Autopsy & Case Report by Editora Cubo

ISSN 2236-1960

v. 6, n. 2, apr./jun. 2016

Photomicrography of the kidney showing the diffuse glomerular mesangial amyloid deposits in a case of AL amyloidosis (H&E, 400X)

Hospital Universitรกrio Universidade de Sรฃo Paulo

ISSN 2236-1960 June 2016, volume 6 number 2

Electronic Journal of the Hospital Universitário – Universidade de São Paulo, São Paulo/SP – Brazil President of the University of São Paulo Professor Marco Antonio Zago Superintendent of the University Hospital Professor Waldir Antônio Jorge

Editorial committee Editor in chief Maria Claudia Nogueira Zerbini, MD, PhD Scientific Editors Aloisio Felipe-Silva, MD, PhD Fernando Peixoto Ferraz de Campos, MD Larry Nichols, MD Support Team Lucimar da Silva Prado - Website content, Hospital Universitário da Universidade de São Paulo Tatiana Massaro - Technical support Editora Cubo, desktop publishing

Sponsors Hospital Universitário - University of São Paulo Indexing PubMed Central Portal de Revistas da USP PKP IBICT Latindex Diadorin Seminarios.org Directory of Open Access Journals DOAJ

Editorial

A glimpse at the future György Miklós Böhma Böhm GM. A glimpse at the future. [editorial]. Autopsy Case Rep [Internet]. 2016;6(2):1-3. http://dx.doi.org/10.4322/acr.2016.036

One should not try to guess what the future holds without considering the past. I state this only to justify my references to personal experiences in the Faculty of Medicine when intending to scrutinize the future that awaits the pathologists. In the 1970s, the nonsense that the Brazilian scientific agencies should preferably support projects of applied sciences became a reality. The stupidity of unqualified ministries is not a contemporary issue. This fact upset me substantially, since I could not see any sense in classifying science in “pure” and “applied” terms. I think that the predictability of benefits offered by the fruits of science is crucially complex and, to say the least, doubtful; it is much better to classify science as either “good” or “bad”. The dominant silliness also detracted my line of research, which consisted of the investigation of pulmonary microcirculation permeability using rats as an experimental model. I could no longer get resources for my projects. As the traditional wisdom taught me to dance according to the music, I submitted a “Project on Atmospheric Pollution” to FAPESP (Research Support Foundation of the State of São Paulo), with the help of professors Lawther and Spector from the St. Bartholomew’s Medical School of London where I did my post doctorate. After all, I knew a bit about rat lungs and suspected that they should suffer from air pollution just like us and, thus, at least I would continue to investigate pulmonary pathology. The vocation, or if you prefer, the interest, of pathologists relies on the understanding and

elucidation of the mechanisms of illnesses. Like so many other professionals, the pathologist is curious, and the satisfaction of curiosities makes life worth living. The biological mechanisms refined over millions of years (interacting positively or negatively with the environment), the triumph of life on this planet called Earth, and the decreed finitude of the beings, provide a rich and fascinating universe to be explored. This belief suggests to me that the future of the pathologist remains granted as ever: the essence of our task will remain the same; however, the environment and the research instruments are changing. But what a change! It is the fastest and the most fantastic of all time. Substrate to investigate shall never lack. Knowledge grows exponentially and, likewise, the mystery that surrounds us. I imagine our understanding domain as a ball undergoing incredible growth from which surface we scrutinize the unknown. The larger its circumference the more of the unknown we may glimpse. The complexity in which we live is undoubtedly increasing; however, it is important to note that there is no loss, but solely complementation. There is no obsolescence of old knowledge. The pathologist’s future is guaranteed as an analyst and synthesizer of diseases and illnesses of humankind, but his/her tools will dramatically change. Lost in the centuries, pioneers tried to unveil the mechanisms of the diseases. They studied the body and its organs with only dissecting instruments at their disposal. Microscopy took more than a millennium to widen their observation. This revolutionary invention,

aFaculty of Medicine - Universidade de São Paulo, São Paulo/SP – Brazil.

Autopsy and Case Reports. ISSN 2236-1960. Copyright © 2016. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided article is properly cited.

A glimpse at the future

developed in the 17th century, permitted the study of tissues and cells. Giovanni Battista Morgagni (1682‑1771) is honored as the father of Modern Pathology, and 150 years later, Rudolf Virchow (1821-1902) was celebrated as the founder of Cellular Pathology. The discoveries accelerated and only a few decades passed to unveil the invisible molecular universe, which does not have a certified paternity; however, the term Molecular Biology is credited to the American, Warren Weaver (1894-1978). Pathology–with a capital P–started to incorporate new techniques for microscopic observation: electronic microscopy, histochemistry, cytochemistry, and immunohistochemistry. I had the privilege to know and work with the father of histochemistry, Lucien Lison (1908-1984), a Belgian genius who attained Brazilian citizenship and was Professor of the Faculty of Medicine of Ribeirão Preto (SP-Brazil). The molecular investigation invaded the laboratories of Pathology and became imperative for many diagnoses: the real‑time quantitative polymerase chain reaction, DNA microarray, DNA sequencing, molecular tillering of pathogens, and many other procedures that multiplied and enlightened our understanding. Of course, some of them come into sudden and unpredictable obsolescence; after all, techniques are ephemeral. In the perspective of the diagnostic routine, they are complementary to the optic microscopy. The pathologists only need to select some tools from the molecular biological arsenal to include in their personal routine. However, they should be able to orient themselves in this “sea of modernity,” to be familiar with the available resources and to use them according to the need of the diagnosis clarification, even when performed in other laboratories. One has to be ever updated. Even if it is tiring on the one hand, it backs off the monotony on the other. I was not born in the Digital Era. However, I have lived its revolution, which was the most radical and violent ever. Several reliable sources state that all the existing knowledge from the dawn of humanity until 2003 is quite insignificant when compared with the added information of the last 12 years. Read The Creative Destruction of Medicine, by Eric Topol1; it is the only reference here and is sufficient for this editorial, in my judgment. I started my studies when phone communication was a privilege and the researchers unveiled the mystery of Golgi’s apparatus. But now, since the millennium, I 2

live in a world where cell phones with their applicative cover the Earth, and the scientists sequenced the six billion bases of the human genome. In my late twenties the future could be foreseen, but not now; at best it is a well-educated guess. Besides the continuity of the disease’s elucidation and the avalanche of new techniques, I will risk vaticinations about autopsies and diagnostic microscopy grounded in experience. In the Faculty of Medicine of Ribeirão Preto, where I worked for 15 years, I had good training in autopsies under the supervision of Professor Fritz Köberle (1910‑1983), who was exceptional in this art of our profession. Assuming the position of Full Professor at the Faculty of Medicine of the University of São Paulo in 1977, my first mission was to modernize the Coroner’s Service of the city of São Paulo (SVOC), which I ran for many years. Simultaneously, I created the Experimental Laboratory of Atmospheric Pollution, and started to investigate the comparative study of the toxicity of automotive exhaustion gasses. The difficulties of performing respiratory function tests in rats compelled the laboratory team to program it on computers. It was then that I woke up to the radical changes that were occurring in the world: a new era shook humanity in never-before-seen speed and violence. In 1983, I proposed to the Faculty’s Congregation the creation of a Discipline of Medical Informatics, which took years to be approved and set up; it was only in 1987 that we succeeded in starting the first course of the new subject. Thus, having experience in autopsies, and some computer literacy, I predicted that radical changes would emerge on the horizon: the practice of autopsies would yield, gradually, to the new techniques of exploitation by the Digital Era tools. Autopsies had already decreased with the clinical diagnosis progress that had exponentially speeded up since the 1950s, concomitantly with the reducing autopsy examination requests. Although the autopsy contributed–and still contributes–substantially to the elucidation of the diseases, resistance to its practice has always existed due to religious, cultural, and even social antagonisms. Consent reluctance by the family is the rule. Several nations avoid autopsies as much as possible; Israel and several Asian nations are good examples. Certainly, the advent of non‑invasive techniques of exploitation would contribute to dispense a significant part of the consecrated routine of corpse examinations honored by the last 200 years and would receive a warm welcome by the world. Autopsy and Case Reports 2016;6(2):1-3

Böhm GM

I developed these ideas in some forgotten journal in the early 1990s, and, surprisingly, received severe criticism from the Council of the Department of Pathology of the Faculty of Medicine of Ribeirão Preto. They registered in the minutes that I was persona non grata! Some years passed and image-computing machines started to be integrated into the corpse examinations. Since 2015, in the Faculty of Medicine of the University of São Paulo, a powerful nuclear magnetic resonance machine joined the effort of several research groups to study the corpses of the SVOC in a multidisciplinary project. The pathologists are information integrators par excellence: they receive clinical, surgical, laboratory, and other important data to reach a diagnosis. Contributory data from radiologists (or better: imagingologists) do not surprise them. However, if the autopsy is completely replaced by a non-invasive examination, their training will suffer marked changes. I consider it improbable that imaging professionals shall take our place; therefore, it is important to think to the future and prepare the pathologists to see with digital eyes. It will be easier than it was to train them on the microscopes 200 years ago. And now, I will deal with the primary activity of the pathologists: the biopsies examinations. Digital technology overcame the imaging analysis. Just reflect on taking money out of the bank by the recognition of our fingerprints–it is a new world. Advanced applicatives exist for anatomopathological image analysis, and the specialized literature has been debating their limitations and advantages over the last few years. As previously mentioned, the Digital Era brought a radical change over a very short period of time. Its adaptations are neither uniform nor easy. Communication and economic practices have both suffered rapid and deep changes; the procedures with which I was educated are unrecognized nowadays: letters, bank checks, and money are effacing.

Not so in Medicine: it is an art notoriously refractory to changes. At the beginning of the 1990s, telemedicine was an experimental practice; today it is quotidian in a great part of the globe and prevailing in some regions, such as Abu Dhabi. The rampart of traditional medical practice won’t resist the impact of cell phones and their applicative. We have to get used to them. The great majority of patients still see doctors in their clinics, but are ever accompanied by Dr. Google. We have to accept it. Creative destruction, a concept created in economy by the Austrian, Joseph Schumpeter, as far back as 1942, is one of the characteristics of the digital revolution and Medicine, earlier or later, will follow its inexorable destiny. We have to be prepared for it. This is the theme of the book written by Eric Topol1 mentioned above. I think that colleagues engaged in the routine of Pathology may rest in peace since their art will survive the upcoming years. Medical practice will take a generation–or a little longer–for a transformation to take place by creative destruction, and the traditional and the ancient will live together for a while during its modern reconstruction. However, I consider it imprudent if those who are responsible for future pathologists ignore the fact that they will act in an environment where devices capable of analyzing pathological preparations will join the already known reading machines of biological signs, images, molecular pathology, and genomic disorders. We need to guard against, and not repeat, the tragedy of the tailors who faced the advent of the sewing machine, a product of the Industrial Revolution that started in England in 1760. Thousands of people became jobless–mainly women–and the great advantages of the sewing machine, which benefitted humanity, were only understood after a lot of suffering.

REFERENCES 1. Topol E. The creative destruction of medicine. New York: Basic Books; 2013.

Correspondence György Miklós Böhm Department of Pathology - Faculty of Medicine - Universidade de São Paulo (USP) Rua Sabara, 76, ap. 22 – Higienópolis – São Paulo/SP – Brazil CEP: 1239-010 Phone: +55 (11) 98962-7933 E-mail: gyorgybohm@terra.com.br Autopsy and Case Reports 2016;6(2):1-3

Image in Focus

Cardiac Myxoma Vera Demarchi Aielloa, Fernando Peixoto Ferraz de Camposb Aiello VD, Campos FPF. Cardiac Myxoma. Autopsy Case Rep [Internet]. 2016;6(2):5-7. http://dx.doi.org/10.4322/acr.2016.030

Image courtesy Dr. Vera Demarchi Aiello Figure. Huge left atrial myxoma (measuring 4.0 × 3.5 cm) occupying almost the whole atrial cavity. Note the warty appearance of the tumor surface. The left atrial appendage (arrowhead) is open and does not show thrombosis.

a b

Laboratory of Pathology - Instituto do Coração - Hospital das Clínicas - Universidade de São Paulo, São Paulo/SP – Brazil. Internal Medicine Division - Hospital Universitário - Universidade de São Paulo, São Paulo/SP – Brazil.

Cardiac Myxoma

Primary cardiac tumors (PCT) are rare, accounting for 0.0017-0.03% in autopsy series,1,2 in contrast to metastatic tumors of the heart, which are 30 times more frequent.3,4 Nearly 75% of PCT are benign and most often represented by a myxoma in 50% of cases in the adult population.5 The World Health Organization defines a cardiac myxoma (CM) as a neoplasm composed of stellate to plump, cytologically bland, mesenchymal cells set in a myxoid stroma.6 Approximately 95% of CMs occurs isolated in a wide range of age. However, they occur more frequently among women in the fifth or sixth decade of life.7-9 For a time, myxomas were believed to arise from endocardial thrombi10 and some evidence suggests an association with Herpes simplex virus 1 infections11; however, their tumoral histogenesis remains unknown. Meanwhile, ultrastructure analysis—added to immunohistochemical investigation—suggests that CM is more likely derived from a pluripotent mesenchymal stem cell or sub-endothelial cell. Chromosomal clonal abnormalities, mostly on chromosome 2, 12, and 17, appear to be implicated in the myxoma formation, although defects on chromosome 1q32, the loss of the Y chromosome, and the telomeric association of chromosome 13 and 15, have also been involved.12-14

symptoms of the following triad will usually be present: (i) embolic phenomena (present in 30-40% of cases and usually associated with a villous surface of the tumour)24; (ii) intracardiac flow obstruction (present in almost 50% of cases); and (iii) constitutional symptoms (present in 20-60% of cases). In general, the most common signs and symptoms are non-specific and include dyspnea, palpitation (due to atrial fibrillation), lower limbs edema, hepatomegaly, angina, syncope, cough, and pulmonary edema. The constitutional symptoms, characterized by fatigue, fever, myalgia, arthralgia, and weight loss, are probably related to interleukin-6 cytokine production.25 The diagnosis of a CM is mostly done with echocardiography, both transthoracic and transesophageal, which represent the imaging modality of choice, although the latter permits precise information for the scheduling of surgery. Due to the rarity and consequent unfamiliarity of most general practitioners with this entity, CMs are sometimes misdiagnosed. Differential diagnosis should include intracardiac thrombus and other cardiac tumors. Keywords: Heart Neoplasms; Myxoma

REFERENCES

CMs are mostly pedunculated and solitary, and arise primarily adjacent to the lamina of the fossa ovalis (corresponding to the embryonic septum primum) and develop in the left atrium in 75% of cases, followed by the right atrium (18%),15 the right and left ventricles (3% in each), and the valves (1%). 15-20 Multiple myxomas represent 5% of the cases, half of which are of bilateral origin.21

1. Benjamin HS. Primary fibromyxoma of the heart. Arch Pathol (Chic). 1939;27:950.

Although CM is a benign tumor, reports on its malignancy are well-known, which include: (i) local relapse; (ii) local invasiveness; and (iii) distant metastasis.12 The potential for malignant transformation is controversial, despite the publication of some reports of sarcomas arising from CM recurrences.22,23

4. Reynen K. Frequency of primary tumors of the heart. Am J Cardiol. 1996;77(1):107. http://dx.doi.org/10.1016/ S0002-9149(97)89149-7. PMid:8540447.

Clinical manifestations of CMs are protean and may vary from asymptomatic cases (with a tumor < 4 cm) to unexpected sudden death (generally caused by blood flow obstruction or embolization). In most cases, the clinical presentation will depend on the tumor size, mobility, and location. One or more 6

2. Straus R, Merliss R. Primary tumor of the heart. Arch Pathol (Chic). 1945;39:74. 3. Lam KY, Dickens P, Chan AC. Tumors of the heart. A 20- year experience with a review of 12,485 consecutive autopsies. Arch Pathol Lab Med. 1993;117(10):1027-31. PMid:8215825.

5. S i l v e r m a n N A . P r i m a r y c a r d i a c t u m o r s . A n n Surg. 1980;191(2):127-38. http://dx.doi. org/10.1097/00000658-198002000-00001. PMid:7362282. 6. Burke AP, Tazelar H, Gomez-Roman JJ, Loire R, et al. World Health Organization: tumours of the lung, pleura, thymus and heart. Lyon: IARC Press; 2004. 7. Goodwin JF. Diagnosis of left atrial myxoma. Lancet. 1963;1(7279):464-8. http://dx.doi.org/10.1016/S01406736(63)92359-6. PMid:13949121. Autopsy and Case Reports 2016;6(2):5-7

Aiello VD, Campos FPF

8. Kusumi T, Minakawa M, Fukui K, et al. Cardiac tumor comprising two components including typical myxoma and atypical hypercellularity suggesting a malignant change. Cardiovasc Pathol. 2009;18(6):369-74 PMid:18619858.

17. Cina SJ, Smialek JE, Burke AP, Virmani R, Hutchins GM. Primary cardiac tumors causing sudden death: a review of the literature. Am J Forensic Med Pathol. 1996;17(4):27181. http://dx.doi.org/10.1097/00000433-19961200000001. PMid:8947350.

9. Wold LE, Lie JT. Cardiac myxomas: a clinicopathologic profile. Am J Pathol. 1980;101(1):219-40. PMid:7446701.

18. Karlof E, Salzberg SP, Anyanwu AC, Steinbock B, Filsoufi F. How fast does an atrial myxoma grow? Ann Thorac Surg. 2006;82(4):1510-2. http://dx.doi.org/10.1016/j. athoracsur.2005.11.014. PMid:16996968.

10. Ryou KS, Lee SH, Park SH, Park J, Hwang SK, Hamm IS. Multiple fusiform myxomatous cerebral aneurysms in a patient with Carney complex. J Neurosurg. 2008;109(2):318-20. http://dx.doi.org/10.3171/ JNS/2008/109/8/0318. PMid:18671646. 11. Li Y, Pan Z, Ji Y, et al. Herpes simplex virus type 1 infection associated with atrial myxoma. Am J Pathol. 2003;163(6):2407-12. http://dx.doi.org/10.1016/S00029440(10)63595-X. PMid:14633612. 12. Amano J, Kono T, Wada Y, et al. Cardiac Myxoma: Its origin and tumor characteristics. Ann Thorac Cardiovasc Surg. 2003;9(4):215-21. PMid:13129418. 13. Richkind KE, Wason D, Vidaillet HJ. Cardiac myxoma characterized by clonal telomeric association. Genes Chromosomes Cancer. 1994;9(1):68-71. http://dx.doi. org/10.1002/gcc.2870090112. PMid:7507703. 14. Dobin S, Speights VO Jr, Donner LR. Addition (1) (q32) as the sole clonal chromosomal abnormality in a case of cardiac myxoma. Cancer Genet Cytogenet. 1997;96(2):181-2. PMid:9216729. 15. Burke AP, Virmani R. Cardiac myxoma. A clinicopathologic study. Am J Clin Pathol. 1993;100(6):671-80. http:// dx.doi.org/10.1093/ajcp/100.6.671. PMid:8249916. 16. Yoshikai M, Kamohara K, Fumoto H, Kawasaki H. Left ventricular myxoma originating from the papillary muscle. J Heart Valve Dis. 2003;12(2):177-9. PMid:12701789.

19. McCarthy PM, Schaff HV, Winkler HZ, Lieber MM, Carney JA. Deoxyribonucleic acid ploidy pattern of cardiac myxomas. Another predictor of biologically unusual myxomas. J Thorac Cardiovasc Surg. 1989;98(6):1083-6. PMid:2586124. 20. Japa D, Mashhadi M, Peter S. Giant left Atrial Myxoma Induces Mitral Valve Obstruction and Pulmonary Hypertension. J Clin Diagn Res. 2016;10(1):ED08-09. PMid:26894077. 21. Vijan V, Vupputuri A, Nair RC. An unusual case of biatrial myxoma in a young female. Case Rep Cardiol. 2016(2016):13. http://dx.doi.org/10.1155/2016/3545480. 22. Shinfeld A, Katsumata T, Westaby S. Recurrent cardiac myxoma: seeding or multifocal disease? Ann Thorac Surg. 1998;66(1):285-8. http://dx.doi.org/10.1016/S00034975(98)00481-0. PMid:9692493. 23. Kasugai T, Sakurai M, Yutani C, et al. Sequential malignant transformation of cardiac myxoma. Acta Pathol Jpn. 1990;40(9):687-92. PMid:2260476. 24. Oliveira R, Branco L, Galrinho A, et al. Cardiac myxoma: a 13-year experience in echocardiographic diagnosis. Rev Port Cardiol. 2010;29(7-8):1087-100. PMid:21066964. 25. Wang JG, Li YJ, Liu H, Li NN, Zhao J, Xing XM. Clinicopathologic analysis of cardiac myxomas: Seven years’experience with 61 patients. J Thorac Dis. 2012;4(3):272-83. PMid:22754666.

