A 38-year-old previously healthy male with a 6-month outpatient history of progressive bilateral visual loss, diagnosed as uveitis, presented with severe jaundice and macular rash. The rashes were diffusely distributed over the trunk and extremities, involving the palms and soles. Laboratory studies revealed leukocytosis, thrombocytopenia, anemia, significant transaminitis (maximal alanine aminotransferase [ALT] level, 233 U/liter; aspartate transaminase [AST] level, 90 U/liter), an alkaline phosphatase level of 2,306 U/liter, and a total bilirubin level of 7.3 mg/dl. Additionally, anti-nuclear antibody (ANA) and scleroderma antibody (Ab) test results were positive. HIV was incidentally detected with a Western blot confirmation and an elevated viral load. The patient denied any sexual activity within the past 24 months, resided at home with his children, and was employed as a contractor in the construction business in the southwestern United States. He denied any recent travel history.At presentation, the patient appeared to be jaundiced, and an oral examination revealed adherent white plaques on the tongue. Erythematous scaly macules, confluent with reticulate patches, were diffusely observed on the trunk and extremities. The palms and soles had hyperkeratotic circinate scales on a background of erythema. The neurological examination was significant for revealing blindness, and the results of the remainder of the physical examinations were unremarkable. A liver biopsy with hematoxylin and eosin (H&E) staining demonstrated severe acute hepatitis and hepatocellular necrosis. Warthin-Starry staining did not demonstrate any spirochetes. Leptospira was not considered, since the patient did not have a history of travel, his outdoor activity did not suggest that etiology, and another organism was serologically detected. Further specific immunohistochemical stains for that organism revealed spiral-shaped organisms and are shown in Fig. 1.

Context.— Automated analyzers have advanced the field of clinical hematology, mandating updated complete blood count (CBC) reference intervals (RIs) to be clinically useful. Contemporary newborn CBC RI publications are mostly retrospective, which some authors have cited as one of their cardinal limitations and recommended future prospective studies. Objective.— To prospectively establish accurate hematologic RIs for normal healthy term newborns at 24 hours of life given the limitations of the current medical literature. Design.— This prospective study was conducted at an academic tertiary care center, and hematology samples were collected from 120 participants deemed to be normal healthy term newborns. Distributions were assessed for normality and tested for outliers. Reference intervals were values between the 2.5th percentile and 97.5th percentile. Results.— The novel RIs obtained for this study population are as follows: absolute immature granulocyte count, 80/μL to 1700/μL; immature granulocyte percentage, 0.6% to 6.1%; reticulocyte hemoglobin equivalent, 31.7 to 38.4 pg; immature reticulocyte fraction, 35.9% to 52.8%; immature platelet count, 4.73 × 103/μL to 19.72 × 103/μL; and immature platelet fraction, 1.7% to 9.8%. Conclusions.— This prospective study has defined hematologic RIs for this newborn population, including new advanced clinical parameters from the Sysmex XN-1000 Automated Hematology Analyzer. These RIs are proposed as the new standard and can serve as a strong foundation for continued research to further explore their value in diagnosing and managing morbidities such as sepsis, anemia, and thrombocytopenia.

Study Objective: To evaluate if smooth muscle cells can be detected in pelvic washings at the time of intact hysterectomy. Design: A multicentered pilot cohort study (Canadian Task Force classification II-2). Setting: Two academically affiliated tertiary referral centers. Patients: Patients undergoing total hysterectomy for benign indications without morcellation by minimally invasive gynecologic surgeons were enrolled from January 2018 to July 2018. Interventions: Pelvic washings were collected at 2 times during surgery: after abdominal entry and after vaginal cuff closure. Cell blocks were generated, and slides were stained using hematoxylin and eosin, smooth muscle actin, and desmin and interpreted by 1 expert pathologist at each institution. Measurements and Main Results: Thirty-eight subjects were recruited; 3 subjects were excluded because of unplanned morcellation. Smooth muscle uterine cells were detected in 1 prewash specimen and 2 postwash specimens. The group with positive washings was noted to have longer procedure times (136 vs 114 minutes), lower blood loss (25 vs 86 mL), and higher uterine weight (242 vs 234 g) compared with negative washings group. Conclusion: Tissue dissemination of uterine cells may be possible at the time of hysterectomy. Larger prospective studies are needed to better describe the incidence of and risk factors for tissue dissemination.

A 57-year-old woman was admitted to the hospital because of fever, sweats, neuropathy, and multiple pulmonary nodules.The patient had been well until nine months earlier, when weakness developed in the left ankle. During the following month, she had fevers, night sweats, and fatigue. Electrophysiologic testing performed elsewhere revealed a posterior tibial neuropathy of mixed demyelinative type. The fevers and night sweats waxed and waned, and the fatigue persisted. Three months before admission, the fevers and night sweats increased, with a rise in the temperature to 38.3°C and rigors. She lost 4.5 kg in weight.Five weeks before admission, the patient entered another hospital, where laboratory examinations were performed. The values for creatinine, uric acid, electrolytes, and bilirubin were normal. The results of other laboratory tests are shown in Tables 1, 2, and 3. Radiographs of the chest showed multiple pulmonary nodules. A computed tomographic (CT) scan of the chest (Fig. 1), obtained without the administration of contrast material, showed multiple nodules, 4 to 20 mm in diameter, predominantly at the periphery of the lung bases but also in the left upper and right middle lobes. Many of the lesions were ill defined, and several contained air bronchograms. A CT scan of the abdomen revealed multiple small hepatic lesions. Microscopical examination of a bone marrow-biopsy specimen showed no abnormalities. She was referred to this hospital.The patient was a housewife. She had a 30-year history of cigarette smoking but had stopped smoking 6 years earlier. She had recently noted a rash on her buttock that was neither pruritic nor painful. There was no history of exposure to industrial dusts, risk factors for human immunodeficiency virus (HIV) infection, cough, dyspnea, hemoptysis, epistaxis, coryza, or sinus infections.On examination, the pulse was 80, the respirations were 18, and the blood pressure was 100/60 mm Hg. A rash on the right buttock was consistent with herpes zoster. A white exudate was present on the right tonsil, and a few crackles were heard at both *Five weeks before admission, leukopenia and lymphopenia were reported.

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