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BACKGROUND: In 2000, an Italian non-governmental organisation (NGO) began a 9-year project to establish a surgical pathology laboratory at the Bugando Medical Centre (BMC) in Mwanza, Tanzania, a country with a low Human Development Index (HDI), and as of 2009, the laboratory was operating autonomously. The present survey aims to evaluate the reproducibility of histological and cytological diagnoses assigned in the laboratory's early years of autonomous activity. We selected a random sample of 196 histological and cytological diagnoses issued in 2010-2011 at the BMC surgical pathology laboratory. The corresponding samples were sent to Italy for review by Italian senior pathologists, who were blinded to the local results. Samples were classified into four diagnostic categories: malignant, benign, inflammatory, and suspicious. The two-observer kappa-statistic for categorised (qualitative) data was then calculated to measure diagnostic concordance between the local Tanzanian pathologists and Italian senior pathologists. The k-Cohen was calculated for concordance in the overall study sample. Concordance and discordance rates were also stratified by subset: general adult, paediatric/adolescent, and lymphoproliferative histopathological diagnoses; fluid and fine needle aspiration (FNA) cytological diagnoses; and PAP tests. Discordance was also categorised by the corresponding hypothetical clinical implications: high, intermediate, and not significant. RESULTS: Overall concordance was 85.2% (167 of 196 diagnoses), with a k-Cohen of 0.7691 (P = 0.0000). Very high concordance was observed in the subsets of adult general pathological diagnoses (90%) and paediatric/adolescent pathological diagnoses (91.18%). Concordance in the subset of PAP tests was 75%, and for fluid/FNA cytological diagnoses it was 56.52%. Concordance among 12 histological subtypes of lymphoma was 75.86%, with substantial discordance observed in the diagnosis of Burkitt lymphoma (five cases diagnosed by Italian pathologists versus 2 by local pathologists). The overall proportion of discordance with high hypothetical clinical implications was 6.1% (12 diagnoses). CONCLUSION: This blind review of diagnoses assigned in Tanzania, a country with low HDI, and in Italy, a country with a very high HDI, seemed to be a sensitive and effective method to identify areas of potential error and may represent a reference point for future, more detailed quality control processes or audits of surgical pathology services located in limited-resource regions.
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PURPOSE: Despite the increasing use of sentinel lymph node (SLN) mapping after colorectal cancer resection, reported node identification and false-negative rates vary considerably. The main aim of this prospective study was to quantify the false-negative rates on SLN mapping after resection and to evaluate factors influencing them. METHODS: Sixty-nine patients with biopsy-proven cancer of the colon and rectum underwent SLN mapping according to a protocol involving the ex vivo submucosal and peritumoral injection of 2-4 ml of Patent Blue V dye. All lymph nodes visualized were marked as SLN and totally embedded, then two 4 microm sections were cut for hematoxylin and eosin staining, and cytokeratin (AE1/AE3) immunostaining. A standard examination of the whole specimen and of the regional non-sentinel lymph nodes was also performed. RESULTS: SLNs were identified in 97.3% of the evaluable cases. A mean of 5.0 SLNs were removed per patient (SD+/-4.2). Nine false negatives were identified. Rectal cancer, tumor size>60mm, number of metastatic non-sentinel lymph nodes, and mucinous tumors were associated with false-negative SLNs. At multivariate analysis, a rectal location and mucinous differentiation were independently associated with false-negative SLNs. CONCLUSIONS: Ex vivo SLN mapping after colorectal cancer surgery is technically feasible with a high identification rate. Tumor size and stage, rectal involvement and a mucinous histology seem to interfere with the reliability of SLN staging. It is mandatory to standardize the procedure and selection criteria in order to deal with the question of the reliability of SLN mapping in colorectal cancer.
