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Inguinal lymph node infection with paragonimiasis
HUMAN PATHOLOGY
Volume 22, No. 8 (August 1991)
decision, but would like to offer an alternate method to study the brain without removal of the entire organ. A liver and/or renal biopsy needle can be passed very easily through the cribriform plate. An unlimited number of tissue fragments from different intracranial sites can be sampled through both nasal cavities by this method. I have been able to demonstrate toxoplasmosis and progressive multifocal leukoencephalopathy by this technique. Clinicians have accepted this procedure well; it avoids unpleasant confrontations between pathologists and clinicians and can yield diagnostic results. I suggest that funeral home personnel be informed when this procedure has been used. Removal of brain tissue through a trocar placed through the cribriform plate is a technique used by embalmers when there is prominent periorbital swelling. RICHARDP. MORIARTY, MD Chesapeake, VA
lnguinal Lymph Node Infection With Paragonimiasis TOtheEditor:-Paragonimiasis is typically an infection of the lungs caused by Purugonimus westermani (lung fluke). Other sites of infection include abdominal, cerebral. and subcutaneous locations. However, inguinal lymph node infection in the absence of other manifestations has not been reported previously. Geographically, there are 22 provinces and cities in China known to harbor paragonimiasis; however, Beijing is not included in this list. We have documented a case of a young girl living in Beijing who was found to have localized inguinal lymph node infection by Paragonimus. The patient was an 8-year-old girl who was noted to have a right inguinal mass of approximately 1 month’s duration in December 1988. No pain, swelling, or fever was noted. In February 1989, she was examined in the outpatient department of Beijing Hospital. A mass, 3.0 X 1.5 cm in size and without pain on palpation, was found in the right inguinal area. It was fixed and sharply demarcated. No other lymph nodes were enlarged. There was no history of fever or cough. Chest x-ray films were normal. The white blood cell count was 7 X IO”/ L. Macroscopically, the mass was soft and reddish-black. On histologic examination, the majority of the lymph node showed serpiginous necrotic granulomas composed of central homogeneous eosinophilic amorphous material surrounded by epithelioid histiocytes and fibrosis. No multinucleated giant cells were found. Eosinophils and Charcot-Leyden crystals were found scattered among the epithelioid histiocytes. A chardcteristic worm was found in one of eight blocks taken from the lymph node. Immediately surrounding the worm was an accumulation of reactive lymphocytes. The histopathologic diagnosis of paragonimiasis of the right inguinal lymph node was established; after biopsy, the patient was observed for 18 months and had no recurrent symptoms. There are a number of agents that have been reported to produce metazoan lymphadenitis, including Ascaris, Strongyloides, Ancylostoma, Trichinella, Filaria. Cysticercus, and Schistosoma. Paragonimus infection, restricted to a lymph node, has not been previously reported. While the lung is a typical site of infection, brain, subcutaneous tissue. and abdominal infections also have been reported. Oh’ reported 27 cases of spinal paragonimiasis. Hatsushika and Endo reported a case of paragonimiasis in the greater omentum in which the 842
worms and/or eggs were either in lymph nodes or in nodules consisting of fibrous tissue.2 J. XIALONG. MD LI WEIHUA, MD 301 Hospital Beijing, People’s Republic of China
1. Oh SJ: Spimtl paragonimiasis. J Ncurtrl Sci 6: 125. 196X 2. Hatsushika R. Endo A: A czsc of paragonimiasis itt greater ome~tttmt. Kawasaki Med J 4: 165, 1978
Histopathologic and Clinical Criteria for Definition of Dysplastic Nevi To the Editor:-1 read with interest the article by Clemente et al on the attempt of the World Health Organization Melanoma Programme to standardize reproducible criteria for dysplastic nevi.’ This is an admirable effort and the results are impressive. It appears that reproducibility may be significantly enhanced by setting a minimum threshold for diagnosis of dysplastic nevi, consisting of two major criteria plus at least two of four minor criteria. However, I am puzzled by the omission of size greater than 5 mm as either a major or minor criterion for dysplastic nevus. No one knows why ordinary acquired nevi tend to stop growing when they reach approximately 5 mm and why dysplastic nevi so often violate this “law of nature.“‘L,YNonetheless, size should be among the most reproducible, objective, and precise of all the criteria that have been used to identify these markers for increased risk of melanoma.‘-” Experience suggests that melanocytic nevi measuring at least 6 mm and fulfilling the criteria of Clemente et al may be more reliable markers than smaller lesions that fulfill the same histologic criteria. Studies of dysplastic nevi that use the criteria of Clemente et al may be well advised to keep track of lesion size when analyzing their data.