Conflict of interest: None Correspondence Vera Demarchi Aiello Surgical Pathology Section - Laboratory of Pathology - Heart Institute - Hospital das Clínicas - Universidade de São Paulo (USP) Av. Dr. Enéas C. Aguiar, 44 – São Paulo/SP – Brazil CEP: 05403-000 Phone: + 55(11) 2661-5252 E-mail: anpvera@incor.usp.br

Autopsy and Case Reports 2016;6(2):5-7

Article / Autopsy Case Report

Amyloidosis: an unusual cause of portal hypertension Vilma Takayasua, Lorena Silva Labordaa, Raquel Bernardellib, Henrique Trombini Pinesic, Marilia Polo Minguete e Silvac, Viviane Chiavellid, Angélica Braz Simõese, Aloisio Felipe-Silvae,f Takayasu V, Laborda LS, Bernardelli R, et al. Amyloidosis: an unusual cause of portal hypertension. Autopsy Case Rep [Internet]. 2016;6(2):9-18. http://dx.doi.org/10.4322/acr.2016.035

ABSTRACT Amyloidosis comprises a group of diseases that occurs in five to nine cases per million patients per year worldwide irrespective of its classification. Although the hepatic involvement in primary amyloidosis is frequent, the clinical manifestations of liver amyloidosis are mild or even absent. The authors report the case of an aged man who complained of diffuse abdominal pain and marked weight loss and presented clinical signs of hepatopathy. Clinical workup revealed portal hypertension with ascites, hemorrhoids, and esophageal varices. The laboratory tests showed the cholestatic pattern of liver enzymes, hyperbilirubinemia, renal insufficiency and massive proteinuria accompanied by the presence of serum pike of monoclonal lambda light chain protein. The outcome was unfavorable, and the patient died. The autopsy findings revealed the diagnosis of amyloidosis predominantly involving the liver and kidneys. The bone marrow examination demonstrated the deposition of amyloid material associated with clonal plasma cells infiltration. The authors call attention to portal hypertension as a rare manifestation of primary amyloidosis. Meanwhile, this diagnosis should be taken into account whenever the hepatopathy is accompanied by laboratory abnormalities consistent with hepatic space-occupying lesions concomitantly with other organs involvement. In the case reported herein, kidney involvement was also present with renal failure, massive proteinuria with monoclonal serum gammopathy, what reinforced the diagnostic possibility of primary amyloidosis. Keywords Amyloidosis; Liver Diseases; Hypertension, Portal; Multiple myeloma

INTRODUCTION Amyloidosis is a protein metabolism disorder that results in extracellular fibrils deposition composed of low-molecular-weight protein subunits with similar chemical, structural, and staining characteristics. 1 Amyloid deposits are related to a diversity of entities of varying etiologies involving several organs and systems.

AL amyloidosis and AA amyloidosis are the most clinically relevant types of the disease. Primary or AL amyloidosis occurs due to a plasma cell clonal disorder that results in the deposition of fragments of immunoglobulin light chains in several tissues.2 This type of amyloidosis, which is mostly found in developed

Internal Medicine Division - Hospital Universitário - Universidade de São Paulo, São Paulo/SP – Brazil. Instituto de Infectologia Emilio Ribas, São Paulo/SP – Brazil. c Internal Medicine Department - Faculty of Medicine - Universidade de São Paulo, São Paulo/SP – Brazil. d Anatomic Pathology - Grupo Fleury, São Paulo/SP – Brazil. e Anatomic Pathology Service - Hospital Universitário - Universidade de São Paulo, São Paulo/SP – Brazil. f Department of Pathology - Faculty of Medicine - Universidade de São Paulo, São Paulo/SP – Brazil. a

Amyloidosis: an unusual cause of portal hypertension

countries, is commonly associated with multiple myeloma and Waldenström macroglobulinemia.1,3 In these cases, the mean age at diagnosis was 65 years, and two-thirds of the patients were males.4,5 Secondary amyloidosis is characterized by the serum amyloid AA and occurs more frequently in developing countries where it is commonly associated with chronic inflammatory diseases, such as rheumatoid arthritis, inflammatory bowel diseases, and chronic infections like tuberculosis and hanseniasis. 6 Less frequent types of amyloidosis include the types called familiar, localized, senile, and those related to dialysis.6 The clinical features of amyloidosis vary according to the number and extension of the involved organs. Histologically, virtually every organ, such as kidney, heart, autonomic and peripheral nervous system, muscle, and skin, may exhibit any degree of amyloid deposition. However, while some patients may present only a single involved organ, others may show systemic involvement.5 Nonspecific symptoms, such as fatigue and weight loss, are the main initial complaints; however, the definite diagnosis is established when symptoms reflect the involvement of a particular organ.7 We present the interesting case of a patient that presented a rare manifestation of amyloidosis, namely: portal hypertension with ascites, esophageal varices, and hemorrhoids.

CASE REPORT A 75-year-old man sought the medical facility complaining of diffuse abdominal pain, abdominal distension, postprandial fullness, hypersalivation, nausea, and frequent vomiting over the last 6 months. He referred some relief of symptoms with the use of a proton pump inhibitor and lost 10 kg of weight during this period. He was diagnosed with hemorrhoids 2 months ago and has been presenting episodes of hematochezia since then. He denied hematemesis and dysphagia. His relatives referred an altered sleep–wake cycle and periods of fluctuating levels of consciousness over the past few days. His medical history included dyslipidemia, and a recent diagnosis of chronic liver disease of undetermined etiology. He was taking furosemide, cholestyramine, chlortalidone, and pantoprazole. He was a smoker (60 packs/year) and a social drinker. He came from an endemic region 10

of schistosomiasis and his wife recently had been diagnosed with the intestinal form of this disease. The physical examination revealed an ill-looking patient, icteric, and dehydrated. He was afebrile, his blood pressure was 80/60 mmHg, his pulse was a regular 72 beats per minute, and his room air oximetry was 97%. He was lucid and oriented in time and space, and the Glasgow Coma Scale was 15. The neurologic examination was normal. He had a jugular venous distension at 45 degrees, and lower limbs edema was present. The pulmonary examination disclosed bilateral diffuse crackles and hypophonesis of the heart sounds. The abdomen was distended; the liver was palpable until 7 cm below the xiphoid appendix (left liver lobe enlargement); and large ascites was present. The laboratory work-up is shown in Table1. Other examinations included: ANA – HEp-2 = 1/320, nucleolar pattern, normal determination of complement fractions C3 and C4. Urinalysis showed proteinuria, 37,000 erythrocytes/ mm3, hyaline, and granular casts, and 24-hour urine protein was 7 g. Hepatitis B and C, and HIV serologies were negative. The anti‑mitochondria antibody was negative, and ceruloplasmin and copper determinations were within the normal range. The rectum biopsy was negative for Schistosoma sp eggs. The monoclonal component was identified in the serum protein electrophoresis as a lambda chain by immunofixation. The abdominal ultrasound (US) showed an enlarged liver with a globular shape, and nonspecific heterogeneous echotexture of the parenchyma. The biliary system, pancreas, and kidneys were normal. A huge amount of free ascitic fluid and bilateral pleural effusion were present. The hepatic Doppler US showed a normal gauge of the hepatic veins with multiphasic hepatofugal blood flow. The portal and superior mesenteric veins were enlarged with reduced velocity hepatopetal blood flow. The upper digestive endoscopy disclosed small and medium caliber esophageal varices, hypertensive gastritis, and a healing duodenal ulcer. The abdominal computed tomography showed an enlarged liver at the expense of the left and caudate lobes, plus splenomegaly, and ascites. Doppler echocardiography showed a mild double aortic lesion (mean systolic left ventricular/aortic gradient of 9 mmHg), mild diastolic left ventricular dysfunction, and preserved systolic function. Renal biopsy was not performed due to the patient’s critical clinical status. Autopsy and Case Reports 2016;6(2):9-18

Takayasu V, Laborda LS, Bernardelli R, et al.

A diagnostic paracentesis was undertaken and the results were consistent with portal hypertension (serum‑ascites albumin gradient = 2.37 g/dL) and a high number of neutrophils consistent with the diagnosis of spontaneous bacterial peritonitis, which was treated with the administration of albumin and ceftriaxone. The patient’s condition evolved with persistent altered mental status, and after 2 weeks of hospitalization he suddenly presented thoracic pain with no ischemic electrocardiogram changes nor elevation in myocardial necrosis markers. Two days

after this complaint he presented cardiac arrest and died. An autopsy was performed.

AUTOPSY FINDINGS At gross examination, the autopsy confirmed general findings of portal hypertension, such as severe ascites (4.0 L), splenomegaly, gastric and esophageal varices with no signs of bleeding. The spleen (341 g; reference value [RV]: 112 g) and the liver (2800 g; mean RV: 1720 g) were enlarged (Figure 1) and had

Table 1. Initial laboratory workup Result

Result

Hemoglobin

18.0

12.3-15.3 g/dL

Potassium

4.9

3.5-5.0 mEq/L

Hematocrit

52.6

36.0-45.0%

Sodium

142

136-146 mEq/L

Leukocytes

8,090

4.4-11.3 × 10 /mm

ALT

9-36 U/L

Segmented

45-70%

AST

10-31 U/L

Eosinophils

1-4%

ALP

1106

53-128 U/L

Basophils

0-2.5%

γGT

788

2-30 U/L

Lymphocytes

18-40%

Amylase

102

30-118 U/L

Monocytes

2-9%

Lipase

100

13-60 U/L

Platelets

351

150-400 × 10 /mm

3.0

0.3-1.2 mg/dL

INR

1.49

1.0

TP/Albumin

4.9/2.87

6.4-8.3/3.5-5.2 g/dL

Urea

165

5-25 mg/dL

Ferritin

784

22-322 ng/mL

Creatinine 3.57 0.4-1.3 mg/dL CRP 17 ALP = alkaline phosphatase; ALT = alanine aminotransferase; AST = aspartate aminotransferase; γGT = gamma-glutamyl transpeptidase; INR = international normalized ratio; RV = reference value; TB = total bilirubin; TP = total protein.

Figure 1. A - Gross aspect of the enlarged liver showing a slight nodular surface; B - Gross aspect of the enlarged spleen showing a pale cut surface and whitish fibrin deposits on peritoneal surface (bottom). Autopsy and Case Reports 2016;6(2):9-18

Amyloidosis: an unusual cause of portal hypertension

a particularly firm and waxy consistency. Despite showing a fine nodular capsular surface, the liver did not show macroscopic portal tract fibrosis or cirrhosis. These gross findings raised the suspicion of an infiltrative disease and cytological smears were taken from the liver and the spleen. These samples were curiously difficult to smear onto the slides due to their waxy consistency. The smears showed abundant amorphous material, which was purple on May-Grünwald-Giemsa stain and densely orangophilic on Papanicolaou stain (Figure 2). Intermingled spindle cells looked compressed by the waxy material. The heart was also enlarged (435 g; mean RV: 340 g), the kidneys had a nodular surface, and the cortex was pale. Renal samples were collected for immunofluorescence. The histological examination showed a diffuse and dense deposition of amyloid, confirmed by Congo red staining and apple-green birefringence under polarized light in several organs. The liver and the spleen showed massive and compressive sinusoidal deposition (Figure 3). Small vessels were also affected, particularly some hepatic veins. The heart showed moderate diffuse interstitial deposition and some vascular amyloid deposition. Also, a focus of organizing thrombosis was detected in the myocardium (Figure 4).

The kidneys showed diffuse mesangial glomerular amyloid deposition. The cortical interstitium showed fibrosis and interstitial hyalinization with some peritubular and capillary amyloid deposits (Figure 5). The tubules were atrophic with hyaline cylinders. Immunofluorescence showed a weak reaction for immunoglobulin A (IgA) and kappa light chain in the mesangium and tubules. Lambda light chain fluorescence was moderate, global, and diffuse in glomerular mesangium, and focal in the interstitium and vessels. Immunofluorescence was negative for IgG, IgM, C1q, C3, and fibrinogen. The bone marrow showed moderate amyloid deposition and increased cellularity, which was mainly due to granulocytic proliferation, but also due to an increased plasma cell count. Erythroid and megakaryocytic cell series were preserved. Plasma cells were generally typical, isolated, or in small clusters, and made up about 10% of the bone marrow nucleated cells. These cells were positive for Epithelial Membrane Antigen (EMA) and focally for CD138, and negative for CD56 and cyclin D1. Kappa and lambda light-chains were detected in a proportion of 1:1, which was consistent with a monoclonal lambda plasma dyscrasia (Figure 6). A small component of reactive CD20+ B and CD3+ T lymphocytes were detected. These findings were consistent with primary AL amyloidosis with multiorgan clinical manifestations related to a bone marrow plasma cell dyscrasia.

Figure 2. Photomicrography of smears. A, B - Liver and spleen, respectively, showing amorphous and dense orangophilic material (amyloid). The spindle cells in B (stromal and lymphocytes) are compressed by the amyloid. Papanicolaou stain (400X in A and 200X in B). 12

Autopsy and Case Reports 2016;6(2):9-18

Takayasu V, Laborda LS, Bernardelli R, et al.

Figure 3. Photomicrography. A - Portal and periportal amyloid deposition in the liver (H&E, 100X); B - Sinusoidal deposition with obliteration of hepatic vein (H&E, 100X); C - Remnant lymphoid follicle in the spleen with diffuse sinusoidal amyloid deposits (H&E, 100X); D - Detail of splenic amyloid substitution (H&E, 400X).

Minor amyloid deposition was also detected in the tongue, thyroid, lungs, lymph nodes, pancreas, and venules and capillary vessels in the bowels. A previous rectal biopsy was reviewed and no amyloid deposition was detected retrospectively.

DISCUSSION We present the case of a 75-year-old man with AL lambda light-chain amyloidosis with systemic involvement associated with plasma cell dyscrasia, the diagnosis of which was made at the autopsy. The liver and kidneys were the most involved organs, and the prevailing symptoms were hepatic failure, portal hypertension, and nephrotic syndrome. The patient presented hepatomegaly, altered canalicular hepatic Autopsy and Case Reports 2016;6(2):9-18

enzymes (alkaline phosphatase and gamma glutamyl transpeptidase), increased prothrombin time, jaundice associated with portal hypertension confirmed by the presence of ascites (with high serum-ascites albumin gradient), esophageal varices, hemorrhoids, hepatic encephalopathy, massive proteinuria, hypoalbuminemia, and renal failure. Amyloid deposits in the liver are reported to be present in up to 54% of patients with AL amyloidosis.8 This rate is considered to be underestimated because of the lack of liver biopsy in all cases. However, autopsy series show that hepatic amyloidosis may be present in up to 96% of the AL amyloidosis cases.9-11 The clinical features of hepatic amyloidosis are generally mild. Hepatomegaly and alkaline phosphatase elevation are the most common findings. 13

Amyloidosis: an unusual cause of portal hypertension

Figure 4. Photomicrography of the myocardium. A - Interstitial amyloid deposits (H&E, 400X); B - Focal organizing thrombosis in a small artery (H&E, 200X).

Figure 5. Photomicrography of the kidneys. A - Diffuse glomerular mesangial amyloid deposits (H&E, 400X); B,Â C - Congo red staining 200X and 400X, respectively; D - Apple-green color of Congo red staining under polarized light (original magnification 200X). 14

Autopsy and Case Reports 2016;6(2):9-18

Takayasu V, Laborda LS, Bernardelli R,Â etÂ al.

Figure 6. Photomicrography of bone marrow. A - Interstitial deposits of amyloid (H&E, 200X); B - Increased population of plasma cells (H&E, 400X); C, D - Kappa and lambda plasma cells, respectively, showing a clonal expansion of lambda plasma cells (kappa and lambda light chains immunohistochemistry; 40X).

However, weight loss may be present in 72% of cases, fatigue in 60%, abdominal discomfort in 53%, and loss of appetite in 26%.11-13 Hepatomegaly may be present in 57-83% of patients and does not relate to the amount of the amyloid deposition.14,15 Less frequent symptoms include early satiety, edema, anorexia, nausea, ascites, purpura, splenomegaly, and spiders. Cholestatic jaundice, although rare, is associated with poor prognosis.12 Portal hypertension is a rare complication of hepatic amyloidosis16-18 and seems to be related to reduced sinusoidal lumen and increased resistance to blood flow due to massive perisinusoidal amyloid deposits.18,19 Mortality reaches 80% when esophageal varices bleeding occurs.20 The presence of ascites is found in 10-20% of the cases and is generally due to Autopsy and Case Reports 2016;6(2):9-18

heart failure and/or nephrotic syndrome rather than portal hypertension. 21-23 Our patient concomitantly presented nephrotic syndrome, but the serum-ascites albumin gradient was high (2.37 g/dL), which is consistent with ascites of portal hypertension origin. In hepatic amyloidosis, the hepatic enzymes work up frequently shows an increase alkaline phosphatase determination as the hallmark alteration.11 In a series of 98 patients with hepatic amyloidosis, the increment of this enzyme was present in 86% of cases; 61% of them showed dosages above 500 UI/L. Aspartate aminotransferase was increased (two times the upper limit of the RV) in 37% of the patients.11 At admission, our patient presented nephrotic proteinuria associated with renal function impairment. Indeed, the kidney is the organ mostly involved in AL 15

Amyloidosis: an unusual cause of portal hypertension

amyloidosis. The amyloid fibrils may be deposited either in the glomeruli as in the arteries, veins, tubules, and interstitium. Proteinuria ranges from a mild to a massive amount and is present in 70-75% of the cases; one-third of patients present nephrotic syndrome and 20% of them evolve to end-stage renal disease.4,24 In a study comprising 145 patients25 with biopsy‑proven AL amyloidosis, the patients with renal disease presented the lambda light-chain in the proportion of 12:1, while in the patients without renal disease this proportion was 4:1. Furthermore, among the 84 patients with renal amyloidosis, those with lambda light-chain presented higher proteinuria (7 g/24 hours) in comparison with the patients whose light-chain was kappa (3 g/24 hours). In this study, the lambda light-chain amyloid seemed to be more nephrotoxic than the kappa. The magnitude of proteinuria and the renal failure were the limiting factors for survival in the patients with AL amyloidosis.25,26 The cardiac involvement, found in 60% of the patients with amyloidosis, was also present in our patient but with less clinical relevance. Characterized by interventricular septum and free ventricular wall thickening; 27 this involvement resulted in diastolic dysfunction and heart failure. Our patient presented jugular venous distension and diastolic myocardial dysfunction, which could be explained, even mildly, by the cardiac involvement. The atypical chest pain presented 2 days before the patient’s death–although it was not accompanied by myocardial necrosis markers nor any electrocardiographic ischemic changes–may be interpreted as being of ischemic origin, in the light of the findings at autopsy, and may have contributed to the cause of death. Sudden death, syncope secondary to arrhythmias or bundle branch block, as well as angina pectoris, and myocardial infarction due to amyloid deposits in coronary arteries are also manifestations of cardiac amyloidosis.28 The International Myeloma Working Group formulated the diagnostic criteria for AL amyloidosis, requiring the presence of all of the following: (i) the presence of an amyloid-related systemic syndrome; (ii) positive amyloid staining by Congo red staining in any tissue or the presence of amyloid fibrils by electronic microscopy; (iii) evidence that amyloid is light-chain-related established by direct examination of the amyloid; and (iv) evidence of plasma cell proliferative disorder.29,30 16

The presence of plasma cell dyscrasia may be demonstrated by the presence of the serum or urinary M protein, abnormal serum free light-chain, or clonal plasma cells proliferation in the bone marrow.24,29,30 The diagnosis of plasma cell myeloma could be based on the presence of M-protein in the serum in the setting of myeloma-related end organ damage (amyloidosis) and bone marrow monoclonal plasma cell proliferation. According to WHO classification, the amount of clonal plasma cells in bone marrow of multiple myeloma patients usually exceeds 10%, but no minimal level is designated, since 5% of patients with symptomatic myeloma have less than 10% marrow plasma cells. Thereafter, in the setting of myeloma-related end‑organ damage with M-protein in the serum or urine, the diagnosis of multiple myeloma can be made even with less than 10% of clonal plasma cells in the bone marrow.31 However, other typical findings of multiple myeloma as hypercalcemia, anemia and bone lesions were lacking. In the case reported herein, the serum protein electrophoresis depicted the presence of a monoclonal spike identified as lambda light-chain by the immunofixation technique. Indeed, the lambda light chain is responsible for 75% of all cases of the AL amyloidosis, while the kappa light chain occurs in 25% of cases, and biclonality in 5% of cases, as observed in the series (121 cases of AL amyloidosis) of Palladini et al.32 The definite diagnosis of amyloidosis requires histological confirmation. The kidney or hepatic biopsy will render the diagnosis in 90% of cases; however, this invasive procedure has inherent non-negligible complications. The reason why it was not performed in our patient was because of his poor clinical status and the increased risk of bleeding. The mean survival time of the patients with AL amyloidosis ranges between 12 and 18 months4,33 and is even smaller when associated with multiple myeloma. The hepatic involvement34 decreases the survival time to between 10 and 14 months, the association with portal hypertension to 8-9 months,11 and the presence of cholestatic jaundice to 3-5 months.12,34 Renal failure and restrictive cardiomyopathy are frequently related to the cause of death.15 Since the hepatic involvement is not the predominant form of presentation of AL amyloidosis, it is important to consider this diagnosis in a patient with hepatomegaly of unknown cause, and even Autopsy and Case Reports 2016;6(2):9-18

Takayasu V, Laborda LS, Bernardelli R, et al.

more the pattern of bilirubin, ALT, AST, ALP, and γGT abnormalities in this case is classic for hepatic space-occupying diseases as sarcoidosis, metastases or amyloidosis. Furthermore, the involvement of other organs, such as the kidney, heart, autonomic and peripheral nervous system, muscle, and skin should always be evaluated. In our case, the presence of renal function impairment, massive proteinuria, and serum monoclonal gammopathy reinforced the diagnostic possibility of primary amyloidosis.

