- Email: [email protected]
First trimester pregnancy loss associated with varicella zoster virus infection: Histological definition of a case
Case Studies FIRST TRIMESTER PREGNANCY LOSS ASSOCIATED WITH VARICELLA ZOSTER VIRUS INFECTION: HISTOLOGICAL DEFINITION OF A CASE CALVIN E. OYER, MD, RUYAC,AI, MD, JOHN J. COUGHLIN, MD, AND DON B. SINGER, MD
stains and electron microscopy were confirmatory. HUM PATHOL 28:94--95. Copyright © 1998 by W.B. Saunders Company Key words: Chickenpox, varicella zoster virus, embryo, first trimester, placenta. Abbreviations: VZV, varlcella zoster virus.
Pathological demonstration of varicella infection in first trimester aborted tissue is reported. A 24-year-old primigravida manifested chickenpox infection about 38 days after her last menstrual period or at 24 days age of the embryo. The conceptus survived another 4 to 5 weeks. The macerated embryo and placental tissue revealed nuclear changes consistent with variceIla infection. Immunohistochemical
Varicella zoster virus (VZV), a DNA virus of the herpes virus family, causes chickenpox as a primary infection and herpes zoster when recurrent. An infected pregnant woman can transmit the virus transplacentally to the fetus with consequences of embryopathy a n d / o r abortion. We report a case of transplacental chickenpox in the first trimester with histological definition of infected embryonal and placental tissue. CASE REPORT A 24-year-old gravida 1 para 0 woman was exposed to chickenpox 4 weeks after her last menstrual period. Maternal chickenpox was noted 10 days later at an estimated 24 days of developmental age. At 11 postmenstrnal weeks routine ultrasound examination revealed intrauterine demise. The surgical specimen consisted of fragmented placental tissue and fragments of macerated embryonal tissue. The foot length was 0.6 cm consistent with late embryonal or early fetal age, ie, approximately 8 developmental weeks. Microscopic examination revealed nuclear viral inclusions in autolyzed embryonal tissue (Fig 1). The placenta had acute and chronic vilfitis with glassy appearing nudei suggesting inclusions (Fig 2). Immunohistochemical stains using Cyfimmune VZV rabbit antiserum (Lee Biomolecular Research Laboratory, Inc, San Diego, CA) showed strong reactivity (Fig 3A). There was only minimal reactivity to herpes simplex antiserum and none to cytomegalovirns antiserum. Electron microscopy performed in the placental tissue in the region of the glassy nuclei revealed viral capsids consistent with the herpes group (Fig 3B).
FIGURE 1. A clump of cells in autolyzed embryonal tissue showing glassy nuclei with nuclear inclusions. (Hematoxylin and eosin stain; original magnification ×40 objective.)
riages and live births in controls and in patients afflicted with varicella during the first 20 weeks of gestation. Inflammatory changes characterized by necrosis, chronic inflammation, and giant cells have been noted in second and third trimester placental a n d / o r fetal tissue by Garcia in 19635 and subsequently by others, eq° Viral-like inclusions were noted in the lungs of a 12-week macerated fetus by Robertson and McKeever, 1° the only previous report of pathological changes in the first trimester.
COMMENT Death in utero within 3 to 5 days after VZV maternal infection was reported at 7 and 8 weeks of gestation in two cases. 1 In a prospective study of 542 mothers infected before 13 postmenstrual weeks, Enders et al noted spontaneous pregnancy loss before 20 weeks in 6% of 501 cases. 2 First trimester maternal varicella infection was associated with first trimester spontaneous abortion in 3 out of 40 cases reported by Balducci et al.~ The losses occurred at 6, 6, and 9 weeks of gestation. Placental examination was nonrevealing in the one case in which it was undertaken. However, in a controlled study, Pastuszak et al 4 found similar proportions of miscar-
From the Departments of Pathology and Obstetrics and Gynecology, Women and Infants' Hospital and Brown University School of Medicine, Providence, RI. Address correspondence and reprint requests to CalvinE. Oyer, MD, Department of Pathology,101 Dudley Street, Providence, R102905. Copyright © 1998 by W.B. Saunders Company 0046-8177/97/2901-001558.00/0
FIGURE 2. A chorionic villus with chronic inflammatory infiltrate. Inset: a nuclear inclusion in an inflammatory cell. (Hematoxylin and eosin stain; original magnifications x20 and ×40 objective.)
