GRANULOMATOSE LINFOMATOIDE

ABSTRACT Lymphomatoid granulomatosis (LYG) is a rare extranodal Epstein-Barr virus (EBV) associated B-cell lymphoproliferative disorder. Most cases occur between the fourth and sixth decades of life and the male-to-female ratio is 2:1. The lung is the most frequently involved organ. Radiographically, pulmonary disease is characterized by multiple variable size nodules. Histologically, the lesions show angiocentricity, are rich in T cells, have large atypical B cells, lymphocytic infiltration of the vascular wall and a variable necrosis. LYG is a distinct entity that can usually be differentiated from other EBV-associated B-cell lymphoproliferative disorders on the basis of the combination of clinical presentation and histology. The authors described the case of a 53-year-old woman who was previously diagnosed with sarcoidosis, histoplasmosis, and later with non-Hodgikin B Lymphoma. The lungs presented diffuse alveolar damage, exsudative phase, and infiltration by lymphomatoid granulomatosis. The patient became unstable and died. Grading of these lesions is important because it dictates the treatment choice. Keywords: Lymphomatoid granulomatosis, Epstein-Barr virus, pulmonary nodules

Primary endometrial large cell neuroendocrine carcinoma with melanocytic differentiation

High-grade endometrial carcinomas are aggressive neoplasms of difficult histological classification. Neuroendocrine differentiation in endometrial carcinomas is rare. This is the report of an endometrial large cell neuroendocrine carcinoma with foci of melanocytic differentiation in a 75-year-old woman with abnormal post-menopausal uterine bleeding for 2 years. Two initial biopsies were inconclusive. Histopathological examination of the uterus revealed large cell neuroendocrine carcinoma associated with endometrioid carcinoma and foci of melanocytic differentiation, pT3a (FIGO IIIA). There were metastases in the rectum serosa and lungs. After 8 months of diagnosis and surgical treatment, the patient is on chemotherapy and radiotherapy. We highlight the morphological characteristics and criteria that allow the definitive anatomopathological diagnosis, including immunohistochemical markers used to identify the cell types present in this unprecedented association

Primary endometrial large cell neuroendocrine carcinoma with melanocytic differentiation

High-grade endometrial carcinomas are aggressive neoplasms of difficult histological classification. Neuroendocrine differentiation in endometrial carcinomas is rare. This is the report of an endometrial large cell neuroendocrine carcinoma with foci of melanocytic differentiation in a 75-year-old woman with abnormal post-menopausal uterine bleeding for 2 years. Two initial biopsies were inconclusive. Histopathological examination of the uterus revealed large cell neuroendocrine carcinoma associated with endometrioid carcinoma and foci of melanocytic differentiation, pT3a (FIGO IIIA). There were metastases in the rectum serosa and lungs. After 8 months of diagnosis and surgical treatment, the patient is on chemotherapy and radiotherapy. We highlight the morphological characteristics and criteria that allow the definitive anatomopathological diagnosis, including immunohistochemical markers used to identify the cell types present in this unprecedented association

Alterações morfológicas no sistema digestivo de 93 pacientes infectados pelo vírus da imunodeficiência humana: um estudo de autopsias

Involvement of the digestive system in patients with acquired immunodeficiency syndrome (AIDS) is frequent and many changes in these patients are diagnosed only at autopsy. There are few studies of autopsy with detailed analysis of this system and only one was conducted in Brazil. We evaluated each segment of the digestive system in 93 consecutive autopsies of patients infected with human immunodeficiency virus (HIV) and the importance of these lesions to death. Of these, 90 (96.8%) patients had AIDS. We reviewed medical records, autopsy reports and histological sections from tongue to rectum stained with hematoxylin-eosin. When necessary, we analyzed special stains and immunohistochemistry to investigate infections. There was damage to the digestive system in 73 (78.5%) cases. The most common infections were candidiasis (42%), cytomegalovirus (29%), histoplasmosis (11.8%), toxoplasmosis (9.7%) and mycobacterial infection (9.7%). Malignancies were rare, present in four (4.3%) cases (two Kaposi's sarcoma, one adenocarcinoma and one metastatic embryonal carcinoma). All segments showed lesions: tongue (48.6%), esophagus (44.8%), stomach (44.7%), colon (43.2%) and small intestine (28.9%). The lesions found were immediate cause of death in five (5.4%) cases. In another 36 (38.7%) cases the basic disease was systemic and also compromised the digestive system.Envolvimento do sistema digestório em pacientes com síndrome da imunodeficiência adquirida (AIDS) é frequente e muitas alterações nesses pacientes são diagnosticadas apenas à autopsia. Há escassos estudos de autopsia com análise detalhada desse sistema e apenas um deles foi realizado no Brasil. Neste estudo avaliamos cada segmento do sistema digestório em 93 autopsias consecutivas de indivíduos infectados pelo vírus da imunodeficiência humana (HIV) e a importância dessas lesões para o óbito. Desses, 90 (96,8%) pacientes apresentavam AIDS. Revisamos prontuários médicos, relatórios de autopsias e cortes histológicos da língua ao reto corados pela técnica de hematoxilina-eosina. Quando necessário, analisamos colorações especiais e imuno-histoquímica para pesquisar infecções. Havia lesões no sistema digestório em 73 (78,5%) casos. As alterações mais comuns foram infecciosas: candidíase (42%), citomegalovirose (29%), histoplasmose (11,8%), toxoplasmose (9,7%) e infecção por micobactérias (9,7%). Neoplasias malignas foram raras, presentes em quatro (4,3%) casos (dois sarcomas de Kaposi, um adenocarcinoma gástrico e um carcinoma embrionário metastático). Todos os segmentos apresentaram lesões: língua (48,6%), esôfago (44,8%), estômago (44,7%), intestino grosso (43,2%) e intestino delgado (28,9%). As lesões encontradas foram causa imediata do óbito em cinco (5,4%) casos. Em outros 36 (38,7%) casos a doença básica era sistêmica comprometendo, também, o sistema digestório