5. Kyle RA, Greipp PR. Amyloidosis (AL). Clinical and laboratory features in 229 cases. Mayo Clin Proc. 1983;58(10):665-83. PMid:6353084.

This case was very puzzling because the clinical features were suitable for other frequent diagnoses, and (i) the electrophoresis result was not available while the patient was alive; (ii) the echocardiogram did not depict the described granular sparkling appearance of the thickened cardiac walls; and (iii) the rectal biopsy lacked amyloid deposition. During hospitalization, the main diagnostic hypothesis remained on the hepatosplenic schistosomiasis with portal hypertension associated with glomerular complications related to the parasite immune response. Favoring this hypothesis, our patient came from an endemic region of Schistosoma mansoni and had a familiar history of this diagnosis. Further investigation, unfortunately, was hampered by the patient’s clinical status. The autopsy was fundamental for the precise diagnosis of this case, showing the outstanding value of this study for teaching purposes, quality control of medical care, and reliability of the death certificate.

8. Lovat LB, Persey MR, Madhoo S, Pepys MB, Hawkins PN. The liver in systemic amyloidosis: Insights from 123I serum amyloid P component scintigraphy in 484 patients. Gut. 1998;42(5):727-34. http://dx.doi.org/10.1136/ gut.42.5.727. PMid:9659172.

REFERENCES 1. Glenner GG. Amyloid deposits and amyloidosis. The beta-fibrilloses (first of two parts). N Engl J Med. 1980;302(23):1283-92. http://dx.doi.org/10.1056/ NEJM198006053022305. PMid:6154243. 2. Merlini G, Comenzo RL, Seldin DC, Wechalekar A, Gertz MA. Immunoglobulin light chain amyloidosis. Expert Rev Hematol. 2014;7(1):143-56. http://dx.doi.org/10.1586/1 7474086.2014.858594. PMid:24350907. 3. Gertz MA, Lacy MQ, Dispenzieri A. Amyloidosis. Hematol Oncol Clin North Am. 1999;13(6):1211-33, ix. http://dx.doi.org/10.1016/S0889-8588(05)70122-2. PMid:10626146. 4. Kyle RA, Gertz MA. Primary systemic amyloidosis: clinical and laboratory features in 474 cases. Semin Hematol. 1995;32(1):45-59. PMid:7878478. Autopsy and Case Reports 2016;6(2):9-18

6. Pinney JH, Lachmann HJ. Systemic AA amyloidosis. Subcell Biochem. 2012;65:541-64. http://dx.doi. org/10.1007/978-94-007-5416-4_20. PMid:23225016. 7. Park MA, Mueller PS, Kyle RA, Larson DR, Plevak MF, Gertz MA. Primary (AL) hepatic amyloidosis: clinical features and natural history in 98 patients. Medicine. 2003;82(5):291-8. http://dx.doi.org/10.1097/01. md.0000091183.93122.c7. PMid:14530778.

9. Ebert EC, Nagar M. Gastrointestinal manifestations of amyloidosis. Am J Gastroenterol. 2008;103(3):776-87. http://dx.doi.org/10.1111/j.1572-0241.2007.01669.x. PMid:18076735. 10. Girnius S, Seldin DC, Skinner M, et al. Hepatic response after high-dose melphalan and stem cell transplantation in patients with AL amyloidosis associated liver disease. Haematologica. 2009;94(7):1029-32. http://dx.doi. org/10.3324/haematol.2008.001925. PMid:19454500. 11. Park MA, Mueller PS, Kyle RA, Larson DR, Plevak MF, Gertz MA. Primary (AL) hepatic amyloidosis: clinical features and natural history in 98 patients. Medicine (Baltimore). 2003;82(5):291-8. http://dx.doi.org/10.1097/01. md.0000091183.93122.c7. PMid:14530778. 12. Gertz MA, Kyle RA. Hepatic amyloidosis (primary [AL], immunoglobulin light chain): the natural history in 80 patients. Am J Med. 1988;85(1):73-80. http://dx.doi. org/10.1016/0002-9343(88)90505-0. PMid:3389383. 13. Buck FS, Koss MN. Hepatic amyloidosis: morphologic differences between systemic AL and AA types. Hum Pathol. 1991;22(9):904-7. http://dx.doi.org/10.1016/00468177(91)90180-W. PMid:1916751. 14. Levine RA. Amyloid disease of the liver. Correlation of clinical, functional and morphologic features in forty-seven patients. Am J Med. 1962;33(3):349-57. http://dx.doi.org/10.1016/0002-9343(62)90231-0. PMid:14464647. 15. Kyle RA, Bayed ED. Amyloidosis: review of 236 cases. Medicine (Baltimore). 1975;54(4):271-99. http:// dx.doi.org/10.1097/00005792-197507000-00001. PMid:1152671. 16. Aramaki T, Terada H, Okumura H, et al. Portal hypertension secondary to intrahepatic arterio-portal shunt in primary amyloidosis: a case report. Gastroenterol Jpn. 1989;24(4):410-3. PMid:2777017. 17

Amyloidosis: an unusual cause of portal hypertension

17. Norero B, Pérez-Ayuso RM, Duarte I, et al. Portal hypertension and acute liver failure as uncommon manifestations of primary amyloidosis. Ann Hepatol. 2014;13(1):142-9. PMid:24378278. 18. Wang YD, Zhao CY, Yin HZ. Primary hepatic amyloidosis: a mini literature review and five cases report. Ann Hepatol. 2012;11(5):721-7. PMid:22947537. 19. Lee SS, Hadengue A, Girod C, Braillon A, Lebrec D. Reduction of intrahepatic vascular space in the pathogenesis of portal hypertension. In vivo and in vitro studies in the rat. Gastroenterology. 1987;93(1):157-61. PMid:3582902. 20. Bion E, Brenard R, Pariente EA, et al. Sinusoidal portal hypertension in hepatic amyloidosis. Gut. 1991;32(2):227-30. http://dx.doi.org/10.1136/ gut.32.2.227. PMid:1864548. 21. Serra L, Poppi MC, Criscuolo M, Zandomeneghi R. Primary systemic amyloidosis with giant hepatomegaly and portal hypertension: a case report and a review of the literature. Ital J Gastroenterol. 1993;25(8):435-8. PMid:8286779. 22. Levy M, Polliack A, Lender M. The liver in amyloidosis. Digestion. 1974;10(1):40-51. http://dx.doi. org/10.1159/000197521. PMid:4847635. 23. Gregg J, Herskovic T, Bartholomew L. Ascites in systemic amyloidosis. Arch Intern Med. 1965;116(4):605-10. http:// dx.doi.org/10.1001/archinte.1965.03870040119024. PMid:5835364.

26. Sezer O, Eucker J, Jakob C, Possinger K. Diagnosis and treatment of AL amyloidosis. Clin Nephrol. 2000;53(6):417-23. PMid:10879660. 27. Dubrey SW, Hawkins PN, Falk RH. Amyloid diseases of the heart: assessment, diagnosis, and referral. Heart. 2011;97(1):75-84. http://dx.doi.org/10.1136/ hrt.2009.190405. PMid:21148582. 28. Reichling JJ, Kaplan MM. Clinical use of serum enzymes in liver disease. Dig Dis Sci. 1988;33(12):1601-14. http:// dx.doi.org/10.1007/BF01535953. PMid:2904353. 29. Kyle RA, Rajkumar SV. Criteria for diagnosis, staging, risk stratification and response assessment of multiple myeloma. Leukemia. 2009;23(1):3-9. http://dx.doi. org/10.1038/leu.2008.291. PMid:18971951. 30. Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria diagnosis of multiple myeloma. Lancet Oncol. 2014;15(12):e538-48. http://dx.doi.org/10.1016/S14702045(14)70442-5. PMid:25439696. 31. Campos E, Swerdlow SH, Harris NL, Pileri S, Stein H, Jaffe ES. The 2008 WHO classification of lymphoid neoplasm and beyond: evolving concepts and approached applied. Blood. 2011;117(19):5019. http://dx.doi.org/10.1182/ blood-2011-01-293050. PMid:21300984. 32. Palladini G, Russo P, Bosoni T, et al. Identification of amyloidogenic light chains requires the combination of serum-free light chain assay with immunofixation of serum and urine. Clin Chem. 2009;55(3):499-504. http://dx.doi.org/10.1373/clinchem.2008.117143. PMid:19131635.

24. Pozzi C, Locatelli F. Kidney and liver involvement in monoclonal light chain disorders. Semin Nephrol. 2001;22(4):319-30. PMid:12118397.

33. Tan SY, Pepys MB, Hawkins PN. Treatment of amyloidosis. Am J Kidney Dis. 1995;26(2):267-85. http://dx.doi. org/10.1016/0272-6386(95)90647-9. PMid:7645531.

25. Gertz MA, Leung N, Lacy MQ, et al. Clinical outcome of immunoglobulin light chain amyloidosis affecting the kidney. Nephrol Dial Transplant. 2009;24(10):3132-7. http://dx.doi.org/10.1093/ndt/gfp201. PMid:19403931.

34. Peters RA, Koukoulis G, Gimson A, Portmann B, Westaby D, Williams R. Primary amyloidosis and severe intrahepatic cholestatic jaundice. Gut. 1994;35(9):1322-52. http:// dx.doi.org/10.1136/gut.35.9.1322. PMid:7959246.

Conflict of interest: None Submitted on: March 7th, 2016 Accepted on: April 20th, 2016 Correspondence Vilma Takayasu Internal Medicine Division - Hospital Universitário - Universidade de São Paulo (USP) Avenida Professor Lineu Prestes, 2565 – Butantã – São Paulo/SP – Brazil CEP: 05508-000 E-mail: vilmatakayasu@uol.com.br

Autopsy and Case Reports 2016;6(2):9-18

Article / Autopsy Case Report

Gonococcal endocarditis: an ever-present threat Fernando Peixoto Ferraz de Camposa, Vitor Sérgio Kawabataa, Márcio Sommer Bittencourta, Silvana Maria Lovisolob, Aloísio Felipe-Silvab, Ana Paula Silva de Lemosc Campos FPF, Kawabata VS, Bittencourt MS, Lovisolo SM, Felipe-Silva A, Lemos APS. Gonococcal endocarditis: an ever‑present threat. Autopsy Case Rep [Internet]. 2016;6(2):19-25. http://dx.doi.org/10.4322/acr.2016.037

ABSTRACT The incidence of severe complications of the Neisseria gonorrhoeae infection has presented variations over recent decades since the advent of penicillin. Gonococcal endocarditis (GE) still remains an ever-present threat afflicting the society’s poor and sexually active young population. This entity frequently requires surgical intervention and usually exhibits a poor outcome. The interval between the onset of symptoms and the diagnosis does not usually exceed 4 weeks. One of the characteristics of GE is a proclivity for aortic valve involvement with large vegetation and valve ring abscess formation. The authors report the case of a young man with a 2-week history of fever, malaise, weakness, and progressive heart failure symptoms, who had no previous history of genital complaints or cardiopathy. The physical examination was consistent with acute aortic insufficiency, which was most probably of an infectious origin. The echocardiogram showed thickened aortic cusps and valve insufficiency. After hospital admission, the patient’s clinical status worsened rapidly and he died on the second day. The autopsy findings disclosed aortic valve destruction with vegetation and a ring abscess besides signs of septic shock, such as diffuse alveolar damage, acute tubular necrosis, and zone 3 hepatocellular necrosis. The blood culture isolated N. gonorrhoeae resistant to penicillin and ciprofloxacin. The authors call attention to the pathogen of this particular infectious endocarditis, and the need for early diagnosis and evaluation by a cardiac surgery team. Keywords Endocarditis, Bacterial; Neisseria gonorrhoeae; Aortic valve; Autopsy

CASE REPORT A 28-year-old male patient sought the emergency facility complaining of fever over the previous 2 weeks accompanied by headache and malaise. Up to this point, he had been treated with an antipyretic. Three days earlier, he began feeling retrosternal pain radiating to the back, which progressed to palpitations,

dry cough, nausea, vomiting, progressive dyspnea, orthopnea, and lower limbs edema before he attended the hospital. He denied previous diseases, regular use of medications, alcohol consumption, tobacco smoking, or use of illicit drugs. Retrospectively, we could not obtain any evidence of promiscuous sexual

Internal Medicine Division – Hospital Universitário – Universidade de São Paulo, São Paulo/SP, Brazil. Anatomic Pathology Service – Hospital Universitário – Universidade de São Paulo, São Paulo/SP, Brazil. c Bacteriology Center – Adolpho Lutz Institute, São Paulo/SP, Brazil. a

Gonococcal endocarditis: an ever-present threat

activity or a history of urethral complaint. He worked in a marble factory and was used to heavy-lifting work without physical constraint.

thickness, preserved systolic function, and aortic valve

The physical examination revealed an ill-looking patient who was tachypneic, tachycardic, and febrile (38.3°C), with 120/40 mmHg blood pressure and 86% room air oximetry. His skin, mucosae, and conjunctivae examinations were normal. An auscultation of his heart revealed the presence of an intermittent third heart sound, plus an ejection murmur radiating to the carotids, and a diastolic murmur—the latter two at the base of the heart. Pulmonary auscultation revealed decreased sounds in the right base. The abdominal examination revealed a mildly enlarged liver, and the lower limbs exhibited bilateral edema. Laboratory examinations showed a marked leukocytosis 22,800 leukocytes/mm3 (reference value [RV]: 4.4-11.3 × 103/mm3). There were no other abnormalities in the remaining blood cell count and the biochemical work-up. Urinalysis showed sterile leukocyturia (20,000 leukocytes/mm3). HIV and syphilis serology were negative. The electrocardiogram was normal; the plain thoracic X-ray showed a normal cardiac silhouette and an alveolar space‑filling opacity in both inferior pulmonary lobes accompanied by a tiny pleural effusion on the right side (Figure 1). The transthoracic echocardiogram revealed normal‑sized cardiac chambers as well as normal septum and posterior wall

comprising vancomycin, gentamicin, and ceftriaxone

thickening with marked diastolic reflux. The patient was hospitalized and an empiric antibiotic regimen was started because of the suspected diagnosis of acute infective endocarditis. The outcome was unfavorable with severe hypotension and persistent respiratory failure requiring vasoactive drugs infusion and non-invasive respiratory support, which meant that the transesophageal echocardiography could not be performed. On the second day of hospitalization, the patient presented cardiac arrest and was unresponsive to the advanced cardio life support maneuvers. The autopsy was performed after informed consent by the family. On the day following the patient’s death, one out of three blood cultures was positive for Neisseria gonorrhoeae. Bacterial identification was performed using VITEK-2 compact (version 07.01, BioMérrieux, France) and confirmed by manual biochemical tests.1 The isolate was resistant to penicillin and ciprofloxacin, but was susceptible to ceftriaxone. Antibiotic susceptibility was determined by disk diffusion according to Clinical and Laboratory Standards Institute guidelines.2

Figure 1. Plain thoracic x-ray showing a normal cardiac silhouette and a heterogeneous opacity in the right inferior pulmonary lobe with a small ipsilateral pleural effusion. 20

Autopsy and Case Reports 2016;6(2):19-25

Campos FPF, Kawabata VS, Bittencourt MS, Lovisolo SM, Felipe-Silva A, Lemos APS

AUTOPSY FINDINGS At the opening of the pericardial cavity, moderate yellowish serous pericardial fluid was observed. The heart weighed 392 g (mean RV [mRV]: 327 g), and both ventricles were dilated with mild thickening of the left ventricular wall (Figure 2A). The aortic valve had three cusps and was conspicuously damaged by the formation of vegetation (Figure 2B). The left coronary cusp was perforated and the right coronary cusp was copllapsed. The myocardium and the aortic valve ring’s contiguous endocardium showed an extensive area of necrosis, which was identified on gross examination as a whitish area in a valve ring abscess (Figure 2C and 2D).

Histologically, the valve was replaced by a loose fibrous connective tissue, fibrin, and neutrophils, which were identified on the histological examination (Figure 3A and 3B). The histologic examination of this lesion showed a marked diffuse inflammatory infiltrate predominantly composed of polymorphonuclear neutrophils that extended to the myocardial fibers and the pericardial adipose tissue, which is consistent with a valve ring abscess (Figure 3A, 3B, and 3C). Gram‑negative diplococci were found upon Brown–Hopps staining (Figure 3D). The other three valves were enlarged without vegetation or any other lesion. Terminal brain congestion and edema (1397 g, mRV: 1365 g) were observed. The lungs (right = 470 g, left = 395 g; mRV: 450 g and 375 g, respectively)

Figure 2. Gross examination of the heart. A - Hypertrophy of the left ventricular wall and collapsed aortic valve cusps; B - Detail of the aortic valve showing one preserved posterior noncoronary cusp and complete destruction of the two coronary cusps. The left coronary cusp is perforated (arrow) and the other showed vegetation (arrowhead); C and D - Valve ring abscess (arrowhead). Autopsy and Case Reports 2016;6(2):19-25

Gonococcal endocarditis: an ever-present threat

Figure 3. Photomicrography of the valve and ring abscess. A - Panoramic view of the left coronary cusp with a deposition of fibrin and inflammatory exsudate. Note the extensive inflammatory infiltration surrounding the cusps’ implantation (H&E, 12.5X); B - Panoramic view of the valve ring abscess (H&E, 12.5X); C - Acute inflammation of the surrounding myocardium (H&E, 200X); D - Gram-negative diplococci within the abscess (arrows) (Brown–Hopps, 1000X). showed congestion, edema, and diffuse aggregates of intra-alveolar histiocytes, which sometimes contained hemosiderin or erythrocytes (hemophagocytosis due to sepsis), areas of diffuse alveolar damage with fibrin deposition, and reactive pneumocytes (acute respiratory distress). The liver weighed 1970 g (mRV: 1700 g) and showed diffuse congestion of the sinusoids with pericentral ischemic necrotic foci (shock), and mild portal inflammatory infiltration by lymphocytes and monocytes consistent with reactive hepatitis. The gallbladder, the pancreas, and the gastrointestinal system showed no significant changes. The lymph nodes and the spleen (180 g, mRV: 112g) were congested with diffusely distributed lymphoid follicles, occasional sinusoidal neutrophils, and focal 22

histiocytes containing erythrocytes (hemophagocytosis related to sepsis). The bone marrow showed preserved maturation of the three hematopoietic series with mild granulocytic reactivity. The kidneys (right = 158 g, left = 149 g; mRV for both: 313 g) showed congestion and acute tubular necrosis (due to shock). Both adrenal glands (right = 5 g, left = 4.5 g; mRV for both: 11.5 g) showed cortical foci of necrosis (adrenal stress due to sepsis and shock). The periadrenal adipose tissue showed a fibrin embolus into a medium caliber artery that was interpreted as due to the sepsis’ intravascular coagulation or may have the origin from the aortic vegetation. The urogenital tract was preserved except for the presence of mild chronic mononuclear inflammatory infiltration in the prostatic urethra and in the bladder. Autopsy and Case Reports 2016;6(2):19-25

