Autopsy & Case Report by Editora Cubo

ISSN 2236-1960

v. 6, n. 4, oct./dec. 2016

Photomicrography of the biopsy of the maxilla showing diffuse inflammatory infiltrate, rich in xanthomatous macrophages and evident lymphocytes emperipolesis (H&E 200X) in a case of Rosai-Dorfman disease.

Hospital Universitรกrio Universidade de Sรฃo Paulo

ISSN 2236-1960 December 2016, volume 6 number 4

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 Alex K Williamson, MD Key colaborator Gabriel Nuncio Benevides, MD Support Team 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

The autopsy as the cornerstone for education and research in cardiology Vera Demarchi Aielloa Aiello VD. The autopsy as the cornerstone for education and research in cardiology. [editorial]. Autopsy Case Rep [Internet]. 2016;6(4):1-3. http://dx.doi.org/10.4322/acr.2016.055

In the era of advanced techniques of medical imaging, it is becoming increasingly difficult to support the role of the traditional autopsy in the diagnosis of diseases, including those of the cardiovascular system. But for those devoted to the study of cardiovascular pathology there is no doubt about the quantity and quality of information that autopsies can provide other than the gross evaluation of the heart and vessels. Two examples of such important contribution became evident from the analysis of two cases published in the current issue of Autopsy & Case Reports. 1,2 The two of them had an inflammatory commitment of the myocardium as the main condition leading to death. One case probably represents a viral myocarditis in a child and the other a complication of drug intake in the form of hypersensitivity myocarditis. On both occasions, the careful gross and histological postmortem examinations of the heart were fundamental to the understanding of the patients’ evolution and correlation with the clinical findings. They brought also relevant contribution to the education of the clinical teams about the possible recognition of the primary myocardial diseases prior to death and on how to manage the patients. Presently, there is no substitute for autopsy when we consider the precise sampling of lesions, especially in the heart, which topographic anatomy requires full understanding of the intrinsic morphology of subsystems like valves, coronary arterial system and specialized tissues for the conduction of the

electrical stimulus. Regardless of the high resolution of cardiovascular imaging and even the possibility of 3-dimensional printing of hearts from the magnetic resonance or computerized tomography images, the direct examination of the anatomical specimens is still the gold standard. While, nowadays, virtual histology is just a promising method of image analysis, new conditions and diseases are continuously being described based on the detailed microscopic examination of vessel walls and the myocardium. A good example of such discovery is the recent recognition of medium-sized and large vessels involvement in the so-called IgG4 related diseases. A careful study of an obstructed coronary artery in a case originally attributed to ordinary coronary atherosclerosis, gives the perspective of a systemic disease to be looked for in selected cases as described by Gutierrez et al.3 The impact of autopsy in education deserves to be discussed in detail. Not just the immediate correlation obtained from the cases clinically studied, but also the analysis of stored specimens is essential in de education of clinicians, surgeons, imaging professionals and pathologists. In a tertiary Cardiology center and University hospital, a study aimed at analyzing the discrepancy between clinical and autopsy diagnoses 4 depicted a concordance rate of 71.1% for acute myocardial infarction, 75% for aortic dissection, 73.1% for infective endocarditis and 35.2% for pulmonary embolism.

Laboratory of Pathology - Heart Institute - School 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 the article is properly cited.

The autopsy as the cornerstone for education and research in cardiology

Considering a previously published categorization, 5 major discrepancies that were not clinically identified and having potential adverse effect on survival were found in 30% of the cases. It is unequivocal the value of such findings when we consider that residents and doctors in training were able to learn from the discrepancies detected. Another study investigated the role of the autopsy in the modern undergraduate medical curriculum in the United Kingdom, based on interviews with medical educators. Along with the discussion about the pros and cons of autopsy during medical education, it was generally felt that students should be exposed to autopsies, but the interviewees provided alternatives such as video-conferences, demonstrations and the study of museum specimens.6 In this regard, tribute has to be paid to the great pioneer of education in Cardiology, Dr. Maude Abbott, one of the first women to attend McGill University in Canada, who worked in the early 1900s. She devoted herself to the study and categorization of congenitally malformed hearts but, more importantly, organized in 1906 the International Association of Medical Museums.7 Her demonstrations of malformed hearts together with her didactical drawings and efforts to correlate with the existing methods of diagnosis called the attention of the international community and inspired doctors to study the congenital heart defects. Since then, demonstration of anatomical specimens has been an essential tool in the education of pediatric cardiologists and cardiac surgeons. In 2007, we tried to answer the question about the role of cardiac autopsy in the recent years and also the reasons for the decline in their numbers over the time.8 We recognized that autopsy may be considered expensive and that hospital administrators must be convinced that information obtained from autopsies improves the quality of health care. Moreover, we acknowledged the value of the existing anatomical archives all over the world for the purpose of education and research in Cardiology. In fact, in a recent publication, the need to maintain and preserve such precious specimens through three-dimensional digital imaging was stressed by the International Society for Nomenclature of Paediatric and Congenital Heart Disease.9 Using technologies of scanning and three‑dimensional printing it is now possible to produce replicas of the original specimens. These 2

techniques are of course also available for the study of living patients, but the grounds for the understanding of heart morphology and of precise image processing, at this moment continue to come from the experience obtained with anatomical specimens. It is impressive to recognize how the recent advances in imaging can allow us to observe structures of the heart which up to know were exclusively examined by histology. An example is the very recent publication by Shinohara et al, showing the structure and course of the cardiac conduction atrioventricular axis after the imaging of anatomical specimens by the technique of High-Resolution Phase-Contrast Computerized Tomography.10 This new development has come a long way, but has farther yet to go, and surely will depend on the correlation with histological findings. Finally, a word about the “minimally invasive autopsy”, 11 a resource that combines imaging technologies with minimal histological sampling: it is probably the goal to be sought by both pathologists and imaging professionals. Perhaps for the cardiovascular system, especially for the heart as previously explained and based on its complex three-dimensional structure, this combination of techniques will not reach excellence as for the solid organs in a short period of time. But it will be certainly achieved, with the fundamental contribution of pathologists and the knowledge harvested from autopsies.

REFERENCES 1. Jedidi M, Tilouche S, Masmoudi T, et al. Infant acute myocarditis mimicking acute myocardial infarction. Autops Case Rep. 2016;6(4):15-19. http://dx.doi. org/10.4322/acr.2016.052. 2. Katta N, Balla S, Aggarwal K. Clozapine-induced hypersensitivity myocarditis presenting as sudden cardiac death. Autops Case Rep. 2016;6(4):9-13. http://dx.doi. org/10.4322/acr.2016.054. 3. Gutierrez PS, Schultz T, Siqueira SA, Borges LF. Sudden coronary death due to IgG4-related disease. Cardiovasc Pathol. 2013;22(6):505-7. PMid:23830124. http://dx.doi. org/10.1016/j.carpath.2013.05.003. 4. Saad R, Yamada AT, Rosa FHP, Gutierrez PS, Mansur AJ. Comparison between clinical and autopsy diagnoses in a cardiology hospital. Heart. 2007;93(11):14149. PMid:17395672. http://dx.doi.org/10.1136/ hrt.2006.103093. Autopsy and Case Reports 2016;6(4):1-3

Aiello VD

5. Battle RM, Pathak D, Humble CG, et al. Factors influencing discrepancies between premortem and postmortem diagnoses. JAMA. 1987;258(3):339-44. PMid:3599326. http://dx.doi.org/10.1001/jama.1987.03400030055031. 6. Burton JL. The autopsy in modern undergraduate medical education: a qualitative study of uses and curriculum considerations. Med Educ. 2003;37(12):1073-81. PMid:14984113. http://dx.doi.org/10.1046/j.13652923.2003.01710.x. 7. Evans WN, Béland MJ. The paediatric cardiology Hall of Fame: Maude Elizabeth Abbott. Cardiol Young. 2010;20(2):124-32. PMid:20405546. http://dx.doi. org/10.1017/S1047951110000119. 8. Aiello VD, Debich-Spicer D, Anderson RH. Is there still a role for cardiac autopsy in 2007? Cardiol Young. 2007;17(S2, Suppl 2):97-103. PMid:18039403. http:// dx.doi.org/10.1017/S1047951107001205.

9. Seslar SP, Shepard CW, Giroud JM, et al. Lost treasures: a plea for the systematic preservation of cadaveric heart specimens through three-dimensional digital imaging. Cardiol Young. 2015;25(8):1457-9. PMid:26675590. http://dx.doi.org/10.1017/S1047951115002589. 10. Shinohara G, Morita K, Hoshino M, et al. Three Dimensional visualization of human cardiac conduction tissue in whole heart specimens by high-resolution phase-contrast CT imaging using synchrotron radiation. World J Pediatr Congenit Heart Surg. 2016;7(6):700-5. PMid:27834761. http://dx.doi.org/10.1177/2150135116675844. 11. Blokker BM, Wagensveld IM, Weustink AC, Oosterhuis JW, Hunink MG. Non-invasive or minimally invasive autopsy compared to conventional autopsy of suspected natural deaths in adults: a systematic review. Eur Radiol. 2016;26(4):1159-79. PMid:26210206. http://dx.doi. org/10.1007/s00330-015-3908-8.

Correspondence Vera Demarchi Aiello Surgical Pathology Section - Laboratory of Pathology - Heart Institute - Hospital das Clínicas - Universidade de São Paulo (USP) Avenida Dr. Enéas Carvalho Aguiar, 44 – São Paulo/SP – Brazil CEP: 05403-000 Phone: +55 (11) 2661-5252 anpvera@incor.usp.br

Autopsy and Case Reports 2016;6(4):1-3

Image in Focus

“Bread and butter” fibrinous pericarditis Pedro Mansueto Melo de Souzaa, Adriele Machado dos Santosa, Eurides Martins Paulinob, Carlos Gustavo Hirtha,c, Conceição Aparecida Dornelasa Souza PMM, Santos AM, Paulino EM, Hirth CG, Dornelas CA. “Bread and butter” fibrinous pericarditis. Autopsy Case Rep [Internet]. 2016;6(4):5-7. http://dx.doi.org/10.4322/acr.2016.050

Image courtesy Dr. Pedro Mansueto Melo de Souza and Dra. Conceição Aparecida Dornelas

Figure 1. Gross view of the block of the thoracic organs showing the anatomic relationship between the lungs with “beefy red consolidation” and the heart recovered by bright yellow fibrin in a “bread and butter” pattern

Department of Pathology and Forensic Medicine - Faculty of Medicine - Universidade Federal do Ceará, Fortaleza/CE – Brazil. Faculty of Medicine of Sobral - Universidade Federal do Ceará, Sobral/CE – Brazil. c Cancer Institute of Ceará, Fortaleza/CE – Brazil. a

“Bread and butter” fibrinous pericarditis

Pericarditis is the inflammatory process involving the pericardium as a result of a systemic disease or a primary pericardium disorder.1 The actual incidence of pericarditis is difficult to ascertain,2 most probably because of under-reported or misdiagnosed cases. In the 19th century, Sir William Osler stated that pericarditis was one of the most serious diseases overlooked by practitioners.3 Even so, the rate of hospitalization by this diagnosis is estimated in 3.32 cases per 100,000 person-years, which corresponds to 0.2% of all causes of hospitalization in cardiology centers,4 with an incidence of 1.06% found in autopsy case series.5 Didactically, pericarditis can be morphologically classified in five types: (i) fibrinous; (ii) serous; (iii) purulent; (iv) hemorrhagic; or (v) caseous. 6 The image presented herein refers to a typical fibrinous pericarditis, also known as “bread and butter” pericarditis.7 In such an entity, the pericardium, which is regularly smooth and bright, becomes opaque and granular, and macroscopically resembles two pieces of buttered bread pressed together then pulled apart. The histology shows the deposition of fibrin and leukocytic exudate involving the pericardial leaflets.8 Antonio Benivieni (1443-1502), a Florentine physician and a contemporary of Leonardo da Vinci, was assigned the first description of fibrinous pericarditis. However, René Laennec (1781-1826), also known for creating the stethoscope, was the first to register the analogy of this type of pericarditis with “buttered bread”9 in his book, A Treatise on the Diseases of the Chest and on Mediate Auscultation.10 The image presented in Figure 1 was obtained during the autopsy of a 25-year-old man who presented a 5-day history of high-grade fever, odynophagia, chest pain, and bloody sputum. He was hospitalized presenting marked leukocytosis with blasts in the peripheral blood smear and died 14 days later due to multiple organ failure. The autopsy revealed fibrinous pericarditis with a brighter yellow exudate than usual (probably due to hyperbilirubinemia, with direct and indirect bilirubin levels of 4.61 mg/dL and 2.07 mg/dL, respectively), lungs with “beefy red consolidation” due to alveolar edema, hemorrhage, hyaline membrane, and diffuse neutrophilic infiltrate. The patient’s bone marrow was hypercellular at the expense of immature myeloid cells with areas of necrosis. The immunohistochemical study evidenced 6

diffuse positivity for myeloperoxidase; CD117-positivity for 30% of the viable cells; CD34-positivity for 1% of the viable cells; and negativity for the terminal deoxynucleotidyl transferase–all of which were consistent with the diagnosis of M3 acute myeloid leukemia (French-American-British classification).11 Acute myocardial infarction, trauma/surgery, infection, uremia, systemic diseases, and neoplasia are among the most common causes of fibrinous pericarditis. Among the neoplasia, lung and breast malignancies stand out, followed by lymphomas and leukemia,12 although pericardial infiltration by nonlymphocytic leukemia is rarer.13 In a large case series of 420 postmortem examinations of the heart in acute leukemia,14 only 20 patients had symptoms of heart disease in life, and 9 of them had pericarditis at autopsy. In only 2 of the 9 patients, the pericarditis was the result of leukemic cell infiltrates into the pericardium; in 4 patients it was hemorrhagic; and in 2 it was pyogenic. Only 1 case remained with uncertain etiology, being fibrinous and unassociated with pericardial leukemic infiltrates, hemorrhages, or organisms, which also occurred in our case. The histopathologic study of the pericardium failed to reveal neoplastic cells, microorganisms, and viral inclusion; therefore, the precise etiology of the pericardial disease was not disclosed. Keywords: Pericarditis; Leukemia; History of Medicine

REFERENCES 1. Imazio M, Gaita F, LeWinter M. Evaluation and treatment of pericarditis: a systematic review. JAMA. 2015;314(14):1498-506. PMid:26461998. http://dx.doi. org/10.1001/jama.2015.12763. 2. Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet. 2004;9410(363):717-27. PMid:15001332. http://dx.doi. org/10.1016/S0140-6736(04)15648-1. 3. Osler W. The principles and practice of medicine: designed for the use of practitioners and students of medicine. 3th ed. New York: D. Appleton and Company; 1898 [cited 2016 Sept 9]. 694 p. Available from: https:// archive.org/stream/principlespracti00osleuoft 4. Kyto V, Sipila J, Rautava P. Clinical profile and influences on outcomes in patients hospitalized for acute pericarditis. Circulation. 2014;130(18):16016. PMid:25205801. http://dx.doi.org/10.1161/ CIRCULATIONAHA.114.010376. Autopsy and Case Reports 2016;6(4):5-7

Souza PMM, Santos AM, Paulino EM, Hirth CG, Dornelas CA

5. Friman G, Fohlman J. The epidemiology of viral heart disease. Scand J Infect Dis. 1993;88(Suppl):7-10. PMid:8516667. 6. Kumar V, Abbas AK, Aster JC. Robbins & Cotran pathologic basis of disease. 9th ed. Philadelphia: Elsevier Saunders; 2015. 7. Waller BF, Taliercio CP, Howard J, Green F, Orr CM, Slack JD. Morphologic aspects of pericardial heart disease: part II. Clin Cardiol. 1992;15(4):291-8. PMid:1563133. http:// dx.doi.org/10.1002/clc.4960150413. 8. Klatt EC. Robbins & Cotran atlas of pathology. 3rd ed. Philadelphia: Elsevier Saunders; 2015.

11. Bennett JM, Catovsky D, Daniel MT, et al. Proposed revised criteria for the classification of acute myeloid leukemia: a report of the French-American-British Cooperative Group. Ann Intern Med. 1985;103(4):620-5. PMid:3862359. http://dx.doi.org/10.7326/0003-4819103-4-620. 12. Roberts WC. Pericardial heart disease: its morphologic features and its causes. Proc Bayl Univ Med Cent. 2005;18(1):38-55. PMid:16200146.

9. Cohen MB. Cross your heart: some historical comments about fibrinous pericarditis. Hum Pathol. 2004;35(2):1479. PMid:14991530. http://dx.doi.org/10.1016/j. humpath.2003.08.029.

13. Chu J, Demello D, O’Connor DM, Chen S, Gale GB. Pericarditis as presenting manifestation of acute nonlymphocytic leukemia in a young child. Cancer. 1983;52(2):322-4. PMid:6574803. http://dx.doi. org/10.1002/1097-0142(19830715)52:2<322::AIDCNCR2820520222>3.0.CO;2-U.

10. Laennec RTH. A treatise on the diseases of the chest and on mediate auscultation. London: R. Gilbert; 1824 [cited 2016 Aug 2]. 671 p. Available from: https://archive.org/ details/treatiseondiseas1829laen

14. Roberts WC, Bodey GP, Wertlake PT. The heart in acute leukemia: a study of 420 autopsy cases. Am J Cardiol. 1968;21(3):388-412. PMid:4295426. http://dx.doi. org/10.1016/0002-9149(68)90143-4.

Conflict of interest: None Correspondence Pedro Mansueto Melo de Souza Department of Pathology and Forensic Medicine - Faculty of Medicine - Universidade Federal do Ceará (UFC) Rua Monsenhor Furtado, s/n – Rodolfo Teófilo – Fortaleza/CE – Brazil CEP: 60441-750 Phone: +55 (85) 988489581 pedro.mansueto.m.s@gmail.com

Autopsy and Case Reports 2016;6(4):5-7

Article / Autopsy Case Report

Clozapine-induced hypersensitivity myocarditis presenting as sudden cardiac death Natraj Kattaa, Sudarshan Ballaa, Kul Aggarwala Katta N, Balla S, Aggarwal K. Clozapine-induced hypersensitivity myocarditis presenting as sudden cardiac death. Autopsy Case Rep [Internet]. 2016;6(4):9-13. http://dx.doi.org/10.4322/acr.2016.054

ABSTRACT Hypersensitivity myocarditis is a rare but serious adverse effect of clozapine, a commonly used psychiatric drug. We report the case of sudden cardiac death from clozapine-induced hypersensitivity myocarditis diagnosed at autopsy. A 54-year-old Caucasian male on clozapine therapy for bipolar disorder presented with a sudden onset of shortness of breath. Laboratory studies were significant for elevated N-terminal prohormone of brain natriuretic peptide. During his hospital stay, the patient died of sudden cardiac arrest from ventricular tachycardia. The autopsy revealed hypersensitivity myocarditis, which usually occurs in the first 4 weeks after the initiation of clozapine. A 4-week monitoring protocol, including laboratory assessment of troponin and C-reactive protein, may assist in the early diagnosis of this potentially fatal condition. Keywords Clozapine; Hypersensitivity; Myocarditis; Death, Sudden, Cardiac

INTRODUCTION Clozapine, a newer atypical antipsychotic, is often considered as the gold standard therapy in the management of treatment-resistant schizophrenia,1 and has often been used off-label for the treatment of bipolar disorder.2 It is associated with minor adverse effects, such as sedation, weight gain, constipation, urinary incontinence, and severe adverse effects, such as agranulocytosis and seizures.3 Also, clozapine has been associated with an underreported but serious condition known as clozapine-induced hypersensitivity myocarditis (CIHSM). 4-7 Although there are few reported cases of in vivo diagnosis and successful treatment,8-10 unfortunately CIHSM is often diagnosed only by histological examination of an autopsied heart specimen as it can potentially cause sudden cardiac death (SCD). Awareness of this condition,

and understanding the clinical clues and diagnostic methods, may help in the early diagnosis of CIHSM and enable appropriate intervention to prevent SCD.

CASE REPORT The patient was a 54-year-old Caucasian male with a history of anxiety, bipolar disorder, and chronic kidney disease (CKD) stage III secondary to hypertensive nephrosclerosis. He was referred to our facility for the evaluation of shortness of breath and tachycardia. The patient attributed his shortness of breath to anxiety. He denied any chest pain or palpitations. There was no history of orthopnea, paroxysmal nocturnal dyspnea, or lower limb swelling. His vital signs showed

Division of Cardiovascular Medicine - Department of Medicine - University of Missouri School of Medicine, Columbia/MO, USA.

