Evaluation of the LCR based assay for detecting C trachomatis 517

sensitivity of the LCR kit is identical with that results. Therefore, we recommend the LCR of the PCR kit and that the LCR kit can detect and PCR kits for the routine diagnosis of C tra-

two or more EBs per assay. The average num- chomatis infection. J Clin Pathol: first published as 10.1136/jcp.49.6.517 on 1 June 1996. Downloaded from ber of plasmids in one EB was estimated to be This work was supported by Grants-in-Aid of Scientific about 10.' These results, therefore, indicate Research from the Ministry of Education, Science and Culture, that 20 copies or more of the plasmid can be Japan (63570204) and Project Research Grants, Kawasaki amplified and detected by the LCR kit under Medical School (6-506). 1 Cates W Jr, Wasserheit JN. Genital chalmydial infections: the conditions used. Dille et al' reported that epidemiology and reproductive sequelae. Am J Obstet the sensitivity of the LCR kit which targets the Gynecol 1991;164:1771-81. 2 Loeffelholz MJ, Lewinski CA, Silver SR, Purohit AP, major outer membrane protein gene and the Herman SA, Buonagurio DA, et al. Detection of Chlamy- plasmid appeared to be three EBs per assay dia trachomatis in endocervical specimens by polymerase chain reaction. J7 Clin Microbiol 1992;30:2847-51. using purified EBs which were counted by 3 Miyashita N, IijimaY, Matsumoto A. Evaluation of the sen- optical microscopy with Giemsa staining. sitivity and specificity ofpolymerase chain reaction test kit, AMPLICOR Chlamydia trachomatis. Microbiol Immunol Their results lead us to wonder whether the 1994;38:81-85. accuracy ofthe particle counting, together with 4 Miyashita N, Matsumoto A. Microbiology of chlamydiae- with emphasis on physicochemistry, antigenicity and drug the purity of the EB fraction used in their tests, susceptibility of Chlamydia pneumoniae-. KawasakiMedJ3 were sufficient for this highly sensitive assay. 1994;20:1-17. 5 Miyashita N, Matsumoto A. Establishment of a particle- C psittaci has also been reported to contain counting method for purified elementary bodies of plasmids,10 but they were not amplified in chlamydiae and evaluation of sensitivities of the IDEIA Chlamydia kit and DNA probe by using the purified either of the assays used in the present study, elementary bodies. J Clin Microbiol 1992;30:2911-16. indicating the sequence differences between C 6 Dille BJ, Butzen CC, Birkenmeyer LG. Amplification of Chlamydia trachomatis DNA by ligase chain reaction. J trachomatis and C psittaci. No evidence was Clin Microbiol 1993;31:729-31. obtained for the presence of plasmids in C 7 Schachter J, StammWE, Quinn TC, AndrewsWW, Burczak JD, Lee H. Ligase chain reaction to detect Chlamydia tra- pneumoniae organisms isolated from humans. chomatis infection of the cervix. 7 Clin Microbiol In conclusion, the newly developed LCR test 1994;32:2540-43. 8 Sriprakash KS, Macavoy ES. Characterization and se- kit, which can be used as a non-radioactive quence of a plasmid from the trachoma biovar of Chlamy- method, is extremely sensitive and specific for dia trachomatis. Plasmid 1987;18:205-14. 9 Palmer L, Falkow S. A common plasmid of Chlamydia tra- the detection of C trachomatis organisms. The chomatis. Plasmid 1986;16:52-62. manipulation procedures for this assay are 10 Lovett M, Kuo C-C, Holmes K, Falkow S. Plasmids of the genus Chlamydia. In: Nelson JD, Grassi C, eds. Current simple and designed to minimise carry-over chemotherapy and infectious disease, Vol 2. Washington, DC: contamination which can cause false positive American Society for Microbiology, 1980:1250-2.

I Clin Pathol 1996;49:517-519 http://jcp.bmj.com/ Caseous necrosis in cutaneous leishmaniasis

E Peltier, P Wolkenstein, M Deniau, E-S Zafrani, JWechsler on September 25, 2021 by guest. Protected copyright.