Campos FPF, Kawabata VS, Bittencourt MS, Lovisolo SM, Felipe-Silva A, Lemos APS

DISCUSSION Gonorrhea has remained a global public health problem since ancient times, mostly afflicting society’s poor and sexually active young population and newborns. The incidence is estimated at 600,000 cases annually in the USA. 3 In the history of medicine, although it has taken a long time to achieve an efficient treatment for gonorrhea, the control of the disease has been difficult due to the significant number of asymptomatic cases. In 1879, Albert Ludwig Sigesmund Neisser, a German physician and bacteriologist studying patients with urethritis and ophthalmia neonatorum, discovered N. gonorrhoeae, a fastidious Gram-negative diplococcus, which was further proved to be an exclusively human pathogen. The gonococcal infection has a diverse clinical presentation varying from asymptomatic cases, symptomatic infection restricted to the genital tract, pharynx, or rectum, and disseminated infection, which mostly involves the skin and the joints. Although much rarer, other sites may be involved in the disseminated form, such as the heart, meninges, bones, and liver.4,5 According to Albert Newman’s publication of 1933,6 the Ricord’s Treatise on Venereal Disease (1838) was the first publication showing that the gonorrheal infection could disseminate systemically and involve the heart, but the isolation of N. gonorrhoeae from a patient with endocarditis was held by Thayer and Blumer7 in 1895. In the pre-antibiotic era (i.e. before 1938), gonorrhea was responsible for up to 26% of all bacterial endocarditis8-12 and was almost uniformly fatal. 8,13 Since then, the number of endocarditis infections substantially declined, although gonorrhea remained among the four most frequent sexually transmitted diseases worldwide.14 The incidence of gonococcal endocarditis (GE) substantially decreased after the advent of penicillin. 8 In parallel, a better outcome was observed, with an 88.5% survival rate (in a report of 26 patients treated exclusively with antibiotics).13 For uncertain reasons many cases occurred during the last three decades of the 20th century, but numbers decreased again in the first decade of the 21st century.13 However, surprisingly, GE currently seems to be showing a resurgence.8 Up to 70 cases of GE were published from 1939 to 2014, 38 of them within the period from Autopsy and Case Reports 2016;6(2):19-25

1980 to 2014. 13,15 Based on these reviews, GE is characterized by the involvement of a young population, afflicting, in 85% of the cases, patients between 15 and 35 years old, with a slight predominance among males.8,12 GE usually develops in native and intact valves, presenting large vegetation that involves the aortic valve in 50-72% of the cases, accompanied by ring abscesses.8 The primary gonococcal disease or related urinary symptoms occur in 21-27% of the cases, concomitantly or months before the diagnosis of endocarditis.13,15,16 The marked valvular destruction observed in GE explains the high incidence of surgical intervention, which has been reported to be undertaken in 58-72% of the cases; unlike the endocarditis caused by other pathogens. 15,17 Although the availability of new‑generation antibiotics and refined cardiac surgery techniques, the mortality of GE remains high. The mortality rate was 23% in the review of Ramos et al.15 involving 38 cases diagnosed from 1980 to 2014. Unfortunately, the clinical picture of GE does not enable its differentiation from other endocarditis. However, some characteristics may call attention to this entity, which include: (i) the time elapsed from the initial symptoms until the diagnosis is intermediate (nearly 4 weeks) between the formerly called sub‑acute endocarditis, typically caused by streptococci, and the acute staphylococcal endocarditis9; (ii) young patients; (iii) native and intact valves; (iv) proclivity for aortic valve involvement; and (v) drastic evolution with acute heart failure. Signs and symptoms almost invariably include the presence of fever, cardiac murmur, tachycardia, and signs or symptoms of heart failure. Eventually, arthritis, embolization phenomena, and splenomegaly may be present. A laboratory work-up is not diagnostic, but it may reveal anemia, leukocytosis, and an increase in acute phase proteins. Echocardiography—either transthoracic or transesophageal—almost inevitably renders the presence of vegetation or show valvular thickening and dysfunction. In our case, indeed surprisingly, despite the huge size of the vegetation and the leaflets destruction, the transthoracic echocardiography was of little help for the diagnosis. Blood cultures are positive in more than 90% of cases, which is notably different from other forms of disseminated gonococcal infection where blood 23

Gonococcal endocarditis: an ever-present threat

cultures show the positivity ranging between 10% and 30%.8 The development of disseminated gonococcal disease occurs mostly in asymptomatic infection and is associated with host susceptibility that includes complement deficiency, systemic lupus erythematosus, HIV infection, and peculiarities of some strains, such as (i) nutritional requirements (arginine‑hypoxanthine‑uracil growth requirement); (ii) the absence of the surface Protein II complex (generally associated with chromosomal mutation [penA mtr]), which confers more resistance to neutrophil-mediated killing and less intergonococcal adherence; and (iii) the expression of surface protein IA, which confers serum resistance and easier translocation into bilayer membranes.8,18 Our patient fulfilled the epidemiological characteristics of GE and presented a 2-week history of fever. Apparently, symptomatic gonococcal urethritis was not present at the time of the endocarditis diagnosis, since genital complaints were not referred. However, the urinalysis showed a sterile leukocyturia, which could suggest the presence of asymptomatic urethritis. Moreover, although non-specific, the prostatic urethra also showed an inflammatory infiltration, which could raise suspicion of the pathogen’s port of entry. On admission, the diagnosis of infective endocarditis involving the aortic valve was not troublesome. Besides, the apparent recent-onset heart failure symptoms in a previously healthy young patient, the long-term fever, the presence of murmurs at the base of the heart, the wide pulse pressure, the normal cardiac silhouette on thoracic radiography, and the normal electrocardiogram favored the diagnosis of acute aortic valve insufficiency, most probably of infectious origin. Although the transthoracic echocardiogram could not depict aortic vegetation, it confirmed the aortic valve insufficiency with morphological abnormality (thickening). The empirical antibiotic therapy was reasonable for a wide range of pathogens, but, unfortunately, as shown in the literature, the outcome was rapidly fatal. The patient did not have the chance to be evaluated by a cardiac surgery team because of the high risk of removal to a cardiology center and the rapid progression to death. We dare consider that even if this patient had been operated on, the outcome would have likely been the same because of the presence of the large ring abscess 24

depicted at autopsy. Although the etiological diagnosis was done postmortem, the antibiotic regimen choice was appropriate ensuring that it was not the limiting factor for survival. In view of the autopsy findings, our opinion is that the chance of this patient’s survival was lost when the diagnosis could not be concluded during the initial consultations.

ACKNOWLEDGEMENTS The authors are thankful to the Microbiology unit of the Central Laboratory of University Hospital of São Paulo for gonococcal isolation and susceptibility tests as well as to Conceição Zanelato and Maria Vaneide de Paiva for assistance in microbiological tests at Adolfo Lutz Institute REFERENCES 1. Janda WM, Knapp J. Neisseria and Moraxella catarrhalis. In: Murray PR, Baron EJ, Jorgensen JH, Landry ML, Pfaller MA, editors. Manual of clinical microbiology. 8th ed. Washington, DC: ASM Press; 2003. chap. 38. 2. Clinical and Laboratory Standards Institute (CLSI). Performance standards for antimicrobial disk susceptibility tests, approved standard. 12th ed. Wayne, PA: Clinical and Laboratory Standards Institute; 2015. CLSI document M02-A12. 3. Bolan GA, Sparling PF, Wasserheit JN. The emerging threat of untreatable gonococcal infection. N Engl J Med. 2012;366(6):485-7. http://dx.doi.org/10.1056/ NEJMp1112456. PMid:22316442. 4. Thompson EC, Brantley D. Gonococcal endocarditis. J Natl Med Assoc. 1996;88(6):353-6. PMid:8691495. 5. Holmes KK, Counts GW, Beaty HN. Disseminated gonococcal infection. Ann Intern Med. 1971;74(6):97993. http://dx.doi.org/10.7326/0003-4819-74-6-979. PMid:4996345. 6. Newman AB. The prognosis in gonococcal endocaditis: Review of literature and report of case with spontaneous recovery. Am Heart J. 1933;8(6):821-33. http://dx.doi. org/10.1016/S0002-8703(33)90144-1. 7. Thayer WS, Blumer G. Ulcerative endocarditis due to the gonococcus: gonorrheal spticemia. Bull Johns Hopkins Hosp. 1896;7:57-63. 8. Jackman JD Jr, Glamann DB. Gonococcal endocarditis: twenty-five year experience. Am J Med Sci. 1991;301(3):22130. http://dx.doi.org/10.1097/00000441-19910300000012. PMid:2000895. Autopsy and Case Reports 2016;6(2):19-25

Campos FPF, Kawabata VS, Bittencourt MS, Lovisolo SM, Felipe-Silva A, Lemos APS

9. Thayer WS. Bacterial or infective endocarditis: the Gibson lectures of 1930. Edinburgh Med J. 1931;38:237-65, 297-329. 10. Stone E. Gonorrheal endocarditis. J Urol. 1934;31:86995. 11. Williams RH. Gonococcic endocarditis. A study of twelve cases with postmorten examinations. Arch Intern Med (Chic). 1938;61(1):26-38. http://dx.doi.org/10.1001/ archinte.1938.00180070031003. 12. W a l l T C , P e y t o n R B , C o r e y G R . G o n o c o c c a l endocarditis: a new look at an old disease. Medicine (Baltimore). 1989;68(6):375-80. http:// dx.doi.org/10.1097/00005792-198911000-00005. PMid:2509857. 13. Nie S, Wu Y, Huang L, Pincus D, Tang YW, Lu X. Gonococcal endocarditis: a case report and literature review. Eur J Clin Microbiol Infect Dis. 2014;33(1):237. http://dx.doi.org/10.1007/s10096-013-1921-x. PMid:23856883.

14. World Health Organization (WHO). Sexual and reproductive health [Internet]. 2016 [cited 2016 Mar 27]. Available from: http://www.who.int/reproductivehealth/ news/stis-estimates-2015/en/ 15. Ramos A, García-Pavía P, Orden B, et al. Gonococcal endocarditis: a case report ans review of the literature. Infection. 2014;42(2):425-8. http://dx.doi.org/10.1007/ s15010-013-0541-9. PMid:24163221. 16. Romero Tarín E, González Antuña M, Calzón Díaz S, Riesgo Miranda MA. Gonococcal endocarditis. Rev Esp Cardiol. 1987;40(4):293-6. PMid:3659524. 17. Prendergast BD, Tornos P. Surgery for infective endocarditis: who and when? Circulation. 2010;121(9):1141-52. http:// dx.doi.org/10.1161/CIRCULATIONAHA.108.773598. PMid:20212293. 18. Britigan BE, Cohen MS, Sparling PF. Gonococcal infection: a model of molecular pathogenesis. N Engl J Med. 1985;312(26):1683-94. http://dx.doi.org/10.1056/ NEJM198506273122606. PMid:2860565.

Conflict of interest: None Submitted on: May 3rd, 2016 Accepted on: June 2nd, 2016 Correspondence Fernando Peixoto Ferraz de Campos Internal Medicine Division – Hospital Universitário – Universidade de São Paulo (USP) Av. Professor Lineu Prestes, 2565 – Butantã – São Paulo/SP – Brazil CEP: 05508-000 Phone: +55 (11) 3091-9275 E-mail: fpfcampos@gmail.com

Autopsy and Case Reports 2016;6(2):19-25

Article / Autopsy Case Report

Fatal pancreatic pseudocyst co-infected by Raoultella planticola: an emerging pathogen Fernando Peixoto Ferraz de Camposa, Tiago Borges Guimarãesb, Silvana Maria Lovisoloc Campos FPF, Guimarães TB, Lovisolo SM. Fatal pancreatic pseudocyst co-infected by Raoultella planticola: an emerging pathogen. Autopsy Case Rep [Internet]. 2016;6(2):27-31. http://dx.doi.org/10.4322/acr.2016.034

ABSTRACT Raoultella planticola is an aerobic Gram-negative bacterium belonging to the Enterobacteriaceae family. Initially identified in the 1980s, its pathogenic potential was further recognized when the first case of bacteremia was reported. Since then, only a few infections caused by this pathogen have been described. Although considered an opportunistic agent, fatal outcomes are associated with the infection by this pathogen, since it is more prevalent among the patients with immunodeficiency. The authors report the case of a middle-aged man diagnosed with end-stage renal disease and alcoholic pancreatitis, who was admitted to the emergency department with septic shock. Physical examination disclosed peritoneal irritation and a laparotomy was undertaken. Purulent peritonitis was found as well as a retroperitoneal abscess, which was drained. The postoperative period was troublesome, and the patient died. The autopsy showed a ruptured, infected pancreatic cyst and purulent peritonitis, among other findings. The culture of the peritoneal fluid and two blood sample sets were positive for R. planticola. The authors call attention to the importance of this emerging pathogen associated with severe gastrointestinal infections. Keywords Enterobacteriaceae Infections; Pancreatic Diseases; Peritonitis; Autopsy

CASE REPORT A 52-year-old man was brought to the emergency

imaging referred the presence of pneumobilia.

unit complaining of colicky upper abdominal pain

He was a tobacco smoker and a heavy drinker,

over the previous 7 days, which had worsened in

but denied illicit drugs use. He was not taking any

the last 2 days and was accompanied by nausea

antibiotics, antiemetics, or painkillers before coming

and vomiting. His past medical history included two

to the hospital. On admission, he looked critically ill,

episodes of pneumonia, one of which was complicated

emaciated (body mass index was 18), dehydrated,

with thoracic empyema and chronic pancreatitis with

tachypneic, tachycardic, and with poor peripheral

acute exacerbation 2 years ago, hypertension, and

perfusion. His blood pressure was 70/50 mmHg,

stage IV chronic renal disease. The biliopancreatic

room air oximetry was 88%, and Glasgow coma

Internal Medicine Division - Hospital Universitário - University of São Paulo, São Paulo/SP – Brazil. Anatomic Pathology Department - Faculty of Medicine - University of São Paulo, São Paulo/SP – Brazil. c Anatomic Pathology Service - Hospital Universitário - University of São Paulo, São Paulo/SP – Brazil. a

Fatal pancreatic pseudocyst co-infected by Raoultella planticola: an emerging pathogen

scale was 15. Cardiac and pulmonary examinations were unremarkable, but his abdomen was distended, diffusely painful with rebound tenderness and the presence of normal bowel sounds. The laboratory work-up revealed mild anemia and leukocytosis with marked left shift, acute renal failure with metabolic acidosis, increased hepatic enzymes and normal amylase, lipase, bilirubin, and clotting tests. With the clinical diagnosis of peritonitis, the patient underwent an exploratory laparotomy, which disclosed an enormous amount of free purulent effusion within the abdominal cavity, edema of the intestinal loops and the great omentum, and an abscess in the retro-cavity of the epiplon (at the tail of the pancreas). The surgical procedure consisted of peritoneal lavage, abscess drainage, and closure of the abdominal wound with a Bogotá bag. The patient was referred to the intensive care unit in the early postoperative period, where, despite mechanical ventilatory support and vasoactive drugs, hemodynamic instability remained uncontrolled, and the patient died less than 24 hours after hospitalization. The culture obtained from the abdominal cavity was positive for Escherichia coli, Group F β-hemolytic Streptococcus, and Raoultella planticola; the latter two agents were also isolated in two blood culture sets.

Bacterial identification was performed using VITEK-2 compact (version 07.01, BioMérrieux, France).

AUTOPSY FINDINGS The ectoscopic examination of the corpse showed a median xipho-pubic surgical incision and a Bogotá bag closure of the abdomen. At the opening of the cavities, pleural adhesion in the left hemithorax was present, and 400 mL of sero-hemorrhagic effusion covered the swollen viscera of the peritoneal cavity, which was thoroughly coated with a fibrinoid material. The pancreas weighed 183 g (reference value: 60-100 g) and presented a distorted shape surrounded by increased fat tissue. At the cut surface, the usual lobulation was effaced; the color was mousy and intermingled by white areas of a hardened consistency. A purplish 3 cm pseudocyst was present with the rupture of the external wall (Figure 1). The microscopy revealed that the pancreatic parenchyma was replaced by extensive fibrosis, acinar atrophy, intraductal eosinophilic protein plugs, and chronic inflammatory infiltration (Figure 2A and 2B). The surrounding pancreatic fat tissue, as well as the whole peritoneum, was thoroughly coated with fibrin, which, at histology, confirmed the presence

Figure 1. Gross appearance of the pancreas showing the replacement of the pancreatic parenchyma with fat tissue and, at the center, the perforation hole of the pseudocyst. 28

Autopsy and Case Reports 2016;6(2):27-31

Campos FPF, Guimarães TB, Lovisolo SM

of peritonitis (Figure 2C). The internal surface of the pseudocyst presented acute inflammatory infiltration, venules thrombosis, and granulation tissue (Figure 2D). Other findings consisted of small areas of lungs atelectasis, and alterations consistent with long-term tobacco abuse (respiratory bronchiolitis and tracheal squamous metaplasia); myocardial hypertrophy, bone marrow hypercellularity at the expense of myeloid hyperplasia; and changes consistent with shock, such as a loss of hepatocytes centrilobular trabeculation and vacuolation, acute tubular necrosis, and acute splenitis.

DISCUSSION Initially labeled as Klebsiella planticola, in 1981,1 R. planticola was subsequently identified, in 2001, by Drancourt et al.2 based on 16S rRNA genes and rpo B sequence analyses. Therefore, R. planticola is a Gram-negative, aerobic, encapsulated nonmotile

bacillus, belonging to the Enterobacteriaceae family, which requires laboratory refinements for its precise identification. These challenges were responsible for previous misidentification to such an extent that some cases formerly classified as K. pneumoniae or Klebsiella oxytoca could, in fact, be R. planticola.3-6 Although R. planticola is an environmental bacterium found in the water, soil, and plants, it is also isolated from nearly all human tissues and fluids.7-8 After its identification, the clinical significance of R. planticola remained uncharacterized for almost a decade.8 However, since the description of the case of septicemia reported by Freney et al.9 in 1984 (identified as Klebsiella trevisanii at the time), many other cases of infections in humans have been reported; therefore the pathogenicity of R. planticola needs to be revised. The actual incidence of R. planticola infection is difficult to estimate because of misidentification and underreported cases. To date, this infection is still rare.

Figure 2. A and B - Photomicrography of the pancreas showing substantial replacement of the pancreatic parenchyma by fibrous tissue and chronic inflammatory infiltration wrapping the remaining pancreatic acini and the dilated pancreatic duct with a protein plug and calcification (H&E,4X); C - Photomicrography of the peripancreatic tissue showing the fat tissue and the marked peritonitis (H&E,10X); D - Photomicrography of the pseudocyst’s inner lining showing the absence of epithelium (H&E, 20X). Autopsy and Case Reports 2016;6(2):27-31

Fatal pancreatic pseudocyst co-infected by Raoultella planticola: an emerging pathogen

The infection by this emerging pathogen is associated with either immunosuppression states, such as neoplasia, chronic renal disease, and diabetes mellitus, or invasive procedures and trauma.7,10 The infection sites reported so far that are caused by R. planticola are: (i) sepsis/bacteremia; 9,11-17 (ii) pneumonia; 14-18 (iii) abdominal infections;8,10-12,19-21 (iv) urinary tract;22,23 (v) skin and soft tissues;24-26 and (vi) conjunctivitis,27 which account for a little more than 20 cases. R. planticola was originally described as being sensitive to cephalosporins, aminoglycosides, fluoroquinolones, and carbapenems. However, recent studies18,28,29 have reported the emergence of carbapenem-resistant strains, which has changed what was an easily treatable infection into a therapeutic challenge. Polymicrobial infection of the peritoneal cavity concomitant with positive blood cultures, which included R. planticola among the other isolated agents, had also been reported.19 Considering the aforementioned concepts on R. planticola, our patient presented many characteristics found among the reported cases. The site of infection (i.e. the gastrointestinal tract in this case), has been reported as the second site of infection after bacteremia.10,11 Yokota et al.11 support the hypothesis that R. planticola colonizes the gastrointestinal tract and becomes a potential source of infection. Our patient was a heavy drinker with the clinical diagnosis of chronic pancreatic disease, and had previous hospitalizations due to pneumonia and thoracic empyema, which confers some degree of malnutrition besides chronic renal disease. Both chronic organic failures associated with immunologic disturbance,10,11,18,19 facilitated the infection caused by R. planticola. We deemed the presence of pneumobilia as an important risk factor for the development of the polymicrobial infection of our patient’s pancreatic cyst since there must have had a contact between the intestinal flora and the biliopancreatic system. R. planticola, as the other bacteria of the Enterobacteriaceae family, is an opportunistic agent of the intestinal environment, and under immunosuppression it acts as an invasive agent. The fatal outcome of this patient is closely related to his poor clinical status and severe disease. We cannot blame the R. planticola for being entirely responsible for the drastic outcome; however it did play a role in the development of this severe infection. The antibiogram of the R. planticola strain involved in our case showed sensitivity to cephalosporins, 30

fluoroquinolones, and carbapenems, but the severity of the infection and the early fatal outcome hampered the evaluation of the antimicrobial response. In our literature search of R. planticola infections, we found only one case of pancreatic infection; therefore, we call attention to the rarity of this case.