Clozapine-induced hypersensitivity myocarditis presenting as sudden cardiac death

a regular heart rate of 110 bpm, a respiratory rate of 20/min, and blood pressure of 118/78 mmHg. He was afebrile and had peripheral capillary oxygen saturation of 96% on room air. Jugular venous pressure was normal. For the past 6 weeks he had been treated with clozapine for his psychiatric illness. An electrocardiogram showed sinus tachycardia with nonspecific ST-T wave changes. The chest radiograph was unremarkable. Troponin T (Tn‑T) was normal at < 0.01 ng/mL (normal range [NR]: < 0.01 ng/mL), but N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was elevated at 750 pg/mL (NR: 0.0-125.0 pg/mL) and D-Dimer was elevated at 3.1 mcg/mL (NR: 0.00-0.50 mcg/mL). A complete blood count with differential was normal with a normal eosinophil count. The serum chemistry was significant for creatinine of 1.6 mg/dL (NR: 0.67-1.17 mg/dL), which was unchanged from the baseline. A chest radiograph showed minimal lineal bibasilar atelectasis. A ventilation perfusion scan was performed, which suggested low probability for pulmonary embolism. There was no evidence of deep venous thrombosis on venous ultrasound of the lower limbs. Transthoracic echocardiogram revealed normal left ventricular systolic function (the ejection fraction was calculated at 57.7% using the Teicholz formula) with mild diastolic dysfunction. On the third day of admission, the patient sustained sudden cardiac arrest due to pulseless ventricular tachycardia. An autopsy of the heart was performed for transplant purposes, excluding other

body parts, as per the family request. The pre‑dissection weight of the heart was 319 g (NR: 338–589 g). All four chambers were normal in size. All four valves leaflets were thin, delicate, and freely movable without vegetation. Sections of the coronary arteries were free of significant atherosclerotic disease. No acute intraluminal coronary thrombus was seen. The sections of the right atrial wall revealed normal sinoatrial node. Histological examination of myocardial sections showed patchy perivascular mixed inflammation with some associated fibrosis (Figure 1A). There were histiocytes, lymphocytes, and neutrophils, as well as eosinophils with interstitial inflammation (Figure 1B). There was no significant myocyte damage. The diagnosis of CIHSM was made and was attributed as the cause of SCD.

DISCUSSION C lo za p in e , a lth o u g h co mmo n ly u s e d f o r treatment-resistant schizophrenia, is occasionally used as an off-label indication for bipolar disorder.1,2 Neutropenia and seizures are well-reported serious adverse effects of clozapine.3 CIHSM, a drug-related myocarditis, is an under-reported severe condition.4-7 Hypersensitivity myocarditis is the most common form of drug-induced myocardial disease, among others, such as toxic myocarditis, endocardial fibrosis (caused by medications such as fenfluramine, ergotamine tartrate, phentermine, methysergide), drug-induced cardiomyopathy (caused by medications such as

Figure 1. Photomicrography of the myocardium. A - A “roadmap” pattern of perivascular mixed inflammation with eosinophils (arrow) (H&E, 100X); B - Higher power view of the perivascular inflammation showing small round lymphocytes, histiocytes, and eosinophils with bilobed nuclei (arrow) (H&E, 400X). 10

Autopsy and Case Reports 2016;6(4):9-13

Katta N, Balla S, Aggarwal K

anthracycline, chloroquine), and giant cell myocarditis.11 Several medications, including clozapine, sulfonamides, penicillin, methyldopa, furosemide, tetracycline, azithromycin, aminophylline, and phenytoin are associated with hypersensitivity myocarditis. 12-14 The pathological process of hypersensitivity myocarditis comprises an eosinophilic infiltration of the myocardium; therefore, it is considered as a sub-type of eosinophilic myocarditis.11,15 Eosinophilic myocarditis is frequently associated with systemic hypereosinophilic conditions, such as hypereosinophilic syndrome, Churg-Strauss syndrome, and parasitic infections that have a high peripheral eosinophil count, as well as patients awaiting cardiac transplant who are on intravenous inotropic agents. 11,15,16 In contrast, the peripheral eosinophil count is often normal in hypersensitivity myocarditis; therefore, it is not useful for a diagnosis. In our patient, parasitic infections and hypereosinophilic systemic diseases were considered less likely as he had a normal peripheral eosinophil count. Kilian et al.5 first described the association between clozapine and myocarditis in 1999. The reported incidence of CIHSM is widely variable. A 2007 retrospective analysis study of 116 cases in Australia reported an incidence between 0.7% and 1.2% of all clozapine treated cases.4 The incidence of myocarditis in some studies was noted to be as high as 8.5%.6 Since many patients are either undiagnosed or unreported, it is challenging to assess the accurate incidence of CIHSM. Several studies have suggested a wide range of onset times of CIHSM symptoms after the initiation of clozapine. While cases have been reported as early as 16 days after the initiation of the drug,4 up to 75% of the patients develop symptoms within the first month,17 85% cases within the first two months,17 and a few cases may develop symptoms up to 2 years later.4 Initial presenting symptoms of CIHSM can be nonspecific flu-like symptoms, such as malaise, fatigue, pleuritic chest pain, cough, and rash, and may be evident as a clinical sign of hypersensitivity.11 Sinus tachycardia is one of the early clinical signs detected in 90% of the CIHSM cases.18 Clozapine may induce autonomic imbalance, decreased parasympathetic tone, and increased sympathetic drive; in so doing, it can cause resting tachycardia.19 Although the exact mechanism of CIHSM is unclear, increased circulating plasma catecholamine from a high sympathetic drive could be Autopsy and Case Reports 2016;6(4):9-13

responsible for triggering an inflammatory response resulting in myocarditis; therefore, beta‑adrenergic blockade may reduce the incidence and the severity.20 Wang20 illustrated that clozapine-treated mice had a substantial increase in myocardial inflammation that correlated with higher plasma catecholamine levels, and that subsequent blockade of beta-adrenergic receptors with propranolol significantly attenuated these effects.20 During hospitalization, our patient had persistent sinus tachycardia with a heart rate ranging from 110 bpm to 140 bpm, which reduced to 101 bpm with the use of metoprolol. Further diagnostic clues may emanate from measuring cardiac troponin, NT-proBNP, and C-reactive protein (CRP) as they are often elevated in CIHSM. In a case control study conducted in Australia, Ronaldson et al.7 showed that 90% of the diagnosed CIHSM cases had elevated troponins within 4 weeks of starting clozapine; whereas CRP was elevated in 70% of these cases. However, in five cases where Tn-T was normal, CRP was elevated. The study also suggested that a combination of CRP (> 100 mg/L) and cardiac troponin (> 2 upper limit normal) had 100% sensitivity in identifying CIHSM. 18 Based on these results, Ronaldson et al.18 proposed a monitoring protocol, including periodical assessment of cardiac troponin and CRP, during the first 4 weeks of initiation of the drug regardless of symptoms. Our patient had normal Tn-T, and CRP was not measured. Another cardiac biomarker NT-proBNP has been widely used in diagnosing and estimating the prognosis of heart failure; however, its role in myocarditis has not been well studied. Since our patient had elevated NT-proBNP, we believe further studies are warranted to better define its role in myocarditis in general, and CIHSM in particular. An echocardiogram may provide diagnostic information with wall motion abnormalities in severe CIHSM cases, but in cases of less severe focal disease its utility is questionable as the findings may be nonspecific. Ronaldson et al.18 reported impaired left ventricular function in 66% of their patients diagnosed with CHISM; however, they did not specify if it was a systolic or a diastolic dysfunction. Our patient had normal systolic function with mild diastolic dysfunction, which is a common finding in his age group. Similar to other types of myocarditis, the diagnostic modality of choice for CIHSM is cardiac magnetic resonance imaging (CMR). The use of T2 weighted 11

Clozapine-induced hypersensitivity myocarditis presenting as sudden cardiac death

images increased the sensitivity to 84% and the specificity to 74% in diagnosing myocarditis.21 Contrast enhancement with gadolinium has been shown to further increase diagnostic accuracy.21,22 Endomyocardial biopsy (EMB) is often considered the gold standard test in detecting myocarditis. 23 The 2007 ACC/AHA/ESC/HFSA guidelines recommend EMB in cases of suspected hypersensitivity myocarditis.24 EMB also yields low sensitivity in focal myocarditis. CMR has been shown to improve the diagnostic yield of EMB by aiding targeted area biopsy.22 Similar to other drug-induced hypersensitivity myocarditis, the treatment of CIHSM includes supportive management and discontinuation of the drug. Significant clinical improvement can be expected in patients with myocarditis with intensive hemodynamic monitoring and supportive management.25 Although the role of corticosteroids is questionable, we did find a few published case reports on the beneficial effect of steroids in severe cases of myocarditis complicated by cardiogenic shock. 14,26-28 Also, azathioprine has been used as an adjunct in the treatment of patients with steroid-resistant hypersensitivity myocarditis and cardiogenic shock.29

CONCLUSION We report the case of CIHSM presenting as SCD where the diagnosis was made at autopsy. Clozapine‑induced hypersensitivity myocarditis is a rare and serious condition. A high index of clinical suspicion is needed for a timely diagnosis. The vast majority of these patients may present with vague symptoms or are unable to relay their symptoms. Serum cardiac biomarkers and imaging modalities, including CMR, can help in the diagnosis of CIHSM. Implementing a 4-week monitoring protocol with periodical assessment of troponins, after the initiation of clozapine, CRP may be a sensitive tool in the early diagnosis of this serious adverse reaction.

REFERENCES 1. Asenjo Lobos C, Komossa K, Rummel-Kluge C, et al. Clozapine versus other atypical antipsychotics for schizophrenia. Cochrane Database Syst Rev. 2010;(11):Cd006633. PMid:21069690. 12

2. Kant R, Chalansani R, Chengappa KN, Dieringer MF. The off-label use of clozapine in adolescents with bipolar disorder, intermittent explosive disorder, or posttraumatic stress disorder. J Child Adolesc Psychopharmacol. 2004;14(1):57-63. PMid:15142392. http://dx.doi.org/1 0.1089/104454604773840490. 3. Miller DD. Review and management of clozapine side effects. J Clin Psychiatry. 2000;61(Suppl 8):14-7. PMid:10811238. 4. Haas SJ, Hill R, Krum H, et al. Clozapine-associated myocarditis: a review of 116 cases of suspected myocarditis associated with the use of clozapine in Australia during 1993-2003. Drug Saf. 2007;30(1):47-57. PMid:17194170. http://dx.doi.org/10.2165/00002018200730010-00005. 5. Kilian JG, Kerr K, Lawrence C, Celermajer DS. Myocarditis and cardiomyopathy associated with clozapine. Lancet. 1999;354(9193):1841-5. PMid:10584719. http://dx.doi. org/10.1016/S0140-6736(99)10385-4. 6. Reinders J, Parsonage W, Lange D, Potter JM, Plever S. Clozapine-related myocarditis and cardiomyopathy in an Australian metropolitan psychiatric service. Aust N Z J Psychiatry. 2004;38(11-12):915-22. PMid:15555025. http://dx.doi.org/10.1080/j.1440-1614.2004.01481.x. 7. Ronaldson KJ, Fitzgerald PB, McNeil JJ. Clozapine-induced myocarditis, a widely overlooked adverse reaction. Acta Psychiatr Scand. 2015;132(4):231-40. PMid:25865238. http://dx.doi.org/10.1111/acps.12416. 8. Hatton JL, Bhat PK, Gandhi S. Clozapine-induced myocarditis: recognizing a potentially fatal adverse reaction. Tex Heart Inst J. 2015;42(2):155-7. PMid:25873829. http://dx.doi.org/10.14503/THIJ-133633. 9. Park Y, Ahn SG, Ko A, et al. Hypersensitivity myocarditis confirmed by cardiac magnetic resonance imaging and endomyocardial biopsy. Korean J Intern Med. 2014;29(2):236-40. PMid:24648808. http://dx.doi. org/10.3904/kjim.2014.29.2.236. 10. Pieroni M, Cavallaro R, Chimenti C, Smeraldi E, Frustaci A. CLozapine-induced hypersensitivity myocarditis*. Chest. 2004;126(5):1703-5. PMid:15539749. http://dx.doi. org/10.1378/chest.126.5.1703. 11. Gerald J, Berry KAA. In Myocardiits: from Bench to Bedside. 2nd ed. Totowa: Humana Press; 2003. p. 32570. 12. Ben m’rad M, Leclerc-Mercier S, Blanche P, et al. Drug-induced hypersensitivity syndrome: clinical and biologic disease patterns in 24 patients. Medicine. 2009;88(3):131-40. PMid:19440116. http://dx.doi. org/10.1097/MD.0b013e3181a4d1a1. 13. Pursnani A, Yee H, Slater W, Sarswat N. Hypersensitivity myocarditis associated with azithromycin exposure. Ann Intern Med. 2009;150(3):225-6. PMid:19189924. http:// Autopsy and Case Reports 2016;6(4):9-13

Katta N, Balla S, Aggarwal K

dx.doi.org/10.7326/0003-4819-150-3-20090203000027. 14. Taliercio CP, Olney BA, Lie JT. Myocarditis related to drug hypersensitivity. Mayo Clin Proc. 1985;60(7):4638. PMid:4010343. http://dx.doi.org/10.1016/S00256196(12)60870-2. 15. Magnani JW, Dec GW. Myocarditis: current trends in diagnosis and treatment. Circulation. 2006;113(6):87690. PMid:16476862. http://dx.doi.org/10.1161/ CIRCULATIONAHA.105.584532. 16. Takkenberg JJ, Czer LS, Fishbein MC, et al. Eosinophilic myocarditis in patients awaiting heart transplantation. Crit Care Med. 2004;32(3):714-21. PMid:15090952. http:// dx.doi.org/10.1097/01.CCM.0000114818.58877.06. 17. Hägg S, Spigset O, BAHons AB, Söderström TG. Myocarditis related to clozapine treatment. J Clin Psychopharmacol. 2001;21(4):382-8. PMid:11476122. http://dx.doi.org/10.1097/00004714-200108000-00005. 18. Ronaldson KJ, Fitzgerald PB, Taylor AJ, Topliss DJ, McNeil JJ. A new monitoring protocol for clozapine-induced myocarditis based on an analysis of 75 cases and 94 controls. Aust N Z J Psychiatry. 2011;45(6):458-65. PMid:21524186. http://dx.doi.org/10.3109/00048674. 2011.572852. 19. Cohen H, Loewenthal U, Matar M, Kotler M. Association of autonomic dysfunction and clozapine. Heart rate variability and risk for sudden death in patients with schizophrenia on long-term psychotropic medication. Br J Psychiatry. 2001;179(2):167-71. PMid:11483480. http:// dx.doi.org/10.1192/bjp.179.2.167. 20. Wang JF, Min JY, Hampton TG, et al. Clozapine-induced myocarditis: role of catecholamines in a murine model. Eur J Pharmacol. 2008;592(1-3):123-7. PMid:18627770. http://dx.doi.org/10.1016/j.ejphar.2008.06.088. 21. Abdel-Aty H, Boye P, Zagrosek A, et al. Diagnostic performance of cardiovascular magnetic resonance in patients with suspected acute myocarditis: comparison of different approaches. J Am Coll Cardiol. 2005;45(11):1815-22. PMid:15936612. http://dx.doi. org/10.1016/j.jacc.2004.11.069.

22. Mahrholdt H, Goedecke C, Wagner A, et al. Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology. Circulation. 2004;109(10):12508. PMid:14993139. http://dx.doi.org/10.1161/01. CIR.0000118493.13323.81. 23. Laser JA, Fowles RE, Mason JW. Endomyocardial biopsy. Cardiovasc Clin. 1985;15(1):141-63. PMid:3916087. 24. Cooper LT, Baughman KL, Feldman AM, et al. The Role of Endomyocardial Biopsy in the Management of Cardiovascular DiseaseA Scientific Statement From the American Heart Association, the American College of Cardiology, and the European Society of Cardiology Endorsed by the Heart Failure Society of America and the Heart Failure Association of the European Society of Cardiology. J Am Coll Cardiol. 2007;50(19):191431. PMid:17980265. http://dx.doi.org/10.1016/j. jacc.2007.09.008. 25. Yanagisawa T, Inomata T, Watanabe I, et al. Clinical significance of corticosteroid therapy for eosinophilic myocarditis. Int Heart J. 2011;52(2):110-3. PMid:21483171. http://dx.doi.org/10.1536/ihj.52.110. 26. Kim CH, Vlietstra RE, Edwards WD, Reeder GS, Gleich GJ. Steroid-responsive eosinophilic myocarditis: diagnosis by endomyocardial biopsy. Am J Cardiol. 1984;53(10):14723. PMid:6720598. http://dx.doi.org/10.1016/S00029149(84)91473-5. 27. Watanabe N, Nakagawa S, Fukunaga T, Fukuoka S, Hatakeyama K, Hayashi T. Acute necrotizing eosinophilic myocarditis successfully treated by high dose methylprednisolone. Jpn Circ J. 2001;65(10):923-6. PMid:11665801. http://dx.doi.org/10.1253/jcj.65.923. 28. Zaacks SM, Klein L, Tan CD, Rodriguez ER, Leikin JB, Leikin J. Hypersensitivity myocarditis associated with ephedra use. J Toxicol Clin Toxicol. 1999;37(4):4859. PMid:10465246. http://dx.doi.org/10.1081/CLT100102440. 29. Aggarwal A, Bergin P, Jessup P, Kaye D. Hypersensitivity myocarditis presenting as cardiogenic shock. J Heart Lung Transplant. 2001;20(11):1241-4. PMid:11704488. http:// dx.doi.org/10.1016/S1053-2498(01)00313-8.

Conflict of interest: None Submitted on: September 13th, 2016 Accepted on: November 22nd, 2016 Correspondence Natraj Katta Division of Cardiovascular Medicine - Department of Medicine One Hospital Drive, CE306, Columbia, MO 65212 - USA Phone: +1 (573) 882-7272/Fax: +1 (573) 884-7743 kattan@health.missouri.edu Autopsy and Case Reports 2016;6(4):9-13

Article / Autopsy Case Report

Infant acute myocarditis mimicking acute myocardial infarction Maher Jedidia, Samia Tiloucheb, Tasnim Masmoudia, Maha Sahnouna, Youssef Chkirbènea, Sarra Mestiric, Lamia Boughamourab, Mohamed Ben Dhiaba, Mohamed Kamel Souguira Jedidi M, Tilouche S, Masmoudi T, et al. Infant acute myocarditis mimicking acute myocardial infarction. Autopsy Case Rep [Internet]. 2016;6(4):15-19. http://dx.doi.org/10.4322/acr.2016.052

ABSTRACT Myocarditis is an inflammatory disease of the myocardium with heterogeneous clinical manifestations and progression. In clinical practice, although there are many methods of diagnosis of acute myocarditis, the diagnosis remains an embarrassing dilemma for clinicians. The authors report the case of 9-month-old infant who was brought to the Pediatric Emergency Department with sudden onset dyspnea. Examination disclosed heart failure and resuscitation was undertaken. The electrocardiogram showed an ST segment elevation in the anterolateral leads with a mirror image. Cardiac enzyme tests revealed a significant elevation of troponin and creatine phosphokinase levels. A diagnosis of acute myocardial infarction was made, and heparin therapy was prescribed. The infant died on the third day after admission with cardiogenic shock. The autopsy showed dilatation of the ventricles and massive edema of the lungs. Histological examinations of myocardium samples revealed the presence of a marked lymphocytic infiltrate dissociating myocardiocytes. Death was attributed to acute myocarditis. The authors call attention to the difficulties of differential diagnosis between acute myocarditis and acute myocardial infarction especially in children, and to the important therapeutic implications of a correct diagnosis. Keywords Myocarditis; Myocardial Infarction; Diagnosis, Differential; Infant Death

CASE REPORT A 9-month-old girl, with no documented medical history, was brought to the Pediatric Emergency Department for sudden onset dyspnea. She had a recent history of rhinorrhea and cough. On examination, she had a pulse of 180/min (normal range: 80-160/min), a blood pressure of 70/40 mmHg, and a respiratory rate of 48/min with chest indrawing (normal value: 30-40/min). Her temperature was 38.9 °C. The electrocardiogram (ECG) showed ventricular

tachycardia, which spontaneously returned to a regular rhythm with extrasystoles (Figure 1). Acute heart failure was diagnosed. Orotracheal intubation and mechanical ventilatory assistance were immediately started, and the patient was transferred to the pediatric intensive care unit. A diagnostic work-up was subsequently performed. The chest x-ray showed cardiomegaly with bilateral pulmonary congestion (Figure 2).

