—  SPECIALTY CONFERENCE HANDOUT  — Infectious Disease Pathology Sunday March 21 , 7:30 PM Harding Clinical histories are printed below. Click on the case numbers for text and references of each case. Click on each slide thumbnail image for an enlarged view Infections In the Pediatric Population Moderator: JEANNETTE GUARNER Emory University, Decatur, GA Disclosure: In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose. Panelists: MIGUEL REYES-MUGICA, Children's Hospital of Pittsburgh, Pittsburgh, PA LILI MILES, Cincinnati Children's Hospital Medical Center, Cincinnati, OH CARLOS R. ABRAMOWSKY, Emory University - Egleston Children's Hospital, Atlanta, GA BEVERLY B. ROGERS, Children's Medical Center, Dallas, TX JEANNETTE GUARNER, Emory University, Decatur, GA Clinical Histories and Still Images are displayed below. Click on slide thumbnail images for an enlarged view. If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137. Case 1 - Click here for Text and References Submitted by: Miguel Reyes-Mugica - Children's Hospital of Pittsburgh, Pittsburgh, PA Clinical Summary: In 1995, 6 year-old girl presented with a large left neck mass at the Children's Hospital of Pittsburgh. Her past medical history was relevant for biliary cirrhosis secondary to extrahepatic biliary obstruction (biliary atresia), treated with a Kasai procedure. At one year of age, she underwent an orthotopic liver transplant (OLTx). At the time of her hospital admission, five years after the liver transplant, relevant laboratory results included: , Hb= 12.2; Ht= 35.1; WBC= 7.6K/DL: Plt.=296 K/dL; Neut.= 49%; Lymph.= 31%; Mon.= 9%; Eos.=10%; Bas./Band= 1%. SGTP/SGOT= 44/39 IU/L; ALKP/GGTP= 157/22 IU/L. Renal function tests, electrolytes and glucose were within normal limits. Uric acid= 3 mg/dL. The mass was removed and sent to pathology. Representative photomicrographs are presented for discussion. Case 1 - Figure 1 Imprint taken from the excised mass. Cells are monomorphous, mid-sized, with a small amount of cytoplasm, focally vacuolated. Nuclei reveal fine, granular chromatin, and several inconspicuous nucleoli. There are numerous apoptotic bodies due to increased cell turnover. Diff-Quik®, 40X Diff-Quik Case 1 - Figure 2 Low power photomicrograph (10X) showing the extensive effacement of the nodal architecture by a monotonous proliferation with a prominent "starry sky" pattern. The upper portion of the image shows partial preservation of the architecture. Case 1 - Figure 3 Mid-power image (20X) featuring numerous macrophages with phagocytized cellular debris surrounded by a monomorphous proliferation of neoplastic lymphoid elements with intermediate size. Case 1 - Figure 4 High-power photomicrograph (40X) revealing the very scanty cytoplasm, finely granular chromatin and multiple amphophilic nucleoli. Numerous apoptotic bodies and several mitotic figures are also shown. Case 1 - Figure 5 Immunohistochemical staining is positive for CD20 in the proliferating lymphoid cells. CD20 Case 1 - Figure 6 Immunohistochemistry for Ki67 is positive in essentially all lymphoid neoplastic elements. Ki67 Case 1 - Figure 7 Another low power view of the architectural effacement with a prominent starry sky pattern. Case 1 - Figure 8 The numerous tingible body macrophages, imparting the classic "starry sky" pattern reflect a high level of cell apoptosis and turnover. Case 1 - Figure 9 Additional detail on the scavenging macrophages. Case 1 - Figure 10 Panoramic view of the touch imprint to show the high cellularity and monotony of the proliferating lymphoid cells. Case 1 - Figure 11 Immunohistochemistry for CD10 is ++ positive in lymphoid elements. Case 1 - Figure 12 Immunohistochemistry for BCL6 is +++ positive. Case 1 - Figure 13 In situ hybridization for EBER (10X). Case 1 - Figure 14 In situ hybridization for EBER (20X). Case 2 - Click here for Text and References Submitted by: Carlos R. Abramowsky - Emory University - Egleston Children's Hospital, Atlanta, GA Clinical History: An adequate for gestation newborn female was delivered at term by elective cesarean section, with good Apgar scores. The infant's initial evaluation was unremarkable. The mother was a healthy 31 year old, well to do African from Liberia and the pregnancy was uncomplicated. However, intractable postpartum bleeding led to a hysterectomy with a diagnosis of retained placenta. The placenta and uterus were examined in the pathology department with extensive sampling of the placenta. A diagnosis of placenta accreta was rendered. The newborn developed fever and leucocytosis in the first week of life and she was treated for bacterial sepsis although all cultures were eventually negative. Her physical examination was unremarkable except for slight hepatomegaly. A TORCH and other viral and malaria studies were negative, but serum IgM was 250 mg/dL (normal: up to 25mg/dL), consistent with a congenital infection. Head imaging was negative but an eye exam showed chorioretinitis. In the first 3 weeks she appeared mildly ill with lethargy and poor feeding. At day 20 postpartum, the mother developed a respiratory infection with pleural effusion and her clinical workup led to the diagnosis of pulmonary tuberculosis. On this basis, a similar diagnosis was entertained in the