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As an approach to the study of inflammation, strategies were evaluated for quantitative assessment of plasma exudate from the cutaneous microvasculature. Measurements were based on recovery of Evans blue dye (EB) from rat skin. After preliminary studies to evaluate extraction methods, almost complete EB recovery was accomplished by homogenizing tissue in a mixture of acetone, water and sodium sulfate. When sources of potential variation were identified, expression of results as agonist-induced plasma accumulation provided precise results based on EB measurements. Also, the feasibility of parallel biochemical studies was demonstrated.

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As experience with the acquired immunodeficiency syndrome has grown during the last decade, it has become important to recognize interactions between the opportunistic infections and malignancies that complicate the course of patients with acquired immunodeficiency syndrome. Our recent experience as described in this paper reveals that Kaposi's sarcoma and cryptococcal infection can associate in such a manner. The first reported case of oral Cryptococcus neoformans infection within a Kaposi's sarcoma lesion in a patient with acquired immunodeficiency syndrome is described. Based on the clinical course of this patient, it is an important consideration that the sarcoma may have harbored and even protected the fungus during systemic amphotericin B therapy.

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The clinicopathologic features of nine cases of sinonasal tract leiomyosarcoma (SNTL) referred to the Armed Forces Institute of Pathology, Washington, DC, during the period from 1970 through 1988 are described. This report represents the largest study to date on SNTL, and our results are compared with the 21 previously reported cases of SNTL. Of the nine cases described, patients ranged in age from 22 to 86 years (mean, 55 years). The most frequent clinical presentation was nasal obstruction unilaterally. The neoplasms were limited solely to the nasal cavity in four cases (44%) and involved both the nasal cavity and paranasal sinuses in the remaining five cases. Light microscopic, immunocytochemical, and ultrastructural features served to characterize these tumors as malignant neoplasms of smooth-muscle origin. In contrast with previous studies, immunocytochemistry was employed to differentiate SNTL from other spindle cell malignancies of the region, using newly available monoclonal antibodies to smooth-muscle antigens. Treatment was surgical. Radiotherapy or chemotherapy did not appear to affect the progression of the disease. Furthermore, no relationship was found between the aggressiveness of SNTL and morphologic parameters (eg, mitotic count and tumor size). Instead, prognosis was dependent on the distribution of disease at presentation. Of all 30 patients with SNTL described to date, 10 had the neoplasm confined solely to the nasal cavity. The 10 neoplasms did not recur. We conclude that SNTL may best be regarded as a locally aggressive neoplasm with only limited metastatic potential and that it could be curable by complete surgical excision.

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Pneumocystis carinii involvement of the pleural cavity in a patient with the acquired immune deficiency syndrome was documented by cytologic as well as scanning and transmission electron microscopic study of pleural fluids. Histologic examination of the pleura and the subpleural lung revealed vasculitis and infarctlike necrosis as well as P carinii in the tissue. Although a few cases of extrapulmonary P carinii infection have been reported, this appears to be the first time its presence in pleural fluid has been documented.

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Previously identified as a platelet-activating factor, 1-0-alkyl-2-acetyl-sn-glyceryl-3-phosphorylcholine recently has been described as an inflammatory mediator with vasoactive and leukotactic properties. Histologic studies suggested that the local microvascular effects of this potent acetylated alkyl phosphoglyceride were limited in extent. Also, cytologic characterization of exudates was incomplete in tissue sections. Therefore, skin window chambers were used as an alternate model in which to explore the ability of the active form of this lipid mediator to diffuse in tissue. In addition, skin windows provided a convenient means to characterize the leukocytic exudates. Based on measurements of agonist-induced plasma exudation, the effect of 1-0-hexadecyl-2-acetyl-sn-glyceryl-3-phosphorylcholine appeared to be limited to the superficial microvasculature underlying the skin window surface. This interpretation was supported by a brief histologic study that revealed vascular labeling by colloidal carbon mostly in a narrow 150-microns dermal zone beneath chambers containing the phospholipid agonist. Finally, the leukocytic exudate recovered at 3 hours consisted of neutrophils and a small number of eosinophils. Thus the skin window model was useful to further characterize the leukocytic exudate, and it suggested that the potent vasoactive effects of the acetylated alkyl phosphoglyceride were limited by local conditions in tissue so as to produce a highly focused inflammatory response.