Department of Legal Medicine - Farhat Hached University Hospital, Sousse – Tunisia. Department of Pediatrics - Farhat Hached University Hospital, Sousse – Tunisia. c Department of Pathology - Farhat Hached University Hospital, Sousse – Tunisia. a

Infant acute myocarditis mimicking acute myocardial infarction

Figure 1. Twelve-lead electrocardiogram (ECG) showing ventricular tachycardia (ECG on admission). A control ECG achieved after 3 hours showed ST segment elevation in the anterolateral leads (V3-V6) and ST depression on V1-V2 producing a “mirror image” (Figure 3). Myocardial necrosis markers disclosed an increased CPK at 2066 UI/L (RV: 95-195 UI/L) and a significant elevation of troponin I level (1.92 ng/mL). A diagnosis of acute myocardial infarction was established, and heparin therapy was started. An echocardiogram showed a diffuse hypocontractility and dilation of the left ventricle without any other abnormality. The infant died on the third day after admission due to cardiogenic shock, and a forensic autopsy was performed because of the unexplained cause of death. Figure 2. Chest x-ray showing cardiomegaly with bilateral pulmonary congestion. Laboratory exams showed hyperkalemia at 5.6 mmol/L with normal renal function, increased serum lactate dehydrogenase (1234 UI/L; reference value [RV]: 230-4600 UI/L), normal creatine phosphokinase (CPK), and a slight increase of troponin I level (0.81 ng/mL; RV: < 0.25 ng/mL). Initial treatment consisted of cardiac drugs, alkalinization, and antibiotic therapy. 16

AUTOPSY FINDINGS The deceased was 78 cm in height and weighed 10 kg. The external examination showed an apparently healthy infant presenting cyanosis of the lips. Internal examination disclosed a normal appearance of the scalp, skull, and brain. The heart weighed 70 g (RV: 40 g). Coronary arteries were normal and had a normal origin. Both ventricles were dilated, and the heart muscle was homogeneous (Figure 4A and 4B). Autopsy and Case Reports 2016;6(4):15-19

Jedidi M, Tilouche S, Masmoudi T, et al.

Figure 3. Twelve-lead electrocardiogram (ECG) showing ST segment elevation on the anterolateral leads (V3–V6) and ST depression on V1–V2 (ECG 3 hours after admission).

Figure 4. A and B - Gross examination of the heart: right and left ventricles dilatation with homogeneous heart muscle. The lungs were markedly congested and massively edematous. Histological examinations of the heart revealed the presence of an important lymphocytic infiltrate dissociating myocardiocytes with scattered ischemic or necrotic focal points (Figure 5A and 5B). Autopsy and Case Reports 2016;6(4):15-19

Microscopic sections of the remaining internal organs did not show any abnormality, except for massive lung edema. The toxicology screening, which included conventional medicines (salicylates, tricyclics, benzodiazepines, phenothiazines, and paracetamol), 17

Infant acute myocarditis mimicking acute myocardial infarction

Figure 5. Photomicrography of the heart. A - Myocardiocytes dissociated by interstitial edema and inflammatory infiltrate (H&E, 40X); B - High magnification view shows the inflammatory infiltrate consisting predominantly by lymphocytes (H&E, 400X). pesticides (organophosphates, carbamate, chloralose), and alcohol, was negative. Death was attributed to acute heart failure due to acute myocarditis. In addition to the toxicological study, no other cause of myocarditis was further investigated.

DISCUSSION Myocarditis is an inflammatory disease of the myocardium with heterogeneous clinical manifestations and progression.1,2 Infectious myocarditis is the most common; it is often caused by a virus and is occasionally associated with bacterial infections. 2,3 The clinical features of acute myocarditis vary from case to case, ranging from oligosymptomatic cases to heart failure and sudden unexpected death.1,4,5 In clinical practice, although there are many methods of diagnosis of acute myocarditis, including clinical symptoms, laboratory exams, ECG, echocardiogram, magnetic resonance imaging (MRI) findings, and cardiac endo-myocardial biopsy,1 the diagnosis of myocarditis remains an embarrassing dilemma for clinicians, especially in children where the symptoms may vary substantially.2,6,7 Acute myocarditis may be associated with heart tissue necrosis in some cases. The exact pathogenesis is unclear; hypotheses state that ischemia is a consequence of local endothelial dysfunction, coronary 18

spasms, and in situ thrombi formation.1,8,9 Also, it may clinically resemble myocardial infarction. 1,2,10 The differential diagnosis between acute myocarditis and acute myocardial infarction can be very challenging and sometimes indistinguishable in children.11 In this case, ECG repolarization abnormalities in a single coronary distribution (ST segment elevation in anterolateral leads), plus serum elevation of CPK and troponin, entirely mimic an acute myocardial infarction presentation, which was firstly suspected by the pediatricians. Cardiomyopathy was also raised before the echocardiogram signs. Usually, in adult care, ST segment abnormality associated with an elevation of specific biomarkers of cardiac injury—especially troponin—confirm myocardial infarction and allow interventional catheterization.7,12 This is largely because there is a high prevalence of atherosclerotic coronary artery disease in the adult population. In children, the causes of elevated troponin differ from that of adults. The most common causes are myocarditis and cardiomyopathy; however, coronary-related ischemia is rare.7,13 Clinicians should consider the diagnosis of acute myocarditis in children who present troponin elevation and acute heart failure. Endomyocardial biopsy remains the gold standard exam for diagnosing myocarditis. However, due to its invasiveness with a high risk of complications and the possibility of false negative results, it is not often performed in common practice.10,14 MRI is a good diagnostic tool and when Autopsy and Case Reports 2016;6(4):15-19

Jedidi M, Tilouche S, Masmoudi T, et al.

the “Lake Louise Criteria”14 are applied, the sensitivity and specificity of MRI prove to be high compared to endomyocardial biopsy.15 A correct diagnosis of myocarditis has significant therapeutic implications for patients, and non-realization of MRI can be criticized in this case. An MRI could have guided the diagnosis of myocarditis in this infant.

7. Harris TH, Gossett JG. Diagnosis and diagnostic modalities in pediatric patients with elevated troponin. Pediatr Cardiol. 2016;37(8):1469-74. PMid:27573217. http:// dx.doi.org/10.1007/s00246-016-1459-7. 8. C o o p e r L T J r . M y o c a r d i t i s . N E n g l J M e d . 2009;360(15):1526-38. PMid:19357408. http://dx.doi. org/10.1056/NEJMra0800028.

In this instance, we confirmed the important role of forensic autopsy in explaining the cause of death in such a challenging case.

9. Kühl U, Pauschinger M, Bock T, et al. Parvovirus B19 Infection Mimicking Acute Myocardial Infarction. Circulation. 2003;108(8):945-50. PMid:12925460. http:// dx.doi.org/10.1161/01.CIR.0000085168.02782.2C.

REFERENCES

10. van Nierop J, Limburg A, van Ofwegen-Hanekamp CEE. Myocarditis mimicking acute myocardial infarction. Neth Heart J. 2015;23(10):502-4. PMid:26178204. http:// dx.doi.org/10.1007/s12471-015-0732-3.

1. Zhang T, Miao W, Wang S, Wei M, Su G, Li Z. Acute myocarditis mimicking ST-elevation myocardial infarction: a case report and review of the literature. Exp Ther Med. 2015;10(2):459-64. PMid:26622337. 2. Pomara C, Villani A, D’Errico S, Riezzo I, Turillazzi E, Fineschi V. Acute myocarditis mimicking acute myocardial infarction: a clinical nightmare with forensic implications. Int J Cardiol. 2006;112(1):119-21. PMid:16310266. http://dx.doi.org/10.1016/j.ijcard.2005.08.060. 3. Karjalainen J, Heikkilä J. Incidence of three presentations of acute myocarditis in young men in military service. A 20-year experience. Eur Heart J. 1999;20(15):11205. PMid:10413642. http://dx.doi.org/10.1053/ euhj.1998.1444. 4. Rossetti B, Nguisseu G, Buracci A, Migliorini L, Zanelli G. Myocarditis Mimicking an Acute Coronary Syndrome: a case related to Salmonella enteritis. Gastroenterol Res Pract. 2009;2009:1-2. PMid:19997519. http://dx.doi. org/10.1155/2009/931853. 5. Abe T, Tsuda E, Miyazaki A, Ishibashi-Ueda H, Yamada O. Clinical characteristics and long-term outcome of acute myocarditis in children. Heart Vessels. 2013;28(5):632-8. PMid:23064719. http://dx.doi.org/10.1007/s00380-0120296-8. 6. Amabile N, Fraisse A, Bouvenot J, Chetaille P, Ovaert C. Outcome of acute fulminant myocarditis in children. Heart. 2006;92(9):1269-73. PMid:16449512. http:// dx.doi.org/10.1136/hrt.2005.078402.

11. Costantini M, Tritto C, Licci E, et al. Myocarditis with ST-elevation myocardial infarction presentation in young man: a case series of 11 patients. Int J Cardiol. 2005;101(1):157-8. PMid:15860403. http://dx.doi. org/10.1016/j.ijcard.2004.01.023. 12. Ohman EM, Armstrong PW, Christenson RH, et al. Cardiac troponin T levels for risk stratification in acute myocardial ischemia. N Engl J Med. 1996;335(18):133341. PMid:8857016. http://dx.doi.org/10.1056/ NEJM199610313351801. 13. Lin C-H, Lin W-C, Ho Y-J, Chang J-S. Children with chest pain visiting the emergency department. Pediatr Neonatol. 2008;49(2):26-9. PMid:18947012. http:// dx.doi.org/10.1016/S1875-9572(08)60007-8. 14. Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular magnetic resonance in myocarditis: A JACC White Paper. J Am Coll Cardiol. 2009;53(17):147587. PMid:19389557. http://dx.doi.org/10.1016/j. jacc.2009.02.007. 15. Caforio ALP, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013;34(33):2636-48, 2648a-2648d. PMid:23824828. http://dx.doi.org/10.1093/eurheartj/eht210.

Conflict of interest: None Submitted on: September 8th, 2016 Accepted on: November 18th, 2016 Correspondence Maher Jedidi Department of Legal Medicine - Farhat Hached University Hospital Sousse Tunisia Phone: +216 (98) 536-440/Fax: + 216 (73) 226-702 jedidimaher@yahoo.fr Autopsy and Case Reports 2016;6(4):15-19

Article / Autopsy Case Report

Balo’s concentric lesions with concurrent features of Schilder’s disease in relapsing multiple sclerosis: neuropathological findings Maher Kurdia,b, David Ramsaya Kurdi M, Ramsay D. Balo’s concentric lesions with concurrent features of Schilder’s disease in relapsing multiple sclerosis: neuropathological findings. Autopsy Case Rep [Internet]. 2016;6(4):21-26. http://dx.doi.org/10.4322/acr.2016.058

ABSTRACT Atypical inflammatory demyelinating syndromes are rare neurological diseases that differ from multiple sclerosis (MS), owing to unusual clinicoradiological and pathological findings, and poor responses to treatment. The distinction between them and the criteria for their diagnoses are poorly defined due to the lack of advanced research studies. Balo’s concentric sclerosis (BCS) and Schilder’s disease (SD) are two of these syndromes and can present as monophasic or in association with chronic MS. Both variants are difficult to distinguish when they present in acute stages. We describe an autopsy case of middle-aged female with a chronic history of MS newly relapsed with atypical demyelinating lesions, which showed concurrent features of BCS and SD. We also describe the neuropathological findings, and discuss the overlapping features between these two variants. Keywords Multiple Sclerosis; Atypical Inflammatory Demyelination; Balo’s Concentric Sclerosis; Schilder’s Disease; Pathology

CASE REPORT A 45-year-old woman presented in another hospital with a history of generalized tonic clonic seizure and acute confusion. She was admitted to the intensive care unit for close observation. Her past medical history revealed that she had been diagnosed clinically with multiple sclerosis (MS) in 2005, and had shown a good response to various combinations of methylprednisolone, cyclophosphamide, and interferon. During the course of her illness, she had a history of multiple admissions to the hospital with several relapses between 2005 and 2006. Her disease settled in the remitting phase for 7 years. In this current admission, her medical condition deteriorated and she became unresponsive to the usual medical

treatment. Brain magnetic resonance imaging (MRI) with gadolinium contrast showed space-occupying lesions in the right and left frontal white matter, with the left showing concentric rings with an onionskin pattern (Figure 1). Blood chemistry revealed a normal blood count and normal renal and liver function. HIV anti‑nuclear antibody, anti-dsDNA, rheumatoid factor, and anti‑phospholipid antibody were negative. Cerebrospinal fluid (CSF) analysis was negative for anti-aquaporin-4 (anti-AQP4) antibody with absent oligoclonal band immunoglobulin G (IgG). The concentration of very long-chain fatty acids was normal. The patient was treated with high-dose

Department of Pathology - Schulich School of Medicine & Dentistry - Western University - London/ON – Canada. Department of Pathology - Montreal Neurological Institute - McGill University - Montreal/QC – Canada.

Balo’s concentric lesions with concurrent features of Schilder’s disease in relapsing multiple sclerosis: neuropathological findings

Figure 1. Brain MRI (T1 weighted images with contrast) shows a space-occupying lesion in the left frontal white matter, surrounded by mild edema. The lesion has a concentric onion-skin-like pattern (A - sagittal plane and B axial plane).

methylprednisolone, after which her clinical symptoms did not improve. Unfortunately, she had a sudden cardiorespiratory arrest from which she could not be resuscitated. The family requested a general autopsy including the brain and spinal cord. The general autopsy revealed a pulmonary embolus as a cause of her death. The formalin-fixed brain and spinal cord were referred to our institution for neuropathological consultation.

NEUROPATHOLOGICAL ASSESSMENT The fixed brain weight was 1226 g. The whole brain showed a very mild atrophy. The brain-cut protocol was performed. There were symmetrical areas of brown-gray discolorations of the centrum semiovale extending into the digitate white matter. These lesions were found in the anterior part of the right frontal lobe (Figure 2A), the dorsal part of the left frontal lobe (Figure 2B and 2C), and the parietal occipital regions. The left frontal lesion (measuring 2.3 × 3.3 cm) showed distinct arranged grossly viable laminae with a concentric globe. 22

The right frontal lesion showed clearly visible subcortical U-fiber (SCUF). The focal lesions in the parietal-occipital regions were partially cystic. Sections from the left and right frontal lesions were examined using light and electron microscopy. We used different staining protocols on the sections taken from the right and left frontal lobes. Hematoxylin and eosin (H&E) with Luxol fast blue (LFB) (Figure 3A and 4) was the main staining method. We also created combined stains (Bielschowsky silver stain with LFB (Figure 3B) and neurofilament with LFB (Figure 3C), performed on the left frontal lesion to highlight the SCUF, to examine the axonal process, and to assess the myelin in relation to the axons. With the aid of the pathological staging of CNS demyelination, we found that the left frontal lesion histologically showed an ill-defined area of late active plaque associated with alternating bands of preserved and non-preserved myelin in wavy patterns. Both bands showed preserved axons by neurofilament stain (Figure 3C). The right frontal lesion showed an ill‑defined area of late active plaque with a deep loss of myelin (Figure 4). LFB stain showed spared SCUF in both lesions. Both frontal lesions showed typical features of demyelination with few macrophage‑engulfed Autopsy and Case Reports 2016;6(4):21-26

Kurdi M, Ramsay D

Figure 2. A - Gross section of the right frontal lobe showing a brown-gray lesion; B and C - Gross examination of brain slices showing symmetrical brown-gray discolorations of the centrum semiovale extending into the digitate white matter (red arrow).

Figure 3. Histological sections of the left frontal lesion treated with different stains. A - H&E and LFB (10X); B - Bielschowsky with LFB (10X); C - Neurofilament with LFB (10X). The lesion shows a concentric pattern of myelinated and non-myelinated layers with spared subcortical U-fibers. The neurofilament shows intact axons.

myelin in the main plaque center, scant perivascular lymphocytic cuffs, few macrophages, and gliosis. There were no features of acute ischemia in the affected areas. Periodic acid-Schiff (PAS) stain showed Autopsy and Case Reports 2016;6(4):21-26

no evidence of specific variants of leukodystrophies. The optic nerve, optic chiasm, brainstem, spinal cord, and cerebellum were unremarkable. Ultrastructural examination of poorly preserved fixed tissue only 23

Balo’s concentric lesions with concurrent features of Schilder’s disease in relapsing multiple sclerosis: neuropathological findings

showed scattered myeloid and zebra bodies (Figure 5). The myelin was degenerated and the axons were somewhat preserved.

DISCUSSION Atypical inflammatory demyelinating syndromes are rare neurological diseases that differ from MS, owing to unusual clinicoradiological or pathological findings, and poor responses to treatments.1 These syndromes include neuromyelitis optica, acute disseminated

Figure 4. Histological section of the right frontal lesion treated with H&E and LFB (10X) shows the gradual loss of myelin in deep white matter, which is associated with spared subcortical U-fibers (arrow).

encephalomyelitis, tumefactive demyelination, Balo’s concentric sclerosis (BCS), Schilder’s disease (SD), and Marburg’s MS. If patients present with atypical MRI findings, atypical presentation, or do not respond well to the treatment that is usually effective for MS, these syndromes should be considered. Because some of these syndromes are associated with MS, the overlapping features are poorly defined, and may complicate the diagnosis. Our patient had a 7-year history of chronic MS. She recently relapsed with newly acute symmetrical demyelinating lesions of the frontal lobe. The left frontal lesion showed Balo’s pattern while the right frontal lesion showed demyelination with spared SCUF. BCS was described in 1928 by a Hungarian neuropathologist: Josef Bal.2 It characteristically occurs as a discrete concentrically layered lesion in the cerebral white matter.2 This distinctive appearance helps to distinguish it from other demyelinating lesions of conventional MS. The average age of onset of BCS is 34 years and seems to be more common in patients of East Asian origin.3 BCS may occur simultaneously with MS-like lesions or may herald the onset of MS, indicating that, in certain patients, they seem to be different manifestations of the same disease rather than separate pathological entities.4 It can occur with anti-AQP4 antibody seropositive and seronegative neuromyelitis optica.5 On brain MRI, the lesion appears as concentric rings with alternating high and low

Figure 5. Ultrastructural examination of the lesion by electron microscopy. A - Myeloid bodies; B - Zebra bodies. 24

Autopsy and Case Reports 2016;6(4):21-26

Kurdi M, Ramsay D

intensity with minimal surrounding edema. It can be multiple at onset or occur as solitary lesions.6 Not all patients with BCS have oligoclonal bands: in a study of 11 patients with BCS, CSF synthesis of oligoclonal bands was present in one patient only.7 Pathologically, Balo’s lesions are well described and classically consist of cerebral white matter oligodendrocytes loss and demyelination, with sparing of the cortical grey matter.8 The lesions have an alternating ring appearance of relative myelin preservation and loss with relative axonal sparing, which gives them a so-called onion bulb appearance.9 Astrocytopathy has been proposed as a hallmark feature of BCS.8 Several hypotheses have been proposed to explain the pathogenesis of the concentric lesions. The lesions seem to arise around a perivenular zone in response to an unknown stimulus that causes macrophages and activated microglia to produce cytokines and oxygen free radicals, which are responsible for inducing demyelination.10 Hypoxia inducible factor 1α might give a degree of neuroprotection to preserve the myelin between the rings of demyelination. Astrocyte AQP4 and connexin are markedly reduced in these areas.11 In our patient’s case, the left frontal lesion showed features of BCS with preserved SCUF. The right frontal lesion showed a leukodystrophy-like pattern that involved the centrum semiovale to the digitate of white matter. These features can be seen in Schilder’s variant.

SD, also known as myelinoclastic diffuse sclerosis, was first described by Schilder in 1912.12 It is a sporadic atypical demyelinating brain disease that usually affects children. However, It can also occur in the third and fourth decades of life and appears to respond to vigorous treatment with corticosteroids. This rare disease results in formation of one or two bilateral large tumefactive plaques.13 In 1986, Poser et al.13 established diagnostic criteria for the non-invasive diagnosis of SD. These criteria can be summarized as follows: (i) clinical symptoms and signs atypical for an early course of MS; (ii) a normal CSF, or atypical for MS; (iii) one or two symmetrical bilateral plaques measuring at least 3 × 2 cm and involving the centrum semiovale of the cerebral hemispheres; (iv) no fever, viral or mycoplasmal infection, or vaccination preceding the symptomatology; and (v) a normal serum concentration of very long-chain fatty acids. Additionally, it was noted that in SDs, CSF-restricted oligoclonal bands are generally absent, and that large bilateral areas of demyelination were mandatory for the diagnosis.14 Some cases of SD represent adrenoleukodystrophy or “transitional” cases with MS. Adrenoleukodystrophy has been ruled out through clinical presentation, biochemical tests, and PAS. The distinction between BCS and SD is summarized in Table 1.