REFERENCES 1. Bagley ST, Seidler RJ, Brenner DJ. Klebsiella planticola sp. nov.: a new species of Enterobacteriaceae found primarily in nonclinical environments. Curr Microbiol. 1981;6(2):105-9. http://dx.doi.org/10.1007/BF01569013. 2. Drancourt M, Bollet C, Carta A, Rousselier P. Phylogenetic analyses of Klebsiella species delineate Klebsiella and Raoultella gen. nov., with description of Raoultella ornithinolytica comb. nov., Raoultella terrigena comb. nov. and Raoultella planticola comb. nov. Int J Syst Evol Microbiol. 2001;51(Pt 3):925-32. http://dx.doi. org/10.1099/00207713-51-3-925. PMid:11411716. 3. Monnet D, Freney J, Brun Y, Boeufgras JM, Fleurette J. Difficulties in identifying Klebsiella strains of clinical origin. Zentralbl Bakteriol. 1991;274(4):456-64. http://dx.doi. org/10.1016/S0934-8840(11)80081-2. PMid:1863314. 4. Westbrook GL, O’Hara CM, Roman SB, Miller JM. Incidence and identification of Klebsiella planticola in clinical isolates with emphasis on newborns. J Clin Microbiol. 2000;38(4):1495-7. PMid:10747132. 5. Alves MS, Dias RC, de Castro AC, Riley LW, Moreira BM. Identification of clinical isolates of indole-positive and indolenegative Klebsiella spp. J Clin Microbiol. 2006;44(10):3640-6. http://dx.doi.org/10.1128/ JCM.00940-06. PMid:16928968. 6. Monnet D, Freney J. Method for differentiating Klebsiella planticola and Klebsiella terrigena from other Klebsiella species. J Clin Microbiol. 1994;32(4):1121-2. PMid:8027329. 7. Kim SW, Kim JE, Hong YA, Ko GJ, Pyo HJ, Kwon YJ. Raoultella planticola peritonitis in a patient on continuous ambulatory peritoneal dialysis. Infection. 2015;43(6):7715. http://dx.doi.org/10.1007/s15010-015-0788-4. PMid:25958102. 8. Alves MS, Riley LW, Moreira BM. A case of severe pancreatitis complicated by Raoultella planticola infection. J Med Microbiol. 2007;56(5):696-8. http:// dx.doi.org/10.1099/jmm.0.46889-0. PMid:17446297. 9. Freney J, Fleurette J, Gruer LD, Desmonceaux M, Gavini F, Leclerc H. Klebsiella trevisanii colonisation and septicaemia. Lancet. 1984;1(8382):909. http://dx.doi. org/10.1016/S0140-6736(84)91368-0. PMid:6143213. 10. Ershadi A, Weiss E, Verduzco E, Chia D, Sadigh M. Emerging pathogen: a case and review of Raoultella Autopsy and Case Reports 2016;6(2):27-31

Campos FPF, Guimarães TB, Lovisolo SM

planticola. Infection. 2014;42(6):1043-6. http://dx.doi. org/10.1007/s15010-014-0638-9. PMid:24902523.

2014;107(11):911-3. http://dx.doi.org/10.1093/qjmed/ hcu087. PMid:24733944.

11. Yokota K, Gomi H, Miura Y, Sugano K, Morisawa Y. Cholangitis with septic shock caused by Raoultella planticola. J Med Microbiol. 2012;61(Pt 3):446-9. http:// dx.doi.org/10.1099/jmm.0.032946-0. PMid:22096135.

20. Lee JH, Choi WS, Kang SH, et al. A case of severe cholangitis caused by Raoultella planticola in a patient with pancreatic cancer. Infect Chemother. 2012;44(3):210-2. http://dx.doi.org/10.3947/ic.2012.44.3.210.

12. Puerta-Fernandez S, Miralles-Linares F, Sanchez-Simonet MV, Bernal-Lopez MR, Gomez-Huelgas R. Raoultella planticola bacteraemia secondary to gastroenteritis. Clin Microbiol Infect. 2013;19(5):E236-7. http://dx.doi. org/10.1111/1469-0691.12102. PMid:23574552.

21. Teo I, Wild J, Ray S, Chadwick D. A rare case of cholecystitis caused by Raoultella planticola. Case Rep Med. 2012;2012:601641. PMid:22690225.

13. Li J, Lan R, Xiong Y, et al. Sequential isolation in a patient of Raoultella planticola and Escherichia coli bearing a novel ISCR1 element carrying blaNDM-1. PLoS One. 2014;9(3):e89893. http://dx.doi.org/10.1371/journal. pone.0089893. PMid:24594606. 14. Freney J, Gavini F, Alexandre H, et al. Nosocomial infection and colonization by Klebsiella trevisanii. J Clin Microbiol. 1986;23(5):948-50. PMid:3711281. 15. Castanheira M, Deshpande LM, DiPersio JR, Kang J, Weinstein MP, Jones RN. First descriptions of blaKPC in Raoultella spp. (R. planticola and R. ornithinolytica): report from the SENTRY antimicrobial surveillance program. J Clin Microbiol. 2009;47(12):4129-30. http://dx.doi. org/10.1128/JCM.01502-09. PMid:19812278. 16. Hu AY, Leslie KA, Baskette J, Elsayed S. Raoultella planticola bacteraemia. J Med Microbiol. 2012;61(Pt 10):1488‑9. http://dx.doi.org/10.1099/jmm.0.041129-0. PMid:22820690. 17. González-González L, Álvarez-Otero J, Ferreiro JLL, Aguado JF. Cholangitis and bacteremia caused by Raoultella planticola. Med Clin. 2015;144(5):230‑4. http://dx.doi. org/10.1016/j.medcli.2014.04.010. PMid:24994005. 18. Xu M, Xie W, Fu Y, Zhou H, Zhou J. Nosocomial pneumonia caused by carbapenem-resistant Raoultella planticola: a case report and literature review. Infection. 2015;43(2):245-8. http://dx.doi.org/10.1007/s15010015-0722-9. PMid:25595510. 19. Salmaggi C, Ancona F, Olivetti J, Pagliula G, Ramirez GA. Raoultella planticola-associated cholangitis and sepsis: a case report and literature review. QJM.

22. Olson DS Jr, Asare K, Lyons M, Hofinger DM. A novel case of Raoultella planticola urinary tract infection. Infection. 2013;41(1):259-61. http://dx.doi.org/10.1007/s15010012-0294-x. PMid:22802099. 23. Koukoulaki M, Bakalis A, Kalatzis V, et al. Acute prostatitis caused by Raoultella planticola in a renal transplant recipient: a novel case. Transpl Infect Dis. 2014;16(3):4614. http://dx.doi.org/10.1111/tid.12213. PMid:24750300. 24. Wolcott R, Dowd S. Molecular diagnosis of Raoultella planticola infection of a surgical site. J Wound Care. 2010;19(8):329-32. http://dx.doi.org/10.12968/ jowc.2010.19.8.77710. PMid:20852504. 25. O’ Connell K, Kelly J, Niriain U. A rare case of soft-tissue infection caused by Raoultella planticola. Case Rep Med. 2010;2010:134086. PMid:20811592. 26. Kim SH, Roh KH, Yoon YK, et al. Necrotizing fasciitis involving the chest and abdominal wall caused by Raoultella planticola. BMC Infect Dis. 2012;12(1):59. http://dx.doi. org/10.1186/1471-2334-12-59. PMid:22423899. 27. Zuberbuhler B, Abedin A, Roudsari A. A novel case of chronic conjunctivitis in a 58-year-old woman caused by Raoultella. Infection. 2014;42(5):927-9. http://dx.doi. org/10.1007/s15010-014-0624-2. PMid:24865691. 28. Tseng SP, Wang JT, Liang CY, Lee PS, Chen YC, Lu PL. First report of blaIMP-8 in Raoultella planticola. Antimicrob Agents Chemother. 2014;58(1):593-5. http://dx.doi. org/10.1128/AAC.00231-13. PMid:24145534. 29. Tang H-X, Wu A-W, Song J-L, Yang L, Chen D-Q, Lin Y-P. Extensively drug-resistant Raoultella planticola carrying multiple resistence genes including blaNDM-1. JMM Case Rep. 2014;1(3). http://dx.doi.org/10.1099/ jmmcr0.000265.

Conflict of interest: None Submitted on: March 10th, 2016 Accepted on: April 14th, 2016 Correspondence Fernando Peixoto Ferraz de Campos Internal Medicine Division - Hospital Universitário - University of São Paulo (USP) Av. Professor Lineu Prestes, 2565 – Butantã – São Paulo/SP – Brazil CEP: 05508-000 Phone: +55 (11) 3091-9275 E-mail: fpfcampos@gmail.com Autopsy and Case Reports 2016;6(2):27-31

Article / Clinical Case Report

Indeterminate cell histiocytosis successfully treated with phototherapy Maria Claudia Nogueira Zerbinia, Mirian Nacagami Sottoa, Fernando Peixoto Ferraz de Camposb, Andre Neder Ramires Abdoc , Juliana Pereirac,d, José Antônio Sanches Juniore, Jade Cury Martinse Zerbini MCN, Sotto MN, Campos FPF, et al. Indeterminate cell histiocytosis successfully treated with phototherapy. Autopsy Case Rep [Internet]. 2016;6(2):33-38. http://dx.doi.org/10.4322/acr.2016.038

ABSTRACT First described in 1985, intermediate cell histiocytosis is a rare disorder of the cutaneous dendritic cell group with a varied clinical presentation and evolution. The pathologic substrate is constituted by the proliferation of indeterminate cells (ICs) that are immunophenotypically characterized by the positivity of CD1a, CD68, and faint/focal S100, plus the negativity for CD207 (langerin). The authors present the case of a healthy elderly woman who presented generalized dome-shaped reddish cutaneous nodules over her trunk, neck, face, and extremities over a period of 18 months. A laboratory and imaging work-up ruled out internal involvement. The skin biopsy was consistent with IC histiocytosis. The patient was treated with narrowband ultraviolet B phototherapy, which resulted in an excellent short-term outcome. Keywords Histiocytosis; Skin Diseases; Phototherapy

CASE REPORT A 76-year-old Caucasian woman sought medical care complaining of the presence of scattered nodules all over her body surface. She referred the onset of the appearance of a few dispersed lesions on the neck 18 months before. Since then, new lesions had appeared in the inframammary region, abdomen, and back, which centrifugally spread to the lower and upper limbs, and finally to the face involving the nose and ears. The patient was reluctant to seek medical

care until the lesions began to appear in exposed areas, especially on her face. During this period, she maintained in good health. She had recently used a corticoid cream over her face with subjective improvement. She denied fever, weight loss, or any other complaint except for hopelessness caused by her appearance. Her medical history included the diagnosis of hypertension and the regular use of valsartan, levanlodipine, clopidogrel,

Department of Pathology - Faculty of Medicine - University of São Paulo, São Paulo/SP – Brazil. Internal Medicine Division - Hospital Universitário - University of São Paulo, São Paulo/SP – Brazil. c Hematologic Oncology Department - Instituto do Câncer de São Paulo, São Paulo/SP – Brazil. d Department of Hematology - Faculty of Medicine - Universisity of São Paulo, São Paulo/SP – Brazil. e Dermatology Department - Faculty of Medicine - Hospital das Clínicas - University of São Paulo, São Paulo/SP – Brazil. a

Indeterminate cell histiocytosis successfully treated with phototherapy

and simvastatin; she also had a myocardial infarction 10 years ago, which had been treated with an angioplasty. The physical examination showed an apparently depressed patient, weighing 78 kg, with a height of 1.58 m, and normal vital signs. The skin examination revealed multiple reddish or brown dome‑shaped, non-pruriginous, painless papules of varying sizes (1-5 mm) of firm consistency that eventually ulcerated (Figure 1). The remaining examination was normal. The laboratory work-up, which included a total blood cell count and erythrocyte sedimentation rate, electrolytes, renal function tests, calcium, hepatic enzymes, uric acid, thyroid function, protein electrophoresis, β2 microglobulin, and immunoglobulin dosage, was within the normal range. Serology for HIV1 and HIV2, hepatitis B, hepatitis C, syphilis, antinuclear antibody, and anti-DNA were negative. A bone radiological inventory ruled out any lesion. A thoracic tomography disclosed signs consistent

with pulmonary emphysema. The positron emission tomography-computed tomography scans showed multiple hypermetabolic cutaneous lesions, but no other suspicious lesions were described. The magnetic resonance imaging showed no evidence of central nervous system disease. Therefore, she was deemed free of internal disease. The patient was submitted to a skin biopsy, which revealed a dense superficial dermal infiltrate composed of histiocytoid cells with oval-shaped nuclei sometimes presenting longitudinal chromatin grooves. Sparse multinucleated cells and plasma cells were also present. Small lymphocytes surrounded groups of histiocytes. The epidermis showed spongiosis, lymphocytes exocytosis, and a focally ulcerated area (Figures 2A, B). Immunostains were focally positive for S100 (Figure 2C) and CD68 (Figure 2D); diffusely positive for CD1a (Figures 3A, B) and were negative for CD207 (langerin) (Figure 3C). The Ki67 labeling index was about 60% (Figure 3D). Based on these findings, the diagnosis was concluded as an indeterminate dendritic cell tumor; also called indeterminate cell (IC) histiocytosis. The BRAF V600 mutation was negative in the neoplastic cells (sequencing analysis of BRAF gene mutations technique). With the diagnosis of IC histiocytosis of exclusive cutaneous involvement (single multifocal system), corticosteroid (prednisone 0.5 mg/kg/day) was started but the patient’s blood pressure increased. Muscular pain and headache ensued and another treatment modality needed to be scheduled. Taking into account the patient’s intolerance to the intermediate steroids dose, age, and comorbidities, a reasonable option was local therapy, so the patient was treated with narrowband ultraviolet B (UVB) phototherapy three times a week for 2 months. The lesions started effacing after the first month of the phototherapy and completely subsided on the third month leaving local hyperpigmentation. The patient is now at the sixth month of follow-up and is completely symptomless (Figure 4); she did not report any adverse reactions.

DISCUSSION Figure 1. Skin examination showing in A - disseminated nodular lesions over the face; B - over the trunk and the inframammary region; C - over the lateral face of the thorax; and D - over the back. 34

Histiocytoses comprise a group of disorders characterized by the proliferation of monocytes, macrophages, and dendritic cells, which are not involved Autopsy and Case Reports 2016;6(2):33-38

Zerbini MCN, Sotto MN, Campos FPF,Â etÂ al.

Figure 2. Histology and Immunostains of the skin biopsy. A - Dense infiltrate in the dermis (H&E, 100X); B - Infiltrate composed by histiocytoid cells, lymphocytes, plasma cells and multinucleated cells (H&E, 400X); C - S100 partially positive in epidermal Langerhans cells and dermal infiltrate (anti-S100, 200X); D - CD68 positive in histiocytoid cells of the dermal infiltrate (anti-CD68, 200X).

Figure 3. Photomicrography of the Immunostains of the skin biopsy in A and B - CD1a diffusely positive in dermal histiocytoid cells and epidermal Langerhans cells (anti-CD1a, 200X); C - CD207 (Langerin) negative in the demal infiltrate and positive in the epidermal Langerhans cells (anti-CD207, 200X); D - Ki67 positive in about 60% of the dermal cells infiltrate (anti-Ki67, 400X). Autopsy and Case Reports 2016;6(2):33-38

Indeterminate cell histiocytosis successfully treated with phototherapy

the epidermal Langerhans cells and other dermal antigen-presenting cells (ICs and dendritic cells) make up the major component of the skin’s immune system. The proliferation of such cells will categorize the histiocytoses in (i) Langerhans cell histiocytosis (LCH): (ii) non-Langerhans cell histiocytosis (NLCH); and (iii) IC histiocytosis (ICH).3 Although the latter has been proposed to be a variant of the NLCH,4 in 2008 the World Health Organization (WHO) incorporated ICH into the tumors of the hematopoietic and lymphoid tissue tumors.5 The precise origin of the IC is under debate. While some researchers believe that they are precursors of Langerhans cells, which, when en route to the epidermis, remained arrested into the dermis and did not acquire the Birbeck granules,6-8 other researchers believe they are “veiled dendritic cells” that migrate from the skin to the regional lymph nodes.9 Additionally, experimental evidence points toward the myeloid lineage for the bone-marrow-derived dendritic cells by presenting myeloid lineage markers, such as CD13 and CD33.10-13 Figure 4. Cutaneous examination after the sixth month of therapy. The face is free of lesions - A; and some erythematous scar-like lesions remain on the trunk - B, C and D.

Thus, ICs are dendritic elements of the skin (specifically of the dermis, but occasionally the epidermis as well), which express CD1a, CD68, and feeble S100. The absence of the Birbeck granules– and therefore the lack of the expression of CD 207 (langerin)–differentiates IC from Langerhans cells.

in a response to primary disease. The nomenclature of histiocytosis has changed substantially over the last half century, which is now based on the primary involved cell in the pathophysiology of the disease.

In 1985, Wood et al. 8 first described the IC histiocytosis. Despite being much more common in adults, 14 ICH has been reported in all ages and no gender predominance has been observed. Clinically, ICH is characterized by cutaneous (sparing mucosae) pinky to reddish, varying sized, non-itchy, painless papules or nodules that appear in otherwise healthy persons. A reactive form triggered by cutaneous diseases, such as scabies and pityriasis rosea, has been reported.15,16 Such lesions may be single, a discrete group of lesions, or multiple generalized papules spread over the trunk, face, and extremities, which may present spontaneous remission, stable disease, or remission and recurrence. 4,9,16-18 The exclusive cutaneous presentation is the rule; however, bone and corneal involvement have been reported. 19,20 The clinical differential diagnosis of ICH is represented by generalized eruptive histiocytosis, a non-Langerhans cell histiocytosis, but in this condition the histiocytes do not express CD1a and S100 protein. The ICH

The bone marrow pluripotent stem cells, under the influence of (i) granulocyte-macrophage colony stimulating factor (GM-CSF); and (ii) tumor necrosis factor alpha (TNFα) differentiate into a particular group of specialized cells with the functions of antigen presentation and phagocytosis–the dendritic cells.1 These cells move into the blood stream and migrate to the dermal and epidermal layers of the skin. Within the tissue (skin) the dendritic cell precursors under the action of the transforming growth factor β1 (TGF‑β1) develop the Birbeck granules and therefore will differentiate into the Langerhans cells. The other cells will not suffer the action of such a cytokine and will remain as two different populations of dendritic cells.2 Along with different subpopulations of lymphocytes, 36

Autopsy and Case Reports 2016;6(2):33-38

Zerbini MCN, Sotto MN, Campos FPF, et al.

histopathological differential diagnosis is represented by Langerhans cell histiocytosis where the dendritic cells display cytoplasmic Birbeck granules at transmission electron microscopy exam and positivity to CD207 (langerin). The rarity of this entity imposes certain difficulties in establishing any relationship with other malignancies. However, concomitant or not, cases of ICH have been reported in association with low-grade B-cell lymphoma18,21 and other hematologic malignancies years after their initial diagnosis. The optimal treatment for ICH is not clear, but similarly to LCH, identifying the initial presentation and organ or system involvement is critical for choosing the appropriate modality of therapy (a systemic work-up prior to the initiation of treatment should be considered). Case reports describe a wide range of effective therapies that include UVB phototherapy, thalidomide, methotrexate, and surgical excision for solitary lesions.22,23 As far as we know, based on published data, this is the third case treated with narrowband UVB with very few side effects, good tolerability, and an excellent short-term result.24,25

REFERENCES 1. Thomas R, Lipsky PE. Dendritic cells: origin and differentiation. Stem Cells. 1996;14(2):196-206. http:// dx.doi.org/10.1002/stem.140196. PMid:8991539. 2. Toebak MJ, Gibbs S, Bruynzeel P, Scheper J, Rustemeyer T. Dendritic cells: biology of the skin. Contact Dermat. 2009;60(1):2-20. http://dx.doi.org/10.1111/j.16000536.2008.01443.x. PMid:19125717. 3. Bakry OA, Samaka RM, Kandil MA, Younes SF. Intermediate cell histiocytosis with naïve cells. Rare Tumors. 2013;5(1):e13. http://dx.doi.org/10.4081/ rt.2013.e13. PMid:23772299. 4. Ventura F, Pereira T, Luz Duarte M. Intermediate cell histiocytosis in association with acute myeloid leukemia. Dermatol Res Pract 2010;2010:569345-9. 5. Weiss LM, Chan JKC, Fletcher CDM. Other rare dendritic cell tumors. In: Swerdlow SH, Campo E, Harris NL et al. editors. World Health Organization classification of tumors of the hematopoietic and lymphoid tissues. Lyon: WHO Press; 2008. chap. 14; p. 365. 6. Vener C, Soligo D, Berti E, et al. Indeterminate cell histiocytosis in association with later occurrence of acute myeloblastic leukaemia. Br J Dermatol. Autopsy and Case Reports 2016;6(2):33-38