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A preliminary diagnosis of tuberculosis can be established by the detection of acid-fast bacilli (AFB) and confirmed by culture of the microorganism. To evaluate an alternative method of diagnosis, the distribution of mycobacterial antigens in lung tissue specimens was characterized by an indirect peroxidase-antiperoxidase method and was compared to the detection of AFB by Ziehl-Neelsen stain. Histologic specimens were obtained from 59 hospital patients. Of nine patients with mycobacterial disease, seven had antigen detected in tissue. In two patients with tuberculous pneumonia, the distribution of mycobacterial antigens was approximately the same as that of AFB. In contrast, in four patients with caseating pulmonary granulomas, clumps of mycobacterial antigens were demonstrated in necrotic areas of the granulomas where there were few or no AFB. In one patient with Mycobacterium intracellulare infection, cross-reactive antigens stained weakly. Antigen was not found in tissue from two patients; one had miliary lung granulomas, and the second had mediastinal lymph node granulomas. Mycobacterial antigens were not detected in specimens from 50 control patients with nonmycobacterial diseases. On the basis of this study of 59 cases, immunohistochemical detection of microbial antigens appears to be useful for establishing the mycobacterial etiology of caseating pulmonary granulomas.

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The dermal microvasculature is an integral component of skin windows. However, in spite of the obvious dependence of the skin window model on vascular function, its almost exclusive application has been the study of leukocyte function and recovery of the cellular components of inflammatory exudates. In the studies reported here, skin window chambers were employed for assessment of function of the underlying microvasculature in rats given intravenous infusions of Evans blue dye or colloidal carbon. Increased vascular permeability was documented by photometric measurement of Evans blue dye, and vascular labeling of dermal vessels with colloidal carbon was assessed histologically. Zymosan-activated serum elicited accumulation of both leukocytes and Evans blue dye in chamber fluid overlying skin windows, confirming the responsiveness of the preparations. With serotonin as a model vasoactive substance, both increased vascular permeability and vascular labeling were directly related to serotonin concentration in the chamber fluid. It is estimated that plasma exudates were distributed as approximately 10% in the fluid and 90% in the dermis. Finally, serotonin-induced exudates recovered from the 0.3-ml chambers were estimated to be up to 3 microliter of plasma based on Evans blue dye measurement or up to 70 micrograms of protein based on Lowry assay. Thus, soluble components of skin window exudates were recovered for examination, and the dermal microvasculature was shown to be an important functional component of the skin window model that was directly accessible for study.

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The potent vasoactive and leukotactic properties of acetyl glyceryl ether phosphorylcholine (AGEPC) were further characterized histologically. After intravenous infusion of colloidal carbon and local injection of AGEPC, microscopic examination of rat cremaster muscle and skin revealed histamine-like vascular labeling restricted to postcapillary venules. Ultrastructural studies demonstrated subendothelial carbon accumulation in labeled venules. In rat skin, vascular labeling with colloidal carbon was an equally sensitive indicator of AGEPC-induced vasoactivity as was Evans blue dye extravasation for the assessment of AGEPC-induced increased vascular permeability (i.e., 1 pmole of AGEPC consistently initiated both vascular labeling and increased vascular permeability). In addition to its potent vasoactive effects in rabbits and rats, concomitant leukocyte emigration was observed in venules within 15 minutes after intradermal injection of AGEPC. In rabbit skin, AGEPC was equally as potent for the induction of leukocyte infiltrates as for the stimulation of increased vascular permeability. However, the vasoactive properties of AGEPC appeared to be neutrophil independent as well as independent of mast cell and platelet stimulation; these data suggest that AGEPC may act upon the microvasculature by direct stimulation of the venular endothelial cells. Thus, the putative role of AGEPC as a potent inflammatory mediator includes both the vasoactive and the leukotactic aspects of the acute inflammatory process.

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A 60-year-old man developed a left VIth-nerve paralysis and underwent biopsy of an extramedullary plasmacytoma in the sphenoid sinus. Immunohistochemistry demonstrated cytoplasmic IgD and lambda determinants. Subsequent specimens from left clavical and thoracic epidural lesions also showed a plasma cell neoplasm with IgD and lambda determinants. No abnormal plasma cells were found in bone marrow specimens. Lambda Bence-Jones protein and monoclonal IgD-lambda protein in the serum were detected several months after onset. The patient died with disseminated plasmacytoma 1 year after diagnosis. The mode of presentation, pattern of metastasis, and secretory features were typical of extramedullary plasmacytoma arising in the upper airway. Immunohistochemistry was more productive than serum electrophoresis and immunoelectrophoresis for following the course of this neoplasm.

