Atrophy

• looks suspicious for adenocarcinoma at first glance.
• the nuclei are small and hyperchromatic.
• No prominent nucleoli are seen.
• Some glands are lined by obviously benign flattened atrophic epithelium.
• The immunostain for high molecular weight cytokeratin can be helpful in distinguishing between atrophy (fragmented basal cell layer) from atrophic variant of prostatic adenocarcinoma (no basal cell layer).

Atypical adenomatous hyperplasia

• It may show the infiltrative architecture of cancer,
• lacks the cytologic features such as prominent nucleoli.
• The immunostain for high mol. wt. Cytokeratin will show fragmented basal cell layer in most cases.

Post-Atrophic Hyperplasia

• Post-atrophic hyperplasia architecturally mimics adenocarcinoma
• lacks the cytologic features.
• In difficult cases, the immunostain for high mol. wt. cytokeratin can be performed which would show at least a few basal cells in post-atrophic hyperplasia.

Sclerosing Adenosis

• small glands with infiltrative growth pattern in a cellular spindled stroma.
• The plump spindle cells in the stroma are nicely seen here.
• The lining acinar epithelial cells lack cytologic atypia – no significant nuclear or nucleolar enlargement is seen
• Myoepithelial differentiation in basal cells of the acini of Sclerosing adenosis is illustrated with the immunostain for muscle specific actin.

Cowper’s Glands

• They have a lobular configuration and are often associated with skeletal muscle fibers
• The glands are lined by goblet cells distended with mucin.
• The small hyperchromatic nuclei are pushed to the periphery.
• Sometimes ducts lined by cuboidal cells are present in the center of the lobules.

Mucinous Metaplasia

• Mucinous metaplasia is seen in about 1% of prostates.
• It may occasionally resemble prostatic adenocarcinoma. However, it lacks prominent nucleoli and the does not show immunoreactivity for PSA and PAP.
• The cells are positive for PAS, mucicarmine and Alcian blue.

Prostatic xanthoma

• Prostatic xanthoma is an uncommon benign lesion that may mimic high-grade prostatic adenocarcinoma.
• It consists of lipid-laden macrophages that may be arranged in small circumscribed nodules or infiltrating cords extending into the stroma
• diffusely positive for CD68 (shown here), and negative for CAM5.2, PSA, and PSAP.

Examination with a dissecting scope (40x original magnification) revealed the following. Some of them were moving!

1. Diphyllobothrium latum, the broad fish tapeworm
2. Dracunculus medinensis, the Guinea worm
3. Spirometra spp., the cause of sparganosis in humans
4. the agents of gnathostomiasis: Gnathostoma spinigerum and Gnathostoma hispidum

When I was a resident (not said in a gravely old voice…yet) Joe ran the blood bank at Walter Reed Army Medical Center teaching several years of residents throughout the national capital area everything you wanted to or needed to know about blood banking and not a lot of minutia to clog your brain in risk of losing the big picture and important need to know material. During that time Joe also taught at the Osler review course for pathology. My class and those before and after me benefited from Joe’s interests in computer programming, going through courses and quizzes written on a Macintosh! Of course, Joe at the time was the only one smart enough to have a Mac but I eventually caught on. Last but not least, around the same time Joe started the website Blood Bank Guy (no doubt with a Mac) and was responsible for our department website, still in the infancy of the Internet and later dismantled to a shell of its former shelf following increased DOD restrictions on public web content in 2001. Little remains of that today.

Fortunately, as Joe has moved on he has kept up Blood Bank Guy, lecturing, teaching and mentoring & has added podcasts and a Blood Bank Guy Blog.

Joe’s teaching style is to inform and educate through evidence-based medicine. Those of us who were fortunate to learn blood banking from Joe learned as much about the subject as we did about being effective communicators and being part of the treatment team and being able to defend your decisions that clinicians would respect. He was one of the few attendings I had who could do this and teach it.

Now if Joe could just stop being an ardent Detroit Red Wings fan, I might just have a little respect for the guy, but no one is perfect.