2007;156(6):1357-61. http://dx.doi.org/10.1111/j.13652133.2007.07880.x. PMid:17459045. 7. Kolde G, Brocker EB. Multiple skin tumors of indeterminate cells inadult. J Am Acad Dermatol. 1986;15(4 Pt 1):5917. http://dx.doi.org/10.1016/S0190-9622(86)70209-0. PMid:3095403. 8. Wood GS, Hu CH, Beckstead LH, Turner RR, Winkelmann RK. The intermediate cell proliferative disorder: report of a case manifesting as an unusual cutaneous histiocytosis. J Dermatol Surg Oncol. 1985;11(11):1111-9. http:// dx.doi.org/10.1111/j.1524-4725.1985.tb01399.x. PMid:3902927. 9. Berti E, Gianotti R, Alessi E. Unusual cutaneous histiocytosis expressing an intermediate immunophenotype between Langerhans’ cells and dermal macrophages. Arch Dermatol. 1988;124(8):1250-3. http://dx.doi. org/10.1001/archderm.1988.01670080062020. PMid:3401031. 10. Thomas R, Davis LS, Lipsky PE. Isolation and characterization of human peripheral blood dendritic cells. J Immunol. 1993;150(3):821-34. PMid:7678623. 11. Lenz A, Heine M, Schuler G, Romani N. Human and murine dermis contain dendritic cells: isolation by means of a novel method and phenotypical and functional characterization. J Clin Invest. 1993;92(6):2587-96. http://dx.doi.org/10.1172/JCI116873. PMid:8254016. 12. O’Doherty U, Peng M, Gezelter S, et al. Human peripheral blood contains two dendritic cell sub-sets: one mature and one immature. Immunology. 1994;82(3):487-93. PMid:7525461. 13. Peters JH, Gieseler R, Thiele B, Steinbach F. Dendritic cells: from ontogenetic orphans to myelomonocytic descendants. Immunol Today. 1996;17(6):273-8. http://dx.doi.org/10.1016/0167-5699(96)80544-5. PMid:8962630. 14. Rodrígues-Jurado R, Vidaurri-de la Cruz H, DuránMckinster C, Ruíz-Maldonado R. Indeterminate cell histiocytosis. Clinical and pathological study in a pediatric patient. Arch Pathol Lab Med. 2003;127(6):748-51. PMid:12741905. 15. Hashimoto K, Fujiwara K, Mehregan A. Current topics of immunohistochemistry as applied in skin tumors. J Dermatol. 1993;20(9):521-32. http:// dx.doi.org/10.1111/j.1346-8138.1993.tb01333.x. PMid:7693783. 16. Ratzinger G, Burgdorf WHC, Metze D, Zelger BG, Zelger B. Indeterminate cell histiocytosis: fact or fiction? J Cutan Pathol. 2005;32(8):552-60. http://dx.doi.org/10.1111/ j.0303-6987.2005.00382.x. PMid:16115054. 17. Miracco C, Raffaelli M, de Santi MM, Fimiani M, Tosi P. Solitary cutaneous reticulum cell tumor. Enzyme immunohistochemical and electron-microscopic analogies with IDRC sarcoma. Am J Dermatopathol. 1988;10(1):4737

Indeterminate cell histiocytosis successfully treated with phototherapy

53. http://dx.doi.org/10.1097/00000372-19880200000006. PMid:2845833. 18. Rezk S, Spagnolo D, Brynes R, Weiss L. Indeterminate cell tumor: a rare dendritic neoplasm. Am J Surg Pathol. 2008;32(12):1868-76. http://dx.doi.org/10.1097/ PAS.0b013e31818593d6. PMid:18813122. 19. Flores-Stadler EM, Gonzales-Crussi F, Greene M, Thangavelu M, Kletzel M, Chou PM. Indeterminate-cell histiocytosis: immunophenotypic and cytogenetic findings in an infant. Med Pediatr Oncol. 1999;32(4):250-4. http://dx.doi. org/10.1002/(SICI)1096-911X(199904)32:4<250::AIDMPO2>3.0.CO;2-#. PMid:10102017. 20. Calatayud M, Güell JL, Gris O, Puig J, Arrondo E, Huguet P. Ocular involvement in a case of systemic indeterminate cell histiocytosis: a case report. Cornea. 2001;20(7):76971. http://dx.doi.org/10.1097/00003226-20011000000021. PMid:11588435. 21. Bettington A, Lai J, Kennedy C. Indeterminate dendritic cell tumour presenting in a patient with follicular lymphoma. Pathology. 2011;43(4):372-5. http://dx.doi. org/10.1097/PAT.0b013e32834685b7. PMid:21566494.

22. Toth B, Katona M, Harsing J, Szepesi A, Karpati S. Indeterminate cell histiocytosis in a pediatric patient: successful treatment with Thalidomide. Pathol Oncol Res. 2012;18(2):535-8. http://dx.doi.org/10.1007/s12253011-9405-8. PMid:21688087. 23. Fournier J, Ingraffea A, Pedvis-Leftick A. Successful treatment of indeterminate cell histiocytosis with lowdose methotrexate. J Dermatol. 2011;38(9):937-9. PMid:21366676. 24. Bard S, Torchia D, Connelly E, Duarte A, Badiavas E, Schachner L. S100-negative indeterminate cell histiocytosis in an Africa American child responsive to narrow ultraviolet B. Pediatr Dermatol. 2011;28(5):5247. http://dx.doi.org/10.1111/j.1525-1470.2011.01305.x. PMid:21916959. 25. Ishibashi M, Ouchi T, Tanikawa A, Ishiko A. Indeterminate cell histiocytosis successfully treated with ultraviolet B phototherapy. Clin Exp Dermatol. 2008;33(3):301-4. http://dx.doi.org/10.1111/j.1365-2230.2007.02667.x. PMid:18261137.

Conflict of interest: None Submitted on: May 30th, 2016 Accepted on: June 10th, 2016 Correspondence Maria Claudia Nogueira Zerbini Department of Pathology - Faculty of Medicine - Universidade de São Paulo (USP) Avenida Dr. Arnaldo, 455 – Cerqueira Cesar – São Paulo/SP – Brazil CEP: 01246-904 Phone: +55 (11) 3061-7415 E-mail: czerbini@usp.br

Autopsy and Case Reports 2016;6(2):33-38

Article / Clinical Case Report

A huge ovarian mucinous cystadenoma causing virilization, preterm labor, and persistent supine hypotensive syndrome during pregnancy Suna Kabil Kucura, Canan Acarb, Osman Temizkanb, Aysim Ozagarib, Ilay Gozukaraa, Atif Akyolb Kabil Kucur S, Acar C, Temizkan O, Ozagari A, Gozukara I, Akyol A. A huge ovarian mucinous cystadenoma causing virilization, preterm labor, and persistent supine hypotensive syndrome during pregnancy. Autopsy Case Rep [Internet]. 2016;6(2):39-43. http://dx.doi.org/10.4322/acr.2016.029

ABSTRACT Mucinous cystadenoma (MC) of the ovary is an unilateral, multilocular cystic benign epithelial tumor. Supposed to be hormone responsive, MC reaches huge sizes during pregnancy. Aortocaval compression is common during pregnancy, especially when the pregnant woman is in the supine position. However, the compression recovers with a change in position. The authors report the first case of a huge mucinous cystadenoma of the ovary complicating pregnancy and causing virilization, premature labor, and persistent supine hypotensive syndrome. Keywords Pregnancy; Cystadenoma; Mucinous; Ovary; Virilism; Obstetric Labor; Premature

INTRODUCTION The incidence of ovarian tumors complicating pregnancy ranges between 1% and 2%.1 Most of these tumors are benign, such as mature cystic teratoma and serous cystadenoma 2,3; however, malignancy does occur, but shows an incidence of 1/10,000-50,000.4 Adnexal masses are usually asymptomatic during pregnancy unless they reach large sizes. Diagnosis may be done incidentally during routine obstetric ultrasound examination. Mucinous cystadenomas (MCs) are benign epithelial tumors that can reach up to 40 cm in diameter during pregnancy.5 Fifteen percent of ovarian tumors are mucinous and 25% of them show a potential malignant transformation.6 In this report, we presented an ovarian MC that measured 27 × 30 cm at its longest axis, which

a b

was detected during pregnancy. The tumor caused virilization, premature birth, and inferior vena cava (IVC) syndrome, but no fetal growth impairment. To the best of our knowledge, this is the first case of an ovarian MC of such size causing virilization, preterm labor, and IVC syndrome.

CASE REPORT A 22-year-old pregnant woman (gravida 2, para 1) presented to the outpatient clinic with dyspnea, palpitation, and lower limbs edema in the 33rd gestational week. Her blood pressure was 80/40 mmHg in both the upright and the lying down

Department of Obstetrics and Gynecology - Faculty of Medicine - Dumlupinar University - Kütahya – Turkey. Department of Obstetrics and Gynecology - Sisli Etfal & Research Hospital - Istanbul – Turkey.

A huge ovarian mucinous cystadenoma causing virilization, preterm labor, and persistent supine hypotensive syndrome during pregnancy

positions. Her pulse rate was 130 beats per minute in the upright position and 140 beats per minute when lying down. Ultrasonography revealed an intrauterine pregnancy consistent with the gestational age, normal amniotic fluid index, and echo Doppler ultrasound findings. A multiloculated, cystic, right adnexal mass with a regular surface extending from the true pelvis to 5 cm away to the right side of xyphoid process was disclosed. Abdominal magnetic resonance images confirmed the presence of a right ovarian mass measuring 27 × 30 cm over the uterus occupying the right hemiabdomen (Figure 1A and 1B). Past medical history revealed that the patient had the diagnosis of a 7 cm right ovarian cyst in the 10th week of pregnancy. Her laboratory tests were normal except for a mild anemia (hemoglobin of 11.2 g/L; reference value: 12.0-15.5 g/L). On physical examination, signs of virilization, such as acne, oily skin, and abdominal hirsutism were present (Figure 2). Persistent hypotension, tachycardia, and edema were attributed to the compression of the IVC caused by the mass. The patient was hospitalized, and betamethasone was administered for fetal lung maturation. After 5 days of hospitalization, the patient entered labor and an emergency laparotomy was performed since she’d had a previous caesarean section. After a midline skin incision, a 27 cm right ovarian mass weighing 5.5 kg was observed. A lower uterine

incision was undertaken and a female infant was born with an Apgar score of 8 after the first minute, weighing 2700 g. The child had no signs of virilization. A right salpingo-oophorectomy was performed on the mother (Figure 3). Mean arterial blood pressure and pulse rate returned to normal after the operation. The patient was discharged on the sixth postoperative day. The signs of virilization faded away 3 months after the operation. Histopathology confirmed mucinous cystadenoma with marked luteinizing stroma. Macroscopically, the cyst was multilocular with a smooth external surface. The cut surface showed multiple trabeculae but no solid areas. The maximum thickness of the cyst wall was 1.5 cm. Microscopically, the tumor was composed of glands and cysts lined by a single layer of columnar cells with abundant intracellular mucin. Cellular stratification was minimal, and nuclei were basally located without atypia. Beneath the lining epithelium and amongst the glandular structures, large polygonal cells with eosinophilic to clear cytoplasm, a central round nucleus, and a prominent nucleolus, consistent with luteinized stromal cells, were seen (Figure 4). On immunohistochemical research, these cells were positive for vimentin and inhibin (Figure 5). Estrogen and progesterone receptors and human chorionic gonadotropin (HCG) were negative.

Figure 1. A and B - T2-weighted magnetic resonance imaging of the abdomen showing the gravid uterus with single fetus (black arrows), cephalic presentation and back to the right, and a voluminous cyst with apparent excrescence in the inferior aspect (white arrow). 40

Autopsy and Case Reports 2016;6(2):39-43

Kabil Kucur S, Acar C, Temizkan O, Ozagari A, Gozukara I, Akyol A

DISCUSSION

Figure 2. Postoperative macroscopic view of the hypogastric region showing the abdominal hirsutism.

Figure 3. Gross view of the cyst during the salpingoâ&#x20AC;&#x2018;oophorectomy.

The frequency of an ovarian tumor during pregnancy, which is diagnosed by ultrasonography is 1.14%. Ninety percent of these tumors are smaller than 5 cm, and generally are spontaneously absorbed before the 16th week of pregnancy. 7 Although the symptoms caused by these masses were considered as physiological changes of pregnancy in the past, pregnancies complicated with adnexal masses have been increasingly reported due to the increased availability of imaging techniques. MCs of the ovary during pregnancy have been reported with different presentations. 5,8â&#x20AC;&#x201C;11 Virilization related to ovarian pathology is uncommon during pregnancy. The local factors secreted by the tumor and the mechanical pressure of the tumor on the stromal cells have been proposed as the possible reasons for virilization.12,13 MCs usually arise from the ovary, as in the presenting case. However, MCs from ectopic ovarium tissue in organs, such as the omentum, appendix, or pancreas, have also been reported. 14,15 The origin or the pathogenesis of MCs in other organs is not yet well defined. Theories suggest that: (i) MC may be the result of ectopic ovarian tissue or teratoma; and (ii) MC may result from a peritoneal invagination and therefore form a cyst with further mesothelium mucinous metaplasia. In the pancreas and the liver, MC presents ovarian-type or ovarian-like subepithelial stroma, which is the criterion for the diagnosis.16

Figure 4. Photomicrography of the cystic tumor showing glands lined by a single layer of columnar cells containing a large amount of mucin and luteinized stromal cells with large nuclei and eosinophilic to clear cytoplasm (H&E,Â A - 100X and B - 400X). Autopsy and Case Reports 2016;6(2):39-43

A huge ovarian mucinous cystadenoma causing virilization, preterm labor, and persistent supine hypotensive syndrome during pregnancy

Figure 5. Photomicrography of the cystic tumor showing strong positivity for inhibin in the stromal luteinized cells while the mucinous epithelium is negative (immunohistochemistry 200X). There are different approaches to the adnexal masses during pregnancy. In a series comprising 36 cases of pregnancies with adnexal masses, Balci et al.17 concluded that watchful waiting should be adopted unless an unexpected event emerges requiring surgical intervention. Ovarian tumors during pregnancy may complicate with torsion, rupture, infarction, fetal intrauterine growth impairment, fetal malpresentation, preterm labor, and dystocia preventing normal vaginal delivery. In the past, an elective operation was recommended during the second trimester in order to decrease these complications. Lee et al.18 stated that conservative treatment was safer than elective surgery performed during the second trimester for patients with a low malignancy risk. Indeed, an emergency procedure undertaken after an expectant management did not show worse obstetric outcomes when compared with elective surgery. 18 However, some researchers still advocate elective surgery.7 In this setting, in our clinic, we prefer to adopt the expectant management in pregnancies with adnexal benign masses in the absence of any complications. The presenting case was referred to our clinic in the 33rd week of pregnancy with signs of dyspnea, palpitation, and edema. A rapid-growing adnexal cystic mass was present and was believed to be hormone sensitive due to the virilization stigmata. However, the patient’s immunohistochemistry was negative for estrogen and progesterone. 42

Data on immunohistochemical staining for estrogen and progesterone receptors of MCs during pregnancy are conflicting. Although Qublan et al. 5 reported estrogen receptor positivity on immunohistochemical staining of virilizing MC during pregnancy, our case lacked this positivity. Bolat et al.8 recently reported a case of MC in pregnancy in which the immunohistochemistry was negative for estrogen and progesterone receptors but was positive for human chorionic gonadotropin (HCG). The virilization of our patient can be explained by the luteinizing stroma found in the histopathological examination.5,18 HCG is the most important hormone; it provides the luteinizing stroma, and therefore the virilization stigmata are supposed to cease with the end of the pregnancy. However, in our case, tumor cells were HCG negative by the immunohistochemistry. In the virilizing MC cases during pregnancy reported by Bolat et al.8 and Antoniou et al.,19 luteinized stromal cells were negative for estrogen and progesterone receptors but positive for HCG. To our knowledge, this present case of an MC complicating pregnancy with virilization is the first in the literature to be estrogen, progesterone, and HCG negative. It could be speculated that another mechanism should be responsible for virilization in these patients. Similarly, we could not find any reported case with IVC syndrome associated with an MC complicating pregnancy with virilization. 8,11 Intrauterine growth retardation has been reported in cases of large-sized abdominal masses, but interestingly, such impairment was not observed in our case.5 Meanwhile, we believe that the intra-abdominal pressure provided by the ovarian mass, in the present case, was also responsible for the preterm delivery. Clinicians should keep in mind that hemodynamic derangements consistent with IVC syndrome that do not respond to left-side recumbence or upright position during pregnancy might be due to abdominal masses complicating pregnancy. Symptoms recover immediately after surgical decompression.

REFERENCES 1. Leiserowitz GS. Managing ovarian masses during pregnancy. Obstet Gynecol Surv. 2006;61(7):463-70. http://dx.doi.org/10.1097/01.ogx.0000224614.51356.b7. PMid:16787549. 2. Usui R, Minakami H, Kosuge S, Iwasaki R, Ohwada M, Sato I. A retrospective survey of clinical, pathologic, and Autopsy and Case Reports 2016;6(2):39-43

Kabil Kucur S, Acar C, Temizkan O, Ozagari A, Gozukara I, Akyol A

prognostic features of adnexal masses operated on during pregnancy. J Obstet Gynaecol Res. 2000;26(2):89-93. http://dx.doi.org/10.1111/j.1447-0756.2000.tb01289.x. PMid:10870299. 3. Sherard GB 3rd, Hodson CA, Williams HJ, Semer DA, Hadi HA, Tait DL. Adnexal masses and pregnancy: a 12-year experience. Am J Obstet Gynecol. 2003;189(2):358-62, discussion 362-3. http://dx.doi.org/10.1067/S00029378(03)00731-2. PMid:14520194. 4. Zanotti KM, Belinson JL, Kennedy AW. Treatment of gynecologic cancers in pregnancy. Semin Oncol. 2000;27(6):686-98. PMid:11130476. 5. Qublan HS, Al-Ghoweri AS, Al-Kaisi NS, Abu-Khait SA. Benign mucinous cystadenoma with stromal luteinization during pregnancy: a hormonally responsive tumor and a rare cause of fetal intrauterine growth restriction. J Obstet Gynaecol Res. 2002;28(2):104-7. http://dx.doi.org/10.1046/ j.1341-8076.2002.00020.x. PMid:12078969. 6. Ioffe OB, Simsir A, Silverberg SG. Pathology. In: Berek JS, Hacker NF, editors. Practical gynecologic oncology. Los Angeles: Lippincott Williams & Wilkins; 2000. p. 213-4.

http://dx.doi.org/10.1111/j.1447-0756.2007.00542.x. PMid:17578373. 12. MacDonald PC, Grodin JM, Edman CD, Vellios F, Siiteri PK. Origin of estrogen in a postmenopausal woman with a nonendocrine tumor of the ovary and endometrial hyperplasia. Obstet Gynecol. 1976;47(6):644-50. PMid:934553. 13. Verhoeven AT, Mastboom JL, van Leusden HA, van der Velden WH. Virilization in pregnancy coexisting with an ovarian mucinous cystadenoma: A case report and review of virilizing ovarian tumors in pregnancy. Obstet Gynecol Surv. 1973;28(9):597-622. http://dx.doi.org/10.1097/00006254197309000-00001. PMid:4614154. 14. Cohen I, Altaras M, Lew S, Jaffe R, Ben-Aderet N. Huge mesenteric mucinous cystadenoma in normal pregnancy. Obstet Gynecol. 1988;71(6 Pt 2):1030-2. PMid:3374916. 15. Tica AA, Tica OS, Saftoiu A, Camen D, Tica VI. Large pancreatic mucinous cystic neoplasm during pregnancy: what should be done? Gynecol Obstet Invest. 2013;75(2):132-8. http:// dx.doi.org/10.1159/000346176. PMid:23343567.

7. Agarwal N, Parul, Kriplani A, Bhatla N, Gupta A. Management and outcome of pregnancies complicated with adnexal masses. Arch Gynecol Obstet. 2003;267(3):148-52. http:// dx.doi.org/10.1007/s00404-001-0287-y. PMid:12580154.

16. Cauchy F, Lefevre JH, Mourra N, Parc Y, Tiret E, Balladur P. Mucinous cystadenoma of the mesocolon, a rare entity frequently presenting with features of malignity: two case reports and review of the literature. Clin Res Hepatol Gastroenterol. 2012;36(1):e12-6. http://dx.doi. org/10.1016/j.clinre.2011.09.006. PMid:22074643.

