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Radiation necrosis versus tumor recurrence is an extremely common differential diagnosis in post-therapy biopsy specimens (Table 21 medicine in the 1800s 25/200 mg aggrenox caps visa. Most commonly, there is a mixture of both residual/recurrent tumor and radiation necrosis, and some data suggest that the ratio of the two provides meaningful prognostic information. Also, the post-therapy tumor sometimes appears cytologically inert or "stunned" and it is difficult to know whether these cells are "coming or going"; in other words, it is not clear if tumor cells would have died given additional time or if they were in an early state of recovery. Although less severe than full-blown radiation necrosis and usually not life threatening, radiation encephalopathy tends to progress over many years and significantly diminishes quality of life. Neuroprotective agents, such as lithium, have been studied and may reduce the frequency of this complication. For instance, in an autopsy study of 22 pediatric glioma patients treated with radiation, there were foci of demyelination in 7, necrosis in 6, and cortical atrophy in 4 cases. Over time, this may lead to tissue loss and hydrocephalus ex vacuo, a stark contrast to the increasing mass effect seen with tumor progression in diffuse gliomas. Foci of radiation necrosis, on the other hand, can be nearly impossible to distinguish from recurrent glioma in individual cases. Such cases or those with lesser degrees of injury such as blood-brain barrier disruption and inflammation are often referred 494 to as "pseudoprogression" when the worrisome neuroimaging changes resolve partially or fully on follow-up imaging. Necrotic foci appear yellow to tan-brown, with foci of dystrophic calcification being white and chalky. If there are superimposed foci of hemorrhage, they may have a variegated appearance, similar to that of glioblastoma. Histopathology Although it is not always possible to distinguish radiation-induced from inherent tumor-associated pathology, there are several helpful histologic clues (see Table 21. Vascular changes are usually prominent and likely play an important pathogenic role in radiation damage. As one of the few actively proliferating cell types in the brain, the endothelial cell is particularly sensitive. The pathologic changes are often those of conventional radiotherapy, although the severity is exaggerated. Foci of almost amorphous, paucicellular, congealed fibrin-rich tissue are common (tissue looks "fried"). Viable tumor may be scant or totally absent and the peritumoral brain is often highly gliotic, sometimes with considerable radiation-induced atypia. Radiation-induced cytologic atypia is common and similar to other parts of the body, involving tumor cells, endothelial cells, and adjacent brain parenchymal cells, such as reactive astrocytes and even neurons. Such changes pose substantial diagnostic challenges in terms of glioma classification and grading.
Aspiration Pneumonia and Lung Abscess There are multiple scenarios for aspiration pneumonia treatment yeast in urine buy aggrenox caps 25/200 mg with amex, including cases caused by chemical pneumonitis (so-called Mendelson syndrome), airway obstruction, exogenous lipoid pneumonia, chronic interstitial fibrosis, diffuse bronchiolar disease, bacterial pneumonia, and lung abscess. These may or may not be invested by giant cells but are usually found in purulent exudate or granulomatous foci. In the organizing phase of the pneumonia, food particles may be found within polyps of organizing pneumonia in the alveolar ducts and alveoli. Lobular pneumonia, lipoid pneumonia, organizing pneumonia, and bronchiolitis, alone or in combination, may also be seen. In clinical practice, diffuse alveolar damage accompanied by tissue necrosis is nearly always a manifestation of lung infection. Actinomycetes species tend to form similar-appearing granules, and both they and the bacteria of botryomycosis are typically found in the midst of purulent exudates. Hemorrhagic mediastinitis in a previously healthy adult is essentially pathognomonic for inhalational anthrax. The lymph node parenchyma generally is teeming with intact and fragmented grampositive bacilli, which can be identified as B. In those patients in whom pulmonary parenchymal changes are found, the alveolar spaces contain a serosanguineous fluid with minimal fibrin deposits and some mononuclear cells but few if any neutrophils. Also, because sepsis is an integral component of the pneumonia, it is important to collect blood culture specimens. The small, gram-negative coccobacillary organisms are difficult to identify in a tissue Gram stain, and the use of silvering techniques. In the microbiology laboratory, Gram stain and culture of respiratory secretions are useful for diagnosis, but blood cultures are often negative. Serologic tests are available but probably would not provide timely information in an outbreak situation. A smear can also be prepared for Gram stain and the aspirate needle rinsed in nonbacteriostatic sterile saline or nutrient broths for culture. Microbiology Microbiology techniques in current use for the laboratory diagnosis of bacterial pneumonia are summarized in Box 7. The work-up of respiratory secretions such as sputum in the microbiology laboratory may or may not be indicated based on the clinical and immunologic status of the patient. The value of microbiologic work-up for community-acquired pneumonias has been questioned Cytopathology the stereotypic cellular response to pyogenic bacteria is acute inflammation, characterized by variable numbers of neutrophils. Bacteria may be visualized in various stained preparations made from respiratory tract secretions and washings using the Papanicolaou and Diff-Quik methods. Pneumonia in the hospitalized or immunocompromised patient requires an aggressive strategy to collect a good sputum sample for Gram stain and culture. Because histology laboratories do not generally observe the same level of caution in reagent preparation and storage as microbiology laboratories, it is worth remembering that tissue sections are prone to false-positive results from in vitro bacterial contamination. In those cases where bacteria are visible on H&E-stained sections, the Gram stain can be helpful in confirming a presumptive etiology.
