A Case of Primary Cutaneous Mucinous Carcinoma with Neuroendocrine Differentiation

Primary cutaneous mucinous carcinoma is a rare malignant tumor that originates from the deepest portion of the eccrine sweat duct. Common sites of involvement are the face and scalp. Biopsy shows dermal epithelial cell islands embedded in mucin pools separated by fibrous septae. It is difficult to differentiate this tumor histologically from metastatic adenocarcinoma. Recurrence after excision is common but metastases are rare. We report a primary cutaneous mucinous carcinoma with neuroendocrine differentiation on the right cheek of a 63-year-old man.     

Multisystem Inflammatory Syndrome in Adults Accompanied with Kikuchi-Fujimoto Disease

We herein report a case of multisystem inflammatory syndrome in adults (MIS-A) complicated with Kikuchi-Fujimoto disease (KFD). A previously healthy 41-year-old man presented with painful swelling of the cervical lymph nodes, fever, diarrhea, conjunctivitis, edema, and hypotension one month after the onset of asymptomatic coronavirus disease 2019. Laboratory investigations revealed an elevation of CRP, and echocardiography indicated diastolic dysfunction. We diagnosed the patient to have MIS-A. Histopathology of the lymph nodes showed necrotizing lymphadenitis. After the initiation of hydrocortisone and diuretics, his symptoms resolved immediately. This case suggested that post-viral immune dysregulation in MIS-A could play a role in the etiology of KFD.     

Electron microscopic localization of substance P and enkephalin in axon terminals related to dendrites of catecholaminergic neurons

Morphological and pharmacological data suggest that catecholaminergic neurons receive afferent axons positively labeled for the peptides, substance P and [Met⁵]enkephalin. In the present study, electron microscopic immunocytochemistry was used to determine whether a positive reaction for these peptides could be localized to axon terminals forming synapses with catecholaminergic neurons in the locus coeruleus and A2 regions of rat brain. Adjacent sections through these areas were incubated with antiserum to either substance P, [Met⁵]-enkephalin, or tyrosine hydroxylase, a specific marker for catecholaminergic neurons. The sections were subsequently processes by the peroxidase-antiperoxidase immunocytochemical technique. In both the locus coeruleus and A2 region, tyrosine hydroxylase was localized primarily to perikarya and dendrites of intrinsic neurons; whereas substance P and enkephalin-like immunoreactivity was localized to axons and axon terminals. The axon terminals showing positive reactions for substance P and [Met⁵]-enkephalin were morphologically similar to each other and to one type of axon terminal which formed synapses with dendrites labeled for tyrosine hydroxylase. This type of axon terminal always formed asymmetric synaptic junctions and contained 3–4 large (75–100 nm) dense vesicles (LDVs) and many small (40–60 nm) clear vesicles (SCVs). The reaction product for substance P and [Met⁵]-enkephalin was distributed throughout the lumen of the LDVs and formed a rim of labeling around the outer boundaries of the SCVs. These findings demonstrate that substance P and [Met⁵]-enkephalin-positive reactions are selectively localized to subcellular organelles in axon terminals in the locus coeruleus and A2 region of rat brain. They further suggest that the labeled axon terminals form synapses with dendrites of the catecholaminergic neurons.     

Columnar metaplasia in the remnant esophagus is a long-term indicator for pneumonia after radical esophagectomy

Background

This study investigated the long-term risk factors for pneumonia after esophageal reconstruction using a gastric tube via the posterior mediastinal route following esophagectomy for esophageal cancer. The influence of columnar metaplasia in the remnant esophagus was specifically assessed.

Methods

Among 225 patients who underwent esophagectomy between January 2004 and December 2010, the subjects were 54 patients who could be followed up for more than 5 years. Routine oncologic follow-up consisted of CT scanning of the abdomen and chest every 4–6 months and annual endoscopy. Data on the occurrence of pneumonia were collected by retrospective review of chest CT scans. Risk factors for pneumonia investigated by univariate and multivariate analyses included the age, gender, diameter of the stapler, length of the intrathoracic remnant esophagus, anastomotic stricture, and presence of columnar metaplasia in the remnant esophagus.

Results

The median age was 62.4 years (interquartile range: 55.8–68.0 years). Forty-three patients were men. Pneumonia was detected in 39 patients (72.2%). The incidence of columnar metaplasia in the remnant esophagus increases with time. Anastomotic stricture was significantly related to the absence of columnar metaplasia on endoscopy in the first year after esophagectomy (p = 0.013). Univariate analysis showed that the frequency of pneumonia was significantly related to the intrathoracic remnant esophagus length ≥4.4 cm (p = 0.014), age over 65 years (p = 0.014), and the presence of columnar metaplasia in the remnant esophagus in the fifth year after esophagectomy (p = 0.005). Among them, age over 65 years and the presence of columnar metaplasia in the remnant esophagus in the fifth year after esophagectomy were found to be independent indicators of the postoperative pneumonia by multivariate analysis.