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Neoplasias Colorrectales/patología , Colorantes , Metástasis Linfática/diagnóstico , Colorantes de Rosanilina , Biopsia del Ganglio Linfático Centinela , Anciano , Neoplasias Colorrectales/cirugía , Reacciones Falso Negativas , Femenino , Humanos , MasculinoRESUMEN
PCR protocols for immunoglobulin heavy chain (IgH) gene rearrangements amplification make easy the NHL-B identification. In this study we analyzed PCR products by Capillary Electrophoresis (CE) and GeneScan (GS) software, wich offers clear advantages over the conventional methods such as agarose gels (AGGE), characterized by hight rate of false negative and false positive results. We suggested some criteria--not included in previous NHL-B issues--useful to a correct analysis of results in GS. Since 2003, we collected 2,977 samples (2,770 peripheral blood and bone marrow, and 207 tissues) for GS analysis from NHL-B patients. At beginning PCR products were detected by both AGGE and CE. FR2 and FR3 VH regions were amplified by PCR seminested; together with Bcl-6 "housekeeping" gene from the same sample, as marker of DNA quality and PCR efficiency. Bcl-2/IgH and Bcl1/IgH traslocations were also analyzed for follicular and mantle cells lymphomas respectively. Resolution and sensitivity tests, developed with serial diluitions of clonal products in water and in DNA from healthy individuals, showed for GS 1% of resolution limit (3% AGGE) and 0.5% of sensitivity (5% AGGE). Our criteria for correct interpretations of results are: a) use of "house-keeping" gene Bcl-6; b) costant reference scales for hight and molecular weight; c) clonal peak at least twice higher than adiacent peaks; d) position of clonal peak (central or eccentric) as regards to policlonal peaks distributions. e) peaks features for oligoclonal or biallelic rearrangements evaluation. GS is an ideal method for detecting IgH rearrangements and some characteristic traslocations. The precise determination of the size of the PCR product can be used for the minimal residual disease evaluation. Moreover, it allows semi-quantitative resolution of fragments only one base different in size and may be more objective than gel-based methods.
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Electroforesis Capilar , Linfoma de Células B/diagnóstico , Proteínas de Neoplasias/análisis , Proteínas Sanguíneas/análisis , Médula Ósea/química , Médula Ósea/patología , Ciclina D1/genética , ADN de Neoplasias/genética , Proteínas de Unión al ADN/genética , Reordenamiento Génico de Cadena Pesada de Linfocito B , Genes de Inmunoglobulinas , Genes bcl-2 , Humanos , Cadenas Pesadas de Inmunoglobulina/genética , Linfoma de Células B/química , Linfoma de Células B/genética , Linfoma de Células B/patología , Reacción en Cadena de la Polimerasa/métodos , Proteínas Proto-Oncogénicas c-bcl-2/análisis , Proteínas Proto-Oncogénicas c-bcl-6 , Estudios Retrospectivos , Sensibilidad y Especificidad , Programas Informáticos , Translocación GenéticaRESUMEN
Recently, many progresses have been recorded in the molecular and histogenetic characterization of the haematopoietic and lymphoid tumours, resulting in important classifying changes. As a consequence, the exact definition of lymphoma subtype requires an integration between traditional morphologic "expertise" and several bio-functional data obtained from advanced and complex ancillary techniques (immunohistochemistry, molecular biology and cytogenetics). At the same time, the data provided by gene expression profiling studies are going to deeply modify the therapies in haematological cancers. These studies are expected to allow the achievement of single-patient-tailored genic therapy; for this reason it is necessary to get biological samples of good quality. Indeed, while these progresses contribute to highlight the pathologist's diagnostic role, they should make us reflect on the state of the art of the Italian haemolymphopathology diagnostics and on its ability to cope up with the new challanges. The aim of this article is to outline a realistic picture of the present condition, and to explain the reasons for setting up, inside SIAPEC-IAP, the Haemolymphopathology Italian Group (H.I.G.). The purpose of H.I.G. will be twofold: first of all, scheduling of a series of projects so as to the haemolymphopathological diagnostic standardization; secondly, building a national network among all the pathologists involved in this exciting and complex field of the anatomic pathology.