Look forward to your posts Joe as one of my continued references for those 3 AM blood bank calls for the right answer.

Answer, Part II: What is the most common source of infection worldwide? Domestic pigs. What about in the United States? Wild game

According to a publication by the Centers for Disease Control and Prevention (Roy et al.”Trichinellosis Surveillance — United States, 1997–2001.” Centers for Disease Control and Prevention), trichinellosis has been steadily decreasing in the United States due to tightened regulations on pig farming and pork processing. They state:

Although trichinellosis was associated historically with eating Trichinella-infected pork from domesticated sources, wild game meat was the most common source of infection during 1997–2001. During this 5-year period, 72 cases were reported to CDC. Of these, 31 (43%) cases were associated with eating wild game: 29 with bear meat, one with cougar meat, and one with wild boar meat. In comparison, only 12 (17%) cases were associated with eating commercial pork products, including four cases traced to a foreign source. Nine (13%) cases were associated with eating noncommercial pork from home-raised or direct-from-farm swine where U.S. commercial pork production industry standards and regulations do not apply.

The following is an excellent source of information on trichinellosis with beautiful photos: http://www.trichinella.org/index_synopsis.htm

To make the diagnosis of trichinellosis on tissue section, one needs to recognize the classic appearance of the coiled larvae within tissue (typically skeletal muscle). Here is an image from this case that nicely demonstrates the larva, nurse cell (derived by the host) and stichosome (column of large rectangular cells):

Note that in this case, the larva is located in the skeletal muscle of the tongue, right below the tongue’s epithelium.

It is easiest to appreciate the coiled nature of the larvae by pressing non-fixed infected muscle between 2 slides and examining the tissue under the microscope. Here is an image from a previous case of the week that demonstrates a ‘squash’ prep:

Finally, for those of you non-pathologists who are having a hard time envisioning how a 3-dimensional coiled worm became a series of circles and ovals in tissue section, I’ve created the following diagram. The top image shows a coiled worm that is being cut along its longitudinal axis while making a slide. The bottom image shows how the worm would appear if you are only looking at the part that was cut and put on a slide.

“The studies were biased,” he says. “Sometimes they were overtly biased. Sometimes it was difficult to see the bias, but it was there.” Researchers headed into their studies wanting certain results—and, lo and behold, they were getting them. We think of the scientific process as being objective, rigorous, and even ruthless in separating out what is true from what we merely wish to be true, but in fact it’s easy to manipulate results, even unintentionally or unconsciously. “At every step in the process, there is room to distort results, a way to make a stronger claim or to select what is going to be concluded,” says Ioannidis. “There is an intellectual conflict of interest that pressures researchers to find whatever it is that is most likely to get them funded.”

I don’t find his conclusions particularly surprising, but I think it’s interesting that they’ve found their way into the mainstream media. He makes an excellent point about why public disclosure of these problems is the right choice, despite the fact that public confidence in medical science may be shaken. The ability to admit that we’re wrong is what separates us from the snake oil salesmen.

“If we don’t tell the public about these problems, then we’re no better than nonscientists who falsely claim they can heal,” he says. “If the drugs don’t work and we’re not sure how to treat something, why should we claim differently? Some fear that there may be less funding because we stop claiming we can prove we have miraculous treatments. But if we can’t really provide those miracles, how long will we be able to fool the public anyway? The scientific enterprise is probably the most fantastic achievement in human history, but that doesn’t mean we have a right to overstate what we’re accomplishing.”

100x original magnification

200x original magnification

200x original magnification

Diagnosis?

What is the most common source of infection worldwide? What about in the United States?

Splenic aspiration is an excellent way of diagnosing visceral leishmaniasis. However, the procedure carries the risk of splenic rupture and should only be undertaken by a skilled practitioner. An alternative procedure for diagnosis of visceral leishmaniasis is bone marrow biopsy.

Visceral leishmaniasis is prevalent in some parts of India and Africa, the Mediterranean, and South America.