Conclusion

Pneumonia occurred in 72.2% (39/54) of patients after esophagectomy for esophageal cancer. The presence of columnar metaplasia after esophagectomy is an indicator for pneumonia over the long term.

     

Heterotopic pancreas in the stomach which caused obstructive stenosis in the duodenum

The patient, a 43-year-old Japanese man suffering from duodenal ulcer and reflux esophagitis, was admitted to our hospital because of submucosal tumor in the antrum and obstructive stenosis of duodenum. Several imaging tests could not rule out the possibility of malignant disease. Therefore, the patient was surgically treated. Pathohistological examination of resected tissue demonstrated Heinrich type I heterotopic pancreas in the gastric lesion and submucosal abscess in the duodenal lesion with stenosis. In this case, it was considered that the heterotopic pancreas caused chronic inflammation to form the gastric tumor, and submucosal abscess leading to the severe duodenal stenosis.     

Efficacy of Combination Antifungal Therapy with Intraperitoneally Administered Micafungin and Aerosolized Liposomal Amphotericin B against Murine Invasive Pulmonary Aspergillosis

Targeted intrapulmonary delivery of drugs may reduce systemic toxicity and improve treatment efficacy. In the current study, we evaluated the effects of a combination treatment consisting of inhalation of aerosolized liposomal amphotericin B (L-AMB) with intraperitoneal administration of micafungin (MCFG) against murine invasive pulmonary aspergillosis. The combination of aerosolized L-AMB with intraperitoneal MCFG significantly improved the survival rate, and the fungal burdens and histopathology findings after this treatment were superior to those of the control and both monotherapy groups.Invasive pulmonary aspergillosis (IPA) results in significant morbidity and mortality in severely immunocompromised patients (6). Targeted intrapulmonary delivery of antifungals has the potential to reduce systemic toxicity and improve treatment efficacy as well as prophylaxis (1, 8) and may be used as an optional route in combination with other systemic antifungals. In the current study, we evaluated the efficacy of aerosolized liposomal amphotericin B (L-AMB) both singly and in combination with intraperitoneally administered micafungin (MCFG) in a murine model of IPA.Aspergillus fumigatus MF13 was clinically obtained from a patient admitted to the Nagasaki University Hospital. The minimum effective concentration of MCFG (Astellas Pharmaceuticals Inc., Tokyo, Japan) and the MIC of AMB (Sigma, St. Louis, MO) were determined using the microdilution method in accordance with Clinical Laboratory Standards Institute document M38-A2 (2). Drug interactions were assessed using the checkerboard titration broth microdilution-based method (3), and the fractional inhibitory concentration index was determined as previously described (5).Six-week-old female ICR mice (Charles River Breeding Laboratories, Shiga, Japan) were immunosuppressed and then challenged on day 0 with 5 × 10⁶ conidia of A. fumigatus MF13 intratracheally for monitoring of survival, as previously described (7, 11). Eight-week-old female ICR mice were used to determine fungal burdens and for histopathological examination. Mice were immunosuppressed by subcutaneous injection of cortisone acetate (Sigma, Tokyo, Japan) at 250 mg/kg of body weight and intraperitoneally administered cyclophosphamide (Sigma) at 200 mg/kg on days −2 and 0 for the survival study. Only cortisone acetate (200 mg/kg) was used on days −1, 0, and 1 for fungal-burden analysis and histopathological examination. Mice were assigned into the following groups: (i) control mice, (ii) mice receiving MCFG intraperitoneally, (iii) mice receiving aerosolized L-AMB, and (iv) mice receiving a combination treatment of intraperitoneally administered MCFG and aerosolized L-AMB. Each group consisted of 11 and 10 mice for survival and fungal-burden analyses, respectively. MCFG was administered intraperitoneally once daily at 1 mg/kg/day. L-AMB was administered once daily in an 8-ml suspension (at 1.2 mg/ml) per inhalation. Antifungals were initiated 16 h after inoculation and continued for 5 and 3 days for survival and fungal-burden analyses, respectively. The L-AMB solution was aerosolized using a nebulizer (Muromachi Kikai Co., Ltd., Tokyo, Japan), and mice were exposed to aerosol treatment for 60 min as previously described (9). Control mice were treated with sterile saline. Survival was observed until 11 days following the challenge. For fungal-burden and histopathological examinations, mice were sacrificed 4 h after the treatment on day 3. Numbers of CFU per lung tissue were calculated, and removed lungs were fixed and stained with Grocott''s methenamine silver nitrate and hematoxylin-eosin as previously described (11). Survival and fungal burden data are presented from a combination of two sets of experiments. The concentration in blood and the pharmacokinetics of aerosolized L-AMB were evaluated. Uninfected mice were also exposed to several concentrations of aerosolized L-AMB for 5 days, and blood samples and lungs were collected. AMB concentration was quantified as previously described (10). Survival curves were generated using the Kaplan and Meier method, and statistical differences were evaluated by the log