A 19-year-old white female patient presented with primary amenorrhea. The breasts were underdeveloped and the pubic and axillary hair was very scant. Examination revealed a normal clitoris with slightly underdeveloped labia; a small uterus was felt on pelvic examination but the bvaries were not palpable. The vaginal smear was of the castrate type. FSH and LH radioimmunoassay determinations for 3 consecutive days gave values of 50 m1.U. per milliliter for FSH, and 9.9, 11.9 m1.U. per milliliter for LH. Buccal epithelial cells were negative for Barr’s sex chromatin mass. A diagnosis of gonadal dysgenesis was made and an exploratory laparotomy was performed. Bilateral streak gonads were found, the left one thicker than the right one, On the left gonad there was a small 2 by 1 by 2 cm., irregular, firm nodule which was excised and biopsies were obtained from both streak gonads. The follows:
from the left gonadal nodule revealed a dysgerminoma; the histology was quite typical, consisting of large primitive germ cell types and small mature lymphocytes. In some areas of the tumor there was a definite epithelioid reaction with the formation of giant cells (Fig. 3). The specimen from the left gonad showed dysgenesis. In this gonad there were several collections of cells in the hilum which probably originated from the dysgerminoma. They were large cIear celIs and in one area there was a tuberculoid reaction. The specimen from the right gonad showed dysgenesis. No ova were found. Following the exploratory laparotomy, cytogenetic studies on peripheral leukocytes showed the patient’s karyotype to be 46,XY, not different from that of a normal male (Fig. 4). Thirty-nine cells were counted. Three cells contained 45 chromosomes and 36 cells had 46 chromosomes. Ten cells were karyotyped, seven of which were 46,XY. The other three cells with 45 chromosomes had dissimilar chromosomes missing, indicating artifactual random loss rather than chromosome mosaicism. Subsequent to the histologic findings, panhysterectomy was undertaken. We conclude that: (1) there is an association between male karyotype and gonocytoma 1-dysgerminoma; (2) it is possible to find dysgerminoma in mosaics with 45,X chromosomal pattern and minimal occurrence of XY, hence the importance of counting large numbers of
patients with an XY karyotype-pure or in mosaic form-should be explored for the existence of germ cell tumors in the gonads. In all XY cases it is recommended that the gonads be extirpated. REFERENCES
1. Collins, J. C., and Schoenenberger, A. P.: J. Urol. 87: 710, 1962. 2. Teter, J., and Bocskowski, K.: Cancer 20: 1301, 1967.
Gonococcal sepsis secondary to fetal monitoring HARAGOPAL
M.D. M.D. JR.,
Divisions of Infectious Disease5 and Perin&ology, Department5 of Internal Medicine and Obstetrics and Gyrwcology, Martin Luther King, Jr. Gerwal Hospital, Charles R. Dreuj Postgradu&e Medkal School, and Unixersity of Southern Calijornia School of Medicine, Lo~q Ang&.s, Cakyornia INTRAPARTUM fetal monitoring is generally considered to be safe. However, the microbiologic safety of this procedure has not been evaluated. Cultures of amniotic fluid obtained through this catheter device at random revealed potentially pathogenic bacteria in 15 of the 30 women monitored during labor.’ During this study, we encountered one case of gonococcal amnionitis later followed by neonatal sepsis.
A 14-year-old primipara was admitted on September 4, 1974, 3 hours after the rupture of membranes. Her last menstrual period was on November 11, 1973. During the first trimester, she was examined for sore throat when a routine sputum culture was positive for L%‘eisseria gonorrhoeae. At term the blood pressure was 160/114 mm. Hg; pulse, 100 b.p.m.; respirations, 20 per minute; oral temperature, 98.e F. There was pedal edema but no proteinuria. The uterus was 34 weeks’ size, with 5 cm. cervical dilatation; the presenting part was at station zero. Routine urinalysis, blood cell counts, chest x-rays, and x-ray pelvimetry were unremarkable. The heart and lungs were clear. Laboratory &dta were as follows: glucose, 123 mg. per 100 ml.; blood urea, 4 mg. per 100 ml.; chloride, 105 mEq. per liter; bicarbonate, 22 mEq. per liter: sodium, 139 mEq. per liter; potassium, 3.3 mEq. per liter; lactic dehydrogenase, 214 mu. per milliliter; serum glutamic: oxalacetic transaminase. 12 mu. per milliliter: alkaline phosphatase, 119 mu. per milliliter; total bilirubin, 1.0 mg. per 100 ml.; direct bilirubin, 0.2 mg. per 100 ml.; total protein, 6.5 Gm. per 100 ml.; albuminglobulin ratio, 3.6/2.9. The blood pressure was regulated by appropriate measures. The labor was monitored with an intrauterine catheter* and fetal scalp electrodes.? A live female child was delivered by forceps application 12 hours and 44 minutes after admission. During labor, cultures were obtained from the cervix and amniotic fluid was collected through the intrauterine catheter. The Supported by Henry J. Kaiser Family Foundation Grant 1477-51224-XxX. Reprint requests: Haragopal Thadepalli, M.D., Martin Luther King, Jr. General Hospital, 12021 S. Wilmington Ave., Los Angeles, California 90059. *Transcervical intrauterine kit (B2069), Corometrics Medical Systems, Inc., Wallingford, Connecticut. tSpira1 electrode (B2462), Corometrics Medical Systems, Inc.. Wallingford, Connecticut. No.