The pigment may be found in macrophages symptoms 7dp5dt generic aggrenox caps 25/200 mg buy on-line, in the interstitium, or in both, with very little fibrous response. True asbestos bodies may also be observed if there has been significant exposure to asbestos, as with shipyard welders. Iron oxide pigment is typically nonrefringent when viewed with polarizing microscopy. Differential Diagnosis Siderosis must be distinguished from chronic passive congestion of the lungs and from anthracosis (perivascular and peribronchiolar deposits of anthracotic pigment). Chronic passive congestion manifests as intraalveolar accumulation of numerous hemosiderin-laden macrophages. Although both hemosiderin and exogenous iron pigment that has been ferruginized in vivo stain with Prussian blue, hemosiderin lacks the dark brown to black centers characteristic of iron oxide. However, anthracotic pigment is black throughout, lacking the golden-brown rim characteristic of iron oxide. This disease occurs primarily among hematite miners, iron foundry workers, and welders. Miners and foundry workers may be exposed to significant amounts of silica in the workplace, resulting in siderosilicosis, which is characterized by histologic features of both siderosis and silicosis. Clinical Presentation Iron is minimally fibrogenic, so even patients with heavy exposures are typically asymptomatic. Chest x-rays may suggest interstitial fibrosis owing to shadows cast by the deposits of iron pigment. Perivascular pigment deposition is seen in this histologic section taken from the lung of a welder. A Masson trichrome stain demonstrates the whorled appearance of this heavily pigmented silicotic nodule. Pseudoasbestos bodies with broad yellow sheet silicate cores are seen in this case from a welder. Pseudoasbestos body on a tissue digestion filter from the lung of an iron foundry worker. Energy-dispersive x-ray analysis spectrum of iron oxide particles showing predominant peak for iron (Fe). Detail of dust-laden macrophages, showing the gray-brown granular appearance typical of aluminum oxide. Aluminosis Aluminosis is a pneumoconiosis caused by the inhalation of aluminumcontaining dusts. Although aluminum is relatively ubiquitous within the environment, aluminosis is a rare disease.
Because of this symptoms 3 days after conception cheap aggrenox caps 25/200 mg overnight delivery, it is not unusual that a biopsy is performed to address the differential diagnosis, which represents a potential pitfall for both the clinician and the pathologist (see the Histopathology and Differential Diagnosis sections). Grossly, cerebritis is characterized by a relatively solid area of hyperemia and tissue softening, with an irregular and ill-defined perimeter. Areas of abscess located next to the ventricular system may rupture into it or cause herniation, leading to rapid patient demise. In those instances when a patient does not present to clinical attention until subacute or chronic stages of the disease, the infection is typically walled off via a fibrous capsule. The earliest phase of bacterial cerebritis shows acute vascular injury, with fibrinoid vascular necrosis, vessel obliteration, and surrounding hemorrhage and neutrophils. As tissue necrosis ensues due to the vascular injury, the hypoxic milieu facilitates bacterial growth in the damaged parenchyma. Neutrophilic influx and necrotic tissue combine centrally to yield a pus-filled lesion in which bacteria can often be identified with appropriate stains. During early phases, fibroblasts can manifest 571 Pathogenesis, Incidence, and Demographics Clinical Manifestations and Localization Clinical features of brain abscess include those of the primary infection. On frozen section, cytologically atypical fibroblasts in the developing abscess wall look shockingly similar to microvascular proliferation seen in high-grade astrocytoma, representing the potential diagnostic pitfall in pathology that mirrors the radiologic mimicry of glioblastoma. The fibroblasts lay down extracellular collagen, which matures to form the dense fibrotic capsule. Localized Tuberculous Infections Tuberculomas-that is, localized infections analogous to ordinary bacterial abscesses-are significant causes of mass-producing lesions in endemic countries. Stereotactic biopsies can selectively sample any of these areas, but only the necrotic zone is likely to contain organisms on special stains or culture. Slightly more immunocompetent than immunocompromised patients with infection have been reported. Epidural empyema results in a more discrete, localized, and confined collection of pus evident when the skull is opened. Dematiaceous (pigmented) fungi will also show histochemical staining with Fontana-Masson. The radially arrayed, closely packed fungi show 45-degree angle branching ("tuning fork") and septations at high power magnification. Focal Infections Mimicking Neoplasms and Vice Versa Both cerebral abscess and highly necrotic neoplasms, such as glioblastoma or lymphoma, may present with ring-enhancing lesions on neuroimaging studies.