Table 1. The distinction between Balo concentric sclerosis (BCS) and Schilder’s disease (SD) Age and ethnicity Location Presentation

BCS

Middle aged, East Asian

Children or early young – any ethnicity

Cerebral white matter

Cerebral white matter (semiovale)

Monophasic or with MS

CSF-anti-AQP4 antibody

Can be positive

Negative

CSF-oligoclonal band IgG

Negative

Normal

Multiplicity

Always solitary

Always multiple

Symmetry

Usually asymmetrical

Usually symmetrical

Pathology

Concentricity

Concentricity can be present

Subcortical U-fibers

VLCFA

Never spared

Spared

Astrogliosis

Dense

Mild

Response to treatment

None

Outcome Poor Poor AQP4 = aquaporin 4; CSF = cerebral spinal fluid; IgG = immunoglobulin G; MS = multiple sclerosis; VLCFA = very long‑chain fatty acid. Autopsy and Case Reports 2016;6(4):21-26

Balo’s concentric lesions with concurrent features of Schilder’s disease in relapsing multiple sclerosis: neuropathological findings

CONCLUSIONS Atypical inflammatory demyelinating syndromes are rare neurological diseases with unusual clinicoradiological and pathological findings. BCS and SD are rare variants of this spectrum, which can occur simultaneously with MS. They are difficult to distinguish when they present at acute stages. The possible theory for our patient’s case was that the decedent’s MS was inactive for years then suddenly relapsed with atypical Balo’s lesions that asymmetrically progressed to Schilder’s pattern.

6. Hardy TA, Miller DH. Balo’s concentric sclerosis. Lancet Neurol. 2014;13(7):740-6. http://dx.doi.org/10.1016/ S1474-4422(14)70052-3. 7. Kira J. Astrocytopathy in Balo’s disease. Mult Scler. 2011;17(7):771-9. PMid:21459811. http://dx.doi. org/10.1177/1352458511400475. 8. Hu W, Lucchinetti CF. The pathological spectrum of CNS infl ammatory demyelinating diseases. Semin Immunopathol. 2009;31(4):439-53. PMid:19779719. http://dx.doi.org/10.1007/s00281-009-0178-z.

REFERENCES

9. Stadelmann C, Ludwin S, Tabira T, et al. Tissue preconditioning may explain concentric lesions in Bal.’s type of multiple sclerosis. Brain. 2005;128(Pt 5):97987. PMid:15774507. http://dx.doi.org/10.1093/brain/ awh457.

1. Hardy TA, Reddel SW, Barnett MH, Palace J, Lucchinetti CF, Weinshenker BG. Atypical inflammatory demyelinating syndromes of the CNS. Lancet Neurol. 2016;15(9):96781. PMid:27478954. http://dx.doi.org/10.1016/S14744422(16)30043-6.

10. Masaki K, Suzuki SO, Matsushita T, et al. Extensive loss of connexins in Bal.’s disease: evidence for an auto- antibodyindependent astrocytopathy via impaired astrocyte-oligodendrocyte/myelin interaction. Acta Neuropathol. 2012;123(6):887-900. PMid:22438105. http://dx.doi.org/10.1007/s00401-012-0972-x.

2. Balo J. Encephalitis periaxialis concentrica. Arch Neur Psych. 1928;19(2):242-64. http://dx.doi.org/10.1001/ archneurpsyc.1928.02210080044002. 3. Wang C, Zhang KN, Wu XM, et al. Balo’s disease showing benign clinical course and co-existence with multiple sclerosis-like lesions in Chinese. Mult Scler. 2008;14(3):418-24. PMid:18208888. http://dx.doi. org/10.1177/1352458507084036.

11. Schilder P. Zur Kenntnis der sogenannten diffusen Sklerose. (Über Encephalitis periaxialis diffusa.). Gesamate Neurol Psychiatr. 1912;10(1):1-60. http://dx.doi. org/10.1007/BF02901445. 12. Poser CM, Goutie’res F, Carpentier MA, Aicardi J. Schilder’s myelinoclastic diffuse sclerosis. Pediatrics. 1986;77(1):107-12. PMid:3940347.

4. Purohit B, Ganewatte E, Schreiner B, Kollias S. Balo’s concentric sclerosis with acute presentation and co-existing multiple sclerosis- typical lesions on MRI. Case Rep Neurol. 2015;7(1):44-50. http://dx.doi. org/10.1159/000380813.

13. Poser S, Lüer W, Bruhn H, Frahm J, Brück Y, Felgenhauer K. Acute demyelinating disease. Classifi cation and non-invasive diagnosis. Acta Neurol Scand. 1992;86(6):579-85. PMid:1481644. http://dx.doi. org/10.1111/j.1600-0404.1992.tb05490.x.

5. Graber JJ, Kister I, Geyer H, Khaund M, Herbert J. Neuromyelitis optica and concentric rings of Bal. in the brainstem. Arch Neurol. 2009;66(2):2745. PMid:19204169. http://dx.doi.org/10.1001/ archneurol.2008.539.

14. Leuzzi V, Lyon G, Cilio MR, et al. Childhood demyelinating diseases with a prolonged remitting course and their relation to Schilder’s disease: report of two cases. J Neurol Neurosurg Psychiatry. 1999;66(3):407-8. PMid:10084548. http://dx.doi.org/10.1136/jnnp.66.3.407.

Conflict of interest: None Submitted on: October 23rd, 2016 Accepted on: November 28th, 2016 Correspondence Maher Kurdi Department of Pathology - Montreal Neurological Institute - McGill University 3801 Rue University – Montreal/QC – Canada H3A 2B4 Phone: +1 (519) 878-5584 Drc_marmar@hotmail.com

Autopsy and Case Reports 2016;6(4):21-26

Article / Clinical Case Report

Unmasking histoplasmosis immune reconstitution inflammatory syndrome in a patient recently started on antiretroviral therapy Reuben Kiggundua, Henry W Nabetab, Richard Okiab, Joshua Rheina,c, Robert Lukanded Kiggundu R, Nabeta HW, Okia R, Rhein J, Lukande R. Unmasking histoplasmosis immune reconstitution inflammatory syndrome in a patient recently started on antiretroviral therapy. Autopsy Case Rep [Internet]. 2016;6(4):27-33. http://dx.doi.org/10.4322/acr.2016.048

ABSTRACT Histoplasmosis is the most common endemic mycoses among HIV-infected people. Patients with suppressed cell immunity mainly due to HIV are at increased risk of disseminated disease. Dermatological manifestations of immune reconstitution inflammatory syndrome (IRIS) and cutaneous manifestations of histoplasmosis similar to an IRIS event have been previously described. We report the case of a 43-year-old male who presented with cutaneous disseminated histoplasmosis due to Histoplasma capsulatum var. capsulatum 4 months after the onset of the antiretroviral therapy and some improvement in the immune reconstitution. After 2 weeks of amphotericin B and itraconazole therapy, the scheduled treatment involved fluconazole maintenance therapy, which resulted in an improvement of his skin lesions. Keywords Histoplasmosis; Immune Reconstitution Inflammatory Syndrome; Antiretroviral Therapy, Highly Active, Fluconazole

INTRODUCTION Histoplasmosis is a systemic fungal infection caused by the intracellular dimorphic fungus Histoplasma capsulatum. It is endemic in the USA, but has been reported in South America and Africa.

AIDS‑defining opportunistic infection presenting as an invasive form.6-8 Immune reconstitution inflammatory syndrome

Clinical

(IRIS)-related dermatological manifestations of HIV

presentation of histoplasmosis is nonspecific, and

are common, and cutaneous histoplasmosis following

95% of the patients with H. capsulatum infections

antiretroviral therapy (ART) was previously described.9,10

are asymptomatic. Therefore, the clinical presentation

We report the case of an HIV-infected patient who

of histoplasmosis may vary from asymptomatic to

presented with cutaneous histoplasmosis 4 months

disseminated disease depending on the patient’s

after the onset of ART, with viral suppression and

immunological status.

immunological recovery, which were consistent with

3-5

1,2

Histoplasmosis is an

College of Health Sciences - Infectious Disease Institute - Makerere University, Kampala – Uganda. College of Health Sciences - School of Medicine - Makerere University, Kampala – Uganda. c Department of Medicine - University of Minnesota, Minneapolis/MN – USA. d College of Health Sciences - School of Biomedical Sciences - Makerere University, Kampala – Uganda. a

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.

Unmasking histoplasmosis immune reconstitution inflammatory syndrome in a patient recently started on antiretroviral therapy

an IRIS event. The clinical manifestations, diagnosis, and management of histoplasmosis IRIS are reviewed.

CASE REPORT A 43-year-old male, known to be HIV infected for 6 months, was referred by his primary HIV clinic to the Mulago National Referral Hospital in Uganda with a 2-month history of nodular lesions in the face. Skin findings were also associated with a nonproductive cough, dyspnea, and fever over the past month. The skin nodules started to appear 2 months after ART was initiated, and began as small lesions on the nose that progressed in size and number throughout the face. The patient was initially and empirically treated with azithromycin with the hypothesis of atypical Mycobacterium cuneiform infection, with mild clinical improvement. The patient was started on ART (tenofovir 300 mg/day, lamivudine 300 mg/day, and efavirenz 600 mg/day) and trimethoprim/sulfamethoxazole for prophylaxis at the time of HIV infection diagnosis. His past medical history included the diagnosis of HIV infection 6 months earlier, with a nadir CD4 determination of 42 cells/mm3. On examination, his general condition was fair, with no lymphadenopathy, normal vital signs, and a clear chest exam. Skin examination showed hyper‑pigmented nodular lesions on his face with varying diameters. The larger lesions (approximately 2 cm × 3.5 cm) were on the nose (Figure 1). The abdominal examination did not reveal hepatosplenomegaly. The patient’s chest x-ray was normal; thoracic computed tomography was not performed. Laboratory investigations revealed normal hematological indices and serum electrolytes. The serological test for HIV was positive. The viral load for HIV was undetectable, and CD4 was 108 cells/mm3. Diagnoses of Kaposi sarcoma, bacillary angiomatosis, squamous cell carcinoma, and invasive mycosis were considered. A punch biopsy was obtained from two lesions of the face. Histological examination showed granulomatous dermatitis with round cytoplasmic organelles within the macrophages consistent with H. capsulatum var. capsulatum (Figure 2 and Figure 3). A diagnosis of unmasking mucocutaneous histoplasmosis IRIS was made. The patient was started on intravenous amphotericin B (1 mg/kg) daily 28

and oral itraconazole (400 mg daily) for 2 weeks, besides potassium and magnesium supplementation, paracetamol, and 3 L of intravenous saline daily during hospitalization. Antiretroviral therapy was continued. The patient’s renal function and complete blood count remained within normal ranges during the course of amphotericin. On completion of the amphotericin treatment, the patient’s symptoms regressed and he was discharged after 14 days on oral fluconazole 400 mg daily, as he could not afford the high cost of itraconazole. The patient has been monitored monthly since hospital discharge and continues to improve on fluconazole therapy and ART. His clinical status is favorable; the skin lesions are healing but leaving enduring scarring and partial destruction of the nasal cartilage (Figure 4).

DISCUSSION Histoplasmosis is a common AIDS-defining illness11 caused by H. capsulatum, a dimorphic fungus, which is distributed worldwide and is endemic in both South and North America, particularly in the Ohio and Mississippi river valleys in the latter. H. capsulatum var. capsulatum and H. capsulatum var. duboisii are the variants that cause human disease.12,13 H. capsulatum var. duboisii is described only in Africa; however, both variants are endemic in Uganda. Spores of H. capsulatum are found in the soil and caves inhabited by birds and bats.4 Primary lung infection results from the inhalation of microconidia, which turn into yeast in the lungs. The yeast is then spread to the reticuloendothelial system within 2-3 weeks by tissue macrophages.5,14 The clinical presentation of histoplasmosis depends on the integrity of the immune system. Nearly 95% of the infected people with normal immune systems will remain asymptomatic,1,15 and the remaining will present acute or chronic pulmonary histoplasmosis.15 However, individuals with immunosuppressive disorders affecting cell-mediated immunity may present with disseminated histoplasmosis. HIV-infected people with a CD4 cell count below 100 cells/mm3 are at increased risk for the development of disseminated histoplasmosis, 14,15 which was the case with our patient, who had a CD4 cell count of 42 cells/mm3. Autopsy and Case Reports 2016;6(4):27-33

Kiggundu R, Nabeta HW, Okia R, Rhein J, Lukande R

Figure 1. Cutaneous lesions throughout on the face before the antifungal treatment. Cough, fever, malaise, weight loss, and hepatosplenomegaly represent the most common clinical features of disseminated histoplasmosis. Although gastrointestinal symptoms are rare, 70% of patients with this disease present gastrointestinal Autopsy and Case Reports 2016;6(4):27-33

i n v o l v e m e n t o n a u t o p s y . 1,16,17 D i s s e m i n a t e d histoplasmosis may be misdiagnosed as tuberculosis or malaria due to the nonspecificity of the symptoms in many health facilities, especially when the laboratory work-up is limited. 29

Unmasking histoplasmosis immune reconstitution inflammatory syndrome in a patient recently started on antiretroviral therapy

Figure 2. Photomicrography of the skin biopsy. A - Normal epidermis and infiltrated dermis (H&E, 100X); B, C, and D - Small, oval, narrow based yeasts consistent with Histopolasma capsulatum (H&E, 400X).

Figure 3. Photomicrography of the skin biopsy showing in A - multiple oval-shaped structures consistent with Histoplasma sp (Grocott, 1000X); in B - PAS staining spores appearing as round or oval structures within the cytoplasm of the macrophages (PAS, 1000X). Cutaneous presentation is found in 6% of patients with disseminated histoplasmosis. 5,16,18 However, mucocutaneous involvement varies by geographic location and occurs more commonly in AIDS patients, particularly in those with suspected IRIS.9,19 AÂ review of the clinical manifestations of disseminated 30

histoplasmosis showed that the dermatological manifestation was more common and more extensive in Brazilian HIV-infected people when compared with North American counterparts.9 A similar tropism for skin and lymph nodes involvement has been observed in African histoplasmosis. NacherÂ etÂ al.20 described a Autopsy and Case Reports 2016;6(4):27-33

Kiggundu R, Nabeta HW, Okia R, Rhein J, Lukande R

patients, and the antibodies remain elevated for an extended time, limiting its use for differentiating relapse from an earlier infection.25-27 Urinary antigen testing offers rapid diagnosis with the sensitivity of 90% for patients with disseminated histoplasmosis and can be used for monitoring the response to therapy.2,25 Assays of histoplasma antigen in our patient’s body fluids were not performed as they are not readily available in Uganda.

Figure 4. Skin examination after 6 months of treatment. higher incidence of disseminated histoplasmosis among patients that recently started on antiretroviral therapy, suggesting that this treatment can lead to unmasking IRIS. Passos et al.21 reported the case of paradoxical histoplasmosis IRIS following re-introduction of HAART in a Brazilian patient that voluntarily stopped his HAART and itraconazole prophylaxis. Breton et al.22 presented four patients with HIV-associated with unmasking and paradoxical disseminated histoplasmosis IRIS. At the time of presentation, our patient was on ART for 4 months, with immunological response and viral suppression, which are features consistent with unmasking IRIS.23,24 Diverse diagnostic modalities with varying sensitivity and specificity are available for the diagnosis of histoplasmosis, including tissue cultures, fungal stains, and serologic tests for detecting antibodies or antigens.5 Isolation of the pathogen in culture media (BACTEC™, Becton Dickinson, Sabouraud’s agar) is the gold standard for the diagnosis; however, the isolation takes more than 4 weeks, which limits its clinical applicability. 25,26 Culture specimens can be obtained from urine, blood, sputum, lymph nodes, bronchoalveolar lavage, or bone marrow aspirate. Serology, although rapid and sensitive, is limited by low specificity because of the cross-reactivity with other fungi. Moreover, serology shows reduced sensitivity in disseminated histoplasmosis and immune suppressed Autopsy and Case Reports 2016;6(4):27-33

Histological examination with the aid of Giemsa, Wright, the periodic acid of Schiff (PAS), or methenamine silver stainings provides a less expensive and rapid diagnosis, but has loose sensitivity for the antigenic tests. H. capsulatum appears in macrophages as ovoid or spherical uninucleate yeasts of 2–4 micrometers with narrow base buds. 5 Pneumocystis jiroveci, Toxoplasma gondii, Penicillium marneffei, Candida glabrata, Leishmania donovani, and Cryptococcus neoformans may appear similar to H. capsulatum on direct microscopy. However, most of the serologic tests are expensive and barely available in Uganda. In our case, the diagnosis was based on the histologic examination of the skin biopsy. Our patient received amphotericin B and itraconazole for 2 weeks, which is the regimen of choice for the management of disseminated histoplasmosis where liposomal or lipid formulations of amphotericin are not available.5,15 The Infectious Diseases Society of America guidelines recommend that patients with disseminated histoplasmosis and HIV should be treated with amphotericin B (0.7-1 mg/kg per day) for 2 weeks followed by itraconazole for at least 12 months. 15 Secondary prophylaxis with itraconazole maintenance therapy (200 mg/day) should be considered for extended periods of immunosuppression. Some literature data suggest withdrawing prophylaxis at CD4 > 150 cells/mm3.12,28 Upon discharge, this patient was started on fluconazole instead of itraconazole because of the cost of the treatment and the unavailability of free dispensing of itraconazole in Uganda. Although fluconazole has some activity against histoplasmosis, it is less efficacious than itraconazole, and has been associated with higher resistance rates.29-31 Antiretroviral therapy substantially improves the outcomes of HIV-infected people with disseminated histoplasmosis. Additionally, there is evidence suggesting that patients on ART who develop 31

Unmasking histoplasmosis immune reconstitution inflammatory syndrome in a patient recently started on antiretroviral therapy

disseminated histoplasmosis IRIS should continue on the ART.32-34 Literature data recommend continuing prophylaxis until the clinical and the laboratory results normalize.29 Our patient received fluconazole 400 mg daily and was monitored monthly in the outpatient clinic. We intend to taper the dose of fluconazole to 200 mg at the twelfth week and withdraw it when the CD4 count exceeds 150 cells/mm 3 and, if available, a normal laboratory antigen assay is achieved. Although our patient is showing immunological improvement, there is a risk of relapse since he is receiving a less suitable drug. Additional studies are needed concerning the management and length of treatment of histoplasmosis with fluconazole to provide a second choice where itraconazole remains prohibitively expensive. We also recommend that clinicians should consider a diagnosis of cutaneous histoplasmosis in HIV-infected persons that present with Kaposi sarcoma-like lesions. Note: The patient signed an informed consent authorizing the publication the pictures of his face.