Primary spontaneous pneumothorax

Pneumothorax is the presence of air in the pleural space, clinically classified as spontaneous when no identifiable precipitating factors exist and non-spontaneous when such factors are present. Further subdivision delineates into primary in the absence of an evident clinical cause and secondary when a causal relationship exists with an underlying medical condition. Thus, primary spontaneous pneumothorax (PSP) is characterized by air in the pleural space in patients without manifest clinical or pulmonary disorders.1,2 The annual incidence of PSP ranges from 7.4 to 18 cases per 100,000 in males and 1.2 to 6 cases per 100,000 in females.3 Patients with PSP typically exhibit a phenotype characterized by leanness and tall stature. Predisposing factors such as family history, Marfan syndrome, thoracic endometriosis, smoking, bronchiolitis, Birt-Hogg-Dubé syndrome, and homocystinuria may be associated with this entity. Changes in atmospheric pressure can also precipitate PSP.3,4 It commonly occurs at rest and is not correlated with physical activity. Most patients with PSP experience sudden ipsilateral pleuritic pain. Chest radiography and clinical history provide a highly accurate diagnosis, while occasional cases with small air volumes may require a computed tomography for diagnosis.1,4 Many authors5-7 suggest that spontaneous rupture of a subpleural bleb or bulla causes PSP. However, the mechanism behind the accumulation of subpleural air has yet to be clearly described. Currently, the likely cause is believed to be the degradation of lung elastic fibers induced by factors like smoking. This degradation increases neutrophils’ and macrophages’ concentration, thereby enhancing elastic degradation.1,3 Air can enter the interlobular septum through alveolar ruptures and accumulate in the subpleural regions. Additionally, pleural porosity has been described as an area where disruption of mesothelial cells in the visceral pleura occurs, leading to their replacement by fibroblastic tissue and increased porosity that permits air to enter the subpleural space.5,6 The treatment of PSP remains controversial, lacking a definitive consensus to date. Some studies indicate that outpatient treatment or sole pleural drainage results in a 38% recurrence rate of PSP. Conversely, patients treated with bullectomy, involving the surgical removal of blebs typically situated at the apex of the lung, combined with pleurodesis—a procedure inducing a fibrotic reaction in the pleura—demonstrate no recurrence.8,9 Ongoing debate surrounds the necessity of routine anatomopathological analysis post-surgery for all patients with PSP, as it might not change the prognosis in numerous cases.5-7 In this report, we present the gross and histopathological findings from a 20-year-old male patient. He stood at 192 cm, weighed 75 kg, with a body mass index of 20.35, and experienced sudden left thoracic pain and dyspnea while walking. An imaging workup revealed a significant air volume in the pleural cavity along with numerous apical blebs in the left lung. Subsequently, the treatment involved apical segment excision of the left lung, followed by pleurodesis. During the surgical approach using video-assisted thoracoscopy, we observed a sizable bulla surrounded by an area displaying increased vascularity and pleural retraction inferiorly, likely attributed to the prior rupture of another bulla or inflation (Figure 1A). The surgical specimen obtained from the apex of the left lung showed several bullae containing hematic contents, likely due to surgical manipulation, alongside areas consistent with previously ruptured bullae (Figure 1B). Microscopic analysis revealed areas demonstrating subpleural and intrapleural air accumulation, such as pleural interstitial emphysema (Figure 1C). Evidence of pleural porosity, characterized by intense fibrous thickening of the visceral pleura interspersed with air within the fibrotic regions, was observed (Figure 1D). The microscopic findings are significant as they correspond with the presumed mechanism involved in bleb formation. Figure 1A - video-assisted thoracoscopy reveals a bulla surrounded inferiorly by an area with increased vascularity and pleural retraction; B - surgical specimen from the lung apex with several bullae (scale bar= 2cm); C - areas exhibiting subpleural and intrapleural air accumulation (H&E; 100x); D - pleural porosity characterized by intense fibrous thickening of the visceral pleura, interspersed with air within the fibrotic regions (H&E; 100x).