It may be viewed as a treatment option as well as a diagnostic test in patients who have limited metastatic disease medicine kit discount aggrenox caps 25/200mg buy line, especially if lung function is compromised. If no previous tumor has been seen and the lesion has the morphologic attributes of a nonpulmonary proliferation, it is necessary to search for a primary site. If paraffinembedded tissue from previous tumor material is available, immunopathologic studies of the previous tumor and the current specimen can be obtained comparatively. Useful information for the distinction between primary and secondary neoplasms in the lung may be derived from details of the clinical evaluation and physical findings. Unfortunately, such information is often not made available to pathologists, even though it is well known to enhance diagnostic accuracy. Open communication is essential if the patient has a history of oncologic disease. The light microscopic features of any given lesion are the cornerstone of pathologic diagnosis. The appearance of the lesion after hematoxylin and eosin staining is often sufficient to determine whether the tumor is primary or metastatic. Carcinomas arising in the lung typically have evolved over several years before coming to clinical attention. The mixture of proliferation and degeneration that characterizes primary carcinomas commonly causes central zones of fibrosis, with entrapment of some residual native pulmonary structures. In contrast, metastases to the lung parenchyma have a "clean" interface with the surrounding tissue and are usually not associated with peripheral zones of fibroinflammatory response. Specifically, primary and metastatic sarcomas, adenocarcinomas with a lepidic growth pattern, and small cell carcinomas are essentially superimposable morphologically. The rest of this section considers five categories of tumors in patients with a known history of extrapulmonary malignant neoplasms: 1. Undifferentiated large polygonal cell malignancies In each group, the differential diagnosis includes at least one primary pulmonary lesion. Although specific neoplastic entities are discussed, the presentation is not all-inclusive. The approach taken in this chapter is intended to provide an example of a differential diagnostic framework. Accordingly, this presentation is organized to reflect the most common morphologic groups in which specific neoplasms are usually placed.
This disorder first came to public attention as an emerging infection following an outbreak in the southwestern United States in 1993; it was causally linked to a previously unrecognized hantavirus medicine grace potter generic aggrenox caps 25/200mg mastercard. The specific type responsible for the cardiopulmonary syndrome, Sin Nombre, is present in rodent feces and is acquired from the environment through inhalation. Morphologic diagnosis is presumptive because hantaviral antigen in endothelial cells, detected by immunohistochemistry, is required for definitive diagnosis. At least five different coronaviruses are known to infect humans, and these cluster into two antigenic groups. Coinfections with other respiratory viruses occur in infants and children presenting with more severe respiratory disease. In certain epidemiologic situations, they can cause pneumonia in children, frail elderly individuals, and immunocompromised adults. Histopathologic findings in lung biopsy and autopsy tissues included acute lung injury (diffuse alveolar damage) in various stages of organization. However, the spectrum of findings included acute fibrinous pneumonia, hyaline membrane formation, interstitial lymphocytic infiltrates, desquamation of alveolar pneumocytes, and areas undergoing organization of the acute-phase injury. Viral inclusions were not identified, and initial immunohistochemical studies failed to reveal viral antigen. Adenovirus Adenovirus comprises several genera, with multiple serotypes that cause infections of the upper and lower respiratory tract, conjunctiva, and gut. Respiratory tract infections are most common and account for approximately 5% to 10% of pediatric pneumonias. These can be especially severe in neonates, children, and immunocompromised persons. These patterns may coexist in some cases, and the pneumonia may be accompanied by hemorrhage secondary to adenovirus-induced endothelial cell damage. Considerable crossover has been documented, however, with both types isolated from patients with disease at either site. Tracheobronchitis and pneumonia due to these viruses are rare in healthy adults with intact immune systems. They occur primarily in patients with underlying pulmonary disease and in association with inhalational and intubational trauma. They also occur in neonates and in patients who are immunosuppressed or compromised by various chronic diseases. Fortunately, immunohistochemistry or in situ hybridization can often resolve this differential diagnosis. This virus can cause considerable morbidity and even death in the neonate, but infection is generally asymptomatic in older healthy children and adults. As in the case of other herpesviruses, primary infection is followed by latency, which persists until immune deficiency or immunosuppressive therapy causes it to reactivate and disseminate. In some cases, atypical inclusions may be seen in cells that are not significantly enlarged, and the nuclei may contain dark-staining homogeneous inclusions that may lack a clear halo.