amniotic fluid was turbid. After delivery, umbilical cord blood wzas also cultured (see Table I). The postpartum period was uneventful for 3 days; then she developed fever of 101’ F. Pelvic examination at this time revealed foul smelling lochia when cultures of the cervix, blood, and the endometrium were obtained. She was then treated with ampicillin (500 mg.) administered by mouth four times a day. She became afebrile on the fifth day and was discharged on the seventh hospital day. The infant weighed 3,450 grams (seventy-fifth percentile), the height was 54 cm. (ninetieth percentile), and the head circumference was 35 cm. (eightieth percentile). The general examination was normal. A superficial abrasion was noted on the scalp but findings were otherwise unremarkable. Newborn blood cultures were not obtained. The Apgar score at birth was 9/9 at 1 and 5 minutes. The child was asymptomatic for 3 days but then the temperature rose to 101’ F. and she was transferred to the special-care nursery. A scab was seen at the site of’ the superficial scalp abrasion noted earlier, but showed no evidence of inflammation or pustule formation. Blood cultures were drawn and treatment was initiated with ampicillin (130 mg.) administered intravenously every 6 hours in addition to kanamycin (24 mg.) every 12 hours given intramuscularly, followed by prompt defervescence. The mother and daughter were discharged on the seventh hospital dav. Maternal, duplicate
corcl, in tryptic
and neonatal soy broth
CfkX: Neisseria (TV) gonorrhoeav Enterobu&r cloacae Staphyloroccus epidermidf$
No growth Arnniotic,jkid:
Total count = 25/mm.s IV. gonorrhoeav Alpha streptococcus not group Diphtheroids Blood
Endon&-wn: IV. gonorrhoeae Cord blood: StaphyloroccuT
Diphtheroids Blood (nwborn-third A’. gonorrhoeae
Scalp wound: Scab formed Not cultured
(BBL) supplemented with sodium polyanetholesulfonate. All cultures were processed by aerobic and anaerobic bacteria. Aerobic bacteria were identified by conventional schema. Anaerobes were identified by their biochemical reactions in prereduced anaerobically sterilized media and gas-liquid chromatography patterns. NtGsmiu gonorrhomu, was identified by its growth on Thayer Martin media in candle-extinction jar, glucose fermentation, and positive oxidase reactions. There arc several pertinent features in this case. The mother was treated for pharyngeal gonorrhea during the first trimester. A past history of gonorrhoea perhaps should alert one to the possible onset of intrapartum gonococcal complications. Several modes of dissemination of gonococcus from the cervix could be postulated. A simple rupture of the membranes might itself be sufficient to cause amnionitis during labor. Prompt initiation of therapy in such instances was previously reported to avert neonatal sepsis.’ Gonococcal scalp wound infections at the site where the electrode had been previously placed is another possible source (Morbidity 8c Mortality Weekly Report, p. 115, 1975, U. S. DHEW Pub. No. [CDC] 754017). Gram stain of amniotic fluid failed to show gramnegative diplococci because they were in undetectably low concentration. Quantitative cultures of this fluid later revealed only 25 colonies of gonococci along with other bacteria per milliliter. It is of interest to note that maternal and cord blood cultures were negative for gonococci; therefore, the transplacental route appears
unlikely. It rvas no surprise that the cervix and the endometrial samples were positive for g~r~~~rr~ue~. Either premature rupture of the membranes or the subsequent insertion of an intrauterine catheter or both might have caused amnionitis. Subsequent transmission of gonococcus to the newborn infant could have been either due to fetal ingestion of infected amniotic fluid or through inadvertent inoculation of gonococci into the fetal scalp by the electrodes inserted during fetal monitoring in the presence of contaminated amniotic fluid. In view of negative cord-blood cultures, transplacental transmission appears to be unlikely in this case. Modified G-am stain of the sections of the placenta, cord, and membranes revealed no bacteria. In a prospective study of microbiology during labor conducted during the same period, about I 10 pre- and postpartum cultures of the cervix were gram stained and cultured for both aerobic and anaerobic bacteria. None of the specimens, with the exception of this case, revealed gram-negative diplococci on Gram stain. Furthermore, none of the 110 cultures obtained in 55 women in the perinatal period showed any other gram-negative bacteria that could have been mistaken for gonococci, viz., veillonella, serratia, and acinetobacter, For this reason, we recommend that the cervical smears obtained during labor should be routinely Gram stained and inspected for gram-negative diplococci. Prompt therapy against gonococci should be initiated when gram-negative diplococci are seen. Such
not be routinely
Thadepalli, H., Appleman, M. D., Maidman, J. E., Chan, W. H., Arce, J. J., Hooper, D. G., Imagawa, D., and Davidson, E. C., Jr.: XV Intersci. Conf. Antimibcrob. Agents Chemother. 227, 1975. Rothbard, M. J., Gregory, T., and Salerno, L. J.: AM. J. OBSTET. GYNECOL. 121: 565, 1975.
