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Granulomatous myocarditis secondary to cornstarch
Granulomatous myocarditis secondary to cornstarch Gissur Brynjolfsson, M.D." Behrooz Eshaghy, M.D.** James V. Talano, M.D.*** Rolf Gunnar, M.D.**** Maywood, III.
Cornstarch was introduced as a lubricating powder for surgical gloves over twenty years ago. The initial animal experiments indicated that starch was satisfactorily absorbed in the abdominal cavity of animals.^' ^ Nevertheless, reports of postoperative granulomatous inflammation dUe to starch glove powder soon appeared in the hterature.^"** To date over 60 such cases have been reported in the American, English, and European literature.^ Starch peritonitis has been associated with abdominal pain, bowel obstruction due to abdominal adhesions, and fever." ' Symptoms have occurred as early as 15 days postoperatively.*^ This paper deals with a granulomatous myocarditis due to starch powder following cardiac catheterization and replacement of the mitral valve. Case report P. K., a 44-year-old white female, presented with a history of her first attack of rheumatic fever at age 9 and repeated episodes until the age of 28. The patient was free of cardiac symptoms until March, 1973, when She developed pedal edema, generalized fatigue, and moderate dyspnea on exertion. She was treated with digoxin and diuretics, and From the Departments of Pathology, Medicine, and Cardiology, Loyola University Medical Center, Maywood, 111. Received for publication Sept. 8, 1976. Accepted for publication Sept. 24, 1976. Reprint requests: Gissur Brynjolfsson, Professor and Chairman, Dept. of Pathology, Loyola University Medical Center, 2160 S. First Ave., Maywood, 111. 60153. •Professor and Chairman, Dept. of Pathology, Loyola University Medical Center, "Instructor in Medicine, Loyola University Medical Center. ***Associate Professor, Dept. of Medicine, Loyola University Medical Center. ****Professor of Medicine and Chief, Section of Cardiology, Loyola University Medical Center.
September, 1977, Vol. 94, No. 3, pp. 353-358
improved. She was rehospitalized a month later with ascites, ankle edema, orthopnea, and paroxysmal nocturnal dyspnea. Physical examination revealed a 2-1- parasternal lift, a palpable and accentuated S,, and a holosystohc Grade IV/VI murmur with a Grade I I / V I mid-diastolic rumble at the apex. S2 was physiologically split and P^ was accentuated. A loud S,, was present at the apex. Other laboratory data were unremarkable. Chest x-ray revealed cardiomegaly and left atrial enlargement, a prominent pulmonary artery, and calcification of the mitral annulus. ECG showed sinus rhythm, right bundle branch block, right axis deviation, and first degree A-V block. The patient underwent cardiac catheterization on April 27,1973 which revealed severe mitral regurgitation with severe pulmonary hypertension. On May 2, 1973 the patient underwent an uneventful valve replacement with a Bjork-Shiley valve. A rhythm strip on May 4,1973 revealed nonparoxysmal junctional tachycardia: later on the same day complete A-V dissociation was observed. On May 5, 1973 rhythm strip was consistent with atrial fibrillation with a rapid ventricular response. This responded to digoxin intravenously with controlled response. The rest of the postoperative course was uneventful. On the ninth postoperative day, the patient experienced a sudden onset of chest pain with hypotension, diaphoresis, and distended neck veins which were thought to be due to pulmonary emboli. The ECG at the time revealed atrial fibrillation with rapid ventricular response. Treatment was not effective and the patient died shortly thereafter. Pathologic findings. The autopsy was restricted to examination of the thoracic organs. T h e pericardial sac was open from previous surgery and the epicardium reddened and partly covered by fibrin deposits. The heart weighed 780 Gm. and showed marked hypertrophy of both ventricles and moderate hypertrophy and dilation of the left atrium. A healing incision was noted across the medial and posterior wall of the left atrium. There were multiple, flat, red-tan mural thrombi in the left atrium, the largest of which was elongated, measuring 10 by 3 cm. (Fig. 1). This thrombus was attached at one end, near the incision, with the other end loose and apparently occluding completely the mitral orifice (Fig. 2). The Bjork-Shiley valve appeared to have been functioning normally. Microscopic examination of numerous sections revealed a widespread, focal inflammatory reaction involving all chambers of the heart. The main features were: interstitial cellular
American
Heart Journal
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Brynjolfsson et al.
Fig. 1. Multiple mural thrombi of left atrium the largest of which covers the mitral orifice.
