiple Drugs for Prolonged
    Time
  – Multiple Drug-Resistant (MDR): Resistant to INH and
    Rifampin
  – Extensively Drug-Resistant (XDR):
     • MDR Plus
     • Resistance to Fluoroquinolone Plus
     • Resistance to One Injectable Drug
                           Case 2

Pulmonary Tuberculosis
  – Histopathology
     • Classic Necrotizing Granulomata
     • Acid-Fast Bacilli at Interface Between Necrotic/Viable Tissue
     • Insensitive and Non-Specific Test
  – Culture
     • Sensitive and Specific Test
     • 10-14 Days
  – Adenosine Deaminase Levels of Fluids
  – Nucleic Acid Amplification of Sputum, Fluids, ? Tissue
                         Case 3

A 28-Year-Old Female Delivers a Healthy Fetus at Term.
  The Mother had No Prenatal Care, but All Screening
  Tests for Infectious Diseases at the Time of Delivery Are
  Negative.
                        Case 3

• Describe the Histopathologic Changes in the Placenta.
• What is This Process Called?
• What are the Causes, both Infectious and Non-
  Infectious, of These Changes?
• What Further Workup is Warranted in This Case?
                     Case 3

Diagnosis: Villitis of Unknown Etiology (VUE)
                      Case 3

Villitis of Unknown Etiology (VUE)
  – Association With Intrauterine Growth Retardation,
    Stillbirths, and Premature Birth
  – Perhaps up to 10% of Placentas in Western Countries
  – Associated With Acute or Chronic Chorioamnionitis
  – ? Immune Pathogenesis
  – More Important if >5% of Villi are Involved
                             Case 3

Villitis of Unknown Etiology (VUE)
  – Histopathology
     •   Mononuclear Infiltrate Within Stroma of Chorionic Villi
     •   May be Present Only at Maternal Surface (Basal Villi)
     •   Often More Severe at Maternal Surface (Basal Villi)
     •   + Giant Cells
                        Case 4

A 44-Year-Old Male is Involved in a Motor-Vehicle Accident
  and Sustains Extensive Trauma to the Right Leg. After a
  Number of Procedures the Patient Develops Non-Union
  of a Tibial Fracture and Osteomyelitis of the Adjacent
  Tibia. Despite Prolonged Therapy, the Leg is Amputated
  Below the Knee. The Section Provided is from the
  Surgical Amputation Margin ~ 12 cm Above the Site of
  Non-Union.
                       Case 4

• What are the Histopathologic Changes? What is the
  Diagnosis? What are the Minimal Criteria for Making
  That Diagnosis?
• Should any Special Stains be Performed? If so, Which
  Ones?
• What Does This Finding Mean in Terms of Prognosis?
• Should Margins be Evaluated in Limb Amputations for
  Diseases Other Than Tumors?
                    Case 4

Diagnosis: Osteomyelitis
                         Case 4

Osteomyelitis
  – Infection of Bone, May be Hematogenous, From
    Trauma, or Iatrogenic
     • Post Surgical
     • Associated with Orthopedic Hardware
  – Serious Infection: Requires up to 6 Weeks of IV
    Antimicrobial Therapy
  – Significance of Osteomyelitis at Surgical Amputation
    Margins has not Been Studied
                           Case 4

Osteomyelitis
  – Histopathology
     • Diagnosis Based on Combination of Inflammation and
       Presence of Necrotic Bone
     • “Acute” and “Chronic” Probably a Meaningless Distinction
     • Granulomatous Variants Exist
        – Infectious: Mycobacterial or Fungal
        – Idiopathic is Non-Infectious
                       Case 5

A 33-Year-Old Female with No Prenatal Care Delivers a
  Healthy Baby at (Estimated) 36-38 Weeks Gestation.
  The Mother has No Past Medical History of Concern and
  has had Previous Normal Pregnancies and Deliveries.
                       Case 5

• One Major Surgical Pathology Textbook States That This
  is not an Infectious Process. Despite That Claim, an
  Immunoperoxidase Stain for Herpes simplex virus (HSV)
  is Performed and is Strongly Positive in These Cells.
• What Does This Mean?
• What do you Tell the Clinician?
• Should They Treat the Mother and/or the Baby?
                         Case 5

• The Patient is Subsequently Found to Have no Known
  Clinical History of HSV Infection. Does This Affect Your
  Interpretation?
• What if the Mother Does Have a History of HSV
  Infection?
• What Other Tests Could be Performed on Tissue
  Sections? What Tests Could be Performed on Serum
  From the Mother?
                    Case 5

Diagnosis: Herpes Simplex Virus (HSV) Deciduitis
                      Case 5

Herpes Simplex Virus Deciduitis
  – Uncommon Diagnosis
  – Varying Opinions Regarding Clinical Importance
  – Arch Pathol Lab Med 1991;115:1141-4
                           Case 5

Herpes Simplex Virus Deciduitis
  – Histopathology
     • Decidual Cells, Often Endothelial Cells, With Nuclear
       Clearing Similar to Viral Cytopathic Effect of HSV Seen in
       Other Tissues
     • Immunoperoxidase Stains Positive for HSV
     • ? Role of in situ Hybridization or Other Tests

				
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