Gonococcal salpingitis in pregnancy RENE R, GENADRY, M.D. BRUCE H. THOMPSON, M.D. JENNIFER R. NIEBYL, M.D. Department of Gynecology and Obstetrics, Hospital, Baltimore, Maryland
cervical cultures for gonorrhea have been reported with increasing frequency in pregnancy as well as in nonpregnant patients. Although pelvic inflammatory disease has occurred in pregnancy, it has usually been associated with septic abortion or has represented an exacerbation of pre-existing disease. Acute purulent salpingitis in pregnancy is rare, and we have been unable to find any previously reported case in which Ne&&z gonor&eue was isolated from the Fallopian tubes during pregnancy. The patient reported here presented with acute abdominal pain simulating appendicitis, and had cultures positive for N. gonorrheae from acutely inflamed Fallopian tubes as well as from the cervix at 14 weeks of pregnancy. POSITIVE
A 21-year-old black woman, para 0, presented at 14 weeks of pregnancy with a history of lower abdominal pain of 24 hours’ duration. She had some nausea and vomiting at the beginning of her pregnancy, but the nausea had increased during the preceding 24 hours and she vomited once on the morning of the admission. The pains were most marked in the right lower quadrant, with radiation to the left lower quadrant and right upper abdominal area. The remainder of her past history was unremarkable. Her physical examination revealed: temperature, 100’ F.; pulse 120 b.p.m.; respirations, 22 per minute; blood pressure, 160/90 mm. Hg. No bowel sounds were audible. The abdomen was diffusely tender with guarding in all four quadrants and rebound tenderness was present in both lower quadrants, more marked on the right. Pelvic examination disclosed a normal-appearing cervix which was soft and closed, with no bleeding, laceration, or unusual discharge. The uterus was enlarged compatible with a 14 week size pregnancy, and there was cervical motion tenderness bilaternally. The adnexa were tender but no masses were present. Reprint 159, Johns
Laboratory blood cell
R. Niebyl, Baltimore,
M.D., Woman’s Clinic Maryland 21205.
serum urea nitrogen,
37 per cent; white normal; electrolytes,
3; amylase, 69: total bilirubin,
less than 0.8 mg. per deciliter. The chest x-ray was normal and the abdominal x-ray revealed a nonspecific gas pattern. The cervical smear showed gram-negative intracellular diplococci, and cervical culture subsequently confirmed the presence of IV. gonowheae. Because of the presumptive diagnosis of acute appendicitis, an exploramry laparotomy was performed. At laparotomy, both tubes were hyperemic and congested. Purulent material dripped from the fimbriated ends, and free pus was present in the peritoneal cavity. The Gram stain of the purulent material showed gram-negative intracellular diplococci, and culture subsequently confirmed the presence of A’. gonorrbae in the tubal exudate. The appendix was normal. Postoperatively, the patient was treated with intravenous cephalothin, 4 Gm. per day, and kanamycin, 1 Gm. per day, for 5 days. She also received progesterone, 100 mg., intramuscularly every 6 hours for 24 hours, and 17-alphahydroxyprogesterone caproate, 250 mg., intramuscularly twice a week. She had a benign postoperative course and was discharged on the seventh hospital day. The remainder of heI pregnancy was uncomplicated and at 37 weeks of gestation she went into labor spontaneously and delivered a normal 2,870 gram male infant. The placenta was normal and weighed 500 grams,
Before making the diagnosis of either acute salpingitis in pregnancy, or recurrent pelvic inflammatory disease associated with pregnancy, it is of utmost importance to assure that one is not dealing with a septic abortion. If there is any suggestive evidence, by either history or physical examination, of interference with the pregnancy, or suggestion of amnionitis, emptying of the uterus is mandatory. Pre-existing pelvic inflammatory disease may undergo exacerbation during the course of an intrauterine pregnancy,j and a patient with no evidence of criminal interference may present with a previousl! unsuspected tubo-ovarian abscess. It is of note that many of these patients have an acute abdomen, often diagnosed preoperatively as appendicitis, twisted ovarian cyst, or ectopic pregnancy. However, the finding of N. gonorrhww on a cervical culture or gram stain does not necessarily explain the picture of acute abdominal pain, as this finding might well be coincidental and the patient have some other intra-abdominal pathology. It has been classically taught that acute gonococcal salpingitis rarely if ever occurs in pregnancy, and several mechanisms have been invoked to explain this observation. The intact fetal membranes, the cervical mucus plug, the absence of menstruation and the decidua covering the openings to the uterine tubes have all been considered barriers to the ascent (of infection. Gonorrhea in the cervix can spread to the tubes via at least two separate routes: (1) by direct ascent through the endometrial cavity, or (2) via vascular channels. The introduction of infection may occur at