newborn when she developed classic miliary disease in her lungs (Figure 1) and hepato-splenomegaly. A PPD skin test showed 6mm of induration but a gastric lavage was positive for Mycobacterium tuberculosis. A review of the many samples of placenta which had been obtained to address the issue of postpartum hemorrhage was undertaken. A single focus of acute villitis and intervillitis with a predominant neutrophilic response and no evidence of granulomatous inflammation was identified (Figures 2,3). An Auramine-O fluorescent stain for acid fast bacteria was positive in this lesion (Figure 4). Anti-tuberculosis therapy was started with INH and Streptomycin. Two days later the child became critically ill with hypoxemia and DIC, worsening liver chemistries and respiratory failure requiring ventilation. Steroids and Pyrazinamide were added with good improvement of her respiratory symptoms. However, after several weeks her liver disease worsened with elevated bilirubin and transaminases and coagulation abnormalities. All these problems were treated with supportive measures with good results except for continuing liver chemistry abnormalities. A liver biopsy revealed multiple non-caseating granulomatous hepatitis with positive acid fast bacteria on microscopic examination and culture (Figures 5-7), despite several weeks of anti-TB therapy. Yet, the patient continued to improve and was discharged at 2 months of age. She remained with mild liver function abnormalities, mild hypersplenism and poor weight gain. At 9 months of age she had improved substantially, gained weight and towards her second year of life had recovered completely with no residual deficits. Anti-TB therapy was suspended at one year of age. Case 2 - Figure 1 Chest Xray of the newborn, shows diffuse densities bilaterally, consistent with a miliary infection. Case 2 - Figure 2 These low and higher magnification views, show the focus of villitis and intervillitis with a primarily neutrophilic inflammatory response (H & E stain). Case 2 - Figure 3 These low and higher magnification views, show the focus of villitis and intervillitis with a primarily neutrophilic inflammatory response (H & E stain). Case 2 - Figure 4 A sequential section of the same focus shown in figures 2 and 3 shows several acid fast bacilli consistent with mycobacteria, using an Auramine-O fluorescent method. Case 2 - Figure 5 At several weeks of age, and with persistent abnormal liver function tests, a liver biopsy of the infant showed non-necrotizing granulomatous hepatitis. Case 2 - Figure 6 At several weeks of age, and with persistent abnormal liver function tests, a liver biopsy of the infant showed non-necrotizing granulomatous hepatitis. Case 2 - Figure 7 An Auramine-O fluorescent stain on the liver biopsy also showed acid fast bacilli which were confirmed to be M.tuberculosis in liver biopsy cultures. Case 2 - Figure 8 This view is from the decidual layers of a placenta from a patient different from our index case, who had chronic tuberculosis and tuberculous meningitis at the time of delivery. The photomicrograph shows necrotizing granulomatous inflammation in the decidua, and the accompanying acid fast stain shows an occasional mycobacterial organism (arrows). There was no evidence of TB infection in the newborn who was treated immediately postnatally. Case 2 - Figure 9 This view is from the decidual layers of a placenta from a patient different from our index case, who had chronic tuberculosis and tuberculous meningitis at the time of delivery. The photomicrograph shows necrotizing granulomatous inflammation in the decidua, and the accompanying acid fast stain shows an occasional mycobacterial organism (arrows). There was no evidence of TB infection in the newborn who was treated immediately postnatally. Case 3 - Click here for Text and References Submitted by: LiLi Miles - Cincinnati Children's Hospital Medical Center, Cincinnati, OH Clinical Summary: This was an infant girl born at 39 weeks gestational age by spontaneous vaginal delivery. The mother was a 34-year-old G5P3(T1P2A0L3). Prenatal testing results were as follows: maternal blood type, O negative; VDRL/RPR, negative; Rubella, non-immune; Hepatitis B surface antigen, negative. At the time of delivery, the Apgars were 8 and 9 at 1 and 5 minutes, respectively. The birth weight was normal for the gestational age, and the placenta was normal grossly. At birth, her lower extremities were atrophic and they did not have spontaneous movement. She started having desaturation episodes with oxygen saturation down into the 40's and questionable apnea, shortly after birth. Neurological workup revealed neurological deficits consistent with lower motor unit disorders. MRI on day 3 of life revealed brain with multifocal enhancement and cystic changes, consistent with previous hemorrhage and/or calcification. Similar changes were also seen in the lumbar spinal cord. Eye examination revealed chorioretinal scarring, OD. Serology was negative for CMV IgG and IgM. She developed extensive apneic spells and subsequently with no spontaneous respiratory effort. She expired at 3 weeks of age after put on DNR by parents due to grave prognosis. The major autopsy findings were microcephaly, hydrocephaly, and extensive necrotizing