F. CRAMER. MD Rochester General Hospital Rochester, NY
STEWARI
2. GreeneMH. Clark WH,Jr, Tucker MA, et 211:Arquirrd pwcu~-sc,~-sof cutaneous malignant melanuma: The familial dyspkistic I~VIISsyndl-ome. N Engl J Med 312:91-97, 1985
The above letter was referred to the authors of the article in question, who offer the following reply: To the E&or:-We agree with Dr Cramer that most dysplastic nevi (DN) are larger than 5 IIIIIL This feature and other
aspects regarding the clinical definition of DN (pigment pattern, surface, elevation, age of patient. etc) were discussed during the meeting organized by the World Health Organization Melanoma Programme held at the National Tumor Institute of Milan between pathologists and clinicians “attempting to find out whether reliable clinical and histopathological diagnoses of DN are achievable,” as stated in the introduction of our report. The major goal of the meeting participants was to verify whether the proposed and discussed criteria for “his-
Volume 22, No. 8 (August 1991)
decision, but would like to offer an alternate method to study the brain without removal of the entire organ. A liver and/or renal biopsy needle can be passed very easily through the cribriform plate. An unlimited number of tissue fragments from different intracranial sites can be sampled through both nasal cavities by this method. I have been able to demonstrate toxoplasmosis and progressive multifocal leukoencephalopathy by this technique. Clinicians have accepted this procedure well; it avoids unpleasant confrontations between pathologists and clinicians and can yield diagnostic results. I suggest that funeral home personnel be informed when this procedure has been used. Removal of brain tissue through a trocar placed through the cribriform plate is a technique used by embalmers when there is prominent periorbital swelling. RICHARDP. MORIARTY, MD Chesapeake, VA
lnguinal Lymph Node Infection With Paragonimiasis TOtheEditor:-Paragonimiasis is typically an infection of the lungs caused by Purugonimus westermani (lung fluke). Other sites of infection include abdominal, cerebral. and subcutaneous locations. However, inguinal lymph node infection in the absence of other manifestations has not been reported previously. Geographically, there are 22 provinces and cities in China known to harbor paragonimiasis; however, Beijing is not included in this list. We have documented a case of a young girl living in Beijing who was found to have localized inguinal lymph node infection by Paragonimus. The patient was an 8-year-old girl who was noted to have a right inguinal mass of approximately 1 month’s duration in December 1988. No pain, swelling, or fever was noted. In February 1989, she was examined in the outpatient department of Beijing Hospital. A mass, 3.0 X 1.5 cm in size and without pain on palpation, was found in the right inguinal area. It was fixed and sharply demarcated. No other lymph nodes were enlarged. There was no history of fever or cough. Chest x-ray films were normal. The white blood cell count was 7 X IO”/ L. Macroscopically, the mass was soft and reddish-black. On histologic examination, the majority of the lymph node showed serpiginous necrotic granulomas composed of central homogeneous eosinophilic amorphous material surrounded by epithelioid histiocytes and fibrosis. No multinucleated giant cells were found. Eosinophils and Charcot-Leyden crystals were found scattered among the epithelioid histiocytes. A chardcteristic worm was found in one of eight blocks taken from the lymph node. Immediately surrounding the worm was an accumulation of reactive lymphocytes. The histopathologic diagnosis of paragonimiasis of the right inguinal lymph node was established; after biopsy, the patient was observed for 18 months and had no recurrent symptoms. There are a number of agents that have been reported to produce metazoan lymphadenitis, including Ascaris, Strongyloides, Ancylostoma, Trichinella, Filaria. Cysticercus, and Schistosoma. Paragonimus infection, restricted to a lymph node, has not been previously reported. While the lung is a typical site of infection, brain, subcutaneous tissue. and abdominal infections also have been reported. Oh’ reported 27 cases of spinal paragonimiasis. Hatsushika and Endo reported a case of paragonimiasis in the greater omentum in which the 842
worms and/or eggs were either in lymph nodes or in nodules consisting of fibrous tissue.2 J. XIALONG. MD LI WEIHUA, MD 301 Hospital Beijing, People’s Republic of China
1. Oh SJ: Spimtl paragonimiasis. J Ncurtrl Sci 6: 125. 196X 2. Hatsushika R. Endo A: A czsc of paragonimiasis itt greater ome~tttmt. Kawasaki Med J 4: 165, 1978
Histopathologic and Clinical Criteria for Definition of Dysplastic Nevi To the Editor:-1 read with interest the article by Clemente et al on the attempt of the World Health Organization Melanoma Programme to standardize reproducible criteria for dysplastic nevi.’ This is an admirable effort and the results are impressive. It appears that reproducibility may be significantly enhanced by setting a minimum threshold for diagnosis of dysplastic nevi, consisting of two major criteria plus at least two of four minor criteria. However, I am puzzled by the omission of size greater than 5 mm as either a major or minor criterion for dysplastic nevus. No one knows why ordinary acquired nevi tend to stop growing when they reach approximately 5 mm and why dysplastic nevi so often violate this “law of nature.“‘L,YNonetheless, size should be among the most reproducible, objective, and precise of all the criteria that have been used to identify these markers for increased risk of melanoma.‘-” Experience suggests that melanocytic nevi measuring at least 6 mm and fulfilling the criteria of Clemente et al may be more reliable markers than smaller lesions that fulfill the same histologic criteria. Studies of dysplastic nevi that use the criteria of Clemente et al may be well advised to keep track of lesion size when analyzing their data.
F. CRAMER. MD Rochester General Hospital Rochester, NY
STEWARI
2. GreeneMH. Clark WH,Jr, Tucker MA, et 211:Arquirrd pwcu~-sc,~-sof cutaneous malignant melanuma: The familial dyspkistic I~VIISsyndl-ome. N Engl J Med 312:91-97, 1985
The above letter was referred to the authors of the article in question, who offer the following reply: To the E&or:-We agree with Dr Cramer that most dysplastic nevi (DN) are larger than 5 IIIIIL This feature and other
aspects regarding the clinical definition of DN (pigment pattern, surface, elevation, age of patient. etc) were discussed during the meeting organized by the World Health Organization Melanoma Programme held at the National Tumor Institute of Milan between pathologists and clinicians “attempting to find out whether reliable clinical and histopathological diagnoses of DN are achievable,” as stated in the introduction of our report. The major goal of the meeting participants was to verify whether the proposed and discussed criteria for “his-