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Neoplasias Hematológicas/diagnóstico , Hematología/organización & administración , Patología Clínica/organización & administración , Sociedades Médicas , Europa (Continente) , Perfilación de la Expresión Génica , Terapia Genética , Neoplasias Hematológicas/patología , Neoplasias Hematológicas/terapia , Hematología/métodos , Humanos , Inmunofenotipificación , Italia , Linfoma/sangre , Linfoma/diagnóstico , Linfoma/patología , Linfoma/terapia , Oncología Médica/métodos , Oncología Médica/organización & administración , Patología Clínica/métodos , Sociedades Médicas/organización & administraciónRESUMEN
Venice had a long tradition and great reputation in the study of anatomical science dating back to the 1300's. The "Serenissima" Republic favoured the study and practice of anatomy as part of medical professional formation. Before the construction of the anatomical theater of San Giacomo dell'Orio, which took place in 1671, anatomical dissections were performed in churches, convents, hospitals and private homes. Even though Venice was not a University seat, it boosted numerous Venetian anatomists, among whom Benedetti, Massa, Santorini, and the medical activity of illustrious professors at the nearby University of Padua such as Vesalio, Falloppio, Spigelio, Vislingio and Morgagni.
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Anatomía/historia , Actitud Frente a la Salud , Catolicismo/historia , Historia del Siglo XV , Historia del Siglo XVI , Historia del Siglo XVII , Historia del Siglo XVIII , Historia Medieval , Humanos , Italia , Religión y Medicina , Cambio Social/historiaRESUMEN
Populations resident in the historical town of Venice and in the inland industrial city of Mestre are at different risk of exposure to environmental pollutants. This case-control study compares the risk of developing lung cancer in the two populations in relation to known risk factors for this neoplasm. A retrospective study of 305 incident cases of lung and 447 frequency-matched population controls was conducted through a standard questionnaire on main risk factors for lung cancer. Completeness of cases was checked against the Venetian Cancer Registry files. The results indicate that lung cancer risk associated with tobacco smoking was high in both areas, although more elevated in Venice islands among heavy smokers. An elevation of risk was associated with housing without a heating system, possibly suggesting a role of worse hygienic conditions. An increased risk associated with exposure to occupational carcinogens was detected in the inland area. In conclusion, lung cancer risk due to tobacco smoking largely affects both the populations, while other risks such as occupation or housing conditions appear to be more population-specific.
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Contaminación del Aire Interior/efectos adversos , Neoplasias Pulmonares/etiología , Fumar/efectos adversos , Adulto , Anciano , Carcinógenos/efectos adversos , Estudios de Casos y Controles , Femenino , Vivienda , Humanos , Incidencia , Italia/epidemiología , Neoplasias Pulmonares/epidemiología , Masculino , Persona de Mediana Edad , Exposición Profesional , Estudios Retrospectivos , Medición de Riesgo , VentilaciónRESUMEN
BACKGROUND: Helicobacter pylori eradication therapy can be unsuccessful in 5 to 20% of patients. AIM: To investigate the validity of a strategy using triple therapies for the retreatment of patients with eradication failure, avoiding retreatment with antibiotics prone to induce resistance after use in the first treatment. PATIENTS AND METHODS: From a consecutive sampling of 108 patients still Helicobacter pylori-positive after a first course of antibiotic-based treatment, 74 (68.5%) agreed to a second course of triple therapy. Group 1 (N = 17): treatment failures on an imidazole (1)-based therapy were retreated with clarithromycin (C)-based regimen; Group 2 (N = 28): failures on a C-based therapy with an I-based regimen; Group 3 (N = 7): failures on an IC-based therapy using an I-based regimen and Group 4 (N = 22): failures on a non-I/non-C based therapy with either an I-based, C-based or IC-based regimen. The presence of Helicobacter pylori was assessed by histology and the CLO-test at study entry and two months after stopping therapy. RESULTS: Nine patients were withdrawn from the study (12.2%) due to a lack of end point endoscopy. Helicobacter pylori was cured after the second course of therapy in all but seven patients [10.7% failure by Per Protocol analysis, 21.6% by Intention-To-Treat analysis]. No statistically significant differences were found between the four groups (Group 1: 92.9% PP, 76.5% ITT; Group 2: 90.9% PP, 71.4% ITT; Group 3: PP and ITT 85.7%; Group 4: PP and ITT 86.4%). Minor adverse events were experienced in nine, none of whom required withdrawal from the drug therapy. CONCLUSIONS: A second course of triple therapy with alternate antibiotics effectively eradicated Helicobacter pylori, with only very few treatment failures. This suggests that the therapeutic strategy employed may be recommended.