meningoencephalitis involving cerebrum, cerebellum and brain stem. There was also necrotizing myelitis, especially involving spinal cord distal to L1. Other autopsy findings included focal myocarditis, aspiration pneumonia, mucus plugs in the bronchus, hepatomegaly with pericentral necrosis, splenomegaly with white pulp hyperplasia, and extramedullary hematopoiesis in multiple organs. The immediate cause of death in the case was respiratory failure. The underlying cause of death was congenital infection extensively involving the central nervous system. Representative gross photos and H&E stained slides from brain and spinal cord are submitted for review. Case 3 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 3 - Figure 1 This coronal section of cerebrum shows multiple areas of necrosis, scattered in the gray and white matter. One white matter cystic necrosis surrounded by calcification is also seen. Case 3 - Figure 2 Closer view of similar changes as those described in the previous figure. Case 3 - Figure 3 The lateral ventricular ependymal lining is destroyed (upper left), the wall of the white matter cystic necrosis is composed of lymphocytes and macrophages (lower left). The surrounding white matter contains many microglial nodules. Case 3 - Figure 4 Coagulative necrosis with calcification involving superficial cortex and leptomeninges. Case 3 - Figure 5 Early cystic changes with the accumulation of proteinaceous material. Case 3 - Figure 6 At the edge of white matter necrosis, there are microglial nodules and gemistocytic astrocytes. Case 3 - Figure 7 Coagulative necrosis of inferior olive with no viable neurons. Case 3 - Figure 8 Only rare viable anterior horn neurons are seen in the lumbar spinal cord. Case 3 - Figure 9 At the margins of the necrotic lesions, spherical structures, filled with bradyzoites are identified. Case 4 - Click here for Text and References Submitted by: Beverly B. Rogers - Children's Medical Center, Dallas, TX Clinical Summary: This 1170 stillborn male fetus was delivered to a 26 year- old G3P2 mother at a gestational age of 27 weeks. The mother had been receiving prenatal care and was referred to Parkland Hospital after documentation of severe fetal hydrops. The fetus was re-imaged, with significant findings including severe fetal hydrops, a markedly enlarged placenta, ascites, a large pericardial effusion, an enlarged heart, and a severe elevation of the middle cerebral artery pressure (maximum peak systolic velocity of 130 cm/sec). The mother was admitted for an intrauterine transfusion and the fetus's hematocrit increased from 5.4 to 10.2 g/dL. Despite intrauterine transfucion, the fetus continued to have severe anemia and decelerations. Therefore, it was decided to induce labor. The infant was delivered by vaginal delivery without complications two days after initial presentation. Apgar scores were 0. Fetal examination showed a 1170 gram male infant with the only significant findings being hydrops and focal skin slippage. Case 4 - Figure 1 A 20X photograph of fetal lung (original magnification) Case 4 - Figure 2 A 100X photograph of fetal lung (original magnification) Case 4 - Figure 3 A 20X photograph of placenta (original magnification) Case 4 - Figure 4 A 100X photograph of placenta (original magnification) Case 4 - Figure 5 The abdomen of this 27 week gestation fetus shows skin slippage characteristic of maceration. In addition, the abdomen is distended, a reflextion of edema. Case 4 - Figure 6 This 20X (original magnification) view of the fetal lung demonstrates premature pulmonary tissue, with a suggestion of cells containing intranuclear inclusions. Case 4 - Figure 7 The 40X (original magnification) view reveals erythroid precursors with inclusions. Case 4 - Figure 8 The intranuclear inclusion is seen in an erythroid precursor at a 100X (original magnification) power. Case 4 - Figure 9 Although villous edema is difficult to diagnose during the second trimester, these villi are enlarged, with loose stroma indicative of edema. Even at the 20X (original) magnification, excessive numbers of red blood cell precursors are noted. Case 4 - Figure 10 A 100X (original magnification) view reveals multiple intravascular erythroid precursors. While inclusions are present, they are less completely formed than the inclusions in the pulmonary erythroid series. It is typical for erythroid precursors in the placenta to have less distinct inclusions than those in the lungs. The reason for this is not known. Case 5 - Click here for Text and References Submitted by: Jeannette Guarner - Emory University, Decatur, GA Clinical Summary: A 7-year-old female presented with 5 days of fever, headache, abdominal pain, and vomiting, without diarrhea. On admission, her hemoglobin was 9.1 mg/dl and platelets were 41,000 platelets/ microliter. Liver function tests were mildly elevated, with an aspartate amino transferase of 107 U/lt and an alanine amino transferase of 112 U/lt. What is your diagnosis? What is the percent parasitemia? Case 5 - Figure 1 Handouts for all Specialty Conferences will be accessible via the "Educational Materials" section on the homepage the morning after each respective conference. Printed copies of the handout will not be available at the meeting.