94
CASE STUDIES
FIGURE 3. (A) Immunohistochemical staining for VZV antigen. PositMty is indicated by the dark granules seen in numerous inflammatory cells. (Original magnification ×40 objective.) (B) Electron micrograph of two viral capsids in a chorionic villus. The capsids are consistent with a virus of the herpes group (Scope magnification x31,680.) 3. BalducciJ, RodisJF, Rosengren S, et al: Pregnancy outcome following first-trimestervaricellainfection. Obstet Gynecol79:5-6, 1992 4. pastuszakAL, LevyM, SchickB, et al: Outcome after maternal variceUa infection in the first 20 weeksof pregnancy. N EnglJ Med 330:901-905, 1994 5. GarciaAGP: Fetal infection in chickenpox and alastrimwith histopathologic study of the placenta. Pediatrics32:895-901, 1963 6. BlancWA:Pathologyof the placenta, membranes, and umbilical cord in bacterial, fungal, and viral infectionsin man, in Naeye RL, KissaneJM;Kmffman N (eds): Perinatal Diseases. Baltimore, MD, Williams & Wilkins, 1981, pp 113-116 7. Pons J-C, Rozenberg F, Imbert M-C, et al: Prenatal diagnosis of second-trimestercongenital varicenasyndrome. Prenat Diagn 11:975-976, !992 8. MichieCA,Acolet D, Charlton R, et al: Varicella-zostercontracted in the second trimester of pregnancy.Pediatr Infect DisJ 11:1050-1053, 1992 9. ScharfA' Scherf O' Enders G' et al: Virusdetecti°n in the fetal tissue°f a premature delivery with a congenital varicella syndrome--A case report. J Pefinal Med 18:317-322, 1990 10. Robertson NJ, McKeeverPA: Fetal and placental pathology in two cases of maternal varicellainfection. 12:545-550, 1992
In the p r e s e n t case, t h e r e was m o r p h o l o g i c a l e v i d e n c e o f VZV i n f e c t i o n in e m b r y o n a l a n d placental tissue f r o m the late e m b r y o n a l stage o f d e v e l o p m e n t . T h e f i n d i n g o f inclusions was c o n s i d e r e d c o n s i s t e n t with VZV i n f e c t i o n in light o f the m a t e r n a l history. Diagnosis was m o r e definitively established with i m m u n o h i s t o c h e m i c a l staining. It a p p e a r s that d e a t h o c c u r r e d at t h e e n d o f t h e e m b r y o n a l stage o f d e v e l o p m e n t a p p r o x i m a t e l y 32 days after t h e o n s e t o f m a t e r n a l symptoms. REFERENCES 1. SiegelM, Fuerst HT, Peress NS: Comparativefetal mortality in maternal virus diseases:a prospectivestudyoff rubella, measles,mumps, chicken pox, and hepatitis. New EnglJ Med 274:768-771, 1958 2. Enders G, Miller E, Cradock-WatsonJ, et al: Consequences of varicella and herpe s zoster in pregnancy: prospective study of 1739 cases. Lancet 343:1548-1551, 1994
FOREIGN BODY HISTIOCYTOSIS REACTION AFTER HIP REPLACEMENT WITH CONCOMITANT METASTATIC ADENOCARCINOMA IN THE SAME LYMPH NODE MICHEL PiOC'H, MD, VERONIQUE DUCROS, MD, RAPHAELLE BARNOUD, MD, DOMINIQUE PASQUIER, MD, MARIE HELENE LAVERRIERE, MD, AND BASILE PASQUIER, MD
Infiltration of regional lymph nodes by macrophages has been shown after total joint arthroplasty. These pelvic lymph nodes were obtained most often from patients during staging procedures for carcinoma and may be a diagnostic pitfall in the frozen section diagnosis of nodal metastasis. We report an mlusual case of association in the same lymph node between histiocytosis and prostatic
carcinoma metastasis. Histiocytosis was caused by wear debris from two different prostheses. Inductively coupled plasma mass spectrometry verified this diagnosis. HUM PATHOL28:95--98. Copyright © 1998 byW.B. Satmders Company Key words: histiocytosis, arthroplasty, lymph node, metastasis. Abbreviation: HES, hematoxylin erythrosin saffron.
From the Departments of Pathology and Biochemistry, Centre Hospitalier Universitaire, Grenoble, France. Address correspondence and reprint requests to Michel P6oc'h, MD, Service d'Anatomie Pathologique, Centre Hospitalier Universitaire, BP 217, 38043 Grenoble cedex 09, France Copyright © 1998 by W.B. Saunders Company
T h e p r o d u c t i o n o f metallic wear debris after arthroplasty has b e e n widely r e p o r t e d . 1,2 In tissues f o u n d a d j a c e n t to t h e i m p l a n t t h e r e is o f t e n a histiocytic reaction~ Wear debris d i s s e m i n a t i o n in l y m p h n o d e s ~6 is c o m m o n a n d o f t e n revealed d u r i n g u n r e l a t e d s u r g e r y for c a r c i n o m a arising in the r e g i o n o f the pelvis. 7-12 To the best o f o u r knowledge, this
0046-8177/97/2901-00i658.00/0 95
stains and electron microscopy were confirmatory. HUM PATHOL 28:94--95. Copyright © 1998 by W.B. Saunders Company Key words: Chickenpox, varicella zoster virus, embryo, first trimester, placenta. Abbreviations: VZV, varlcella zoster virus.