Fig. 2. The flapping mural thrombus has been lifted off the mitral orifice.
infiltrates consisting predominantly of lymphocytes with some monocytes and occasional eosinophils, neutrophils, and plasma cells and small granulomas with multinucleated giant cells and focal myofiber damage or replacement (Fig. 3). In addition to the myocardium, granulomas were found in the endocardium and rarely in the epicardium. There was also an organizing fibrinous pericarditis. The giant cells were of the foreign body type. A rare giant cell resembled myogenic giant cell. In the granulomas, both inside and outside giant cells, an occasional rounded foreign body was noted measuring up to about 14 fim in diameter (Fig. 4), as well as some smaller, irregularly shaped particles of similar foreign material. These foreign bodies were light bluish in the hematoxylin and eosin stained sections and were inconspicuous. These particles
354
stained red with the periodic acid Schiff reagent (PAS), dark bluish-black with Gram's iodine, and exhibited Maltese cross birefringence under polarized light (Fig. 5). They were always associated with inflammatory reaction. In addition to these granules some anisotrophic fiber-like material was noted inside a rare small artery (Fig. 6). These fibers were also associated with giant cell reaction but they did not stain with PAS. In some of the sections granular birefringent material appeared to have broken through the vessel wall (Fig. 7). No starch granules were found intravascularly. Stains for fungi were negative. The granules found in the heart were identical with starch granules from glove powder (Fig. 8). Examination of numerous sections from a dozen hearts from patients who had undergone cardiac catheterization
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1977, Vol. 94, No. 3
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Fig. 4. Endo- and myocardium, left ventricle. Granulomatous inflammation. The arrow points to a foreign body. (Original magnification about x500.) and/or cardiac surgery revealed an occasional intra- or extraarterial granuloma around anisotropic fibers but no starch granules were identified. Sections from the left atrium showed recent mural thrombi. There was some edema of the underlying endocardium with infiltration of an occasional neutrophil. Also noted in some Of the sections was a subendocardial layer of granulation tissue parallel to the endocardial surface. No granulomas were noted in the endocardium of the left atrium. The myocardium in addition showed moderate hypertrophy and scattered small scars, mainly perivascular, with a rare, apparent, inactive, flbrotic Aschoff body. The aortic cusps revealed hyaline fibrosis with some vascularization. There was mild-tomoderate coronary atherosclerosis. Sections of lung showed chronic passive congestion but no granulomas.
American
Heart
Journal
Discussion Although the inflammatory reaction of the heart in this case was widespread, the number of starch granules was relatively small. In some of the granulomatous nodules no starch granules were found and in others, as a rule, there was only one granule present. Some of the granules appeared to be fragmented or partly absorbed. In animal experiments starch granules have been reported completely absorbed within three weeks.^ T h e rate of absorption in h u m a n s is not known. Surgical patients are probably often exposed to
355
Brynjolfsson et al.
Fig. 5. Same field as in Fjg. 4 viewed under polarized light. The foreign body is birefringent and shows a Maltese cross.
\
'HWMx^
Fig. 6. Anisotrophic fiber-like material inside a small artery. Inflammatory reaction with some multinucleated giant cells in the endothelium. (Original magnification about X200.)
starch glove powder. Even if the gloves are carefully washed before the surgical procedure, gloves commonly break during surgery releasing the lubricating glove powder. The amount of contamination is undoubtedly an important factor but the reaction to the same dose is likely to be very variable in different patients. Perhaps the rate of absorption varies from one patient to another. Skin test for hypersensitivity to starch in patients with starch peritonitis have varied from negative to equivocal." " However, Lietze, Rowe and Rowe'^ have demonstrated a high incidence of passive hemagglutination antibodies to potato and tapioca starch in normal persons. The histo-
356
logic picture in our casfe was t h a t of a typical foreign body granuloma but eosinophils were inconspicuous. Although the symptoms of some of the patients with starch granulomatous peritonitis have been quite severe and prolonged almost all of the reported cases have recovered. The death of our patient was due to a sudden mitral occlusion, secondary to a flapping, ribbon-shaped mural thrombus in the left atrium. Whether the granulomatous inflammation contributed to the formation of the mural thrombi, and what role a direct trauma to the endocardium from the surgical procedure played, cannot be settled. The suben-
September,
1977, Vol. 94, No. 3
Granulomatous
myocarditis
and
cornstarch
4^
Fig. 7. Birefringent material apparently breaking through a vessel wall. (Original magnification about X200.)