rank test. To assess fungal burden in lung tissue, geometric means of numbers of CFU per organ were compared by Student''s t test. Statistical significance was defined as a P of <0.05.The MIC of AMB against A. fumigatus MF-13 was 1.0 μg/ml, and the minimum effective concentration of MCFG was 0.0315 μg/ml. The fractional inhibitory concentration index of AMB and MCFG was 1.5, and drug interaction was classified as indifferent (5).Survival periods of monotherapy groups, in which mice either were treated with intraperitoneally administered MCFG or inhaled aerosolized L-AMB were significantly longer than that of the control group (MCFG alone versus the control, P = 0.006; L-AMB versus the control, P < 0.001) (Fig. ​(Fig.1).1). The combination treatment group showed significantly longer survival than the intraperitoneal-MCFG (P < 0.001), aerosolized-L-AMB (P = 0.037), and control (P < 0.001) groups. Numbers of CFU in the lungs of mice in the combination treatment group were significantly reduced compared to those in each of the intraperitoneal-MCFG (P < 0.001), aerosolized-L-AMB (P = 0.027), and control (P < 0.001) groups (Fig. ​(Fig.2).2). The lungs of aerosolized-L-AMB-administered and combination treatment mice showed obviously smaller numbers of hyphae and fewer foci of inflammation than the intraperitoneal-MCFG and control groups (Fig. ​(Fig.3).3). The mean AMB concentrations in the lung tissue following L-AMB inhalation at 1.2, 2.6, and 4.0 mg/ml were 35.5, 73.2, and 94.2 μg/g, respectively. Recorded levels in sera were 0.02, 0.06, and 0.06 μg/ml when inhaled-L-AMB suspensions were administered at 1.2, 2.6, and 4.0 mg/ml, respectively.Open in a separate windowFIG. 1.Survival curves for mice with IPA (Kaplan-Meier plot). Groups of 11 mice were treated with a combination of intraperitoneal administration of MCFG (1 mg/kg/day) and inhalation of aerosolized L-AMB (8 ml at 1.2 mg/ml [open squares]), inhalation of aerosolized L-AMB (8 ml at 1.2 mg/ml [filled triangles]), intraperitoneal administration of MCFG (1 mg/kg/day [open triangles]), and no therapy (control [filled circles]). *, P < 0.05 versus the control; **, P < 0.05 versus the control group, intraperitoneal-MCFG group, or aerosolized-L-AMB group (log rank test). The survival times for all treatment groups were longer than that for controls (P < 0.05). The survival time for the combination treatment group was significantly longer than those of the intraperitoneal-MCFG group and the aerosolized-L-AMB group (P < 0.05).Open in a separate windowFIG. 2.Numbers of CFU from homogenized lung tissues of mice with IPA. Groups of 10 mice were treated once per day with a combination of intraperitoneally administered MCFG (1 mg/kg/day) and inhalation of aerosolized L-AMB (8 ml at 1.2 mg/ml), aerosolized L-AMB (8 ml at 1.2 mg/ml), intraperitoneal MCFG (1 mg/kg/day), and saline (control). CFU counts, as a parameter of A. fumigatus burden in the lungs of IPA mice at 4 h after day 3 of treatment, are shown. *, P < 0.05 (Student''s t test).Open in a separate windowFIG. 3.Histopathology of lung tissues. Both lungs were obtained from IPA mice 4 h after 3 days of treatment with a combination of intraperitoneally administered MCFG and inhalation of aerosolized L-AMB, aerosolized L-AMB, intraperitoneal MCFG, and saline alone as a control. The lungs obtained from aerosolized-L-AMB-treated and combination treatment mice showed obviously smaller numbers of hyphae and fewer foci of inflammation than intraperitoneal-MCFG and control mice. HE, hematoxylin-eosin; GMS, Grocott''s methenamine silver nitrate stain.The current study demonstrated the efficacy of monotherapy of aerosolized L-AMB in a murine IPA model. The AMB concentrations in lung tissue in our study were relatively higher but extremely lower in serum than those from another report of a murine model of intravenously administered L-AMB, although experimental conditions were not the same (10). These results suggested that systemic toxicity generally caused by AMB treatment may be reduced by L-AMB inhalation therapy.The effect of combined intraperitoneal-MCFG and aerosolized-L-AMB treatment was an enhanced survival rate, even though this drug interaction was classified as indifferent in vitro. Since 78% of all control mice died in first 3 days in a survival analysis, we changed the experimental conditions for analysis of fungal burden and histopathological examination. In this model, no mice died before euthanasia, a prerequisite for the organ CFU assay. Both fungal-burden data and histopathological findings supported the survival data in our study.Unlike in our study, Graybill et al. previously reported that combination therapy demonstrated a lack of synergistic effects following intravenous-L-AMB and intraperitoneal-MCFG treatment in a model of murine IPA (4). These discrepancies are likely due to differences between our model and Graybill et al.''s model, including (i) the route of infection, (ii) the status of immunosuppression, and (iii) the administration route of antifungal drugs. These differences also suggest that targeted intrapulmonary delivery of drugs by inhalation raises the drug concentration at the active site of infection in the lungs, thus contributing to the efficacy of combination therapy. Further comparative efficacy studies in a clinical setting are warranted.     