Service d'Anatomie et de Cytologie Pathologiques, Abstract maniasis was diagnosed on culture of skin Hopital Antoine A case oflate stage cutaneous leishmania- biopsy specimens. The presence of Beclere, sis with focal caseous necrosis is reported. caseous necrosis could lead to 157 rue de la Porte de diagnostic Trivaux, The patient, a 30 year old Tunisian man, confusion and result in an erroneous 92141 Clamart, France presented with idiopathic bone marrow diagnosis of, for example, tuberculosis, E Peltier aplasia. Microscopically, minimal chan- syphilis, acne agminata, and sarcoidosis Service de ges were observed in the epidermis: slight with fibrinoid necrosis. This is especially Dermatologie, hyperkeratosis and moderate acanthosis. the case when parasites are scanty or Hopital Henri Mondor, Lesions predominated in the dermis. Epi- absent. 51 Avenue du Marechal thelioid were found in Pathol de Lattre de Tassigny, granulomas the ( Clin 1996;49:517-519) 94010 Creteil Cedex, lower dermis. Some of these lesions were France clearly surrounded by a ring of lympho- Keywords: cutaneous leishmaniasis, caseous necrosis, PWolkenstein cytes and were rarely confluent. A pecu- pathology. Service de liar histological feature was the presence Parasitologie of focal acidophilic and slightly granular M Deniau necrosis at the centre ofsome the tubercu- Cutaneous leishmaniasis, caused by infection loid lesions. Focal fibrinoid necrosis was with a Service d'Anatomie et flagellate protozoon, is endemic in the de Cytologie found in the upper dermis, outside granu- Mediterranean region.' 2 The disease can Pathologiques lomas. A mild to moderate infiltrate of occur in one of four clinical forms: acute leish- E-S Zafrani histiocytes, lymphocytes and plasma cells, maniasis, chronic leishmaniasis, leishmaniasis JWechsler with scanty neutrophils, was observed recidivans, and diffuse cutaneous leishmania- Correspondence to: mainly in the upper dermis. No intracellu- sis.' 3 Ninety per cent of cases of acute cutane- Janine Wechsler, MD. lar or extracellular Leishman-Donovan ous leishmaniases resolve without treatment, Accepted for publication bodies were observed. Acid fast mycobac- healing with scar formation.2 The remaining 1 June 1995 teria, however, were not detected. Leish- cases generally evolve into chronic disease.4 518 Peltier, Wolkenstein, Deniau, Zafrani, Wechsler

Acute and chronic leishmaniases can manifest clinically as papular, nodular, plaque-like, or most commonly, ulcerated lesions, usually J Clin Pathol: first published as 10.1136/jcp.49.6.517 on 1 June 1996. Downloaded from located on skin exposed to the sun.6 7 On histological examination, acute leishman- iasis generally appears as macrophage lysis in the centre of macrophagic granulomas, which are usually associated with numerous lympho- cytes and plasma cells. Chronic leish- maniasis-that is, late stage leishmaniasis, has been well characterised histologically8 9 and commonly presents as tuberculoid lesions without necrosis. However, there is no funda- mental distinction between the tuberculoid lesions of chronic cutaneous leishmaniasis and the later stages of its acute counterpart.'° Case report A 30 year old Tunisian man was referred to our institution for treatment of idiopathic bone marrow aplasia. Physical examination dis- closed multiple and confluent cutaneous le- sions on the patient's left elbow and back (fig 1). The lesions had been spreading for several months, and were crusted and surrounded by