Fig. 8. Glove powder under polarized light. (Original magnification about X200.)
docardial layer of granulation tissue on the left atrium was probably a secondary reaction to edema of the loose subendocardial tissue. This type of a reaction was described many years ago in connection with a giant cell myocarditis.^' There are two possible sources of the starch granules in this case. The starch granules might have been introduced into the coronary circulation during the cardiac catheterization or at the time of the valve replacement. During catheterization contamination could have occurred from the irrigation solution or contrast media which may have been contaminated with starch powder. Introduction of starch granules into the circulation has been known to occur through contamination of syringes and catheters" and anisotropic intra-arterial fibers, resembling cotton or cellulose fibers have been demonstrated quite frequently in various organs at autopsy in patients who have had cardiac surgery or catheterization.'^
Summary
The myocarditis in this case was classified as granulomatous myocarditis rather than giant cell myocarditis since a known foreign body was established as the causative agent. Myogenic giant cells may otherwise be difficult to differentiate from foreign body giant cells and the relationship between giant cell myocarditis and granulomatous myocarditis of unknown etiology is very unclear indeed.'*'
American
Heart
Journal
A 44-year-old white female with chronic rheumatic heart disease and mitral insufficiency was admitted to the hospital for cardiac catheterization and mitral valve replacement. On the ninth postoperative day the patient experienced a sudden onset of chest pain, hypotension, and died shortly thereafter. Autopsy revealed multiple mural thrombi of the left atrium, one of which occluded the mitral orifice. Histologic examination showed a granulomatous and non-specific interstitial myocarditis involving all chambers of the heart. In the granulomas, both inside and outside giant cells, rounded foreign bodies were noted which stained light blue with hematoxylin and eosin, red with the periodic acid Schiff reagent, dark bluish-black with Gram's iodine, and showed Maltese cross birefringence under polarized light. These particles were identical with starch granules from surgical glove powder. The cause of death was acute mitral occlusion from a flapping mural thrombus. REFERENCES 1. Lee, C. M., and Lehman, E. P.: Experiments with nonirritating glove powder, Surg. Gynecol. Obstet. 84:689, 1947. 2. MacQuiddy,' E. L., and Tollman, J. P.: Observations on an absorbable powder to replace talc, Surgery 23:786, 1948. 3. Graham, J. D. P., and Jenkins, M. E.: Value of modified starch as a substitute for talc. Lancet 1:590, 1952.
357
Brynjolfsson et al.
Sneierson, H., and Woo, Z. P.: Starch powder granuloma, Ann. Surg. 142:1045, 1955. McAdams, G. B.: Granulomata caused by absorbable starch glove powder. Surgery 39:329, 1956. Bates, B.i Granulomatous peritonitis secondary to com starch, Ann. Intern. Med. 62:335, 1965. Da vies, J. D., and Neely, J.: The histopathology of peritoneal starch granulomas, J. Pathol. 107:265, 1972. Neely, J., and Davies, J. D,: Starch granulomatosis of the peritoneum, Br. Med. J. 3:625, 1971. Sobel, H. J., Schiffman, R. J., Schwarz, R., and Albert, W. S.: Granulomas and peritonitis due to starch glove powder, Arch. Pathol. 9 1 : June, 1971. 10. Myers, R. N., Deaver, J. M., and Brown, C. E.: Granulomatous peritonitis due to starch glove powder: a clinical and experimental study, Ann. Surg. 151:106, 1960.
358
11. 12.
13. 14. 15. 16.
Saxen, L., and Saxen, E.: Starch granulomas as a problem in surgical pathology. Acta Pathol. Microbiol. Scand. 64:55, 1965. Lietze, A., Rowe, A. H., and Rowe, A.: Die bedeutung unlosliches nahrungspartikel fur die allergie I. StarkeAntikorper beim menschen, AUerg. Asthmaforsch. 15:11, 1969. Berlinger, W.: Diffuse gummose myocarditis, Zentralbl. AUg. Pathol. 21:1045, 1910. Yunis, E. J., and Landes, R. R.: Hazards of glove powder in renal angiography, J. A. M. A. 1 9 3 : July 26, 1965. Dimmick, J. E., et al: Fiber embolization—a hazard of cardiac surgery and catheterization, N. Engl. J. Med. 292:685, 1975. Tesluk, H.: Giant cell versus granulomatous myocarditis. Am. J. Clin. Pathol. 2 6 : Nov., 1956.