An outbreak of avian influenza subtype H9N8 among chickens in South Korea.

Low pathogenic avian influenza subtype H9N8 was diagnosed on a Korean native chicken farm in Gyeonggi province, South Korea, in late April 2004. Clinical signs included moderate respiratory distress, depression, mild diarrhoea, loss of appetite and a slightly elevated mortality (1.4% in 5 days). Pathologically, mucopurulent tracheitis and air sacculitis were prominently found with urate renal deposition. The isolated A/chicken/Kr/164/04 (H9N8) had an Ala-Ser-Gly-Arg (A/S/G/R) motif at the cleavage site of haemagglutinin, which has been commonly found in H9N2 isolated from Korean poultry. Phylogenetic analysis of the haemagglutinin and neuraminidase genes of the H9N8 avian influenza virus (AIV) isolate showed that reassortment had occurred. Its haemagglutinin gene was similar to that of Korean H9N2 AIVs, but its neuraminidase gene was closely related to that of A/WBF/Kr/KCA16/03 (H3N8) isolated from the faeces of wild birds in Korea. The pathogenicity of the isolate was tested on 6-week-old specific pathogen free chickens. The inoculated virus (H9N8) was recovered from most tested organs, including the trachea, lung, kidney, spleen, and caecal tonsil. This is the first report of an outbreak of low pathogenic avian influenza in chickens caused by AIV subtype H9N8.     

Renal epithelioid angiomyolipoma with malignant features: Histological evaluation and novel immunohistochemical findings

Renal epithelioid angiomyolipoma (EAML) is a potentially malignant tumor type whose characteristics and biomarkers predictive of malignant behavior have not been elucidated. Here, we report three cases of renal EAML with malignant features but without histories of tuberous sclerosis complex. Case 1 involved a 29‐year‐old man with a 12‐cm solid mass in the right kidney who underwent radical right nephrectomy. Case 2 involved a 22‐year‐old woman with a retroperitoneal mass who underwent radical right nephrectomy and retroperitoneal tumorectomy. Local recurrence was detected 7 years post‐surgery. Case 3 involved a 23‐year‐old man with a 14‐cm solid mass in the left kidney who underwent radical left nephrectomy. Microscopically, the tumors in all cases demonstrated proliferation of epithelioid cells with atypia, mitotic activity, necrosis, hemorrhage, and vascular invasion. Epithelioid cells in all cases were immunohistochemically positive for melanocytic and myoid markers and weakly positive for E‐cadherin and β‐catenin. Immunohistochemistry revealed activation of the mammalian target of rapamycin pathway. Here, we report the morphological and immunohistochemical features of clinically or histologically malignant renal EAML.     

A novel de novo point mutation of the OCT‐binding site in the IGF2/H19‐imprinting control region in a Beckwith–Wiedemann syndrome patient

The IGF2/H19‐imprinting control region (ICR1) functions as an insulator to methylation‐sensitive binding of CTCF protein, and regulates imprinted expression of IGF2 and H19 in a parental origin‐specific manner. ICR1 methylation defects cause abnormal expression of imprinted genes, leading to Beckwith–Wiedemann syndrome (BWS) or Silver–Russell syndrome (SRS). Not only ICR1 microdeletions involving the CTCF‐binding site, but also point mutations and a small deletion of the OCT‐binding site have been shown to trigger methylation defects in BWS. Here, mutational analysis of ICR1 in 11 BWS and 12 SRS patients with ICR1 methylation defects revealed a novel de novo point mutation of the OCT‐binding site on the maternal allele in one BWS patient. In BWS, all reported mutations and the small deletion of the OCT‐binding site, including our case, have occurred within repeat A2. These findings indicate that the OCT‐binding site is important for maintaining an unmethylated status of maternal ICR1 in early embryogenesis.