ACKNOWLEDGEMENTS The authors wish to thank Dr. Tugume Lillian and Dr. Odong Daniel for participating in patient care. REFERENCES 1. Wheat LJ. Histoplasmosis: a review for clinicians from non-endemic areas. Mycoses. 2006;49(4):274-82. http://dx.doi.org/10.1111/j.1439-0507.2006.01253.x. PMid:16784440. 2. Cottle LE, Gkrania-Klotsas E, Williams HJ, et al. A multinational outbreak of histoplasmosis following a biology field trip in the Ugandan rainforest. J Travel Med. 2013;20(2):83-7. http://dx.doi.org/10.1111/jtm.12012. PMid:23464714. 3. Regional T, Unit R, Helier S. Caecal perforation in a renal transplant patient with disseminated histoplasmosis. 1988;41(9):992-5. PMID: 3056989. 4. Kurowski R, Ostapchuk M. Overview of histoplasmosis. Am Fam Physician. 2002;66(12):2247-52. PMid:12507161. 5. Kauffman CA. Histoplasmosis: a clinical and laboratory update. Clin Microbiol Rev. 2007;20(1):115-32. http:// dx.doi.org/10.1128/CMR.00027-06. PMid:17223625. 6. Pervez MM, Cobb B, Matin N, Shahrin L, Ford ER, Pietroni M. Disseminated histoplasmosis in a patient with advanced 32

HIV disease-lessons learnt from Bangladesh. J Health Popul Nutr. 2010;28(3):305-7. http://dx.doi.org/10.3329/jhpn. v28i3.5561. PMid:20635643. 7. Gutierrez ME, Canton A, Sosa N, Puga E, Talavera L. Disseminated histoplasmosis in patients with AIDS in Panama: a review of 104 cases. Clin Infect Dis. 2005;40(8):1199-202. http://dx.doi.org/10.1086/428842. PMid:15791523. 8. Wheat LJ, Chetchotisakd P, Williams B, Connolly P, Shutt K, Hajjeh R. Factors associated with severe manifestations of histoplasmosis in AIDS. Clin Infect Dis. 2000;30(6):87781. http://dx.doi.org/10.1086/313824. PMid:10854363. 9. Lehloenya R, Meintjes G. Dermatologic manifestations of the immune reconstitution inflammatory syndrome. Dermatol Clin. 2006;24(4):549-70. http://dx.doi.org/10.1016/j. det.2006.06.007. PMid:17010783. 10. Amerson EH, Maurer TA. Immune reconstitution inflammatory syndrome and tropical dermatoses. Dermatol Clin. 2011;29(1):39-43. http://dx.doi.org/10.1016/j. det.2010.09.007. PMid:21095526. 11. Centers for Disease Control – CDC. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. Council of State and Territorial Epidemiologists; AIDS Program, Center for Infectious Diseases. MMWR Suppl. 1987;36(1):1S-15S. PMID: 3039334. 12. Loulergue P, Bastides F, Baudouin V, et al. Literature review and case histories of Histoplasma capsulatum var. dubloisii infections in HIV-infected patients. Emerg Infect Dis. 2007;13(11):1647-52. PMid:18217546. 13. Gugnani HC. Histoplasmosis in Africa: a review. Indian J Chest Dis Allied Sci. 2000;42(4):271-7. PMid:15597674. 14. Chaturvedi S, Frame P, Newman SL. Macrophages from human immunodeficiency virus-positive persons are defective in host defense against Histoplasma capsulatum. J Infect Dis. 1995;171(2):320-7. PMID: 7844367. 15. Wheat LJ, Freifeld AG, Kleiman MB, et al. Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis. 2007;45(7):807-25. http://dx.doi.org/10.1086/521259. PMid:17806045. 16. Bradsher RW. Histoplasmosis and blastomycosis. Clin Infect Dis. 1996;22(Suppl 2):S102-11. PMid:8722836. 17. Kahi CJ, Wheat LJ, Allen SD, Sarosi GA. Gastrointestinal histoplasmosis. Am J Gastroenterol. 2005;100(1):220-31. http://dx.doi.org/10.1111/j.1572-0241.2005.40823.x. PMid:15654803. 18. Verma SB. Chronic disseminated cutaneous histoplasmosis in an immunocompetent individual - a case report. Int J Dermatol. 2006;45(5):573-6. http://dx.doi.org/10.1111/ j.1365-4632.2006.02762.x. PMid:16700795. 19. Delfino E, di Biagio A, Chandrapatham K, Viscoli C, Prinapori R. Disseminated histoplasmosis with mucocutaneous immune reconstitution inflammatory syndrome in an HIV-infected patient. AIDS Res Hum Autopsy and Case Reports 2016;6(4):27-33

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Retroviruses. 2015;31(3):274-5. http://dx.doi.org/10.1089/ aid.2014.0329. PMid:25723353. 20. Nacher M, Sarazin F, El Guedj M, et al. Increased incidence of disseminated histoplasmosis following highly active antiretroviral therapy initiation. J Acquir Immune Defic Syndr. 2006;41(4):468-70. http://dx.doi.org/10.1097/01. qai.0000209927.49656.8d. PMid:16652055. 21. Passos L, Talhari C, Santos M, Ribeiro-Rodrigues R, Ferreira LC, Talnari S. Histoplasmosis-associated immune reconstitution inflammatory syndrome. An Bras Dermatol. 2011;86(4 Suppl 1):S168-72. http://dx.doi.org/10.1590/ S0365-05962011000700044. PMid:22068802. 22. Breton G, Adle-Biassette H, Therby A, et al. Immune reconstitution inflammatory syndrome in HIV-infected patients with disseminated histoplasmosis. AIDS. 2006;20(1):119-21. http://dx.doi.org/10.1097/01. aids.0000199014.66139.39. PMid:16327328. 23. Haddow LJ, Easterbrook PJ, Mosam A, et al. Defining immune reconstitution inflammatory syndrome: evaluation of expert opinion versus 2 case definitions in a South African cohort. Clin Infect Dis. 2009;49(9):1424-32. http:// dx.doi.org/10.1086/630208. PMid:19788360. 24. Robertson J, Meier M, Wall J, Ying J, Fichtenbaum CJ. Immune reconstitution syndrome in HIV: validating a case definition and identifying clinical predictors in persons initiating antiretroviral therapy. Clin Infect Dis. 2006;42(11):1639-46. http://dx.doi.org/10.1086/503903. PMid:16652323.

27. Gomez BL, Figueroa JI, Hamilton AJ, et al. Development of a novel antigen detection test for histoplasmosis. J Clin Microbiol. 1997;35(10):2618-22. PMid:9316918. 28. Murata M, Furusyo N, Otaguro S, Nabeshima S, Ariyama I, Hayashi J. HIV infection with concomitant cerebral toxoplasmosis and disseminated histoplasmosis in a 45-year-old man. J Infect Chemother. 2007;13(1):515. http://dx.doi.org/10.1007/s10156-006-0486-3. PMid:17334730. 29. Wheat J, Hafner R, Korzun AH, et al. Itraconazole treatment of disseminated histoplasmosis in patients with the acquired immunodeficiency syndrome. Am J Med. 1995;98(4):336-42. http://dx.doi.org/10.1016/S00029343(99)80311-8. PMid:7709945. 30. Wheat LJ, Connolly P, Smedema M, Brizendine E, Hafner R. Emergence of resistance to fluconazole as a cause of failure during treatment of histoplasmosis in patients with acquired immunodeficiency disease syndrome. Clin Infect Dis. 2001;33(11):1910-3. http://dx.doi. org/10.1086/323781. PMid:11692303. 31. Wheat J, Marichal P, Vanden Bossche H, Le Monte A, Connolly P. Hypothesis on the mechanism of resistance to fluconazole in Histoplasma capsulatum. Antimicrob Agents Chemother. 1997;41(2):410-4. PMid:9021199. 32. Goldman M, Zackin R, Fichtenbaum CJ, et al. Safety of discontinuation of maintenance therapy for disseminated histoplasmosis after immunologic response to antiretroviral therapy. Clin Infect Dis. 2004;38(10):1485-9. http://dx.doi. org/10.1086/420749. PMid:15156489.

25. Gómez BL, Figueroa JI, Hamilton AJ, et al. Detection of the 70-kilodalton Histoplasma capsulatum antigen in serum of histoplasmosis patients: correlation between antigenemia and therapy during follow-up. J Clin Microbiol. 1999;37(3):675-80. PMid:9986830.

33. Agudelo CA, Rosero DS, Ochoa JE, et al. Disseminated Histoplasmosis: a comparative study between patients with acquired immunodeficiency syndrome and non-human immunodeficiency virus – infected individuals. Am Soc Trop Med Hyg. 2005;73(3):576-82. PMid:16172484.

26. Durkin MM, Connolly PA, Wheat LJ. Comparison of radioimmunoassay and enzyme-linked immunoassay methods for detection of Histoplasma capsulatum var. capsulatum Antigen. J Clin Microbiol. 1997;35(9):2252-5. PMid:9276396.

34. Jenny-Avital E. Successful discontinuation of high-dose fluconazole for Histoplasma capsulatum meningitis in an AIDS Patient after sustained immune reconstitution. J Chem Inf Model. 2004;39(8):1261-2. http://dx.doi. org/10.1086/424753. PMID: 15486865.

Conflict of interest: None Submitted on: July 7th, 2016 Accepted on: September 9th, 2016 Correspondence Reuben Kiggundu College of Health Sciences - Infectious Disease Institute - Mulago Hospital Complex - Makerere University P.O. Box 22418 – Kampala – Uganda reubenkaaja@yahoo.com

Autopsy and Case Reports 2016;6(4):27-33

Article / Clinical Case Report

Endobronchial solitary fibrous tumor Cristiano Claudino Oliveiraa, Marcelo Padovani Toledo de Moraesa, Thomas Colbyb, Gilmar Felisberto Oliveirac, Erica Nishida Hasimotoc, Daniele Cristina Cataneoc, Antônio José Maria Cataneoc, Julio De Faveria Oliveira CC, Moraes MPT, Colby T, et al. Endobronchial solitary fibrous tumor. Autopsy Case Rep [Internet]. 2016;6(4):35-40. http://dx.doi.org/10.4322/acr.2016.053

ABSTRACT Solitary fibrous tumor (SFT) is a mesenchymal neoplasm that appears primarily in the pleura and rarely in intrapulmonary or endobronchial topography. The authors report the case of a 47-year-old woman who presented obstructive respiratory symptoms for 4 years. The chest computed tomography and bronchoscopy showed an obstructive polypoid lesion located between the trachea and the left main bronchus associated with distal atelectasis of the left lung. A resection of the lesion was performed and, macroscopically, the mass was oval, encapsulated, and firm, measuring 2.3 × 1.7 × 1.5 cm. Histology revealed low-grade mesenchymal spindle cell neoplasm, with alternating cellularity, myxoid areas, and mature adipose tissue outbreaks, as well as blood vessels with irregular walls. The immunohistochemical study was positive for CD34, CD99, and BCL2. The diagnosis was SFT in an unusual topography. The patient’s symptoms remitted after tumor excision, and no systemic problems were evident. SFTs primarily affect adults and often follow a benign course; however, their behavior is unpredictable. The presence of necrosis and mitotic activity may portend a poor prognosis. Endobronchial SFTs are rare but should be evaluated and monitored similar to SFTs at other sites, with a long-term follow-up. Keywords Solitary Fibrous Tumors; Bronchi; Immunohistochemistry; Lung Neoplasms; Pathology

INTRODUCTION Solitary fibrous tumor (SFT) is an uncommon soft tissue spindle cell neoplasm with distinctive histology and immunohistochemistry, which is first recognized in the visceral pleura. However, it has been described as originating from many other sites also, such as subcutaneous tissue, deep soft tissues, the head, neck, chest wall, lung, mediastinum, meninges, and the abdominal cavity. 1,2 Pak et al., 3 in a review of the literature, found 800 descriptions of STF in the

pleura, 15 in the lung parenchyma, and only 2 in an endobronchial location.

CASE REPORT A 47-year-old Caucasian woman was diagnosed with late-onset asthma because of a 4-year history of wheezing and productive cough sputum. Despite the asthma treatment, the patient’s symptoms

Department of Pathology - Botucatu School of Medicine - Universidade Estadual Paulista “Julio de Mesquista Filho”, Botucatu/SP – Brazil. Department of Laboratory Medicine and Pathology - Mayo Clinic., Phoenix/AZ, USA. c Department of Surgery and Orthopedics - Botucatu School of Medicine - Universidade Estadual Paulista “Julio de Mesquista Filho”, Botucatu/SP – Brazil. a

Endobronchial solitary fibrous tumor

progressively worsened with episodes of pain in the left hemithorax, and dyspnea with unidentified triggering agents. The patient had no previous or relevant family health problems. The physical examination of the chest showed bilateral vesicular breath sounds that were decreased in the left base. Chest radiography showed a marked volume reduction of the left lung. In a chest computed tomography scan, a rounded lesion was evident, which was partially obstructing the ostium of the left main bronchus (Figure 1A).

The patient underwent a rigid bronchoscopy, which found a mobile polypoid lesion that adhered to the bronchial mucosa. It had a smooth shiny surface, was not friable, and obstructed the left main bronchus (Figure 1B). It was removed endoscopically. On gross examination, the lesion was oval‑shaped, well circumscribed, encapsulated, with a fibroelastic consistency, and measured 2.3 × 1.7 × 1.5 cm and weighed 5.0 g. The cut surface was smooth, homogeneous, and brownish in color (Figure 2A). All material was sampled for microscopic evaluation.

Figure 1. A - Chest CT axial plane showing reduced volume of the left lung and an obstructive lesion (arrow) at the carina obstructing the emergence of the left main bronchus; B - Endoscopic view of the polypoid lesion observed within the left main bronchus.

Figure 2. A - Macroscopic view of the light-brownish oval lesion with a bright and irregular surface; B - Photomicrography of the tumor; histologic section showing varied cellularity of the neoplasia. Note the absence of necrosis (H&E, 50X). 36

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Histological sections of this material showed low‑grade mesenchymal neoplasm without cellular atypia or necrosis, represented by spindle cells arranged in small, loose, fascicular arrangements, with hypercellular and hypocellular areas (Figures 2B and 3A). The hypocellular areas had dense collagen bands and focal myxoid changes. There were focal aggregates of mature fat cells. Blood vessels were irregular in shape and focally showed a “staghorn” configuration (Figures 3B, 3C, 3D).

The mitotic counting was 2 per 10 high‑power fields. The morphological findings were consistent with a benign spindle cell neoplasm. The immunohistochemical study revealed negativity for cytokeratin (AE1/AE3), S100 protein, smooth muscle actin, and desmin. The neoplastic cells were positive for CD34, CD99, and BCL2 (Figure 4A, 4B, 4C, respectively). The histological features were consistent with the diagnosis of SFT. The patient became asymptomatic after the lesion’s excision, and during

Figure 3. Photomicrography of the tumor. A - Hypercellular neoplastic area; spindle cells with minimal atypia. Note the absence of mitotic activity (H&E, 400X); B - Area of less intense cellularity, with dense collagen and focal myxoid degeneration (H&E, 200X); C - Blood vessels with “staghorn” configuration (H&E, 200X); D – Spotlights of mature adipose tissue within the fusocellular neoplastic areas (H&E, 200X).

Figure 4. Photomicrography of the tumor. Immunohistochemistry: A - Positivity for CD 34 (400X); B - Positivity for CD 99 (400X); C - Positivity for BCL 2 (200X). Autopsy and Case Reports 2016;6(4):35-40

Endobronchial solitary fibrous tumor

the 18-month follow-up no other lesions were detected.

DISCUSSION SFT is a mesenchymal neoplasm, often with a hemangiopericytic pattern, 1,2,4 and framed in the group of soft tissue tumors as of uncertain histological type and indeterminate malignancy. 1 This group of tumors also comprises the ossifying fibromyxoid tumor, the mixoinflammatory fibroblast sarcoma, the pleomorphic hyalinizing angiectatic tumor, and the phosphaturic mesenchymal tumor.1 The World Health Organization has classified SFT in the group of fibroblastic/myofibroblastic tumors.2 Since the initial descriptions of this neoplasm, there has been a discussion on the use of the terminology hemangiopericytoma/SFT; currently, SFT is the preferred nomenclature.1,2 This tumor usually affects adults aged between 20 and 70 years, with no gender preference. The clinical behavior is represented by a painless and slow-growing mass, which is eventually associated with compressive symptoms.1,2 In the case reported herein, the patient had an obstruction to the respiratory airway, which was clinically misdiagnosed as late-onset asthma. Macroscopically, these tumors may be encapsulated and they are well-circumscribed, sometimes forming nodules (as noted in visceral topographies), or appearing as exophytic masses (as seen in serous surfaces). In general, the size varies between 5.0 cm and 10.0 cm, the color is grayish‑white, and there is eventual central bleeding and/or necrotic foci. Histologic evaluation reveals varying cell density composed of spindle cells with rounded nuclei, and indistinct cytoplasm with or without mild atypia. Focal hyalinization and thickening of the vessel walls have often been observed and, together with the branch and irregularities of vascular walls (staghorn-like vascular network), this gives the hemangiopericytic-like pattern to the lesion.1,2 Varying proportions of myxoid patterns are also reported.5,6 The presence of mature adipose tissue foci has already been described, mainly in the variant called “fat-forming,” which has a similar outcome and prognosis.7 Regarding the immunohistochemical evaluation, three markers have been highlighted: CD34, CD99, 38

and BCL2, which are positive in 90%, 70%, and 30% of cases, respectively. Variable positivity is described for epithelial membrane antigen and smooth muscle actin. Markers, such as desmin, S100 protein, and cytokeratin, are necessarily negative. 2 Recently, Bouvier et al. 8 described the overexpression of the ALDH1 gene in 84% of cases of SFT. They observed high sensitivity and specificity of the immunohistochemistry for the detection of this gene product for the diagnosis of SFT, especially when associated with the standard markers of this neoplasm.8 This research emphasized their use, particularly in the meninges topography to differentiate it from meningioma, because only 1.2% of meningothelial tumors have an overexpression of this gene.8 Unlike other soft tissue tumors, which have specific chromosomal/genetic alterations, SFT does not have well-defined molecular abnormalities Recently, the literature highlighted gene fusion NAB2/ STAT6, associated with deregulation of the NAB2 gene—a gene regulator of the early growth response 1 transcription factor.9,10 The intrapulmonary or endobronchial location of this tumor is unusual.4,9 Rao et al.4 described the clinical, morphological, and immunophenotypic characteristics of 24 cases of intrapulmonary SFT. 4 They emphasized that the appearance of these tumors in topography may be related to (i) direct continuity between the mesenchyme and subpleural pulmonary interlobular septa; (ii) parenchymal lung fibroblasts; or (iii) invaginations of the visceral pleura.4 In the case presented herein, the presence of myxoid areas and adipose tissue associated with the fibrous component gave rise to the differential diagnosis of a bronchial lipomatous tumor (i.e. adipocytes lesion with discrete cellular atypia). Boland et al.,11 in a study of such cases, showed that even the most atypical lesions reveal a cytogenetic profile consistent with lipomas, and they emphasized that liposarcoma, in this location, is quite unusual. Spindle cell lipoma, a lesion with a variable proportion of adipose tissue, is another differential diagnosis. However, it rarely originates in deep topographies and it lacks the typical irregular shape of the vasculature.2,12 Myofibroblastoma, a common cancer in the breast and abdominal wall, also could be a possibility, but it presents positivity for desmin, which is not observed in SFT.2,12,13 It should be noted that SFT, spindle cell Autopsy and Case Reports 2016;6(4):35-40

Oliveira CC, Moraes MPT, Colby T, et al.

lipoma, and myofibroblastoma are neoplasms with overlapping morphology and immunophenotype features. The expression of CD34 in these tumors emphasizes the plasticity of differentiation of these cells.12,13 The majority of patients with SFT have a benign course following excision. The two most important criteria for bad prognostic predictors are mitotic activity (more than 4 mitoses in 10 high-power fields) and necrosis.1,2 Other criteria for bad prognosis include a tumor size > 5.0 cm, marked cellularity, hemorrhage, and cellular pleomorphism.1 Rao et al.,4 in a study of patients with intrapulmonary SFT, showed that even tumors with mild atypia and lacking mitotic activity or necrosis rarely fare poorly. Therefore, excision and careful clinical follow-up are essential. DeMicco et al.,14 after a study at the MD Anderson Cancer Center, proposed a risk stratification model based on age (cut‑off: 55 years), size (< 5.0 cm, 5.0-10 cm, 10-15 cm, ≥ 15 cm), and mitotic activity (0, 1-3 mitoses, and ≥ 4 mitoses). Each item gives a score, rendering a classification of low risk (0-2 points), moderate risk (3-4 points), and high risk (5-6 points).14 Low-risk patients had an absence of metastases and 100% survival after 5 and 10 years. However, high-risk patients showed only a 15% free rate of metastatic disease after 5 years, 60% survival after 5 years, and 0% survival after 10 years.14 Our patient was classified as low-risk; therefore, rigorous clinical monitoring was recommended. SFT is a compelling neoplasm for clinicians, surgeons, and pathologists, and is often difficult to diagnose. In this case, the challenge was imposed by the location and the morphologic variation with focal adipose tissue and myxoid changes. This report highlights the importance of careful morphological evaluation in risk stratification to predict the biological behavior of this lesion.