In situ hybridization with oligonucleotide probes: applications to infectious agent detection medications used to treat depression order aggrenox caps 25/200mg with amex. Use of immunohistochemistry in the surgical pathology laboratory for the diagnosis of infectious disease. Etiology of community-acquired pneumonia: increased microbiological yield with new diagnostic methods. Morphologic criteria for the preliminary identification of Fusarium, Paecilomyces, and Acremonium species by histopathology. Pseudomicrobes: some potential diagnostic pitfalls in the histopathologic assessment of inflammatory lesions. Cytologic examination of bronchoalveolar lavage fluid from immunosuppressed patients. Fine-needle aspiration and surgical pathology of infectious disease: morphologic features and role of the clinical microbiology laboratory for rapid diagnosis. Bronchoalveolar lavage and lung biopsy in patients with cancer and hematopoietic stem-cell transplantation recipients: a systematic review and meta-analysis. New and emerging etiologies for community-acquired pneumonias with implications for therapy. Pneumonia in the immunocompromised host: the role of bronchoscopy and newer diagnostic methods. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: diagnosis and treatment. Evidence-based algorithms for diagnosing and treating ventilator-associated pneumonia. Diagnosis of ventilator-associated pneumonia: a systematic review of the literature. Rhodococcus equi pneumonia and pulmonary malakoplakia in acquired immunodeficiency syndrome. Pulmonary disease due to aspiration of food and other particulate matter: a clinicopathologic study of 59 cases diagnosed on biopsy or resection specimens. Histopathologic features of Burkholderia cepacia pneumonia in patients without cystic fibrosis. Acute respiratory distress syndrome and pneumonia: a comprehensive review of clinical data. Primary pulmonary botryomycosis diagnosed by fine needle aspiration biopsy: a case report. Pulmonary disease from biological agents: anthrax, plague, Q fever, and tularemia. Index case of fatal inhalational anthrax due to bioterrorism in the United States.
A combined small cell and spindle cell carcinoma of the lung: report of a unique case with immunohistochemical and ultrastructural studies symptoms meningitis 25/200 mg aggrenox caps purchase otc. Combined large cell neuroendocrine carcinoma and spindle cell carcinoma of the lung. Metaplastic squamous cell carcinoma of bronchus simulating giant cell tumor of bone. Bronchogenic sarcomatoid squamous cell carcinoma with osteoclast-like giant cells. Pulmonary carcinosarcoma with heterologous components: report of two cases with literature review. Histological Typing of Lung & Pleural Tumours (International Histological Classification of Tumours). Pleuropulmonary blastoma (pulmonary blastoma of childhood): genetic link with other embryonal malignancies A case of pulmonary blastoma composed of histological features of both pulmonary blastoma and pulmonary endodermal tumor resembling fetal lung. Six cases of well-differentiated adenocarcinoma simulating fetal lung tissues in pseudoglandular stage: comparison with pulmonary blastoma. Pulmonary blastoma with argyrophil cells lacking sarcomatous features (pulmonary endodermal tumor resembling fetal lung). Pulmonary adenocarcinoma of fetal type: alternating differentiation argues in favor of a common endodermal stem cell. Pseudovascular adenoid squamous cell carcinoma of the lung: clinicopathologic of three cases and comparison with true pleuropulmonary angiosarcoma. Pseudovascular adenoid squamous cell carcinoma of the skin: a neoplasm that may be mistaken for angiosarcoma. Angiomatoid carcinoma and "angiosarcoma" of the thyroid gland: a spectrum of endothelial differentiation. Inflammatory pseudotumor of the lung: ultrastructural and light microscopic study of a myxomatous variant. Inflammatory pseudotumor of the lung in adults: radiographic and clinicopathological analysis.
Grok, 27 years: Cytologic features of pulmonary hamartoma: report of a case diagnosed by fine needle aspiration cytology.
Steve, 34 years: If initial aliquots are judged to be nondiagnostic, the saved sample can be recruited.
Brenton, 40 years: Drug-Associated Diffuse Lung Disease An increasing number of medications have been implicated in chronic diffuse lung disease.
Gembak, 65 years: In addition to sclerotic stroma, carcinoids can have amyloid-like stroma and prominent stromal mucin.
Rathgar, 64 years: Second, because these are rare disorders, few pathologists have much experience with their diagnostic subtleties.
Vigo, 25 years: Despite this potential for vasocentric growth, pulmonary hypertension is an uncommon complication of sarcoidosis.
Mufassa, 41 years: Role of immunohistochemistry in differentiating epithelial mesothelioma from adenocarcinoma: review and update.
Trompok, 36 years: This injury in turn leads to diffuse alveolar damage, which is similar in appearance to that observed in adult cases of acute respiratory distress syndrome.
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