8. Bolat F, Parlakgumus A, Canpolat T, Tuncer I. Benign mucinous cystadenoma with stromal luteinization responsible for maternal virilization and fetal intrauterine growth restriction. J Obstet Gynaecol Res. 2011;37(7):893-6. http://dx.doi. org/10.1111/j.1447-0756.2010.01406.x. PMid:21450020.

17. Balci O, Gezginc K, Karatayli R, Acar A, Celik C, Colakoglu MC. Management and outcomes of adnexal masses during pregnancy: A 6-year experience. J Obstet Gynaecol Res. 2008;34(4):524-8. http://dx.doi.org/10.1111/j.14470756.2008.00744.x. PMid:18946936.

9. Noreen H, Syed S, Chaudhri R, Kahloon LE. A large unilocular mucinous cystadenoma in third trimester of pregnancy. J Coll Physicians Surg Pak. 2011;21(7):426-8. PMid:21777533.

18. Lee GSR, Hur SY, Shin JC, Kim SP, Kim SJ. Elective vs. conservative management of ovarian tumors in pregnancy. Int J Gynaecol Obstet. 2004;85(3):250-4. http://dx.doi. org/10.1016/j.ijgo.2003.12.008. PMid:15145260.

10. Ivanov S, Kovachev E, Minkov R, et al. A rare case of pregnancy combined with a large ovarian tumour. Akush Ginekol (Sofiia). 2012;51(Suppl 1):29-32. PMid:23236676. 11. Pather S, Atkinson K, Wang I, Russell P, Kesby G, Carter J. Virilization in pregnancy due to a borderline mucinous ovarian tumor. J Obstet Gynaecol Res. 2007;33(3):384-7.

19. Antoniou N, Varras M, Akrivis C, Demou A, Bellou A, Stefanaki S. Mucinous cystadenoma of the ovary with functioning stroma and virilization in pregnancy: a case report and review of the literature. Clin Exp Obstet Gynecol. 2003;30(4):248-52. PMid:14664425.

Conflict of interest: None Submitted on: January 15th, 2016 Accepted on: April 6th, 2016 Correspondence Suna Kabil Kucur Department of Obstetrics and Gynecology - Evliya Celebi Training and Research Hospital - Faculty of Medicine Dumlupinar University Evliya Celebi Avenue – Okmeydani Street – Kutahya – Turkey Phone: +90532355-9047 Fax: +90274231-6660 E-mail: dr.suna@hotmail.com Autopsy and Case Reports 2016;6(2):39-43

Article / Clinical Case Report

Simultaneous genital ulcer and meningitis: a case of EBV infection Hassan Rahhala, Jairo Tavares Nunesa, Leonardo da Costa Lopesb, Aleksander Snioka Prokopowitschb Rahhal H, Nunes JT, Lopes LC, Prokopowitsch AS. Simultaneous genital ulcer and meningitis: a case of EBV infection. Autopsy Case Rep [Internet]. 2016;6(2):45-49. http://dx.doi.org/10.4322/acr.2016.033

ABSTRACT The Epstein-Barr virus (EBV) is associated with a broad spectrum of diseases, mainly because of its genomic characteristics, which result in different latency patterns in immune cells and infective mechanisms. The patient described in this report is a previously healthy young man who presented to the emergency department with clinical features consistent with meningitis and genital ulcers, which raised concern that the herpes simplex virus was the causative agent. However, the polymerase chain reaction of cerebral spinal fluid was positive for EBV. The authors highlight the importance of this infection among the differential diagnosis of central nervous system involvement and genital ulceration. Keywords Meningitis, Viral; Epstein-Barr Virus Infections; Ulcer; Genital Diseases.

CASE REPORT A 27-year-old previously healthy man sought the medical facility complaining of a 4-day history of unmeasured fever, low back pain, nausea, vomiting, pulsatile headache, nuchal stiffness, and pain. He denied any skin rashes. He had unprotected sexual intercourse followed by the emergence of painless genital ulcers a week before the onset of the neurological symptoms. He had no history of chronic oral ulcers and autoimmune family disorders. The physical examination revealed blood pressure of 140/80 mmHg, pulse rate of 95 beats per minute, respiratory rate of 22 respiratory movements per minute, room air oximetry of 98%, axillary temperature of 37.2ºC, and nuchal stiffness. Brudzinski’s sign was also present, but a funduscopic examination was not performed. Three clustered,

superficial, clean-based, painless ulcers were present on the balanopreputial sulcus (Figure 1). Kernig or Laségue’s signs were absent and the remaining physical examination was normal. Immediately after the initial laboratory work-up had been collected (Table 1), the cerebrospinal fluid (CSF) examination was performed (Table 2) and the patient was hospitalized. The CSF was turbid and xanthochromic after centrifugation. Based on the laboratory data and the CSF mononuclear pleocytosis with negativity of the Gram stain, the hypothesis of aseptic meningitis was highly considered. The presence of genital ulcers following unprotected sexual intercourse raised the concern of meningitis due to the herpes simplex virus type 2; therefore, intravenous acyclovir 10mg/kg/dose every 8 hours

Internal Medicine Department - Hospital das Clínicas - Universidade de São Paulo - São Paulo/SP – Brazil. Internal Medicine Division - Hospital Universitário - Universidade de São Paulo - São Paulo/SP – Brazil.

Simultaneous genital ulcer and meningitis: a case of EBV infection

Table 1. Initial laboratory work-up Exam

Result

Exam

Result

Hemoglobin

16.1

12.3-15.3 g/dL

ALT

9-36 U/L

Hematocrit

47.5

36.0-45.0%

AST

10-31 U/L

Leukocytes

15730

4.4-11.3 × 103/mm3

ALP

53-128 U/L

Bands

1-5%

γGT

2-30 U/L

Segmented

82.8

45-70%

TP/Albumin

6.8/4.1

6,4-8,3/3,5-5,2 g/dL

Eosinophils

1-4%

Amylase

30-118 U/L

Basophils

0.2

0-2.5%

Lipase

13-60 U/L

Lymphocytes

11.4

18-40%

ESR

0-20mm/h

Monocytes

5.6

2-9%

HIV

Negative

Platelets

339000

150-400 × 103/mm3

HBs antigen

Negative

INR

1.09

1.0

Anti-HBc IgM

Negative

Urea

5-25 mg/dL

Anti-HCV

Negative

Creatinine

0.85

0.4-1.3 mg/dL

VDRL

Negative

CRP <5 <10 mg/L ALP = alkaline phosphatase; ALT = alanine aminotransferase; AST = aspartate aminotransferase; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; γGT = gamma-glutamyl transpeptidase; HBc IgM = hepatitis B core IgM HBs = hepatitis B surface; HCV = hepatitis C virus; HIV = human immunodeficiency virus; INR = international normalized ratio; LDH = lactate dehydrogenase; RV = reference value; TP = total protein; VDRL = venereal disease research laboratory.

Table 2. Cerebrospinal fluid examination Parameter

Result

Parameter

Result

Cells

1621

<5/mm

Gram

Negative

RBC

0/mm

Protein

173.8

18-58 mg/dL

Neutrophil

Occasional

Glucose

*mg/dL

Monocytes

30%

Lactate

41.6

<35 mg/dL

Culture

Negative

Lymphocytes 42 70% * = two-thirds of the serum glucose. RBC = red blood cell.

was prescribed. Serum antinuclear antibodies and immunologic tests for syphilis in serum and CSF were tested, which were negative. The patient experienced severe headache during the first 3 days of hospitalization and required dexamethasone and dipyrone for proper analgesia. After a few days, he experienced relief from his head pain, the meningeal irritation signs ceased, and the genital ulcers healed.

Figure 1. Clustered plain, clean-based ulcers in the balanopreputial sulcus. 46

Acyclovir was discontinued after 14 days of therapy, and he was discharged after the final dose. Three weeks after hospital admission, the CSF polymerase chain reaction was negative for cytomegalovirus, varicella virus, and herpes virus types 1, 2, 6, 7, and 8. However, it was positive for Epstein‑Barr virus (EBV). Autopsy and Case Reports 2016;6(2):45-49

Rahhal H, Nunes JT, Lopes LC, Prokopowitsch AS

DISCUSSION Acute meningitis is the inflammation of the central nervous system (CNS) meninges that occurs less than a week from the initial diagnosis. The clinical course may be catastrophic, demanding prompt investigation and proper treatment to reduce mortality and sequelae; therefore, in the case of a clinical suspicion, a lumbar puncture should be performed and antibiotics started. In this setting, CSF analysis may reveal patterns of cell count, protein, and glucose that might point towards an etiology, and the Gram stain is 60–90% sensitive and has almost 100% specificity to indicate a bacterial infection.1 If there is a lymphocytic pleocytosis with normal glucose, and the Gram stain and the CSF culture are negative, the meningitis is called aseptic.1–3 Aseptic meningitis has diverse etiologies, including virus, fungi, mycobacteria, neoplasia, autoimmune, and drug-associated.3 The main etiology is viral, which typically shows a benign course and prognosis.4 Usually the clinical manifestations reveal an acute or subacute onset and comprise fever, headache, photophobia, and nuchal stiffness.2 Patients sometimes may present with overlapping syndromes of meningoencephalitis or encephalomyelitis.4 As mentioned above, the general characteristics of aseptic meningitis is commonly seen in viral etiologies, which present a mononuclear pleocytosis around 500 cells/mm3, mild protein elevation, and normal to mildly decreased glucose. However, especially in the first few days of disease, pleocytosis may reveal a polymorphonuclear predominance, mimicking bacterial infections.3,5 In the context of viral meningitis, the association of xanthochromia may suggest herpes simplex infection, and most commonly, herpes simplex type 2 is the one associated with meningitis as well as with genital ulcers. Our patient’s CSF characteristics could resemble a bacterial infection due to the pleyocytosis (>1,000 cells/mm 3 ) and the elevated protein concentration. The diagnosis of viral etiology was assumed based on the benign clinical course, the predominance of mononuclear cells, the normal glucose concentration, the negative Gram stain, and the negative bacterial culture. The enterovirus is the most common virus associated with aseptic meningitis, particularly the coxsackieviruses and the echoviruses.1,4,6,7 With the Autopsy and Case Reports 2016;6(2):45-49

improvement of the polymerase chain reactions (PCR) for virus detection, other viral agents have been increasingly reported. In a recent study conducted by Bastos et al.6 in the Western Brazilian Amazon, 165 samples were analyzed and one or more agents were detected in 49 CSF samples. The most common agents included enteroviruses (16 cases) and the EBV (11 cases). 6 A previous similar study, by Dupuis et al.7 in New York, analyzed 2,357 samples of patients who exhibited symptoms of encephalitis or meningitis. Viral etiology was found in 340 of those samples, and, similarly, the most common agents were enteroviruses (129 cases) and EBV (85 cases). On the other hand, a prospective study conducted by Nesher et al.1 at the University of Texas analyzed 323 patients with aseptic meningitis, with 89 etiological confirmations, but only three cases were caused by EBV.1 Similarly, a study by Ory et al.8 in Madrid (Spain) evaluated 340 patients with meningitis, which had 194 evidenced etiologies; among them, three were positive for EBV. These different results may be due to varied PCR methodologies and panels of viral agents. Another possibility is the distinct incidence of each virus in these diverse regions. Development of new methodologies and reduced costs of PCR will make the test more available and provide more numbers to be analyzed in the future. EBV is one of the most common isolated viruses in the adult population.9 Typically, the primary infection occurs in the nasopharyngeal epithelial cells, and after a lytic cycle with viral replication, it remains inactive mainly within the memory B cells, but may also be present in T cells, natural killer cells, macrophages, monocytes, smooth muscle cells, and endothelial cells. 7,9 The EBV genome may express different combinations of nuclear antigens and latent membrane proteins, which may correlate with different patterns of latency.9 The patient described in this case study could have had a latent infection and the reactivation of the virus could have caused both genital ulcers and meningitis, but the presence of genital ulcers associated with the patient’s sexual history raised the possibility of a primary infection by sexual transmission. EBV can be found in immune system cells in a chronic phase, and is the most frequent herpesvirus 47

Simultaneous genital ulcer and meningitis: a case of EBV infection

found in association with other microorganisms in the CNS, which may raise doubts of its causative association with CNS disease.7 Despite this uncertainty, EBV has been associated with different manifestations in the CNS, including meningitis, encephalitis, acute cerebellar ataxia, myelitis, acute disseminated encephalomyelitis, and vasculopathy.10,11 Dermatologic manifestations of EBV infection are also diverse and include infectious mononucleosis, papular acrodermatitis of childhood (Gianotti–Crosti syndrome), hypersensitivity to mosquito bites, oral hair leukoplakia, histiocytic necrotizing lymphadenitis (Kikuchi–Fujimoto syndrome), hydroa vacciniforme, and genital ulcers.9,12,13 The reactive non-sexually related acute genital ulcers (NSRAGU), also known as Lipschütz ulcers, are typically acute, painful ulcers, with a clean or fibrinous base, and are commonly found in young women and adolescents. It was first described in 1913 by Lipschütz, and since then diverse agents have been related to these ulcers, with EBV predominance.9,12,13 EBV genital ulceration and its association with sexual activity is theme of speculation by some authors, but there is evidence in the literature to suggest that it may occur even without direct genital exposition to the virus.13-16 Genital ulceration may occur by a cytotoxic immune response to the virus, immune complex deposition (type III hypersensitivity), or direct cytolysis by EBV replication in the keratinocytes. 9,13 NSRAGU is a self-limited condition that resolves in 2–6 weeks without scarring, and requires only symptomatic treatment. The patient described herein had recent unprotected sexual intercourse, and presented genital ulcers in the week prior to the presenting neurological symptoms, which raised the concern of herpes simplex virus type 2 as the causative agent, as well as syphilis. The absence of pain—a typical finding in NSRAGU—makes the ulcer presentation atypical. In spite of this, we concluded that the genital lesions were NSRAGU‑like. Simultaneous genital lesions and meningitis raised the concern of herpes simplex type 2 infection and Behçet’s disease. The herpes simplex type 2 infection causes painful vesicular or ulcerative 48

genital lesions that aggregate and have clean-based, erythematous borders. 17 Patients may describe previous or concurrent lesions with the symptoms of meningitis.17 The herpes simplex type 2 CNS infection may have a distinct course of a benign recurrent meningitis, called Mollaret’s meningitis.18 Behçet’s disease is a systemic autoinflammatory vasculitis that causes frequent oral and/or genital ulcers, cutaneous lesions, ocular manifestations (typically, uveitis), and aseptic meningitis.19 As a systemic vasculitis, it may also affect other organs. Since the clinical history and physical examination did not suggest any specific cause, and the laboratory findings ruled out other etiological agents, we concluded, after the positive PCR in the CSF, that our patient had an EBV infection resulting in meningitis. Also, we dare consider the painless genital ulceration as the initial infection, although we cannot consistently affirm that the genital ulcer was associated with EBV since the presence of this agent was not demonstrated from the genital ulcer. Once the CSF EBV-PCR result was available, the genital lesions had already vanished, which hampered the research. Currently, more epidemiological studies are needed to understand the role of each viral agent in the clinical setting of aseptic meningitis. In addition, it was not fully understood how to investigate those patients in the scenario of advanced PCR techniques.1 This case report illustrates the role of EBV infection in cases of CNS infections and genital ulcers.

REFERENCES 1. Nesher L, Hadi CM, Salazar L, et al. Epidemiology of meningitis with a negative CSF Gram stain: underutilization of available diagnostic tests. Epidemiol Infect. 2016;1(01):189-97. http://dx.doi.org/10.1017/ S0950268815000850. PMid:25989841. 2. Oteo JA. Meningitis aséptica aguda: muchas causas a considerar. Oteo, JA. Enferm Infecc Microbiol Clin. 2012;30(7):359-60. http://dx.doi.org/10.1016/j. eimc.2012.05.004. PMid:22763113. 3. Lee BE, Davies HD. Aseptic meningitis. Curr Opin Infect Dis. 2007;20(3):272-7. http://dx.doi.org/10.1097/ QCO.0b013e3280ad4672. PMid:17471037. 4. Irani DN. Aseptic meningitis and viral myelitis. Neurol Clin. 2008;26(3):635-55, vii-viii. http://dx.doi.org/10.1016/j. ncl.2008.03.003. PMid:18657719. Autopsy and Case Reports 2016;6(2):45-49

Rahhal H, Nunes JT, Lopes LC, Prokopowitsch AS

5. Seehuse DA, Reeves MM, Formin DA. Cerebrospinal fluid analysis. Am Fam Physician. 2003;68(6):1103-8. PMid:14524396. 6. Bastos MS, Lessa N, Naveca FG, et al. Detection of Herpesvirus, Enterovirus, and Arbovirus infection in patients with suspected central nervous system viral infection in the Western Brazilian Amazon. J Med Virol. 2014;86(9):1522-7. http://dx.doi.org/10.1002/ jmv.23953. PMid:24760682. 7. Dupuis M, Hull R, Wang H, et al. Molecular detection of viral causes of encephalitis and meningitis in New York State. J Med Virol. 2011;83(12):2172-81. http://dx.doi. org/10.1002/jmv.22169. PMid:22012726. 8. Ory F, Avellón A, Echevarría JE, et al. Viral infections of the central nervous system in Spain: a prospective study. J Med Virol. 2013;85(3):554-62. http://dx.doi.org/10.1002/ jmv.23470. PMid:23239485. 9. Hall LD, Eminger LA, Hesterman KS, Heymann WR. Epstein-Barr virus: dermatologic associations and implications: part I. Mucocutaneous manifestations of Epstein-Barr virus and nonmalignant disorders. J Am Acad Dermatol. 2015;72(1):1-19, quiz 19-20. http://dx.doi. org/10.1016/j.jaad.2014.07.034. PMid:25497917. 10. Fujimoto H, Asaoka K, Imaizumi T, Ayabe M, Shoji H, Kaji M. Epstein-Barr virus infections of the central nervous system. Intern Med. 2003;42(1):33-40. http://dx.doi. org/10.2169/internalmedicine.42.33. PMid:12583615. 11. Patil AK, Azad ZR, Mathew V, Alexander M. Chronic meningitis and central nervous system vasculopathy related to Epstein Barr vírus. Ann Indian Acad Neurol. 2012;15(4):303-6. http://dx.doi.org/10.4103/09722327.104342. PMid:23349599.

12. Brinca A, Canelas MM, Carvalho MJ, Vieira R, Figueiredo A. Lipschütz ulcer (ulcus vulvae acutum) – a rare cause of genital lesion. An Bras Dermatol. 2012;87(4):622-4. http://dx.doi.org/10.1590/S0365-05962012000400018. PMid:22892780. 13. Haidari G, MacMahon E, Tong CY, White JA. Genital ulcers: it is not always simplex. Int J STD AIDS. 2015;26(1):723. http://dx.doi.org/10.1177/0956462414541241. PMid:24970475. 14. Pagano JS. Is Epstein-Barr virus transmitted sexually? J Infect Dis. 2007;195(4):469-70. http://dx.doi. org/10.1086/510861. PMid:17230404. 15. Taylor S, Drake SM, Dedicoat M, Wood MJ. Genital ulcers associated with acute Epstein-Barr virus infection. Sex Transm Infect. 1998;74(4):296-7. http://dx.doi. org/10.1136/sti.74.4.296. PMid:9924475. 16. Halvorsen JA, Breviq T, Aas T, Skar AG, Slevolden EM, Moi H. Genital ulcers as initial manifestation of EpsteinBarr virus infection: two new cases and a review of the literature. Acta Derm Venereol. 2006;86(5):439-42. http:// dx.doi.org/10.2340/00015555-0140. PMid:16955191. 17. Miller S, Mateen FJ, Aksamit AJ Jr. Herpes simplex virus 2 meningitis: a retrospective cohort study. J Neurovirol. 2013;19(2):166-71. http://dx.doi.org/10.1007/s13365013-0158-x. PMid:23494382. 18. Farazmand P, Woolley PD, Kinghorn GR. Mollaret’s meningitis and herpes simplex virus type 2 infections. Int STD AIDS. 2011;22(6):306-7. http://dx.doi.org/10.1258/ ijsa.2010.010405. PMid:21680663. 19. Al-Araji A, Kidd DP. Neuro-Behçet’s disease: epidemiology, clinical characteristics, and management. Lancet Neurol. 2009;8(2):192-204. http://dx.doi.org/10.1016/S14744422(09)70015-8. PMid:19161910.