REFERENCES 1. Goldblum JR, Folpe AL, Weiss SW. Soft tissue tumors of intermediate malignancy of uncertain type. In: Goldblum JR, Folpe AL, Weiss SW, editors. Enzinger and Weiss’s soft tissue tumors. 6th ed. Philadelphia: Mosby Elsevier; 2014. p. 1093-1160. 2. Fletcher CDM, Bridge JA, Lee JC. Extrapleural solitary fibrous tumor. In: Fletcher CDM, Bridge JA, Hogendoorn Autopsy and Case Reports 2016;6(4):35-40

PCW, Martens F, editors. WHO classification of tumors of soft tissue and bone. Lyon: IARC; 2013. 3. Pak PS, Yanagawa J, Abtin F, Wallace WD, Holmes C, Lee JM. Surgical manegement of endobronchial solitary fibrous tumor. Ann Thorac Surg. 2010;90(2):65961. PMid:20667378. http://dx.doi.org/10.1016/j. athoracsur.2010.02.024. 4. Rao N, Colby TV, Falconieri G, Cohen H, Moran CA, Suster S. Intrapulmonary solitary fibrous tumors: clinicopathological and immunohistochemical study of 24 cases. Am J Surg Pathol. 2013;37(2):155-66. PMid:23108019. http:// dx.doi.org/10.1097/PAS.0b013e31826a92f5. 5. Hasegawa T, Matsuno Y, Shimoda T, Hasegawa F, Sano T, Hirohashi S. Extrathoracic solitary fibrous tumors: their histological variability and potentially aggressive behavior. Hum Pathol. 1999;30(12):1464-73. PMid:10667425. http://dx.doi.org/10.1016/S0046-8177(99)90169-7. 6. Saint Aubain Somerhausen N, Rubin BP, Fletcher CD. Myxoid solitary fibrous tumor: a study of seven cases with emphasis on differential diagnosis. Mod Pathol. 1999;12(5):463-71. PMid:10349983. 7. Guillou L, Gebhard S, Coindre JM. Lipomatous hemangiopericytoma: a fat-containing variant of solitary fibrous tumor? clinicopathologic, immunohistochemical, and ultrastructural analysis of a series in favor of a unifying concept. Hum Pathol. 2000;31(9):110815. PMid:11014579. http://dx.doi.org/10.1053/ hupa.2000.9777. 8. Bouvier C, Bertucci F, Métellus P, et al. ALDH1 is an immunohistochemical diagnostic marker for solitary fibrous tumours and haemangiopericytomas of the meninges emerging from gene profiling study. Acta Neuropathol Commun. 2013;1(1):10. PMid:24252471. http://dx.doi.org/10.1186/2051-5960-1-10. 9. Mohajeri A, Tayebwa J, Collin A, et al. Comprehensive genetic analysis identifies a pathognomonic NAB2/ STAT6 fusion gene, nonrandom secondary genomic imbalances, and a characteristic gene expression profile in solitary fibrous tumor. Genes Chromosomes Cancer. 2013;52(10):873-86. PMid:23761323. http://dx.doi. org/10.1002/gcc.22083. 10. Schweizer L, Koelsche C, Sahm F, et al. Meningeal hemangiopericytoma and solitary fibrous tumors carry the NAB2-STAT6 fusion and can be diagnosed by nuclear expression of STAT6 protein. Acta Neuropathol. 2013;125(5):651-8. PMid:23575898. http://dx.doi. org/10.1007/s00401-013-1117-6. 11. Boland JM, Fritchie KJ, Erickson-Johnson MR, Oliveira AM, Colby TV, Folpe AL. Endobronchial lipomatous tumors: clinicopathologic analysis of 12 cases with molecular cytogenetic evidence supporting classification as “lipoma”. Am J Surg Pathol. 2013;37(11):171521. PMid:24121172. http://dx.doi.org/10.1097/ PAS.0b013e3182a115c9. 39

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12. Magro G, Bisceglia M, Michal M, Eusebi V. Spindle cell lipoma-like tumor, solitary fibrous tumor and myofibroblastoma of the breast: a clinico-pathological analysisof 13 cases in favor of a unifying histogenetic concept. Virchows Arch. 2002;440(3):249-60. PMid:11889594. http://dx.doi.org/10.1007/s00428001-0572-y. 13. Fritchie KJ, Carver IP, Sun Y, et al. Solitary Fibrous Tumor: Is There a Molecular Relationship With Cellular

Angiofibroma, Spindle Cell Lipoma, and Mammary-Type Myofibroblastoma? Am J Clin Pathol. 2012;137(6):96370. PMid:22586056. http://dx.doi.org/10.1309/ AJCPQEG6YNN6CNAL. 14. Demicco EG, Park MS, Araujo DM, et al. Solitary Fibrous Tumors: a clinicalpathological study of 110 cases and proposed risk assessment model. Mod Pathol. 2012;25(9):1298-306. PMid:22575866. http://dx.doi. org/10.1038/modpathol.2012.83.

Conflict of interest: None Submitted on: October 2nd, 2016 Accepted on: November 16th, 2016 Correspondence Cristiano Claudino Oliveira Department of Pathology - Botucatu School of Medicine - São Paulo State University Distrito de Rubião Junior, s/n – Botucatu/SP – Brazil CEP: 18618-970 Phone: +55 (14) 3811-6238 cristiano_c_oliveira@hotmail.com

Autopsy and Case Reports 2016;6(4):35-40

Article / Clinical Case Report

Emphysematous pyelonephritis in a transplanted kidney Cristiano Claudino Oliveiraa, Paula Dalsoglio Garciab, Rosa Marlene Vieroa OliveiraCC,GarciaPD,VieroRM.Emphysematouspyelonephritisinatransplantedkidney.AutopsyCaseRep[Internet]. 2016;6(4):41-47. http://dx.doi.org/10.4322/acr.2016.051

ABSTRACT Emphysematous pyelonephritis is a rare infection characterized by necrosis and gas accumulation in the renal parenchyma, adjacent tissues, and/or urinary collecting system. This entity is rarely reported in transplanted kidneys. Computed tomography imaging is necessary for diagnosis and risk classification. The authors described the case of a 58-year-old man who underwent a kidney transplant and presented sepsis from a urinary tract infection. An abdominal tomography showed some characteristics of emphysematous pyelonephritis associated with an abscess. A graft biopsy, performed 45 days after the transplant, failed to show signs of infection, and tubule-interstitial and vascular rejection were ruled out. The patient had a poor outcome, and a nephrectomy was needed, the pathological analysis of which yielded the diagnosis of chronic pyelonephritis with necrotizing papillitis. The patient became hemodynamically unstable and died. The authors highlight the current tomographic criteria for the diagnosis and treatment of emphysematous pyelonephritis and question the validity of accepting the same standards used to guide the treatment of patients without transplants, and call attention to the importance of the clinical status for the indication of nephrectomy in cases of emphysematous pyelonephritis. Keywords Transplantation, Kidney Diseases, Pyelonephritis.

INTRODUCTION

CASE REPORT

Emphysematous pyelonephritis (EP) is a rare infectious disease with aggressive clinical behavior, which is observed in patients with diabetes mellitus and is rarely described in transplant recipients whose diagnosis depends on the clinical features and tomographic patterns.1-4 We report a case of EP in a transplanted kidney, with a discussion of clinical, radiological, therapeutic, and mainly pathological aspects of this disease.

A 58-year-old diabetic man diagnosed with chronic renal failure due to diabetic nephropathy received a deceased donor kidney transplant after 2 years of chronic peritoneal dialysis. The induction immunosuppressive therapy involved thymoglobulin, and the maintenance was held with tacrolimus, mycophenolate sodium, and prednisone. The immediate postoperative period was troublesome, requiring vasoactive drugs and chemical cardioversion for an atrial flutter. The transplant

a b

Department of Pathology - Botucatu School of Medicine - Universidade Estadual Paulista “Júlio de Mesquita Filho” – Botucatu/SP, Brazil. Department of Internal Medicine - Botucatu School of Medicine - Universidade Estadual Paulista “Júlio de Mesquita Filho” – Botucatu/SP, Brazil.

Emphysematous pyelonephritis in a transplanted kidney

showed delayed graft function requiring hemodialysis for 15 days and, although the diuresis started on the 8th day after surgery, the serum creatinine values slowly decreased. The Doppler ultrasound was performed on the 1st day after the transplantation and no vascular complications were detected. During hospitalization, on the 10th day after the transplant, the patient was prescribed ertapenem for 13 days due to a urinary tract infection caused by ESBL + Klebsiella sp. The immediate postoperative urine culture was negative. The patient also had phlebitis, and vancomycin was added to the treatment. On the 40th hospitalization day, an abdominal computed tomography (CT) showed the image consistent

with a lymphocele in the surgical site, involving the transplanted kidney, which was treated conservatively. At the end of the antibiotic therapy, the patient was discharged with steady creatinine levels of 5.5 mg/dL (reference value: 0.8–1.5mg/dL). At the time of hospital discharge, the urine culture was negative. After 45 days of the transplantation, even with adequate diuresis, serum creatinine values were still high. Therefore, a graft biopsy was performed, which showed a small area of ischemic necrosis, without evidence of signs of residual infection (Figure 1A and 1B). Arteries showed marked intimal fibrosis and a duplication of the internal elastic consistent with previous donor lesions. At surgery, arterial fibroelastosis was not observed

Figure 1. Photomicrography of the kidney biopsy 45 days after transplantation. A – Three areas of the sample are pointed out: (i) unspecific inflammatory process in the subcapsular area, indicated by a circle; (ii) coagulative necrosis, indicated by an arrow; and (iii) tubular degeneration and necrosis indicated by a square (H&E, 20x); B – Cortical with extensive tubular degeneration and necrosis. Note: there were no signs of rejection or infection (H&E, 100X); C – Extensive tubular hydropic degeneration with more detail (H&E, 400X); D – Medulla with intense edema and tubular necrosis; there was an absence of infectious inflammatory infiltrate and papillary necrosis (H&E, 100X). 42

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Oliveira CC, Garcia PD, Viero RM

Figure 2. Abdominal CT images. A – Axial image: the graft surrounded by inflammatory process and gas (arrow) in contact with an abscess (A); perigraft abscess in close contact with the psoas muscle (arrowhead); B – Coronal plane. Note the abscess juxtaposed to the psoas muscle. in the most superficial vessels of the implantation biopsy. There was no evidence of tubule-interstitial and vascular rejection. The immunofluorescence study revealed negativity for C4d. The urine culture was negative at this stage. Two days after the biopsy, the patient returned to the emergency facility presenting severe sepsis due to urinary infection (ESBL+ Klebsiella sp. was isolated from the urine and blood cultures) and was started on antibiotic therapy with imipenem. Over the following days, the patient progressed with worsening clinical status, presenting hypotension, tachycardia, and shock. The abdominal CT showed a homogeneous fluid collection, measuring 9.4 × 7.0 cm, in the upper pole of the graft, with contiguity with the psoas muscle and a gaseous component in the pelvis and chalices of the graft extending to subcutaneous tissue. These findings were consistent with EP and perigraft collection (Figure 2A and 2B).

Figure 3. Gross appearance of the longitudinal section of the formalin fixed transplanted kidney: cortical pale and swollen with multiple microabscesses (arrow) and tiny areas of subcapsular necrosis (arrowhead); medulla with necrotizing papillitis, indicated by a circle.

Fluconazole and polymyxin B were added to the antibiotic regimen. On the same day, based on the clinical and radiological findings, surgical drainage of the collection and graft excision were undertaken. The intraoperative description reported a purulent collection in the upper pole of the graft. This material culture was positive for the same bacteria from the urine and blood cultures. After this procedure, the patient presented refractory septic shock and died.

10.0 × 6.0 × 4.0 cm, weighing 95 grams, with an uneven surface, exhibiting pale areas of imprecise limits. The structures of the renal hilum were preserved. The kidney’s cut surface showed diffuse pallor of the renal parenchyma with mild dilatation of the pelvis and ureter. The cortex was swollen and showed multiple small abscesses. Papillary necrosis was present, and most of the necrotic papilla sloughed into the lumen of the renal pelvis. There were also very small subcapsular areas of ischemic necrosis (Figure 3).

The macroscopic examination of the surgical specimen showed a kidney measuring

The histopathological study of the transplanted kidney was consistent with chronic suppurative

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pyelonephritis with necrotizing papillitis. Histopathological findings showed an extensive acute inflammatory process with multiple abscesses in the cortical. Small areas of superficial ischemic necrosis were also seen. The medulla showed papillary necrosis characterized by ischemic necrosis surrounded by intensive suppurative inflammatory infiltration and calcium deposits. Newly formed vessels and fibrosis were observed in the renal parenchyma (Figure 4A, 4B, 4C, and 4D).

DISCUSSION EP is a rare disorder characterized by necrotizing kidney infection with the production of gas, which builds up in the parenchyma, the perirenal tissues and/or urinary collecting system. It is a pathological condition commonly diagnosed in patients with diabetes mellitus, with a mortality rate of up to 80% when improperly treated. After the 1970s, with the improvement of antibiotics and life support equipment

in the care of critically ill patients, mortality was reduced to the current rate of 20%.1 The most commonly involved etiological agents are represented by Gram-negative bacteria, especially Escherichia coli, identified in 43.6-69% of cases, followed by Klebsiella sp., Proteus sp., Enterobacter sp., and other agents, such as Streptococcus sp. and Candida sp.1,2 In 2014, Arsene et al.3 highlighted the combination of the presence of pathogenic fermenting bacteria in the presence of high levels of serum glucose and impaired tissue perfusion as being responsible for the fast development of this entity.3 Regarding the prognostic predictors, Lu et al. 1 conducted a retrospective study comprising 32 patients with EP, where hypoalbuminemia, bacteremia, hemodialysis, and shock were the initial presentation, which, added to polymicrobial infection, represented factors of a poor outcome. Indeed, shock and polymicrobial infection are the best markers that correlate with poor prognosis. 1 Our patient was readmitted presenting clinical signs of sepsis.

Figure 4. Photomicrography of the kidney. A – Chronic pyelonephritis with necrotizing papillitis (arrow) and, above this area, subcapsular coagulative necrosis (arrowhead) (H&E, 40X). B – Renal cortex with arterial fibroelastosis, indicated by a circle, at the bottom of a shallow area of coagulative necrosis (arrows) (H&E, 200X). C – Chronic pyelonephritis with abscesses (H&E, 400X). D – Necrotizing papillitis (H&E, 400X). 44

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In 2012, Alexander et al.2 reported a literature review comprising 22 cases of EP in transplant patients. These authors reviewed 20 of these 22 cases and showed that 18 patients had diabetes mellitus and aged between 12 and 76 years. In this series, the disease manifested within the period from 2 weeks to 15 years after the transplant. The main etiologic agent was E. coli (55%). Nine of the 20 reviewed patients underwent antibiotic therapy associated with graft excision, and seven received antibiotic therapy associated with percutaneous drainage. The remaining four patients received only antibiotics with full recovery after the treatment. Three deaths occurred among the group of patients who underwent the graft excision.2 Therapeutic schedules for EP are established according to the tomographic findings of the kidney and the perinephric tissues. The most widely used classification is that proposed by Huang and Tseng,5 established by the tomographic evaluation of a native kidney. According to this classification, four classes are defined, which show a correlation with the mortality rate (Table 1). Classes 1, 2, and 3A allow antibiotic therapy and surgical drainage; however, the classes 3B and 4 require nephrectomy, especially when associated with other clinical data, such as hemodynamic instability and thrombocytopenia.2 The use of the Huang and Tseng classification 5 in the case of transplant patients was discussed by Al-Geizawi et al. 4 These authors emphasized that

transplant patients with EP, regardless the extension of the involvement, should be classified as Huang and Tseng Class 4, because, as renal grafts do not have Gerota’s fascia, the spread of the infection to the surrounding tissues is easier. In this context, Al-Geizawi et al. 4 studied 20 transplant patients who presented EP and, considering the renal function impairment (caused by the infection) as the single criterion, proposed a new classification (Table 2) with therapeutics purposes. Therefore, the treatment for Al-Geizawi’s stage 1 classification should be antibiotics and close clinical surveillance with glycemic and electrolyte controls, as well as continuous assessment of immunosuppression. For stage 2, in addition to the latter precautions, surgical drainage and tomographic scans (to monitor the behavior of the infection’s signs) should be added.4 For stage 3, nephrectomy should be indicated in the case of transplanted kidneys. Al-Geizawi et al. 4 reviewed the reports of 16 cases of EP in renal allografts described in the literature, and classified them according to their proposed classification. Among this group, 13 patients presented concordance between both classifications, which meant that the adopted therapeutics were the same regardless of the classification. However, in this study, among these 13 patients, two classified as Al-Geizawi’s stage 3 died after nephrectomy, which was lately performed (five and four days after the

Table 1. Huang and Tseng5 classification based on computed tomography findings, validated for patients with emphysematous pyelonephritis affecting the native kidney Category

Definition

Risk of mortality

Class 1

Gas in the collecting system

Zero

Class 2

Gas in the renal parenchyma with no extension beyond the organ

10%

Class 3 A

Gas and/or abscess in perirenal space

29%

Class 3 B

Gas and/or abscess in para-renal space

19%

Class 4

Bilateral emphysematous pyelonephritis or affecting single solitary kidney

50%

Table 2. Classification of patients with emphysematous pyelonephritis, as Al-Geizawi et al4 Category

Definition

Risk of mortality

Stage 1

Gas in the collecting system

Zero

Stage 2

Gas least 50% of the renal parenchyma, with minimum extension to perirenal space, quickly controlled sepsis

Zero

Stage 3

Gas in more than 50% of the renal parenchyma or extensive spread to perirenal space or evidence of organ failure, or uncontrolled sepsis, or nonresponder shock to therapeutic measures

25%

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Emphysematous pyelonephritis in a transplanted kidney

diagnosis). Among the remaining patients, three presented discordance, namely: (i) one patient, classified as Al-Geizawi’s stage 2, was treated with nephrectomy and presented a favorable outcome; (ii) one patient, classified as Al-Geizawi’s stage 2, was treated with antibiotics without surgical drainage, also evolved favorably; and (iii) one patient, classified as Al-Geizawi’s stage 3, was treated with antibiotics without nephrectomy presented a favorable outcome as well.4 There are few cases of EP in renal allografts, which limits a detailed evaluation of the Al-Geizawi classification. Despite the existence of these classifications, one should not be tied to them: the clinical status, if unsteady and deteriorating, should anticipate the decision by nephrectomy. Notwithstanding the concordance between the aforementioned classifications, two patients died because of the delay in surgical intervention. The success observed in two patients with Al-Geizawi’s stages 2 and 3, respectively, who were treated exclusively with antibiotics, should not be seen as a rule. Delays in surgical interventions, either nephrectomy or drainage, may result in death. CT evaluation is important for diagnosis, classification, and therapeutic scheduling in cases of EP. However, the clinical and laboratory evaluation, with attention to clinical features of sepsis and urine culture, must be taken as the priority mainly in patients at risk, such as patients with diabetes and those who are immunosuppressed, specifically with kidney transplants. 6,7 Alhajjaj and Pasha 8 reported a case similar to the case of our patient. These authors also stated the importance of a surgical approach in these cases due to the infection severity in the context of a patient with impaired immunity. In the case presented herein, the first CT scan— after the first infection treatment—showed an image consistent with lymphocele, and the biopsy sampled small areas of necrosis, hemorrhage, and mild inflammatory process. After the second CT scan—during the second hospitalization—the patient underwent graft removal, which showed the pathologic findings similar to those reported by Archana et al.7 in diabetic patients without kidney transplant: anemic infarctions, abscesses, and fibrosis.7 Our patient had a progressively poor clinical outcome. In the context of the morphological aspects seen in the transplanted 46

kidney, it is likely that the patient had complicated pyelonephritis from the beginning, soon after the transplant. The first treatment did not eradicate the infection, although the culture was negative at the patient’s hospital discharge. The infection relapse and the renal complications were also decisive for the poor outcome. The needle biopsy was important to rule out the possibility of rejection but failed to show the parenchymal infection. The small areas of superficial necrosis should be interpreted, in this case, as evidence of an infectious complication. Archana et al.7 reported a case of EP in a diabetic patient showing microabscesses associated with areas of coagulative necrosis. They emphasized that EP is related to immunity and impaired tissue perfusion. In our case, the most impressive finding was the extensive and destructive infection in an immunosuppressed patient. The necrotic areas were superficial and very small. They should not be considered as infarctions. Thrombi were not found. The presence of arteriosclerosis and the microcirculation compression by the inflammatory process may have contributed to the development of the coagulative necrosis. In our case, we disfavor the idea of vascular complication due to problems with the surgical anastomosis. The Doppler ultrasound on the first day after transplantation ruled out any vascular complications. The Doppler ultrasound on the first three days after transplantation was helpful to detect the acute graft dysfunctions as rejection and surgical complications.9 This image data and the absence of thrombi in the surgical specimen disfavor any renal allograft thrombosis, a condition responsible for 2-7% of early allograft losses in adults occurring in the postoperative period, with a peak incidence of 48 hours. Thrombosis may be related to technical problems during the vascular clamp or, in some cases, to the presence of atheroma, which represents the only independent factor associated with the risk of arterial renal thrombosis.10 Despite the existence of EP classification, the utility of the CT, and the urine culture for therapeutic scheduling, the signs of disease severity should always be placed first and considered for more accurate treatment decisions. In fact, biopsies are not needed for this diagnosis. However, their importance relies on clarifying the differential diagnosis and, maybe, in Autopsy and Case Reports 2016;6(4):41-47

Oliveira CC, Garcia PD, Viero RM

revealing the signs of morphological complications, as seen in this case.