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Infecciones por Helicobacter/tratamiento farmacológico , Helicobacter pylori , Adulto , Anciano , Distribución de Chi-Cuadrado , Intervalos de Confianza , Quimioterapia Combinada , Femenino , Infecciones por Helicobacter/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia del TratamientoRESUMEN
A 60-year-old female with a history of chronic pancreatitis and previous pancreaticojejunostomy has been submitted to distal gastric resection for recurrent perforating ulcers. A carcinoid tumour was identified in the surgical specimen. Hypergastrinaemia was subsequently diagnosed and tumour localization was carried out by a new scintigraphic technique with 111In-Pentetreotide. The tumour was found to be a metastasis confined to a peripancreatic lymph node. Surgery was successful, and 6 months later the patient is still eugastrinaemic. The different imaging methods for the identification of gastrinomas are discussed together with the current therapeutic options.
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Neoplasias Duodenales/diagnóstico por imagen , Gastrinoma/diagnóstico por imagen , Gastrinoma/secundario , Radioisótopos de Indio , Neoplasias Pancreáticas/diagnóstico por imagen , Somatostatina/análogos & derivados , Tomografía Computarizada de Emisión de Fotón Único , Neoplasias Duodenales/secundario , Femenino , Humanos , Metástasis Linfática , Persona de Mediana Edad , Neoplasias Pancreáticas/patologíaRESUMEN
Four cases of gastric carcinoma are described that are associated with an osteoclast-like giant cell (OGC) stromal component. The patients were all middle-aged men (range 53-63 years). Microscopically, the tumors were characterized by a bland cytologic appearance, and an either solid or cribriform pattern. Osteoclast-like giant cells were found adjacent to, or intimately intermixed with, the neoplastic cells in the primary gastric masses and in the lymph nodal metastases and were often associated with lymphocytes, histiocytes, and desmoplastic stroma. By immunohistochemistry, mononuclear cells and OGCs showed diffuse positivity for alpha-1-antichymotrypsin, alpha-1-antitrypsin, and CD68. Neoplastic cells that were positive for keratin and CEA, also showed reactivity for vimentin and the latent membrane protein of Epstein-Barr virus in one case. At follow-up, three patients had died at 13, 15, and 24 months after diagnosis, and one is still alive, without evidence of disease, after 120 months. This report describes a novel variant of gastric carcinoma with distinctive and histologic features.
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Carcinoma/patología , Células Gigantes/patología , Osteoclastos/patología , Neoplasias Gástricas/patología , Carcinoma/metabolismo , Humanos , Inmunohistoquímica , Masculino , Persona de Mediana Edad , Neoplasias Gástricas/metabolismoRESUMEN
Sixty-seven childhood tumors were studied immunohistochemically for the extracellular matrix element type IV collagen, laminin, and fibronectin. Tumors included Ewing's sarcoma, primitive neuroectodermal tumor, small cell osteosarcoma, neuroblastoma or ganglioneuroblastoma, rhabdomyosarcoma, and lymphoma. It was found that small cell osteosarcoma was often positive for fibronectin but not type IV collagen or laminin, a new observation. In the lymphomas, matrix proteins were rarely found. Ewing's sarcoma was variably positive for type IV collagen and laminin, but fibronectin was absent. Extracellular laminin and fibronectin were found in one of two cases of primitive neuroectodermal tumor. In neuroblastoma and ganglioneuroblastoma, the matrix components were rarely found. These results, discrepant with findings in cultured cells, may reflect the altered capacity of tumors to produce these proteins in vitro, which suggests that caution should be exercised in drawing conclusions regarding the nature or histogenesis of tumors from data obtained with cultured tumor cells. Embryonal rhabdomyosarcoma frequently contained all matrix elements in the extracellular space and in a dotlike pattern in the cytoplasm; alveolar rhabdomyosarcoma rarely contained these proteins and never exhibited the dotlike pattern. The frequent finding of matrix proteins in embryonal rhabdomyosarcoma but only rarely in alveolar rhabdomyosarcoma and the unique immunostaining pattern in embryonal rhabdomyosarcoma may prove to be a useful adjunct in the diagnosis of childhood tumors.