Pathological demonstration of varicella infection in first trimester aborted tissue is reported. A 24-year-old primigravida manifested chickenpox infection about 38 days after her last menstrual period or at 24 days age of the embryo. The conceptus survived another 4 to 5 weeks. The macerated embryo and placental tissue revealed nuclear changes consistent with variceIla infection. Immunohistochemical
Varicella zoster virus (VZV), a DNA virus of the herpes virus family, causes chickenpox as a primary infection and herpes zoster when recurrent. An infected pregnant woman can transmit the virus transplacentally to the fetus with consequences of embryopathy a n d / o r abortion. We report a case of transplacental chickenpox in the first trimester with histological definition of infected embryonal and placental tissue. CASE REPORT A 24-year-old gravida 1 para 0 woman was exposed to chickenpox 4 weeks after her last menstrual period. Maternal chickenpox was noted 10 days later at an estimated 24 days of developmental age. At 11 postmenstrnal weeks routine ultrasound examination revealed intrauterine demise. The surgical specimen consisted of fragmented placental tissue and fragments of macerated embryonal tissue. The foot length was 0.6 cm consistent with late embryonal or early fetal age, ie, approximately 8 developmental weeks. Microscopic examination revealed nuclear viral inclusions in autolyzed embryonal tissue (Fig 1). The placenta had acute and chronic vilfitis with glassy appearing nudei suggesting inclusions (Fig 2). Immunohistochemical stains using Cyfimmune VZV rabbit antiserum (Lee Biomolecular Research Laboratory, Inc, San Diego, CA) showed strong reactivity (Fig 3A). There was only minimal reactivity to herpes simplex antiserum and none to cytomegalovirns antiserum. Electron microscopy performed in the placental tissue in the region of the glassy nuclei revealed viral capsids consistent with the herpes group (Fig 3B).
FIGURE 1. A clump of cells in autolyzed embryonal tissue showing glassy nuclei with nuclear inclusions. (Hematoxylin and eosin stain; original magnification ×40 objective.)
riages and live births in controls and in patients afflicted with varicella during the first 20 weeks of gestation. Inflammatory changes characterized by necrosis, chronic inflammation, and giant cells have been noted in second and third trimester placental a n d / o r fetal tissue by Garcia in 19635 and subsequently by others, eq° Viral-like inclusions were noted in the lungs of a 12-week macerated fetus by Robertson and McKeever, 1° the only previous report of pathological changes in the first trimester.
COMMENT Death in utero within 3 to 5 days after VZV maternal infection was reported at 7 and 8 weeks of gestation in two cases. 1 In a prospective study of 542 mothers infected before 13 postmenstrual weeks, Enders et al noted spontaneous pregnancy loss before 20 weeks in 6% of 501 cases. 2 First trimester maternal varicella infection was associated with first trimester spontaneous abortion in 3 out of 40 cases reported by Balducci et al.~ The losses occurred at 6, 6, and 9 weeks of gestation. Placental examination was nonrevealing in the one case in which it was undertaken. However, in a controlled study, Pastuszak et al 4 found similar proportions of miscar-
From the Departments of Pathology and Obstetrics and Gynecology, Women and Infants' Hospital and Brown University School of Medicine, Providence, RI. Address correspondence and reprint requests to CalvinE. Oyer, MD, Department of Pathology,101 Dudley Street, Providence, R102905. Copyright © 1998 by W.B. Saunders Company 0046-8177/97/2901-001558.00/0
FIGURE 2. A chorionic villus with chronic inflammatory infiltrate. Inset: a nuclear inclusion in an inflammatory cell. (Hematoxylin and eosin stain; original magnifications x20 and ×40 objective.)