gradually spreading erythema and induration. A e ..... A diagnosis of cutaneous mycobacteria infec- f r. tion was proposed on the basis of skin biopsy Figure 2 Caseous necrosis surrounded by epithelioid cells findings and antituberculous treatment was and lymphocytes. (Haematoxylin-safrosin, x250.) started. A few weeks later, culture of the biopsy Parasitological findings specimen yielded promastigote forms of leish- Skin biopsy specimens were submitted for mania. Bone marrow aspiration and duodenal parasitological, bacterial, fungal, and mycobac- biopsy were done. Culture remained negative terial culture. for leishmaniasis. Skin tissue culture was nega- Cultures on NNN (Novy-MacNeal-Nicolle) tive after treatment with amphotericin B, medium yielded promastigote forms of leish- despite the presence of iatrogenic immunode- mania. They were characterised by the electro- http://jcp.bmj.com/ pression. Serological tests were negative for phoretic analysis of 15 different enzymes." In leishmania. this patient cutaneous leishmaniasis was caused by infection with Leishmania major, Pathological findings zymodeme MON 25 (MHOMITN/93/CRE32), The skin biopsy specimens were fixed in which is the usual strain encountered in Tuni- Bouin's liquid and embedded in paraffin wax. sia. Cultures for mycobacteria, atypical myco- Serial sections, 3-4 gm thick, were stained with bacteria and fungi were all negative. on September 25, 2021 by guest. Protected copyright. haematoxylin-safrosin, periodic acid-Schiff (PAS) reagent, Ziehl-Neelsen, Giemsa, and Discussion Gomori-Grocott stains. This present case of late stage cutaneous leish- Minimal changes were observed in the maniasis is unusual because of the presence of epidermis on microscopic examination-that focal caseous necrosis associated with tubercu- is, slight hyperkeratosis and moderate acantho- loid lesions in the lower dermis. The histopa- sis. Lesions predominated in the dermis. thology of cutaneous leishmaniasis has been Epithelioid granulomas were found mainly in described extensively8 ' and the later stages of the lower dermis. Some of these lesions were acute leishmaniasis and the chronic form of the clearly surrounded by a ring of lymphocytes disease are usually characterised by tubercu- and were rarely confluent. A peculiar histologi- loid infiltrates in the dermis.1 8-10 12 To our cal feature was the presence offocal acidophilic knowledge, caseous necrosis has not been and slightly granular necrosis at the centre of described previously in the skin, but has been some tuberculoid lesions (fig 2). Focal fibrin- reported previously in lymph nodes.'0 Septic oid necrosis was found in the upper dermis, necrosis has been observed in skin biopsy outside granulomas. A mild to moderate specimens and attributed to the presence of infiltrate of histiocytes, lymphocytes and concomitant infection with Vincent's organ- plasma cells, with scanty neutrophils, was isms,14 Streptococcus viridans, other saprophytic observed mainly in the upper dermis. No streptococci, or Candida albicans." Bacterial, intracellular or extracellular Leishman- mycobacterial and fungal cultures were nega- Donovan bodies were seen on haematoxylin- tive in the present case. However, fibrinoid eosin-safrosin, and Giemsa stained sections. necrosis, which is visually different from No acid fast mycobacteria were observed on caseous necrosis, is common in acute leishma- Ziehl-Neelsen stained sections. No refringent niasis" 16 but less so in the chronic form.'0 material was detected under polarised light. The development of tuberculoid lesions Microorganisms were not seen in sections seems to be caused by expansion of a T cell stained with PAS and Gomori-Grocott. subset producing interleukins 3 and 4 and Caseous necrosis in cutaneous leishmaniasis 519

granulocyte macrophage colony stimulating 5 Dostrowsky A. Relapses in cutaneous leishmaniasis. Ann Trop Med 1936;30:267-74. factor.'7"'- The explanation for the occurrence 6 Biagi F. Sintesis de historias clinicas de leishmaniasis