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Proteínas de la Matriz Extracelular/análisis , Matriz Extracelular/química , Proteínas de Neoplasias/análisis , Neoplasias/química , Adolescente , Adulto , Niño , Preescolar , Colágeno/análisis , Femenino , Fibronectinas/análisis , Humanos , Inmunohistoquímica , Lactante , Laminina/análisis , MasculinoRESUMEN
The morphologic and immunophenotypical features of three embryonal and one spindle cell rhabdomyosarcomas that underwent marked cytologic differentiation after polychemotherapy are described. In all the cases the morphologic changes were associated to disappearance of vimentin immunoreactivity and intense positivity for desmin, muscle specific actins, and myoglobin; in addition the differentiated tumor cells acquired a strong and continuous pericellular staining for laminin. The mitotic activity was significantly decreased. Drug associated differentiation seems to recapitulate the normal myogenic development to the point that the more mature neoplastic cells may represent terminally differentiated elements withdrawn from cell cycle. However, due to the persistence of a small number of poorly differentiated rhabdomyoblasts, the clinical consequences of this phenomenon are unclear.
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Rabdomiosarcoma/patología , Rabdomiosarcoma/terapia , Actinas/análisis , Adolescente , Adulto , Diferenciación Celular/efectos de los fármacos , Preescolar , Desmina/análisis , Femenino , Humanos , Laminina/análisis , Masculino , Neoplasias de los Tejidos Blandos/patología , Neoplasias de los Tejidos Blandos/terapia , Vimentina/análisisRESUMEN
UNLABELLED: Helicobacter pylori (Hp) is connected with active/chronic gastritis, gastric gastric and duodenal ulcer. It is not known whether exogenous factors are involved in Hp infection. The aim of this prospective study, performed on 286 consecutive subjects undergoing upper gastrointestinal endoscopy, was to evaluate the influence of smoking and alcohol consumption on Hp infection. For each patient the following parameters were taken into account: sex, age, smoking (no, < 10, > 10 cig/day) and alcohol (no, < 40, > 40 g ethanol/day) intake, antiulcer therapy (no, H2-blockers, omeprazole, sucralfate), presence of gastric or duodenal ulcer (DU). At least two biopsies from both the antrum and the corpus were obtained for histological examination; the gastritis was classified and scored according to the Sydney system. STATISTICS: chi-squared test (corrected), Fisher's exact test. RESULTS: 43 pts had Hp (27M, 16F; age 57.8 yrs, range 23-91), 47 Hp ++ (25M, 22F; age 61.1, range 19-86), 81 Hp + (48H, 33F; age 56, range 16-84), 115 Hp- (75M, 40F; age 57.8, range 19-84). Hp infection was found to be significantly correlated with presence of ulcer symptoms, gastritis, lymphoid follicles and, among DU patients, with active DU. The other parameters considered did not influence Hp infection. In conclusion smoking habits and alcohol consumption do not affect Hp infection of the stomach.
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Consumo de Bebidas Alcohólicas/patología , Infecciones por Helicobacter/patología , Helicobacter pylori , Fumar/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Consumo de Bebidas Alcohólicas/efectos adversos , Consumo de Bebidas Alcohólicas/epidemiología , Análisis de Varianza , Distribución de Chi-Cuadrado , Úlcera Duodenal/epidemiología , Úlcera Duodenal/etiología , Úlcera Duodenal/patología , Endoscopía Gastrointestinal , Femenino , Infecciones por Helicobacter/complicaciones , Infecciones por Helicobacter/epidemiología , Infecciones por Helicobacter/etiología , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Fumar/efectos adversos , Fumar/epidemiología , Úlcera Gástrica/epidemiología , Úlcera Gástrica/etiología , Úlcera Gástrica/patologíaRESUMEN
Between January 1981 and December 1987, 95 patients with stage IA (34 patients), IIA (42 patients) and stage IIB (19 patients) Hodgkin's disease (HD) were evaluated in our institution. Thirty patients defined as "high risk" because of either bulky mediastinal disease, systemic symptoms or both were treated with combined modality therapy (CMT). The remaining 65 patients considered as "standard risk" because they presented at diagnosis without any known adverse prognostic factor, received radiotherapy (RT) only. The median follow-up was 39 months. The complete remission (CR) rate was 97% (92/95). The actuarial 3 year overall (OS) and disease free survival (DFS) were 93% and 72% respectively with no differences between the two groups of patients. All 65 "standard risk" patients achieved CR; thirteen (20%) relapsed after a median time of 22 months. Twenty seven of 30 "high risk" patients (90%) achieved CR and six of them (22%) had early relapses. No severe pancytopenia episodes or life-threatening complications occurred during therapy. As far as the risk of second neoplasms is concerned, we observed only a single case of acute non lymphoblastic leukemia 48 months after the completion of CMT. These results indicate that in unfavourable early stage HD, CMT is effective with a probability of more than a 70% DFS 3 years after therapy with an acceptable acute and late toxicity. Patients without "high" risk factors showed the expected response after RT. About 60% of the patients who failed RT could be salvaged by chemotherapy (CT) while refractory cases or patients who relapsed after CMT did poorly with a third line chemotherapeutic regimen. Therefore alternative therapeutic approaches including high dose CT followed by autologous bone marrow transplantation should be considered for this subset of patients.