September,
1977, Vol. 94, No. 3
Cornstarch was introduced as a lubricating powder for surgical gloves over twenty years ago. The initial animal experiments indicated that starch was satisfactorily absorbed in the abdominal cavity of animals.^' ^ Nevertheless, reports of postoperative granulomatous inflammation dUe to starch glove powder soon appeared in the hterature.^"** To date over 60 such cases have been reported in the American, English, and European literature.^ Starch peritonitis has been associated with abdominal pain, bowel obstruction due to abdominal adhesions, and fever." ' Symptoms have occurred as early as 15 days postoperatively.*^ This paper deals with a granulomatous myocarditis due to starch powder following cardiac catheterization and replacement of the mitral valve. Case report P. K., a 44-year-old white female, presented with a history of her first attack of rheumatic fever at age 9 and repeated episodes until the age of 28. The patient was free of cardiac symptoms until March, 1973, when She developed pedal edema, generalized fatigue, and moderate dyspnea on exertion. She was treated with digoxin and diuretics, and From the Departments of Pathology, Medicine, and Cardiology, Loyola University Medical Center, Maywood, 111. Received for publication Sept. 8, 1976. Accepted for publication Sept. 24, 1976. Reprint requests: Gissur Brynjolfsson, Professor and Chairman, Dept. of Pathology, Loyola University Medical Center, 2160 S. First Ave., Maywood, 111. 60153. •Professor and Chairman, Dept. of Pathology, Loyola University Medical Center, "Instructor in Medicine, Loyola University Medical Center. ***Associate Professor, Dept. of Medicine, Loyola University Medical Center. ****Professor of Medicine and Chief, Section of Cardiology, Loyola University Medical Center.
September, 1977, Vol. 94, No. 3, pp. 353-358
improved. She was rehospitalized a month later with ascites, ankle edema, orthopnea, and paroxysmal nocturnal dyspnea. Physical examination revealed a 2-1- parasternal lift, a palpable and accentuated S,, and a holosystohc Grade IV/VI murmur with a Grade I I / V I mid-diastolic rumble at the apex. S2 was physiologically split and P^ was accentuated. A loud S,, was present at the apex. Other laboratory data were unremarkable. Chest x-ray revealed cardiomegaly and left atrial enlargement, a prominent pulmonary artery, and calcification of the mitral annulus. ECG showed sinus rhythm, right bundle branch block, right axis deviation, and first degree A-V block. The patient underwent cardiac catheterization on April 27,1973 which revealed severe mitral regurgitation with severe pulmonary hypertension. On May 2, 1973 the patient underwent an uneventful valve replacement with a Bjork-Shiley valve. A rhythm strip on May 4,1973 revealed nonparoxysmal junctional tachycardia: later on the same day complete A-V dissociation was observed. On May 5, 1973 rhythm strip was consistent with atrial fibrillation with a rapid ventricular response. This responded to digoxin intravenously with controlled response. The rest of the postoperative course was uneventful. On the ninth postoperative day, the patient experienced a sudden onset of chest pain with hypotension, diaphoresis, and distended neck veins which were thought to be due to pulmonary emboli. The ECG at the time revealed atrial fibrillation with rapid ventricular response. Treatment was not effective and the patient died shortly thereafter. Pathologic findings. The autopsy was restricted to examination of the thoracic organs. T h e pericardial sac was open from previous surgery and the epicardium reddened and partly covered by fibrin deposits. The heart weighed 780 Gm. and showed marked hypertrophy of both ventricles and moderate hypertrophy and dilation of the left atrium. A healing incision was noted across the medial and posterior wall of the left atrium. There were multiple, flat, red-tan mural thrombi in the left atrium, the largest of which was elongated, measuring 10 by 3 cm. (Fig. 1). This thrombus was attached at one end, near the incision, with the other end loose and apparently occluding completely the mitral orifice (Fig. 2). The Bjork-Shiley valve appeared to have been functioning normally. Microscopic examination of numerous sections revealed a widespread, focal inflammatory reaction involving all chambers of the heart. The main features were: interstitial cellular
American
Heart Journal
353
Brynjolfsson et al.
Fig. 1. Multiple mural thrombi of left atrium the largest of which covers the mitral orifice.