of caseous necrosis is not clear and we did not tegumentaria de Mexico (ulcera de los chicleros). Medicina J Clin Pathol: first published as 10.1136/jcp.49.6.517 on 1 June 1996. Downloaded from Mexico 1953;33:385-96. find any other aetiological agent that could be 7 Al-GindanY, Abdul-Aziz 0, Kubba R. Cutaneous leishman- responsible for it. Caseous necrosis may have iasis in Al-Hassa, Saudi Arabia. Int J Dermatol 1984; 23:194-7. resulted from an imbalance in the immune sys- 8 Kurban AK, Malak JA, Farah FS, Chaglassian HT. Histo- tem of this patient, who presented with a bone pathology of cutaneous leishmaniasis. Arch Dermatol 1966;93:396-40 1. marrow aplasia with leucopenia. 9 Ridley DS. The pathogenesis of cutaneous leishmaniasis. The presence of focal caseous necrosis in Trans R Soc Trop Med Hyg 1979;73:150-60. 10 Ridley DS, Ridley MJ. Late-stage cutaneous leishmaniasis: late stage acute leishmaniasis, in which para- immunopathology of tuberculoid lesions in skin and sites are scanty or absent,' can lead to lymph nodes. BrJfExp Pathol 1984;65:337-46. 11 Rioux JA, Lanotte G, Serres E, Pratlong F, Bastien P, Perri- difficulties in diagnosis. Tuberculosis,20 pre- ere J. Taxonomy of Leishmania. Use of isoenzymes. senting as the lupus vulgaris or the subcutane- Suggestions for a new classification. Ann Parasitol Hum Comp 1990;65:111-25. ous gumma form with spread into the upper 12 Paksoy N, Hekim E. Comparative analysis of clinicopatho- dermis, is the main differential diagnosis. logical features in cutaneous leishmaniasis and lupus vulgaris in Turkey. Trop Med Parasitol 1993;44:37-9. Syphilis at the late secondary stage should also 13 ConvitJ, Kerdel-Vegas F. Disseminated cutaneous leishman- be considered, as well as acne agminata and iasis. Arch Dermatol 1965;91:439-47. 14 Sangueza OP, Sangueza JM, Stiller MJ, Sangueza P. Muco- sarcoidosis with fibrinoid necrosis.20 In addi- cutaneous leishmaniasis: a clinicopathologic classification. tion, patients may not have generated antibod- JAm Acad Dermatol 1993;28:927-32. 15 Essa MH, Mangoud AM, Morsy TA, Aly MA, Salama MM. ies directed against either amastigote or Vascular changes in cutaneous leishmaniasis. J Egypt Soc promastigote antigens.'As cutaneous leishman- Parasitol 1989;19:683-7. 16 Ridley MJ, Ridley DS. Cutaneous leishmaniasis: immune iasis is being encountered more often because complex formation and necrosis in the acute phase. Br J of international travel and the influx of Exp Pathol 1984;65:327-36. 17 Locksley RM, Heinzel FP, Sadick MD, Holaday BJ, immigrants from areas of the world where this Gardner KD Jr. Murine cutaneous leishmaniasis suscepti- parasite is endemic, expedient diagnosis of this bility correlates with differential expansion of helper T-cell subsets. Ann Inst Pasteur 1987;138:744-9. condition may be hampered by the presence of 18 Pirmez C, Cooper C, Paes Oliveira M, Schubach A, caseous necrosis in skin biopsy specimens. Torigian VK, Modlin RL. Immunologic responsiveness in American cutaneous leishmaniasis lesions. J Immunol 1 Farah FS, Malak JA. Cutaneous leishmaniasis. Arch Derma- 1990;145:3100-4. tol 1971;103:467-74. 19 Esterre P, Dedet JP, Frenay C, Chevallie M, Grimaud JA. 2 Strick RA, Borok M, Gasiorowski HC. Recurrent cutaneous Cell populations in the lesion of human cutaneous leishmaniasis. JAm Acad Dermatol 1983;9:437-43. leishmaniasis: a light microscopical, immunohistochemi- 3 Stratigos JD. New aspects on cutaneous leishmaniasis. Derm caland ultrastructural study. Virchows Arch A Pathol Anat Beruf Unwelt 1980;28:139-48. Histopathol 1992;421:239-47. 4 Berlin C. Leishmania recidiva cutis. Arch Dermatol Syph 20 McKee PH, Marsden PA. In: Pathology ofthe skin: with clini- 1940;41:874-85. cal correlations. NewYork: JB Lippincott, 1989:819-20. http://jcp.bmj.com/

_r Clin Pathol 1996;49:519-521 Carcinosarcoma arising in a dermoid cyst of the

ovary on September 25, 2021 by guest. Protected copyright.

D S Arora, S Haldane

Abstract noma and malignant germ cell neoplasms. A case of carcinosarcoma arising within Secondary malignant transformation an otherwise benign cystic teratoma is within a dermoid cyst is a much rarer reported. The patient, a 78 year old occurrence, estimated as less than 2% of nulliparous woman, presented with right all such lesions. Adenocarcinomas are the Department of sided abdominal pain of short duration second most common malignancies aris- Histopathology, and subsequently underwent a bilateral ing within dermoid cysts. Sarcomas alone Royal Devon and salphingo-oophorectomy. Slicing of the or in combination with squamous carci- Exeter Healthcare NHS Trust, left ovary revealed a unilocular cyst noma have been described arising in a Exeter containing hair admixed with soft yeliow mature cystic teratoma. To the best of our D S Arora material with a thin wall apart from a knowledge, no case of sarcoma arising in S Haldane solid area at one pole. Extensive areas of association with adenocarcinoma has Correspondence to: necrosis and cystic degeneration were been described before. Dr D S Arora, present within this mass. Histologically, Clin Pathol 1996;49:519-52 1) Department of (7 Histopathology, the large cyst was a typical mature cystic St James's University teratoma, containing carcinomatous and Keywords: ovary, dermoid cyst, carcinosarcoma. Hospital, Beckett Street, sarcomatous elements. Mature cystic ter- Leeds LS9 7TF. atomas have been reported in association Accepted for publication with a variety of malignant ovarian tu- Malignant transformation within a mature cys- 16 January 1996 mours such as mucinous cystadenocarci- tic teratoma (dermoid cyst) occurs in less than