Conflict of interest: None Submitted on: August 18th, 2015 Accepted on: March 14th, 2016 Correspondence Hassan Rahhal Internal Medicine Department - Hospital das Clínicas - Universidade de São Paulo (USP) Av. Dr. Enéas Carvalho de Aguiar, 155, 8th floor – São Paulo/SP – Brazil CEP: 05403-000 Phone: +55 (11) 2661-6300 E-mail: hassan.r@hc.fm.usp.br

Autopsy and Case Reports 2016;6(2):45-49

Article / Clinical Case Report

Extensive epidermoid cyst of the submental region Estevam Rubens Utumia, Juliane Pirágine Araujob, Irineu Gregnanin Pedrona, Frederico Yonezakic, Gustavo Grothe Machadoc, André Caroli Rochac Utumi ER, Araujo JP, Pedron IG, Yonezaki F, Machado GG, Rocha AC. Extensive epidermoid cyst of the submental region. Autopsy Case Rep [Internet]. 2016;6(2):51-54. http://dx.doi.org/10.4322/acr.2016.031

ABSTRACT Epidermoid cysts are malformations that are rarely observed in the submental region. Imaging has an important role in surgical planning according to the size and location of the cyst in relation to geniohyoid and mylohyoid muscles. This article reports the case of a 15-year-old female patient complaining of submental swelling. The differential diagnosis included infection, tumor, ranula, and abnormalities during embryonic development. The lesion was surgically excised using an extra-oral approach. The histopathological examination revealed a cyst wall lined with stratified squamous epithelium with the presence of several horny scales consistent with the diagnosis of an epidermoid cyst. No recurrences were found after 1 year of follow-up. Keywords Epidermal cyst; Pathology, Oral; Cysts

INTRODUCTION Epidermoid cysts represent 1.6-6.9% of the cysts affecting the head and neck, and less than 0.01% of cases of oral cysts.1,2 Oral epidermoid cysts occur most commonly in the midline of the mouth floor, above or below the geniohyoid muscle, although they can be found laterally as well. Lowry et al.3 classified dermoid and epidermoid cysts in the mouth floor anatomically as sublingual, geniohyoid, or lateral. Epidermoid cysts are usually asymptomatic and may reach extensive sizes before diagnosis. 4,5 Symptoms caused by oral cysts depend on their location and include dysphagia, dysarthria, and breathing difficulty.4-7 Cysts are classified histologically as: (i) epidermoid (lined with epithelium and derived from epidermal and

connective tissue); (ii) dermoid (with a cavity lined with a similar epithelium and containing structures such as sebaceous and sweat glands as well as hair follicles in the underlying connective tissue); and (iii) teratoma (with a cavity lined by epithelium and containing derivatives of the endoderm and mesoderm, such as muscle, intestinal mucosa, respiratory mucosa, bone, blood vessels, and appendages, which are typical of a dermal dermoid cyst).3,8 Overall, epidermoid cysts are the most frequently found type.1,3,5,8 Complete surgical excision is the treatment of choice, and recurrence is uncommon. The location and size of the oral lesions determine the indication for intra- or extra-oral access.6,9,10 The aim of this study

Division of Dentistry - Oral and Maxillofacial Clinical Surgery - Brazilian Air Force Hospital, São Paulo/SP – Brazil. Stomatology Department - School of Dentistry - Universidade de São Paulo, São Paulo/SP – Brazil. c Department of Oral and Maxillofacial Surgery - Hospital das Clínicas - Universidade de São Paulo, São Paulo/SP – Brazil. a

Extensive epidermoid cyst of the submental region

is to present the case of an extensive epidermoid cyst located in the mouth floor, expanding to the submental area, which was surgically removed. Clinical, radiographic, histopathological, and therapeutic modalities are also discussed.

CASE REPORT A 15-year-old Caucasian female presented with the chief complaint of swelling in the submental region that had developed over the last 6 months. Extra-oral examination showed a bulging mass in the submental region causing facial asymmetry. On palpation, the lesion was painless, mobile, and with a resilient

consistency. The overlying skin was intact and normal (Figure 1A). The regional lymph nodes were not involved. Intra-oral examination revealed the presence of all teeth, as well as intact mucosa without any signs of change in the mouth floor. Computed tomography (CT) showed a well‑defined and low-attenuation lesion that contained granular hyperattenuating images in the submental region, which was consistent with a cystic lesion (Figure 1B). Surgical excision with extra-oral access was carried out (Figure 2A) without disruption of the tumor’s capsule. The lesion measured approximately 45 mm at its longest axis, and contained a whitish fluid with the presence of tiny yellowish granules (Figure 2B). The histology showed a cystic lesion, the wall of which

Figure 1. A - Preoperative frontal view showing swelling of the submental region; B - Computed tomography of the neck showing a cystic lesion filled with contents of different attenuations.

Figure 2. A - Intraoperative panoramic view of the tumor; B - Gross examination of the tumor after incision of the capsule, showing drainage of a granular, yellowish fluid. 52

Autopsy and Case Reports 2016;6(2):51-54

Utumi ER, Araujo JP, Pedron IG, Yonezaki F, Machado GG, Rocha AC

was lined by a squamous epithelium with the presence of several horny scales, supported by a fibrous wall of dense connective tissue consistent with the diagnosis of an epidermoid cyst (Figure 3). The outcome was uneventful and no signs of recurrence during the 1 year follow-up was observed. The facial contours became aesthetically normal.

DISCUSSION Epidermoid cysts are rare in the mouth floor and their etiology is still unknown. 1,4,6,8,11,12 Many hypotheses have tried to explain their development; the most accepted one is that they result from ectodermal tissue sequestration of the first and second branchial arches during fetal development.1,6,8 Males are more commonly affected by oral epidermal cysts than females (ratio of 3:1).13 Usually, the lesion is located above the mylohyoid muscle.4,8 However, in the current report, the lesion presented below this muscle as evidenced by clinical and imaging findings as well as surgical findings. The submental location caused swelling, giving the clinical appearance of a “double chin”.4 Impaired speech and troublesome eating are also common complaints in cases of cysts in the same location.4,5,7

The differential diagnosis included infection (odontogenic abscess), tumor (lipoma), mucus extravasation, and abnormal anatomical growth during embryonic development.1,6,7 In this case, infection was ruled out because of the lack of pain, inflammatory signs, and intra-oral infectious focus. A neoplastic hypothesis was not considered because of the clinical and radiographic findings. The keratinized material found in the cystic fluid aspirated in this case eliminated the possibility of ranula, as reported in the literature, with these characteristics.6,12 Although the diagnosis of these lesions requires histopathological examination, imaging exams are useful as a complementary tool providing the tumor’s precise location and its relation with adjacent structures, thereby aiding the surgical planning.14 In our case, the CT showed an apparently homogeneous unilocular cystic lesion, which was different from a ranula that radiates pain, and may cross the midline.15 Cysts located below the geniohyoid muscle, as in the current case, are usually treated by excision with extra-oral access.6,8 In cases located above this muscle, intra-oral access under local anesthesia is sufficient, and provides esthetic and functional results. 7,13,16 Marsupialization has been proposed as an alternative treatment in cases of extensive cysts.15 The prognosis after surgical excision is good and recurrence is uncommon. Malignant transformation of epidermoid cysts is rare, but has been reported.1,4,17 In the present case, the patient had no recurrence after 1 year of postoperative follow-up. Epidermoid cysts, although rare, do occur in the mouth floor; when their presentation form is typical, the diagnostic suspicion is based on clinical features and imaging exams, which are sufficient for the appropriate therapeutic approach.

REFERENCES

Figure 3. Photomicrograph of the cyst wall showing a stratified squamous epithelium with the presence of several horny scales, supported by a fibrous wall of dense connective tissue, associated with nonspecific chronic inflammatory processes (H&E, 200X). Autopsy and Case Reports 2016;6(2):51-54

1. Ozan F, Polat HB, Ay S, Goze F. Epidermoid cyst of the buccal mucosa: a case report. J Contemp Dent Pract. 2007;8(3):90-6. PMid:17351686. 2. De Ponte FS, Brunelli A, Marchetti E, Bottini DJ. Sublingual epidermoid cyst. J Craniofac Surg. 2002;13(2):308-10. http://dx.doi.org/10.1097/00001665-200203000-00024. PMid:12000893. 53

Extensive epidermoid cyst of the submental region

3. Lowry RE, Tempero RM, Davis LF. Epidermoid cyst of the floor of the mouth. J Oral Surg. 1979;37(4):271-3. PMid:285233.

11. Koca H, Seckin T, Sipahi A, Kazanc A. Epidermoid cyst on the floor of the mouth: report of a case. Quintessence Int. 2007;38(6):473-7. PMid:17625630.

4. Waldron CA. Cistos do desenvolvimento. In: Neville BW, Damm DD, Allen CM, Boutquot JE. Palotogia oral e maxilofacial. 2nd ed. Rio de Janeiro: Guanabara Koogan; 2004. p. 24-36.

12. Seah TE, Sufyan W, Singh B. Case report of a dermoid cyst at the floor of the mouth. Ann Acad Med Singapore. 2004;33(4, Suppl):S77-9. PMid:15389314.

5. Jham BC, Duraes GV, Jham AC, Santos CR. Epidermoid cyst of the floor of the mouth: a case report. J Can Dent Assoc. 2007;73(6):525-8. PMid:17672959. 6. Akao I, Nobukiyo S, Kobayashi T, Kikuchi H, Koizuka I. A case of large dermoid cyst in the floor of the mouth. Auris Nasus Larynx. 2003;30(Suppl):S137-9. http://dx.doi. org/10.1016/S0385-8146(02)00121-9. PMid:12543180. 7. Louis PJ, Hudson C, Reddi S. Lesion of the floor of the mouth. J Oral Maxillofac Surg. 2002;60(7):804-7. http:// dx.doi.org/10.1053/joms.2002.33250. PMid:12089697. 8. Calderon S, Kaplan I. Concomitant sublingual and submental epidermoid cysts: a case report. J Oral Maxillofac Surg. 1993;51(7):790-2. http://dx.doi. org/10.1016/S0278-2391(10)80425-2. PMid:8509922.

13. Longo F, Maremonti P, Mangone GM, De Maria G, Califano L. Midline (dermoid) cysts of the floor of the mouth: report of 16 cases and review of surgical techniques. Plast Reconstr Surg. 2003;112(6):1560-5. http:// dx.doi.org/10.1097/01.PRS.0000086735.56187.22. PMid:14578785. 14. Mirza S, Fadi S, Napaki S, Abualruz A. Case report of complicated epidermoid cyst of the floor of the mouth: radiology-hystopathology correlation. Qatar Medical Journal. 2014:12-6. 15. Souza RP, Paes AJOP Jr, Volpato R. O espaço sublingual. Rev Radiol Bras. 2003;36(1):35-40. http://dx.doi. org/10.1590/S0100-39842003000100009.

9. Lima SM Jr, Chrcanovic BR, Paula AM, Freire-Maia B, Souza LN. Dermoid cyst of the floor of the mouth. ScientificWorldJournal. 2003;3:156-62. http://dx.doi. org/10.1100/tsw.2003.04. PMid:12806127.

16. Verma S, Kushwaha JK, Sonkar AA, Kumar R, Gupta R. Giant sublingual epidermoid cyst resembling plunging ranula. Natl J Maxillofac Surg. 2012;3(2):2113. http://dx.doi.org/10.4103/0975-5950.111386. PMid:23833501.

10. Santiago Juan C, Pellicer Soria M, Ramos Asensio R, et al. Dermoid cyst of the floor of the mouth: a case report. An Otorrinolaringol Ibero Am. 2002;29(2):181-6. PMid:12053513.

17. Yalmaz I, Yilmazer C, Yavuz H, Bal N, Ozluoglu LN. Giant sublingual epidermoid cyst: a case report of two cases. J Laryngol Otol. 2006;120(3):E19. http://dx.doi. org/10.1017/S0022215106009194. PMid:16917995.

Conflict of interest: None Submitted on: December 9th, 2015 Accepted on: April 14th, 2016 Correspondence André Caroli Rocha Department of Oral and Maxillofacial Surgery - Hospital das Clínicas - Universidade de São Paulo (USP) Av. Dr. Enéas de Carvalho Aguiar, 255 – Cerqueira César – São Paulo/SP – Brazil CEP: 05403-001 Phone: +55 (11) 2661-6393 E-mail: andcaroli@uol.com.br

Autopsy and Case Reports 2016;6(2):51-54

Article / Clinical Case Report

Inner tubing technique used for the treatment of anastomotic aneurism Márcio Teodoro da Costa Gaspara, Bruno Vinicius Hortences de Mattosb, Milena Cristina Dias Sofiac, Grace Carvajal Mulattic, Alex Ledermanc Gaspar MTC, Mattos BVH, Sofia MCD, Mulatti GC, Lederman A. Inner tubing technique used for the treatment of anastomotic aneurism. Autopsy Case Rep [Internet]. 2016;6(2):55-58. http://dx.doi.org/10.4322/acr.2016.032

Abstract The authors report the case of a 66-year-old male patient diagnosed with a pseudoaneurysm of the distal aorto-aortic anastomosis treated with the inner tubing technique. The patient had been operated on 1 year before when he had an aortic prosthesis implanted as treatment for a ruptured abdominal aortic aneurysm. The inner tubing technique was developed to facilitate the treatment in bifurcated vascular lesions, where endovascular conventional prosthesis is not available. Keywords Aortic Aneurysm, Abdominal; Endovascular Procedures

CASE REPORT A 66-year-old male patient—an ex-smoker— who was previously diagnosed with hypertension, dyslipidemia, non-dialytic chronic renal failure, and benign prostate hyperplasia was admitted to the emergency facility with the diagnosis of a juxtarenal abdominal aortic aneurysm rupture. He was submitted to a thoraco-phreno-laparotomy followed by aneurysmectomy and aorto-aortic Dacron prosthesis insertion. Within the first 24 hours of the postoperative period, mesenteric ischemia and abdominal compartment syndrome ensued, which required an extensive enterectomy involving the small bowel until 1.7 m of the Treitz angle, accompanied by proximal enterostomy, distal stump burial, and Bogotá bag peritoneostomy. The abdominal cavity was closed

after two revisions. On the twentieth postoperative day, after the last surgical procedure, right lower limb ischemia, caused by decompensated chronic arterial occlusion, required transtibial amputation. The patient was discharged after 55 days of hospitalization. Nearly 1 year after these procedures, he was hospitalized for reconstruction of the intestinal transit and incisional hernioplasty with preperitoneal Marlex mesh. A pseudoaneurysm of the distal aorto-aortic anastomosis was diagnosed by a Doppler ultrasound performed during the 1-year follow-up, which was confirmed by a non-contrasted abdominal computed tomography (CT). The latter detected an infrarenal fusiform aneurysm emerging 8 cm below the renal arteries and extending until the emergence of the iliac

Surgery Department - Clinica Multiperfil – Luanda – Angola. Surgery Department - Faculty of Medicine - Universidade de São Paulo - São Paulo/SP – Brazil. c Surgery Division - Hospital Universitário - Universidade de São Paulo - São Paulo/SP – Brazil. a

Inner tubing technique used for the treatment of anastomotic aneurism

arteries (7.3 cm in length and 6.1 cm in diameter). An eccentric thrombus and parietal calcifications were present, and a saccular component (3.7 cm in length and 3.7 cm in diameter) extended until the right common iliac artery, as shown in (Figure 1). In light of the imaging findings and clinical data, some therapeutic options were considered, namely: (i) inner tubing or sandwich; (ii) multilayer flow modulator; (iii) aortomonoiliac endografting plus femorofemoral crossover bypass graft; and (iv) open surgery. However, taking into account the multiple previous surgical interventions, the vascular surgeons chose the inner tubing technique, which was performed as follows: (i) a bilateral inguinotomy with isolation of the common, the internal, and the external femoral arteries; (ii) systemic heparinization; (iii) an arteriography identifying the distal prosthesis, and the common internal and external iliac arteries; (iii) the insertion of bilateral rigid guidewire; (iv) a Viabahn endoprostesis kissing placement (13 × 100 left;

10 × 150 right); (v) a control arteriography (a small endoleak on the left side was detected but blood flow was satisfactorily obtained on both sides); (vi) arterial suture with 5-0 prolene; and (vii) suture of the inguinotomies. The procedure was uneventful, without the need for hemoderivatives transfusion. The patient was fed orally on the first postoperative day and was discharged on the second day. Perfusion was promptly fully re-established, which was assured on the ambulatory follow-up by clinical examination. A control CT was done 1 month after the procedure (Figure 2).

DISCUSSION Endovascular treatment of aneurysms represents, beyond question, a great deal of movement in vascular surgery. In the treatment of patients with increasingly severe conditions, the improvement of prostheses and refinement of the endovascular

Figure 1. Computed tomography of the abdomen. A - Coronal plane; and B - sagittal plane, showing an aortic aneurysm at the site of the distal aorto-aortic anastomosis. 56

Autopsy and Case Reports 2016;6(2):55-58

Gaspar MTC, Mattos BVH, Sofia MCD, Mulatti GC, Lederman A

Figure 2. Computed tomography of the abdomen performed three months after the procedure. A - 3D reformation; and B - coronal plane; patency of the endoprosthesis in the iliac arteries position.

techniques are accompanied by encouraging results1. Several techniques are available for the treatment of aneurysms 2,3,4, but in the case reported herein the inner tubing technique was chosen, which was developed for bifurcation lesions where conventional vascular endoprosthesis are unavailable or the anatomy does not fit the available endoprosthesis 5. The aortomonnoiliac endovascular grafting technique would be, indeed, an adequate procedure for this case, but it would involve a higher surgical risk and the requirement of an aortic endoprosthesis that was unavailable in our service. Thus, a straight stent was set in place to create a “proximal neck,” followed by the insertion (within the first stent) of two other parallel stents using the “kissing” maneuver plotting up a branch in each artery bifurcation5. In our patient, since the previous inserted prosthesis was in the aortic position, it was only necessary to complete the technique by deploying the iliac extensions bilaterally. The first prosthesis served as the basis for fixing the new iliac branches. This technique, besides the preservation of vascular bifurcations,5 presents the following advantages: (i) the use of easily available, off-the-shelf, covered stents without the need for individualized customization; (ii) a full approach by inguinotomy without the need for a laparotomy in a previously operated abdomen; (iii) the preservation of two iliac arteries without the necessity of the performance of an aortic-monoiliac graft associated with a femorofemoral crossover bypass; (iv) the preservation of the hypogastric arteries; (v) reduced hospitalization time; and (vi) reduced time of anesthesia. On the other hand, the main early- and Autopsy and Case Reports 2016;6(2):55-58

mid-term complication of any endovascular procedure/ treatment is represented by the proximal and distal endoleaks. In our case, the proximal endoleak was prevented by using an endoprosthesis gauge adapted to fill the whole lumen of the first prosthesis (confirmed by the control image). The distal leak was resolved by the aneurysm remodeling since the endoprostheses were well located into the iliac arteries. The occlusion of an endoprosthesis is another possible complication of this chosen technique. However, the control CT showed an adequate blood flow and the absence of kinking in the endoprostheses. The inner tubing technique seems to be a viable therapeutic option accompanied by a promising outcome, besides being a minimally invasive method for the correction of complex lesions in high-risk patients with a hostile abdomen.5 Larger studies and longer follow-up are still needed to assure promising results in other cases.

REFERENCES 1. Sakalihasan N, Limet R, Defawe OD. Abdominal aortic aneurysm. Lancet. 2005;365(9470):1577-89. http://dx.doi.org/10.1016/S0140-6736(05)66459-8. PMid:15866312. 2. Kafejian O, Ricci JA, Nem JT Jr, Roberti T, Bolanho E. Aneurisma de aorta abdominal: diagnóstico, tratamento cirúrgico e resultados. Cir Vasc Ang. 1988;4:8-15. 3. Novero ER, Metzger PB, Angelieri FMR, et al. Correção endovascular do aneurisma da aorta abdominal: análise dos resultados de único centro. Radiol Bras. 2012;45(1):1-6. http://dx.doi.org/10.1590/S010039842012000100003. 57

Inner tubing technique used for the treatment of anastomotic aneurism

4. Araujo AG, Souza FHR, Fernandes FH, Barbosa FP, Jatene JA, Câmara PCG. Tratamento endovascular de aneurisma de aorta abdominal pela técnica de Chaminé. Rev Bras Cardiol Invasiva. 2014;22(4):386-9. http://dx.doi. org/10.1590/0104-1843000000065.

5. Lederman A, Saliture FT No, Mioto B No, Bub GL, Lobato MA, Aun R. Inner tubing endograft: a new technique for bifurcation preservation. J Vasc Bras. 2009;8(3):255-8. http://dx.doi.org/10.1590/S167754492009005000013.

Conflict of interest: None Submitted on: January 5th, 2016 Accepted on: March 31st, 2016 Correspondence Márcio Teodoro da Costa Gaspar Hospital Universitário - Universidade de São Paulo (USP) Av. Prof. Lineu Prestes, 2565, Butantã, São Paulo/SP – Brazil CEP: 05508-000 Phone: +55 (11) 94836-3866 E-mail: marcio85gaspar@gmail.com

Autopsy and Case Reports 2016;6(2):55-58