Fig. 2. The flapping mural thrombus has been lifted off the mitral orifice.
infiltrates consisting predominantly of lymphocytes with some monocytes and occasional eosinophils, neutrophils, and plasma cells and small granulomas with multinucleated giant cells and focal myofiber damage or replacement (Fig. 3). In addition to the myocardium, granulomas were found in the endocardium and rarely in the epicardium. There was also an organizing fibrinous pericarditis. The giant cells were of the foreign body type. A rare giant cell resembled myogenic giant cell. In the granulomas, both inside and outside giant cells, an occasional rounded foreign body was noted measuring up to about 14 fim in diameter (Fig. 4), as well as some smaller, irregularly shaped particles of similar foreign material. These foreign bodies were light bluish in the hematoxylin and eosin stained sections and were inconspicuous. These particles
354
stained red with the periodic acid Schiff reagent (PAS), dark bluish-black with Gram's iodine, and exhibited Maltese cross birefringence under polarized light (Fig. 5). They were always associated with inflammatory reaction. In addition to these granules some anisotrophic fiber-like material was noted inside a rare small artery (Fig. 6). These fibers were also associated with giant cell reaction but they did not stain with PAS. In some of the sections granular birefringent material appeared to have broken through the vessel wall (Fig. 7). No starch granules were found intravascularly. Stains for fungi were negative. The granules found in the heart were identical with starch granules from glove powder (Fig. 8). Examination of numerous sections from a dozen hearts from patients who had undergone cardiac catheterization
September,
1977, Vol. 94, No. 3
.•.^-••V
Fig. 4. Endo- and myocardium, left ventricle. Granulomatous inflammation. The arrow points to a foreign body. (Original magnification about x500.) and/or cardiac surgery revealed an occasional intra- or extraarterial granuloma around anisotropic fibers but no starch granules were identified. Sections from the left atrium showed recent mural thrombi. There was some edema of the underlying endocardium with infiltration of an occasional neutrophil. Also noted in some Of the sections was a subendocardial layer of granulation tissue parallel to the endocardial surface. No granulomas were noted in the endocardium of the left atrium. The myocardium in addition showed moderate hypertrophy and scattered small scars, mainly perivascular, with a rare, apparent, inactive, flbrotic Aschoff body. The aortic cusps revealed hyaline fibrosis with some vascularization. There was mild-tomoderate coronary atherosclerosis. Sections of lung showed chronic passive congestion but no granulomas.
American
Heart
Journal
Discussion Although the inflammatory reaction of the heart in this case was widespread, the number of starch granules was relatively small. In some of the granulomatous nodules no starch granules were found and in others, as a rule, there was only one granule present. Some of the granules appeared to be fragmented or partly absorbed. In animal experiments starch granules have been reported completely absorbed within three weeks.^ T h e rate of absorption in h u m a n s is not known. Surgical patients are probably often exposed to
355
Brynjolfsson et al.
Fig. 5. Same field as in Fjg. 4 viewed under polarized light. The foreign body is birefringent and shows a Maltese cross.
\
'HWMx^
Fig. 6. Anisotrophic fiber-like material inside a small artery. Inflammatory reaction with some multinucleated giant cells in the endothelium. (Original magnification about X200.)
starch glove powder. Even if the gloves are carefully washed before the surgical procedure, gloves commonly break during surgery releasing the lubricating glove powder. The amount of contamination is undoubtedly an important factor but the reaction to the same dose is likely to be very variable in different patients. Perhaps the rate of absorption varies from one patient to another. Skin test for hypersensitivity to starch in patients with starch peritonitis have varied from negative to equivocal." " However, Lietze, Rowe and Rowe'^ have demonstrated a high incidence of passive hemagglutination antibodies to potato and tapioca starch in normal persons. The histo-
356
logic picture in our casfe was t h a t of a typical foreign body granuloma but eosinophils were inconspicuous. Although the symptoms of some of the patients with starch granulomatous peritonitis have been quite severe and prolonged almost all of the reported cases have recovered. The death of our patient was due to a sudden mitral occlusion, secondary to a flapping, ribbon-shaped mural thrombus in the left atrium. Whether the granulomatous inflammation contributed to the formation of the mural thrombi, and what role a direct trauma to the endocardium from the surgical procedure played, cannot be settled. The suben-
September,
1977, Vol. 94, No. 3
Granulomatous
myocarditis
and
cornstarch
4^
Fig. 7. Birefringent material apparently breaking through a vessel wall. (Original magnification about X200.)