REFERENCES 1. Lu YC, Chiang BJ, Pong YH, et al. Emphysematous pyelonephritis: clinical characteristics and prognostic factors. Int J Urol. 2014;21(3):277-82. PMid:24033515. http://dx.doi.org/10.1111/iju.12244. 2. Alexander S, Varughese S, David VG, et al. Extensive emphysematous pyelonephritis in a renal allograft treated conservatively: case report and review of the literature. Transpl Infect Dis. 2012;14(6):E150-5. PMid:23025565. http://dx.doi.org/10.1111/tid.12016. 3. Arsene C, Saste A, Arul S, Mestrovich J, Kammo R, Elbashir M et al. A case series of emphysematous pyelonephritis. Case Rep Med. 2014;2014:587926. PMID: 24812561. http://dx.doi.org/10.1155/2014/587926. 4. Al-Geizawi SMT, Farney AC, Rogers J, et al. Renal allograft failure due to emphysematous pyelonephritis: successful non-operative management and proposed new classification scheme based on literature review. Transpl Infect Dis. 2010;12(6):543-50. PMid:20825591. http:// dx.doi.org/10.1111/j.1399-3062.2010.00538.x.

5. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classiﬁcation, management, prognosis, and pathogenesis. Arch Intern Med. 2000;160(6):797805. PMid:10737279. http://dx.doi.org/10.1001/ archinte.160.6.797. 6. Schmidt S, Foert E, Zidek W, van der Giet M, Westhoff TH. Emphysematous pyelonephritis in a kidney allograft. Am J Kidney Dis. 2009;53(5):895-7. PMid:19344987. http://dx.doi.org/10.1053/j.ajkd.2008.12.032. 7. Archana S, Vijaya C, Geethamani V, Savitha AK. Emphysematous pyelonephritis in a diabetic leading to renal destruction: pathological aspects of a rare case. Malays J Pathol. 2013;35(1):103-6. PMid:23817403. 8. Alhajjaj FS, Pasha F. Emphysematous pyelonephritis in renal allograft – a case report. Int J Health Sci (Qassim). 2016;10(2):311-3. PMid:27103911. 9. Contti MM, Garcia PD, Kojima CA, Nga HS, Carvalho MFC, Andrade LG. Quantified power Doppler as a predictor of delayed graft function after renal transplantation. Int Urol Nephrol. 2015;47(2):405-12. PMid:25503640. http:// dx.doi.org/10.1007/s11255-014-0896-6. 10. Ponticelli C, Moia M, Montagnino G. Renal allograft thrombosis. Nephrol Dial Transplant. 2009;24(5):138893. PMid:19182239. http://dx.doi.org/10.1093/ndt/ gfp003.

Conflict of interest: None Submitted on: March 5th, 2016 Accepted on: October 30th, 2016 Correspondence Cristiano Claudino Oliveira Botucatu School of Medicine - Universidade Estadual Paulista “Júlio de Mesquita Filho” (UNESP) Distrito de Rubião Junior, s/nº – Botucatu – São Paulo/SP – Brazil CEP: 18618-000 Phone: +55 (14) 3811-6238 cristiano_c_oliveira@hotmail.com

Autopsy and Case Reports 2016;6(4):41-47

Article / Clinical Case Report

Rosai-Dorfman disease affecting the maxilla Thaís Gimenez Minielloa, Juliane Piragine Araujoa, Norberto Nobuo Sugayaa, Fernando Melhem Eliasb, Oslei Paes de Almeidac, Fabio Abreu Alvesd Miniello TG, Araujo JP, Sugaya NN, Elias FM, Almeida OP, Alves FA. Rosai-Dorfman disease affecting the maxilla. Autopsy Case Rep [Internet]. 2016;6(4):49-55. http://dx.doi.org/10.4322/acr.2016.057

ABSTRACT Rosai-Dorfman disease (RDD), formerly called sinus histiocytosis with massive lymphadenopathy, is a non-neoplastic proliferative histiocytic disorder with behavior ranging from highly aggressive to spontaneous remission. Although the lymph nodes are more commonly involved, any organ can be affected. This study aimed to describe the features and the follow-up of a case of extranodal RDD. Our patient was a 39-year-old woman who was referred with an 11-month history of pain in the right maxilla. On clinical examination, some upper right teeth presented full mobility with normal appearance of the surrounding gingiva. Radiographic exams showed an extensive bone reabsorption and maxillary sinus filled with homogeneous tissue, which sometimes showed polypoid formation. An incisional biopsy demonstrated a diffuse inflammatory infiltrate rich in foamy histiocytes displaying lymphocytes emperipolesis. Immunohistochemistry showed positivity for CD68 and S-100, and negativity for CD3, CD20, and CD30. Such features were consistent with the RDD diagnosis. The patient was referred to a hematologist and corticotherapy was administrated for 6 months. RDD is an uncommon disease that rarely affects the maxilla. In the present case, the treatment was conservative, and the patient is currently asymptomatic after 5 years of follow-up. Keywords Histiocytosis, Sinus; Maxilla; Emperipolesis; Diagnosis, Oral

INTRODUCTION Rosai-Dorfman disease (RDD) or sinus histiocytosis with massive lymphadenopathy is a rare histiocytic disease of unknown etiology. Some studies have reported a relationship with autoimmune diseases, hematological malignancies, post-infectious conditions, and immune dysfunction.1,2 The most common clinical findings of RDD include extensive painless lymphadenopathy with fever, weight loss, anemia, night sweats, tonsillitis, nasal problems,

and hepatosplenomegaly.3 Extranodal involvement can occur in the head and neck, particularly in the paranasal sinus and the nasal cavity. Exclusive bone lesions are exceptionally rare and usually have an unpredictable clinical course.4 The aim of this report is to describe a rare case of RDD affecting the maxilla in association with maxillary sinuses, mucosal thickening, and polypoid lesions. The differential diagnosis and prognosis are discussed.

Stomatology Department - School of Dentistry - Universidade de São Paulo, São Paulo/SP – Brazil. Oral and Maxillofacial Surgery Department - Faculty of Dentistry - University Hospital - Universidade de São Paulo, São Paulo/SP – Brazil. c Oral Pathology Department - School of Dentistry of Piracicaba - Universidade de Campinas, Piracicaba/SP – Brazil. d Stomatology Department - AC Camargo Cancer Center, São Paulo/SP – Brazil. a

Rosai-Dorfman disease affecting the maxilla

CASE REPORT A 39-year-old woman was seen at our institution complaining of teeth mobility and pain of the upper right teeth, which had lasted for 11 months. The patient was an artisan and addicted to marijuana. During the anamnesis, the patient denied any other symptoms or systemic alterations. On intra-oral evaluation, the clinical appearance of the upper teeth gingiva was normal (Figure 1). However, most of the upper teeth presented full mobility. Radiographic exams showed a diffuse osteolytic image in the right maxilla with great destruction of the alveolar bone. The teeth had lost their bone support and presented characteristics of floating teeth. In addition, the lesion destroyed the cortical bone without the expansion of both the buccal and the palatal cortical plates. Polypoid lesions and mucosal thickening of both maxillary sinuses were also evident (Figures 2 and 3). The main clinical diagnostic hypotheses were Langerhans cell histiocytosis (LCH), NK/T-cell lymphoma, and sinus carcinoma. An incisional biopsy of the alveolar bone (upper right canine) was performed, and the histopathological analysis showed an intense diffuse mononuclear cell infiltration rich in xanthomatous cells, some of which had evident emperipolesis of the

lymphocytes. Areas of necrosis were also observed (Figure 4A). The immunohistochemical reactions showed positivity for CD68 and S-100 protein in the xanthomatous cells, and negativity for CD3, CD20, CD30, and CD1a (Figure 4B-E). Considering the clinical, histopathological and immunohistochemical features, the final diagnosis was RDD involving the right maxilla and the sinus. The peripheral blood count showed mild anemia, and normal leukocyte and platelet counts. The patient was referred to a hematologist who ruled out other sites involved trough of a bone scintigraphy and prescribed 40 mg daily of prednisone for 6 months duration, gradually tapering the dose up to a total of 10 months. Bone scintigraphy was undertaken and ruled out other sites of involvement of the skeleton. However, some teeth (right central incisor, right lateral incisor, right second pre-molar, right first molar, and right third molar) needed to be extracted due to their great mobility. The disease showed no progression 15 months after the diagnosis, and the patient remained asymptomatic. After 5 years of treatment, the patient is still asymptomatic and follows a program of oral rehabilitation. The clinical and imaging examinations were steady (Figure 5).

Figure 1. Intra oral examination - A and B showing no alteration of the upper teeth gingiva. 50

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Miniello TG, Araujo JP, Sugaya NN, Elias FM, Almeida OP, Alves FA

Figure 2. A-C - Periapical radiographs show a large reabsorption of the alveolar bone and floating teeth (arrows); D - Panoramic x-ray shows irregular osteolytic image in the right maxilla (arrows).

DISCUSSION RDD is a rare disease of the hematopoietic system with approximately 1,000 cases reported in the English language literature as at 2012. The most common presentation is a painless cervical lymphadenopathy, but eventually the axillary and inguinal nodes become involved. Extranodal involvement is uncommon. However, skin, nasal cavity, and paranasal sinuses may be affected, along with systemic symptoms, such as fever, pain, weight loss, pharyngitis, and nasal obstruction. RDD can be found solely in the skeleton as isolated or multifocal osseous involvement. In the review by Foucar et al.,5 which involved 423 patients with RDD, 33 (7.8%) had osteolytic bone lesions and only 4 presented involvement of the jaw bones. Autopsy and Case Reports 2016;6(4):49-55

Paranasal sinuses represent one of the two most common extranodal sites of RDD. Polyps or mass lesions are commonly observed, and approximately 70% of these patients show concomitant extranodal site involvement, which often involve the eyelid/orbit, skin, or oral cavity. Similarly, in our case, both paranasal sinuses and maxilla were affected, eventually representing extension of the same disease, and the main complaint of the patient was the pain. Cardoso et al.6 reviewed the literature from 1969 to 2011 and found only eight cases of RDD affecting the maxillary bones (six females and two males, aged 18-56 years). In five of these patients, the maxilla was exclusively involved. In the present case, a 39-year-old woman referred intense pain in the region of the upper right maxilla. However, the pain was not associated 51

Rosai-Dorfman disease affecting the maxilla

Figure 3. A - Axial computed tomography (CT) image of the paranasal sinuses showing the thickening of the sinus mucosa (arrow); B - Axial CT image of polypoid lesions within the sinus (arrow; C and D - Axial CT images of the maxilla showing an extensive reabsorption of alveolar bone of right maxilla.

with the teeth according to clinical, radiographic, and pulp vitality tests. X-ray and computed tomography showed an extensive osteolytic lesion involving the alveolar bone of the right maxilla, and bilateral sinusopathy. In addition, both the physical examination and the bone scintigraphy showed no other affected sites. RDD has nonspecific bone imaging findings that may be represented by ill-defined osteolytic or sclerotic lesions. Differential diagnosis of bone lesions includes LCH, metastatic tumor, osteomyelitis, lymphoma, and sarcoidosis.7-9 RDD etiology is uncertain; some studies suggested an inappropriate response of the immune system to 52

the Epstein-Barr virus (EBV) and human herpes virus-6 infections. In fact, high levels of serum antibodies against EBV were found in patients with RDD.3,10 Other studies pointed out the association between RDD and LCH, or considered RDD as an unusual variant of LCH. Interestingly, synchronous or metachronous RDD and LCH were reported in 10 patients.11-13 Our patient had no systemic symptoms, except for a discrete anemia (hemoglobin 10.5g/dL [reference value: 12–14 mg/dL]). The dia gnos is of RDD was confi rm e d b y histological and immunohistochemical studies. Macrophages exhibiting emperipolesis—expressing S-100 and CD1a-negative—can be considered almost Autopsy and Case Reports 2016;6(4):49-55

Miniello TG, Araujo JP, Sugaya NN, Elias FM, Almeida OP, Alves FA

Figure 4. Photomicrography of the biopsy. A - A diffuse inflammatory infiltrate rich in xanthomatous macrophages (H&E 40X); B - Evident lymphocytes emperipolesis is also observed (arrow) (H&E 200X); C - CD3 positive for reactive cells (T lymphocyte cells); D - CD68 showed strong positivity for macrophages with lymphocytes emperipolesis (arrow); E - S-100 was positive in histiocytic cells.

pathognomonic for RDD.14 Such immunohistochemical characteristics were found in our case, which showed immunoreactivity for CD68, S-100, and CD3, and was negative for CD30 and CD1a. Furthermore, xanthomatous macrophages were also be observed.

corticotherapy was used in conjunction with a strict

There is no specific treatment for RDD. In a recent review dealing with a treatment strategy for RDD, 50% of patients did not require any treatment, while others received steroids, antibiotics, chemotherapy, radiation, surgery, and antifungal agents.15 According to Keskin et al.,8 surgery appears to be one of the most effective approaches in the treatment of RDD. However, corticosteroid therapy reduces the fever and the lymphadenopathy and is usually the treatment of choice for controlling the disease. 15 In our case,

is well, and the disease is considered under control

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follow-up. The patient’s maxillary pain was controlled, but the mobility of all teeth of the right maxilla remained unchanged, which required the extraction of some of them. After a 5-year follow-up, the patient without any further treatment requirement. RDD affecting the maxillary bone is extremely rare and requires a close follow-up by the dentist together with the medical team, as it can cause severe bone destruction, plus teeth mobility and loss. Conservative treatment should be considered in such cases, taking into account the possibility of a spontaneous remission. 53

Rosai-Dorfman disease affecting the maxilla

Figure 5. Axial CT images showing sinusopathy in both maxillary sinuses, and control of the bone reabsorption.

REFERENCES 1. Thomson ER, Newman P, Dunstan S, Coull H. The Rosai Dorfman syndrome in a 50-year-old male. Br J Oral Maxillofac Surg. 1989;27(1):39-45. PMid:2920162. http://dx.doi.org/10.1016/0266-4356(89)90125-3. 2. Yontz L, Franco A, Sharma S, Lewis K, McDonough C. A case of Rosai-Dorfman disease in a pediatric patient with cardiac involvement. J Radiol Case Rep. 2012;6(1):1-8. PMid:22690274.

5. Foucar E, Rosai J, Dorfman R. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease): review of the entity. Semin Diagn Pathol. 1990;7(1):1973. PMid:2180012. 6. Cardoso CL, Damante JH, Santos PSS, et al. RosaiDorfman disease with widespread oral-maxillofacial manifestations: a case report. J Oral Maxillofac Surg. 2012;70(11):2600-4. PMid:22330332. http://dx.doi. org/10.1016/j.joms.2011.12.015.

3. Rosai J, Dorfman RF. Sinus histiocytosis with massive lymphadenopathy: a pseudolymphomatous benign disorder. Analysis of 34 Cases. Cancer. 1972;30(5):1174-88. PMid:5083057. http://dx.doi. org/10.1002/1097-0142(197211)30:5<1174::AIDCNCR2820300507>3.0.CO;2-S.

7. Kademani D, Patel SG, Prasad ML, Huvos AG, Shah JP. Intraoral presentation of Rosai-Dorfman disease: a case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93(6):699704. PMid:12142877. http://dx.doi.org/10.1067/ moe.2002.123495.

4. McAlister WH, Herman T, Dehner LP. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease). Pediatr Radiol. 1990;20(6):425-32. PMid:2202971. http:// dx.doi.org/10.1007/BF02075199.

8. Keskin A, Genç F, Günhan Ö. Rosai-Dorfman disease involving maxilla: a case report. J Oral Maxillofac Surg. 2007;65(12):2563-8. PMid:18022485. http://dx.doi. org/10.1016/j.joms.2006.10.003.

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Miniello TG, Araujo JP, Sugaya NN, Elias FM, Almeida OP, Alves FA

9. Akyigit A, Akyol H, Sakallioglu O, Polat C, Keles E, Alatas O. Rosai-Dorfman disease originating from nasal septal mucosa. Case Rep Otolaryngol. 2015; 2015:1-3. http:// dx.doi.org/10.1155/2015/232898. 10. Levine PH, Jahan N, Murari P, Manak M, Jaffe ES. Detection of human herpesvirus 6 in tissues involved by sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease). J Infect Dis. 1992;166(2):2915. PMid:1321861. http://dx.doi.org/10.1093/ infdis/166.2.291. 11. Wang KH, Cheng CJ, Hu CH, Leew WR. Coexistence of localized Langerhans cell histiocytosis and cutaneous Rosai–Dorfman disease. Br J Dermatol. 2002;147(4):7704. PMid:12366428. http://dx.doi.org/10.1046/j.13652133.2002.04879.x. 12. O’Malley D, Duong A, Barry TS, et al. Co-occurrence of Langerhans cell histiocytosis and Rosai-Dorfman disease: possible relationship of two histiocytic

disorders in rare cases. Mod Pathol. 2010;23(12):161623. PMid:20729813. http://dx.doi.org/10.1038/ modpathol.2010.157. 13. Kutty SA, Sreehari S. Co-occurrence of intracranial RosaiDorfman disease and Langerhans histiocytosis of the skull: case report and review of literature. Turk Neurosurg. 2015;25(3):496-9. PMid:26037195. 14. Castillo BTD, Mata-Fernandez C, Soria VJR, Blanco VP, Loughlin G, Campos-Domínguez M. Self-healing extranodal cutaneous Rosai-Dorfman in a child. Pediatr Dermatol. 2015;32(6):e249-59. PMid:26391332. http:// dx.doi.org/10.1111/pde.12676. 15. Pulsoni A, Anghel G, Falcucci P, et al. Treatment of sinus histiocytosis with massive lymphadenopathy (RosaiDorfman disease): report of a case and literature review. Am J Hematol. 2002;69(1):67-71. PMid:11835335. http://dx.doi.org/10.1002/ajh.10008.

Conflict of interest: None Submitted on: October 2nd, 2016 Accepted on: November 28th, 2016 Correspondence Fabio Abreu Alves Stomatology Department - AC Camargo Cancer Center R. Prof. Antônio Prudente, 211 – Sao Paulo/SP – Brazil CEP: 01509-010 Phone: +55 (11) 2189-5129 Fax +55 (11) 2189-5133 falves@accamargo.org.br

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Article / Clinical Case Report

Cytokeratin immunoprofile of primary and metastatic adenoid cystic carcinoma of salivary glands: a report of two cases Cibele Pidorodeski Naganoa, Cláudia Malheiros Coutinho-Camillob, Clovis Antônio Pintob, Fernando Augusto Soaresa,b, Filipa Santosc, Isabel Fonsecac, Silvia Vanessa Lourençoa Nagano CP, Coutinho-Camillo CM, Pinto CA, et al. Cytokeratin immunoprofile of primary and metastatic adenoid cystic carcinoma of salivary glands: a report of two cases. Autopsy Case Rep [Internet]. 2016;6(4):57-63. http://dx.doi.org/10.4322/acr.2016.056

ABSTRACT Distant metastases from salivary gland tumors are considered infrequent: the incidence of distant metastases ranges from 24% to 61% according to different histotypes and to the site of the primary mass. The most common site of distant metastases due to salivary gland malignancies is the lung. From the pathology point of view, cytokeratins (CK) are important differentiation markers in salivary gland tumors, which are often used for the diagnostic process. Their employment also may be useful to identify and confirm the diagnosis of their distant metastases. We report the expression of CK in two cases of primary and metastatic adenoid cystic carcinoma (ACC) and their CK profiles of the primary and metastatic masses. Both patients—one male and one female—were diagnosed with an ACC cribriform and tubular, respectively, with lung metastases. In case 1, the metastatic mass presented the same histotype and CK profile of the primary tumor. For case 2, the metastatic lung mass was distinct from the primary mass (a solid ACC) and presented a different CK profile. Although salivary gland metastatic disease presents a poor prognosis, both patients reported herein are alive despite the presence of the disease in long-term follow-up. Therefore, the modifications seen in the CK profiles do not appear to be predictive of tumor behavior and outcome. The use of a CK profile seems to be useful to identify the nature of a distant mass and its possible correlations with a primary salivary gland tumor. Keywords Salivary Gland Neoplasms; Neoplasm Metastasis; Keratins; Carcinoma, Adenoid Cystic.