94
CASE STUDIES
FIGURE 3. (A) Immunohistochemical staining for VZV antigen. PositMty is indicated by the dark granules seen in numerous inflammatory cells. (Original magnification ×40 objective.) (B) Electron micrograph of two viral capsids in a chorionic villus. The capsids are consistent with a virus of the herpes group (Scope magnification x31,680.) 3. BalducciJ, RodisJF, Rosengren S, et al: Pregnancy outcome following first-trimestervaricellainfection. Obstet Gynecol79:5-6, 1992 4. pastuszakAL, LevyM, SchickB, et al: Outcome after maternal variceUa infection in the first 20 weeksof pregnancy. N EnglJ Med 330:901-905, 1994 5. GarciaAGP: Fetal infection in chickenpox and alastrimwith histopathologic study of the placenta. Pediatrics32:895-901, 1963 6. BlancWA:Pathologyof the placenta, membranes, and umbilical cord in bacterial, fungal, and viral infectionsin man, in Naeye RL, KissaneJM;Kmffman N (eds): Perinatal Diseases. Baltimore, MD, Williams & Wilkins, 1981, pp 113-116 7. Pons J-C, Rozenberg F, Imbert M-C, et al: Prenatal diagnosis of second-trimestercongenital varicenasyndrome. Prenat Diagn 11:975-976, !992 8. MichieCA,Acolet D, Charlton R, et al: Varicella-zostercontracted in the second trimester of pregnancy.Pediatr Infect DisJ 11:1050-1053, 1992 9. ScharfA' Scherf O' Enders G' et al: Virusdetecti°n in the fetal tissue°f a premature delivery with a congenital varicella syndrome--A case report. J Pefinal Med 18:317-322, 1990 10. Robertson NJ, McKeeverPA: Fetal and placental pathology in two cases of maternal varicellainfection. 12:545-550, 1992
In the p r e s e n t case, t h e r e was m o r p h o l o g i c a l e v i d e n c e o f VZV i n f e c t i o n in e m b r y o n a l a n d placental tissue f r o m the late e m b r y o n a l stage o f d e v e l o p m e n t . T h e f i n d i n g o f inclusions was c o n s i d e r e d c o n s i s t e n t with VZV i n f e c t i o n in light o f the m a t e r n a l history. Diagnosis was m o r e definitively established with i m m u n o h i s t o c h e m i c a l staining. It a p p e a r s that d e a t h o c c u r r e d at t h e e n d o f t h e e m b r y o n a l stage o f d e v e l o p m e n t a p p r o x i m a t e l y 32 days after t h e o n s e t o f m a t e r n a l symptoms. REFERENCES 1. SiegelM, Fuerst HT, Peress NS: Comparativefetal mortality in maternal virus diseases:a prospectivestudyoff rubella, measles,mumps, chicken pox, and hepatitis. New EnglJ Med 274:768-771, 1958 2. Enders G, Miller E, Cradock-WatsonJ, et al: Consequences of varicella and herpe s zoster in pregnancy: prospective study of 1739 cases. Lancet 343:1548-1551, 1994
FOREIGN BODY HISTIOCYTOSIS REACTION AFTER HIP REPLACEMENT WITH CONCOMITANT METASTATIC ADENOCARCINOMA IN THE SAME LYMPH NODE MICHEL PiOC'H, MD, VERONIQUE DUCROS, MD, RAPHAELLE BARNOUD, MD, DOMINIQUE PASQUIER, MD, MARIE HELENE LAVERRIERE, MD, AND BASILE PASQUIER, MD
Infiltration of regional lymph nodes by macrophages has been shown after total joint arthroplasty. These pelvic lymph nodes were obtained most often from patients during staging procedures for carcinoma and may be a diagnostic pitfall in the frozen section diagnosis of nodal metastasis. We report an mlusual case of association in the same lymph node between histiocytosis and prostatic
carcinoma metastasis. Histiocytosis was caused by wear debris from two different prostheses. Inductively coupled plasma mass spectrometry verified this diagnosis. HUM PATHOL28:95--98. Copyright © 1998 byW.B. Satmders Company Key words: histiocytosis, arthroplasty, lymph node, metastasis. Abbreviation: HES, hematoxylin erythrosin saffron.
From the Departments of Pathology and Biochemistry, Centre Hospitalier Universitaire, Grenoble, France. Address correspondence and reprint requests to Michel P6oc'h, MD, Service d'Anatomie Pathologique, Centre Hospitalier Universitaire, BP 217, 38043 Grenoble cedex 09, France Copyright © 1998 by W.B. Saunders Company
T h e p r o d u c t i o n o f metallic wear debris after arthroplasty has b e e n widely r e p o r t e d . 1,2 In tissues f o u n d a d j a c e n t to t h e i m p l a n t t h e r e is o f t e n a histiocytic reaction~ Wear debris d i s s e m i n a t i o n in l y m p h n o d e s ~6 is c o m m o n a n d o f t e n revealed d u r i n g u n r e l a t e d s u r g e r y for c a r c i n o m a arising in the r e g i o n o f the pelvis. 7-12 To the best o f o u r knowledge, this
0046-8177/97/2901-00i658.00/0 95