Fig. 8. Glove powder under polarized light. (Original magnification about X200.)
docardial layer of granulation tissue on the left atrium was probably a secondary reaction to edema of the loose subendocardial tissue. This type of a reaction was described many years ago in connection with a giant cell myocarditis.^' There are two possible sources of the starch granules in this case. The starch granules might have been introduced into the coronary circulation during the cardiac catheterization or at the time of the valve replacement. During catheterization contamination could have occurred from the irrigation solution or contrast media which may have been contaminated with starch powder. Introduction of starch granules into the circulation has been known to occur through contamination of syringes and catheters" and anisotropic intra-arterial fibers, resembling cotton or cellulose fibers have been demonstrated quite frequently in various organs at autopsy in patients who have had cardiac surgery or catheterization.'^
Summary
The myocarditis in this case was classified as granulomatous myocarditis rather than giant cell myocarditis since a known foreign body was established as the causative agent. Myogenic giant cells may otherwise be difficult to differentiate from foreign body giant cells and the relationship between giant cell myocarditis and granulomatous myocarditis of unknown etiology is very unclear indeed.'*'
American
Heart
Journal
A 44-year-old white female with chronic rheumatic heart disease and mitral insufficiency was admitted to the hospital for cardiac catheterization and mitral valve replacement. On the ninth postoperative day the patient experienced a sudden onset of chest pain, hypotension, and died shortly thereafter. Autopsy revealed multiple mural thrombi of the left atrium, one of which occluded the mitral orifice. Histologic examination showed a granulomatous and non-specific interstitial myocarditis involving all chambers of the heart. In the granulomas, both inside and outside giant cells, rounded foreign bodies were noted which stained light blue with hematoxylin and eosin, red with the periodic acid Schiff reagent, dark bluish-black with Gram's iodine, and showed Maltese cross birefringence under polarized light. These particles were identical with starch granules from surgical glove powder. The cause of death was acute mitral occlusion from a flapping mural thrombus. REFERENCES 1. Lee, C. M., and Lehman, E. P.: Experiments with nonirritating glove powder, Surg. Gynecol. Obstet. 84:689, 1947. 2. MacQuiddy,' E. L., and Tollman, J. P.: Observations on an absorbable powder to replace talc, Surgery 23:786, 1948. 3. Graham, J. D. P., and Jenkins, M. E.: Value of modified starch as a substitute for talc. Lancet 1:590, 1952.
357
Brynjolfsson et al.
Sneierson, H., and Woo, Z. P.: Starch powder granuloma, Ann. Surg. 142:1045, 1955. McAdams, G. B.: Granulomata caused by absorbable starch glove powder. Surgery 39:329, 1956. Bates, B.i Granulomatous peritonitis secondary to com starch, Ann. Intern. Med. 62:335, 1965. Da vies, J. D., and Neely, J.: The histopathology of peritoneal starch granulomas, J. Pathol. 107:265, 1972. Neely, J., and Davies, J. D,: Starch granulomatosis of the peritoneum, Br. Med. J. 3:625, 1971. Sobel, H. J., Schiffman, R. J., Schwarz, R., and Albert, W. S.: Granulomas and peritonitis due to starch glove powder, Arch. Pathol. 9 1 : June, 1971. 10. Myers, R. N., Deaver, J. M., and Brown, C. E.: Granulomatous peritonitis due to starch glove powder: a clinical and experimental study, Ann. Surg. 151:106, 1960.
358
11. 12.
13. 14. 15. 16.
Saxen, L., and Saxen, E.: Starch granulomas as a problem in surgical pathology. Acta Pathol. Microbiol. Scand. 64:55, 1965. Lietze, A., Rowe, A. H., and Rowe, A.: Die bedeutung unlosliches nahrungspartikel fur die allergie I. StarkeAntikorper beim menschen, AUerg. Asthmaforsch. 15:11, 1969. Berlinger, W.: Diffuse gummose myocarditis, Zentralbl. AUg. Pathol. 21:1045, 1910. Yunis, E. J., and Landes, R. R.: Hazards of glove powder in renal angiography, J. A. M. A. 1 9 3 : July 26, 1965. Dimmick, J. E., et al: Fiber embolization—a hazard of cardiac surgery and catheterization, N. Engl. J. Med. 292:685, 1975. Tesluk, H.: Giant cell versus granulomatous myocarditis. Am. J. Clin. Pathol. 2 6 : Nov., 1956.
September,
1977, Vol. 94, No. 3