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To better characterize pulmonary candidiasis, lung tissue samples from 58 hospital subjects were examined by immunohistochemical analysis with antiserums to candidal mannan and cytoplasmic antigens. In nine cases of invasive pulmonary candidiasis, fungal antigens were abundant in lung specimens and were distributed in two immunohistologic patterns. Antigen dissemination beyond the lung was confirmed by detection of antigenemia by mannan radioimmunoassay in serum samples in cases of pulmonary candidiasis of each immunohistologic pattern. In contrast, minimal, focal quantities of fungal antigens were detected in lung tissue specimens from nine subjects with thrush or aspiration but without pulmonary candidiasis; no antigen was detected in 40 additional cases of noncandidal mycotic, bacterial, viral, and parasitic pneumonias. Immunohistochemical criteria that denote invasive pulmonary candidiasis include the abundance of diffuse candidal antigens in bronchiolar and alveolar fluid and cytoplasmic staining of phagocytes. When compared with routine histologic stains, the diagnostic yield in cases of invasive pulmonary candidiasis was significantly increased by detection of candidal antigenic material. This study of 58 well-documented cases shows that immunohistochemical detection of candidal antigens facilitates the diagnosis of candidal pneumonia and distinguishes clinically significant pulmonary candidiasis from noninvasive aspiration, opportunistic colonization, or specimen contamination.

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Intracutaneous injection of 5 to 50 pmoles of acetyl glyceryl ether phosphorylcholine (AGEPC) induced neutrophil (PMN) infiltrates in rabbit skin. PMN margination and plugging were present in dermal venules within 15 minutes after AGEPC injection, and extravascular PMN were most abundant after 3 hours. There was a sharp decline in PMN numbers when sites were examined 6 hours after AGEPC injection. PMN emigration appeared to occur predominantly from venules in the deep portion of the cutaneous venous plexus, and PMN accumulation was greatest in the deep dermis. Few if any PMN were present in lyso-glyceryl ether phosphorylcholine and human serum albumin sites at all time points studied. This demonstration that extravascularly introduced AGEPC induces PMN infiltrates in vivo provides evidence that this acetylated alkyl phosphoglyceride may be a significant mediator of acute allergic and inflammatory processes with a broader role than its previously described platelet-activating properties.

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Extramedullary plasmacytomas (EMPs) are plasma cell neoplasms that most frequently arise along the upper airways and often do not secrete detectable amounts of M protein at the time of diagnosis. The present report describes the immunohistochemical characterization of an EMP in a young woman. The unlabeled peroxidase-antiperoxidase method was employed to demonstrate cytoplasmic immunoglobulin determinants in routinely processed, paraffin-embedded tissue. Only kappa light chain and lambda heavy chain determinants were found in the cytoplasm of the neoplastic plasma cells; essentially identical results were found in both initial and recurrent lesions separated by a 16-month interval. This exclusive staining of one light chain type associated with only one heavy chain represents a monoclonal staining pattern that is typical of B-cell neoplasms. Such characterization of EMPs on the basis of cytoplasmic immunoglobulin class and type may provide prognostic information analogous to the classification of multiple myeloma by immunoelectrophoresis.

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Tissue specimens from five patients with rheumatic disease who developed lymphadenopathy were studied by an immunoperoxidase method; available biopsy material was examined for cytoplasmic immunoglobulin determinants. Three patients had follicular hyperplasia of lymph nodes with polyclonal patterns. Two patients with Sjogren's syndrome had monoclonal patterns; both of these patients subsequently developed lymphoma with similar monoclonal patterns. Implications of the monoclonal patterns with regard to the biology of these lymphoproliferative disorders are discussed.

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Intradermal injection of 0.1 pmole (52 pg.) of acetyl glyceryl ether phosphorylcholine (AGEPC) in guinea pigs induced increased vascular permeability as assessed by a skin-blueing model. Rabbits and rats showed increased vascular permeability with 1.0 pmole (520 pg.) of AGEPC. On a molar basis, from 1,000 to 10,000 times more histamine was required to induce skin blueing in the same animals. In rabbits and guinea pigs, the increased vascular permeability induced by AGEPC occurred as an early, transient phase and as a delayed, prolonged phase. The early, transient phase was not inhibited by chlorpheniramine doses which markedly reduced or abrogated histamine-induced blueing. AGEPC was 100 to 1000 times more potent than histamine on a molar basis for the induction of vasoconstriction in a blued skin assay in guinea pigs. These studies demonstrate that AGEPC has potent vasoactive properties and provide additional information that implicates this acetylated alkyl phosphoglyceride as a mediator of the acute inflammatory process.

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An immunoperoxidase technique was used to characterize a malignant plasma cell tumor of the mandible in a patient with multiple myeloma. The neoplasm was found to produce only lambda light chains. This type of myeloma is rare and has a more grave prognosis than those which produce gamma or alpha heavy chains, or kappa light chains. The immunoperoxidase technique and the importance of immunologic characterization of malignant plasma cell tumors of the oral region are discussed.

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