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Particular difficulties arise when trying to classify mediastinal fibrosis and determining its etiology and clinical evolution. In this paper, the Authors describe a case of mediastinal fibrosis which was characterized by a specific clinical origins (mild fever-anemia). It was not possible to establish the real etiology of the mediastinal lesion which in the end led to an unfavourable outcome that was linked to the local development of the illness, in spite of its benign histological characteristics.
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Enfermedades del Mediastino , Niño , Femenino , Fibrosis , Humanos , Enfermedades del Mediastino/diagnóstico por imagen , Enfermedades del Mediastino/patología , Mediastino/patología , Tomografía Computarizada por Rayos XRESUMEN
Histological, immunological, and cytogenetic analysis of the same neoplastic tissues have been performed on seven patients with peripheral T-cell lymphomas (PTCL). Clonal chromosomal abnormalities in five cases are reported. The most common chromosomal aberration, observed in four patients, is a rearrangement of chromosome 14 with a breakpoint in q11.2. Aberrations of chromosome 8 also occurred in four patients, three of whom had an extra 8q. The data indicate that breakpoints of malignant diseases affecting similar cell types might cluster to specific chromosomal regions, which can be helpful in recognition and classification of PTCL.
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Aberraciones Cromosómicas , Linfoma/genética , Adulto , Anciano , Bandeo Cromosómico , Femenino , Marcadores Genéticos , Humanos , Cariotipificación , Masculino , Persona de Mediana Edad , Linfocitos TRESUMEN
Paraesophageal inflammatory pseudotumor is the cause of anaemia and intermittent fever. The surgical treatment determines a rapid and complete clinical resolution.
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Fibroma/cirugía , Niño , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Esófago/patología , Femenino , Fibroma/diagnóstico , Fibroma/patología , Humanos , Tomografía Computarizada por Rayos XRESUMEN
The malignant rhabdoid tumor of the kidney determines clinical and prognostic evaluations due to the poor therapeutic answer and to the uncertain prognosis. The Authors describe a case of nephroblastoma with anaplasia of the blastemal elements associated to rhabdomyosarcoma areas.
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Neoplasias Encefálicas/secundario , Corteza Cerebral , Neoplasias Renales/patología , Recurrencia Local de Neoplasia/patología , Neoplasias Primarias Múltiples/patología , Rabdomiosarcoma/secundario , Tumor de Wilms/secundario , Neoplasias Encefálicas/patología , Preescolar , Femenino , Humanos , Rabdomiosarcoma/patología , Factores de Tiempo , Tumor de Wilms/patologíaRESUMEN
We report a case of an infant with a post-necrotizing enterocolitis stenosis, resolved with operative measures. The histologic finding of Cytomegalovirus in the resected sigmoid colon rise the question if the intestinal stricture was the proper consequence of a primary enteric viral infection or a superinfection in a transitory immunodeficiency after the acute phase of necrotizing enterocolitis.
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Enfermedades del Colon/etiología , Infecciones por Citomegalovirus/complicaciones , Enterocolitis Seudomembranosa/complicaciones , Obstrucción Intestinal/etiología , Constricción Patológica/etiología , Enterocolitis Seudomembranosa/patología , Humanos , Lactante , Obstrucción Intestinal/patología , MasculinoRESUMEN
Inflammatory pseudotumor involving the common bile duct, is a very rare event. The Authors were able to observe such a case in a 10 year old boy and report here the peculiar clinical findings.