INTRODUCTION Salivary gland neoplasms are uncommon, and according to the World Health Organization (WHO), they comprise around 40 histological types. Their etiology is unknown, and the only well-established risk factor is ionizing radiation.1

The most common salivary gland malignant neoplasms are mucoepidermoid carcinoma and adenoid cystic carcinoma, and the incidence of these entities varies according to different series studied.1 Both neoplasms are more common in females.

Department of Stomatology - Dental School - Universidade de São Paulo, São Paulo/SP – Brazil. Department of Surgical Pathology - AC Camargo Cancer Center, São Paulo/SP – Brazil. c Instituto Português de Oncologia - Universidade de Lisboa, Lisboa – Portugal. a

Cytokeratin immunoprofile of primary and metastatic adenoid cystic carcinoma of salivary glands: a report of two cases

They have persistent growth and a tendency to metastasize; high-grade tumors grow rapidly and are destructive and symptomatic.1,2 Histopathological diagnosis of salivary gland tumors is, in many cases, challenging, and depends on the understanding of the typical structures of the organ. Salivary gland neoplasms may arise from the different regions of the organ. The glands are composed of structures formed by luminal cells (acinar and ductal cells) and abluminal cells (myoepithelial and basal cells) (Figure 1). These cells exhibit a well-known antigen profile of cytoskeleton proteins, among others, and this profile can help to identify tumor histogenesis, and therefore a better classification.3 The origin of mucoepidermoid carcinoma is reputed to be the excretory duct cells of salivary glands; it is composed of mucous, and intermediate and epidermoid cells. The origin of adenoid cystic carcinoma (ACC) is regarded to be the intercalated duct cells, and is composed of ductal and myoepithelial cells in tubular, cribriform, and solid architectures.1 Distant metastasis from salivary gland tumors is considered to be infrequent. The incidence of distant metastasis varies according to different histotypes and the primary location. The most common site of distant metastasis due to salivary gland malignancies

is the lung; the literature reports that 75-90% of all patients with distant metastasis showed pulmonary involvement. However, metastatic masses from salivary gland neoplasms have been reported also in bone, liver, and lymph nodes.2 We report two cases of primary and metastatic ACC with their cytokeratin (CK) profiles (Ethics Committee CAAE: 07907812.8. 1001.0075).

CASE 1 A 42-year-old male presented a history of an operated ACC of the palate. The surgery comprised an extensive maxillectomy up to the infratemporal and pterygopalatine fossae. Histopathology revealed a cribriform ACC with perineural infiltration and angiolymphatic emboli (Figure 2A and 2B). The patient received radiotherapy at 45 Gy. After a 5-year follow-up, two masses (measuring 10 mm and 6 mm at their longest axis) were detected in the inferior lobule of the right lung, which was excised and diagnosed as metastatic salivary gland cribriform ACC (Figure 2C). The expression of CK7 was detected in luminal structures that intermingled neoplastic myoepithelial cells in cribriform islands of the primary ACC (Figure 3A and 3B). Neoplastic luminal structures

Figure 1. Schematic view of the normal salivary gland structure showing the secretory end-pieces composed of acinar cells surrounded by myoepithelial cells. The intercalated ducts are formed by luminal cells and are surrounded by myoepithelial cells. The excretory ducts are composed of luminal and abluminal cells. 58

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Nagano CP, Coutinho-Camillo CM, Pinto CA, et al.

Figure 2. Photomicrography of the histopathological aspects of primary and metastatic adenoid cystic carcinoma. A and B - Primary cribriform adenoid cystic carcinoma (ACC) of the hard palate. A - Cribriform aspect of the primary mass composed of epithelial (luminal) cells and myoepithelial (abluminal) cells around a nerve bundle (perineural infiltration); B - Cribriform ACC: angiolymphatic spread (emboli) (both H&E, 250X); C - Lung metastatic mass from a salivary gland ACC: cribriform aspects of the metastatic mass intermingling the lung parenchyma (H&E, 250X).

expressed CK7 only focally in the lung metastasis (Figures 3C and 3D). CK14 was focally in the primary ACC, mainly in the luminal structures (Figures 4A, 4B). In the lung mass (4C and 4D), the neoplastic cells were diffusely positive for CK14. The expression of CK18 and CK19 was detected in the luminal structures of the primary mass (Figures 5A, 5B, 6A, and 6B). In the lung mass, expression of CK18 was only focally detected in the luminal structures that were distant from the interface of the lung parenchyma (Figures 5C and 5D). CK19 was focally positive in neoplastic luminal structures of the metastatic mass (Figures 6C and 6D). The patient was further treated with radiation at 30 Gy and is alive with the disease in a 10-year follow-up. Autopsy and Case Reports 2016;6(4):57-63

Figure 3. Photomicrography of the expression of CK7 (clone LL002, AbCAM) in the primary and metastatic adenoid cystic carcinoma (ACC). In A and B, the luminal cells were positive for CK7 in the primary mass; C - Metastatic ACC showing a few neoplastic structures positive for CK7; D - The tumor islands close to the lung parenchyma are mainly negative for CK7, contrasting with the epithelial lining of the pulmonary alveoli that express this cytokeratin. Immunohistochemistry was revealed with DAB (200X, 400X, 100X, and 200X, respectively).

CASE 2 A 66-year-old female presented a mass on the hard palate, which at histopathology was diagnosed as a cribriform ACC with tubular areas. The tumor recurred locally after 8 years, with similar histopathological aspects; however perineural invasion and angiolymphatic spread were not detected. The recurrent lesion was treated with a maxillectomy and radiotherapy at 60 Gy. After 5 years of follow-up, a mass (measuring 8 mm at its longest axis) was found in the right lung. The lesion was surgically treated and diagnosed as a metastasis of a salivary gland ACC (cribriform with solid areas). The histopathological aspects of the primary mass and the metastatic lung mass are illustrated in Figures 7A and 7B. Expression of CK7 was detected in the tubular structures of the primary palatal mass (Figures 8A and 8B). CK7 was focally expressed within the solid metastatic mass (Figures 8C and 8D). CK14 was positive in the primary tumor (Figures 9A and 9B). 59

Cytokeratin immunoprofile of primary and metastatic adenoid cystic carcinoma of salivary glands: a report of two cases

Figure 4. Photomicrography of the expression of CK14 (clone RCK105, AbCAM) in the primary and metastatic adenoid cystic carcinoma (ACC). A - A few luminal structures positive for CK14 in the primary ACC; B - Cribriform nest of the primary mass showing a greater number of luminal structures positive for CK14. In the metastatic specimens (C and D) the majority of neoplastic cells are positive for CK14; In C, the epithelial lining of the pulmonary alveoli is also positive for this marker. Immunohistochemistry revealed with DAB (all figures 200X).

Figure 6. Photomicrography of the expression of cytokeratin 19 (clone A53B/A2, AbCAM) in the primary and metastatic adenoid cystic carcinoma (ACC). A and B - In the primary mass, luminal cells are highly positive for CK19; C and D - Representations of the metastatic lung mass show similar patterns with luminal cells positive for CK19. The epithelial lining of the lung is also positive for this protein. Immunohistochemistry revealed with DAB (200X, 400X, 100X, and 200X, respectively).

Figure 7. Photomicrography of the histopathological aspects of primary and metastatic adenoid cystic carcinoma ACC. A - Primary tubular ACC of the hard palate. Cribriform aspects of the primary mass with marked vascular emboli H&E, 100X); B - Lung metastasis of the palatal ACC of the palate. Cribriform area infiltrating lung alveoli (H&E, 100X). Figure 5. Photomicrography of the expression of CK18 (clone C-04, AbCAM) in the primary and metastatic adenoid cystic carcinoma (ACC). In the primary mass, the luminal cells are highly positive for CK18 (A and B). C and D reveal that only neoplastic structures of the metastatic mass, distant from the lung parenchyma interface show luminal cells positive for CK18. The epithelial lining of the lung is positive for this protein. Immunohistochemistry revealed with DAB (200X, 400X, 100X, and 200X, respectively). 60

The lung mass was mainly negative for CK14, except for focal positive areas (Figure 9C). Only focal positivity was observed for CK18 both in the primary ACC and in the metastatic mass (Figures 10A-10D). CK19 was expressed by luminal cells in the primary mass (Figures 11A and 11B), but only focal areas were positive in the lung metastasis (Figure 11C). The patient is alive with disease after a 3-year follow-up. The immunoprofile of both cases is Autopsy and Case Reports 2016;6(4):57-63

Nagano CP, Coutinho-Camillo CM, Pinto CA,Â etÂ al.

Figure 8. Photomicrography of the expression of CK7 (clone LL002, AbCAM) in the primary and metastatic adenoid cystic carcinoma (ACC). A and B - Luminal cells are positive for CK7 in the primary tubular ACC; C and D - Metastatic ACC showing a few neoplastic cells positive for CK7 within the solid tumor mass. Immunohistochemistry revealed with DAB (100X, 250X, 100X, and 200X, respectively).

Figure 10. Photomicrography of the expression of CK18 (clone C-04, AbCAM) in the primary and metastatic adenoid cystic carcinoma (ACC). A and B - In the primary mass, scattered cells are highly positive for CK18; C and D - Small neoplastic nests within the metastatic mass are positive for CK18. Immunohistochemistry revealed with DAB (100X, 200X, 100X, and 200X, respectively).

Figure 9. Photomicrography of the expression of CK14 (clone RCK105, AbCAM) in the primary and metastatic adenoid cystic carcinoma (ACC). A and B - Luminal cells positive for CK14 in the primary ACC; C - A rare area positive for CK14 in the solid metastatic mass of the lung. Immunohistochemistry revealed with DAB (100X, 200X, and 400X, respectively).

Figure 11. Photomicrography of the expression of cytokeratin 19 (clone A53B/A2, AbCAM) in the primary and metastatic adenoid cystic carcinoma. A and B - In the primary mass, luminal cells are strongly positive for CK19; C - Only a few areas are positive for this protein within the solid metastatic mass. Immunohistochemistry revealed with DAB (100X, 250X, and 400X, respectively).

Autopsy and Case Reports 2016;6(4):57-63

Cytokeratin immunoprofile of primary and metastatic adenoid cystic carcinoma of salivary glands: a report of two cases

Table 1. Cytokeratins (CK) immunoprofile of primary and metastatic adenoid cystic carcinoma Histological type

CK7

CK14

CK18

CK19

Cribriform

+ve (Luminal structures)

+ve (Focal in luminal structures)

+ve (Luminal structures)

Lung metastasis

Cribriform

−ve (Luminal structures); focally positive in scattered cells

+ve Diffusely within the metastatic mass)

+ve (Focal)

Primary mass

Cribriform with tubular areas

+ve (Tubular structures)

+ve (Luminal cells)

+ve (Focal)

+ve (Luminal structures)

Lung metastasis

Cribriform with solid areas

+ve (Focal)

−ve (Luminal structures); +ve (focal)

+ve (Focal)

Mainly negative

Primary mass Case 1

Case 2

+ve: positive; −ve: negative.

summarized in Table 1, which depicts the major differences between primary and metastatic masses.

DISCUSSION ACC is one of the most common salivary gland malignancies. 2 The cases reported herein were of distinct histotypes, which have both arisen from minor salivary glands of the palate. The patients, one male and one female, developed lung metastasis of different ages. According to Bradley,2 age and gender are not associated with the development of salivary gland tumor metastasis. However, a large cohort of the Memorial Sloan Kettering Cancer Center Hospital reports that metastasis from salivary gland malignant tumors is more common in men, who are usually diagnosed at an advanced clinical stage.4 The development of distant metastases from salivary gland tumors depends on four main factors: (i) the site of the lesion; (ii) the size and duration of the disease at the time of the initial diagnosis; (iii) histotype; and (iv) tumor stage. Tumors over 3 cm are highly predictable of distant metastases.2,4 In our cases, the performed mutilating treatment modality (maxillectomy) may have been indicative of large tumors. The WHO 5 defines ACC as a basaloid tumor consisting of epithelial and myoepithelial cells with varied architecture. The solid histotype has a relentless clinical course and a usually fatal outcome, and is more likely to develop distant metastases. Other types of 62

ACC, such as tubular and cribriform, also may develop metastases as shown herein. The histopathological analysis of the primary mass and metastases is critical for a patient’s overall evaluation. As seen in the presented cases, the metastatic mass may or may not follow the architectural patterns of the primary mass. The histopathological findings of the primary mass and lung metastases from patient 1 presented a predominant cribriform pattern. However, the primary mass exhibited a dominant tubular pattern in patient 2, but the lung metastasis was less differentiated with a solid morphology. Immunohistochemistry enhances diagnostic accuracy as it aids in unraveling the architecture of primary tumors and distant metastases. ACC is consistently positive for cytokeratins AE1/3, 34betaE12, CK5/6, CK7, CK14, and CK18, amongst other markers. 3 In our results, the CK expression of the metastatic tumor showed marked changes compared with the primary tumor, mainly with the loss of CK expression. This diversity was observed in case 2, which showed a marked phenotype change in the metastatic mass. This was revealed not only by its morphological aspects but also by the cytokeratin profile. Salivary gland tumors are virtually incurable, and their metastases presents a poor prognosis. Intriguingly, however, our patients are still alive with present evidence of new metastatic nodules in the lungs of both patients. Alterations in CK profiles do not appear to be predictive of tumor behavior and clinical outcome. Modern molecular techniques, such Autopsy and Case Reports 2016;6(4):57-63

Nagano CP, Coutinho-Camillo CM, Pinto CA, et al.

as detection of genetic changes like the translocations with the resulting fusion of the MYB oncogene, are used in large centers as reliable biomarkers of distant metastases.5-7

ACKNOWLEDGEMENTS The authors are thankful to Mr. Fabio Andriolo for the design of Figure 1 and for the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for sponsoring Cibele Pidorodeski Nagano scholarship. REFERENCES 1. World Health Organization (WHO). International Agency for Research on Cancer (IARC). Tumours of the Salivary glands: World Health Organization Classification of tumours: pathology and Genetics of head and neck tumours. Lyon: IARC Press; 2005. 2. Bradley PJ. Distant metastases from salivary glands cancer. J Otorhinolaryngol Relat Spec. 2001;63(4):233-42. PMid:11408820. http://dx.doi.org/10.1159/000055748. 3. Namboodiripad A. A review: immunological markers for malignant salivary gland tumours. J Oral Biol Craniofac Res. 2014;4(2):127-34. PMid:25737930. http://dx.doi. org/10.1016/j.jobcr.2014.05.003.

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4. Ali S, Bryant R, Palmer FL, et al. Distant metastasis in patients with carcinoma of the major salivary glands. Ann Surg Oncol. 2015;22(12):4014-9. PMid:25743328. http://dx.doi.org/10.1245/s10434-015-4454-y. 5. Ettl T, Schwarz-Furlan S, Gosau M, Reichert TE. Salivary gland carcinomas. Oral Maxillofac Surg. 2012;16(3):26783. PMid:22842859. http://dx.doi.org/10.1007/s10006012-0350-9. 6. Simpson RHW, Skalova A, Di Palma S, Leivo I. Recent advances in the diagnostic pathology of salivary carcinomas. Virchows Arch. 2014;465(4):371-84. PMid:25172327. http://dx.doi.org/10.1007/s00428-0141639-x. 7. Gupta R, Balasubramanian D, Clark JR. Salivary gland lesions: recent advances and evolving concepts. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119(6):66174. PMid:25840511. http://dx.doi.org/10.1016/j. oooo.2015.02.481.

Conflict of interest: None Submitted on: May 11th, 2016 Accepted on: October 25th, 2016 Correspondence Silvia Vanessa Lourenço Dental School - Universidade de São Paulo Av. Prof. Lineu Prestes, 2227 – São Paulo/SP – Brazil CEP: 05508-000 Phone: +55 (11) 3091-7884 silvialourenco@usp.br

Nominata

Nominata of the Reviewers of the volume 6, 2016 The Editors of Autopsy and Case Reports thank the peer reviewers listed below for the excellent collaborative work, opinions and comments on the papers published in 2016. Their hard work certainly contributed to maintaining the scientific level of this journal.

Reviewer

Specialty

Institution

Alfredo José Mansur

Cardiology

INCOR

Alex K Williamson

Pathology

Hofstra Northwell School of Medicine - USA

Ana Maria da Cunha Mercante

Pathology

ICESP

Angelina Maria Martins Lino

Neurology

HU USP - HC FMUSP

Antônio Vitor Martins Priante

Head and Neck Surgery

FM Taubaté

Beatriz Monica Sugai

Endoscopy

Grupo Fleury

Carlos Tadashi Yoshizaki

Obstetrics and Gynecology

HU USP

Cid José Sitrângulo Junior

Vascular Surgery

HC FMUSP

Cristina Rúbia Ferreira

Pathology

HU USP

Daisa Silva Ribeiro David

Pathology

HC FMUSP

Dani Ejzemberg

Gynecology

HC FMUSP

Eduardo Luiz Rachid Cançado

Gastroenterology

HC FMUSP

Erasmo Simão da Silva

Vascular Surgery

HC FMUSP

Fábio Rocha Fernandes Távora

Pathologist

Argos Pathology

Fernanda Viviane Mariano

Pathology

UNICAMP

Fernando A. M. Claret Arcadipane

Head and Neck Surgery

FM Jundiaí

Fernando Melhem Elias

Buco Maxillo Facial Surgery

HU-USP

Gil Bernard

Infectious Diseases

HC FMUSP

Hélio Gomes

Neurology

HC FMUSP

Irene Kazue Miura

Pediatrics

HC FMUSP

José Benedito Dias Lemos

Buco Maxillo Facial Surgery

HU USP

José Jukemura

Gastroenterology Surgery

HC FMUSP

Juliana Pereira

Hematology - Oncology

ICESP

Kleber Simões do Espirito Santos

Pathologist

H Beneficência Portuguesa

Larry Nichols

Pathology

Mercer University School of Medicine

Leandro Aurélio Liporoni Martins

Pathology

HC FMUSP

Liliana Mitie Suganuma

Hematology

HC FMUSP

Luiz Alberto Benvenuti

Pathology

INCOR

Luís Felipe da Silva

Vascular Surgery

UFRJ

Luiz Otávio Savassi Rocha

Internal Medicine

UFMG

Maria Angélica Binotto

Pediatrics

INCOR

Maria Beatriz Sampaio Lopes

Pathology

University of Virginia School of Medicine

Nominata

Reviewer

Specialty

Institution

Marcelo Belesso

Hematology - Oncology

ICESP

Marcos de Paula Nogueira

Urology

HU USP

Maria Claudia Nogueira Zerbini

Pathology

FMUSP

Maria Del Pilar Esteves Diz

Oncology

ICESP

Marina Penteado Sandoval

Pathology

The Dermatology Group, PC – New Jersey - USA

Margareth Eira

Infectious Diseases

II Emílio Ribas

Milton de Arruda Martins

Internal Medicine

HC FMUSP

Olavo Henrique Munhoz Leite

Infectious Diseases

HC FMUSP

Oscar Eduardo Hidetoshi Fugita

Urology

HU USP

Paulo Francisco Ramos Margarido

Gynecology

FMUSP - HU USP

Paulo Goffi

Surgery

HU-USP

Paulo Merçon de Vargas

Pathology

UFES

Rodolfo Milani Júnior

Internal Medicine

HC FMUSP

Rodrigo Dias Olmos

Internal Medicine

HU USP

Sheila Aparecida Coelho Siqueira

Pathology

HC FMUSP

Shieh Huei Hsin

Pediatrics

HU USP

Silvia Vanessa Lourenço

Pathology

FO USP

Tarso Adoni

Neurology

HC FMUSP

Thales de Brito

Pathology

FMUSP

Vera Lúcia Aldred

Pathology

HC FMUSP

Vera Demarchi Aiello

Pathology

INCOR

LIST OF ABBREVIATIONS FM Jundiaí - Faculdade de Medicina de Jundiaí FM Taubaté - Faculdade de Medicina de Taubaté FMUSP - Faculdade de Medicina da Universidade de São Paulo FMUSP - HU USP - Faculdade de Medicina da Universidade de São Paulo - Hospital Universitário da Universidade de São Paulo FO USP - Faculdade de Odontologia da Universidade de São Paulo H Beneficência Portuguesa - Hospital da Beneficência Portuguesa HC FMUSP - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo HU USP - Hospital Universitário da Universidade de São Paulo ICESP - Instituto do Câncer do Estado de São Paulo INCOR - Instituto do Coração UFES - Universidade Federal do Espírito Santo UFMG - Universidade Federal de Minas Gerais UFRJ - Universidade Federal do Rio de Janeiro UNICAMP - Universidade Estadual de Campinas

Autopsy and Case Reports 2016;6(4):65-66