Morphological changes in the digestive system of 322 necropsies of patients with acquired immune deficiency syndrome: comparison of findings pre- and post-HAART (Highly Active Antiretroviral Therapy)

Involvement of the digestive system in AIDS pathologies or injuries is frequent. Aiming at comparing the frequency, the importance that these lesions have for death and the survival time in patients using or not using HAART, we studied 322 necropsies classified as follows: Group A - without antiretroviral drugs (185 cases); B - one or two antiretroviral drugs or HAART for less than six months (83 cases); C - HAART for six months or longer (54 cases). In the overall analysis of the digestive system, changes were present in 73.6% of cases. The most frequent was Candida infection (22.7%), followed by cytomegalovirus (19.2%), Histoplasma capsulatum (6.5%), mycobacteria (5.6%), and Toxoplasma gondii (4.3%). T. gondii infection was more frequent in group A compared with group C, and cytomegalovirus (CMV) was more frequent in group A compared with groups B and C (p < 0.05); 2.2% of the deaths were due to gastrointestinal bleeding. Regarding the segments, only in the large intestine, and only cytomegalovirus, were more frequent in group A compared with group C. We conclude that digestive system infections are still frequent, even with the use of HAART. However, the average survival time in group C was more than three times greater than the one in group A and nearly double that of group B, demonstrating the clear benefit of this therapy

[RETRACTED ARTICLE] Gastric and jejunal histopathological changes in patients undergoing bariatric surgery

ABSTRACT BACKGROUND Morbid obesity is a multifactorial disease that is increasingly treated by surgery. OBJECTIVE To evaluate gastric histopathological changes in obese, and to compare with patients who underwent gastrojejunal bypass and the jejunal mucosa after the surgery. METHODS This is an observational study performed at a tertiary public hospital, evaluating endoscopic biopsies from 36 preoperative patients and 35 postoperative. RESULTS In the preoperative group, 80.6% had chronic gastritis, which was active in 38.9% (77.1% and 20.1%, respectively, in the postoperative). The postoperative group had a significant reduction in Helicobacter pylori infection (P=0.0001). A longer length of the gastric stump and a time since surgery of more than two years were associated with Helicobacter pylori infection. The jejunal mucosa was normal in 91.4% and showed slight nonspecific chronic inflammation in 8.6%. CONCLUSION There was a reduction in the incidence of Helicobacter pylori infection in the postoperative group. A longer length of the gastric stump and longer time elapsed since surgery were associated with Helicobacter pylori infection. The jejunal mucosa was considered normal in an absolute majority of patients

GASTRIC AND JEJUNAL HISTOPATHOLOGICAL CHANGES IN PATIENTS UNDERGOING BARIATRIC SURGERY

ABSTRACT Background: Morbid obesity is a multifactorial disease that increasingly is being treated by surgery. Aim: To evaluate gastric histopathological changes in obese, and to compare with patients who underwent gastrojejunal bypass and the jejunal mucosa after the surgery. Methods: This is an observational study performed at a tertiary public hospital, evaluating endoscopic biopsies from 36 preoperative patients and 35 postoperative. Results: In the preoperative group, 80.6% had chronic gastritis, which was active in 38.9% (77.1% and 20.1%, respectively, in the postoperative). The postoperative group had a significant reduction in H. pylori infection (p=0.0001). A longer length of the gastric stump and a time since surgery of more than two years were associated with Helicobacter pylori infection. The jejunal mucosa was normal in 91.4% and showed slight nonspecific chronic inflammation in 8.6%. Conclusion: There was a reduction in the incidence of Helicobacter pylori infection in the postoperative group. A longer length of the gastric stump and longer time elapsed since surgery were associated with Helicobacter pylori infection. The jejunal mucosa was considered normal in an absolute majority of patients