Background: Immunoglobulin M nephropathy (IgMN) is an idiopathic glomerulonephritis (GN) usually presenting clinically as steroid resistant/dependent nephrotic syndrome (NS) with pathology of mesangial proliferative GN or focal and segmental glomerulosclerosis with diffuse predominant mesangial IgM deposits. Not much information is available about its natural history. This is the first Indian study to our knowledge on IgMN in adults and adolescents. Materials and Methods: We evaluated renal biopsies performed at our center between January,'04 to September,'09. Biopsies of all adolescents and adults were evaluated for IgMN and we studied their age, gender distribution, blood pressure (BP), disease duration, steroid/immunosuppressive management and serial serum creatinine (SCr), urinary proteins, and BP values. Patients with other systemic diseases/infections and children were excluded. Results: IgMN constituted 4.3% of 2702 adult renal biopsies. No significant gender predilection was noted. Males presented at average age of 23.1 years, females at 30 years. Steroid-dependent NS was the commonest presentation noted in 75% followed by steroid-resistant NS. Hypertension was noted in 10% patients. Mesangial proliferative GN (MePGN) was commonest histopathological finding noted in 74.4%, followed by focal segmental glomerulosclerosis (FSGS) in 16.2%, and minimal change disease (MCD) in 9.4% biopsies. Sole IgM deposits were noted in 88.5%. All MCD, 35.6% MePGN reached remission, FSGS progressed to renal failure by 1 year. Hypertension, proteinuria, interstitial fibrosis, and FSGS were bad prognosticators. Conclusions: This is the first Indian study of IgMN in adults and adolescents carried out over a period of 5.8 years, which has shown that hypertension, proteinuria, and interstitial fibrosis at presentation have bad prognosis.

Context: Matrix metalloproteinases 2 and 9 (MMP-2 and MMP-9) preferentially degrade the basement membrane, a key step in tumor invasion, metastases, and induction of vascularization of tumor tissue. Aim: To determine MMP-2 and MMP-9 in situ mRNA expressions in colorectal adenocarcinomas from Iraqi patients. Materials and Methods: Forty archived paraffin-embedded colorectal adenocarcinoma samples and their resection margins were enrolled in our study. Thin paraffin embedded sections (3-5 μm thick) of both tumor and resection margins were prepared for each respective biopsy and were used to detect MMP-2 and MMP-9 in situ mRNA expressions based on in situ hybridization technique. Statistical Analysis: Statistical analyses were conducted to describe different variables and parameters in this research, and to describe relationships with each other as well. For the comparisons, the t test of significance was used. The associations were found by chi-square (χ² ) and analysis of variance (ANOVA) tests, or as appropriate, as well as 95% confidence interval. The correlations were calculated using correlation coefficient (r). Statistical significance was defined as P < 0.05. Results: Based on the current outcome, there were significant differences in MMP-2 and MMP-9 in situ mRNA expressions when each tumor sample were compared to its respective resection margin (P < 0.001 and P < 0.001, respectively). When tumor samples were analyzed based on their depth of invasion, means of in situ mRNA expressions of both MMP-2 and MMP-9 were significantly increased in the group in which tumor invaded submucosa into muscularis properia (SMP) compared to that of tumor in serosa (SE) group and tumor invading other organs (OR) group (P < 0.05 and P < 0.05, respectively). Furthermore, when tumor lymph node metastases were questioned, exclusively, MMP-2 in situ mRNA expression was significantly differentiated among N0, N1, and N2 groups (P < 0.05). Regarding the possible correlation between the two investigated parameters with respect to various histopathological variables, both MMP-2 and MMP-9 in situ mRNA expressions have significant positive correlation in tumor samples (r = 0.88), whereas in resection margins, this correlation was absent. Interestingly, MMP-2 and MMP-9 in situ mRNA expressions were found to correlate positively as well as significantly within tumor differentiation [well-differentiated (WD) adenocarcinoma: r = 0.78; moderately differentiated (MD) adenocarcinoma: r = 0.90; and poorly differentiated (PD) adenocarcinoma: r = 0.91], tumor stage (A-B: r = 0.70 and C-D: r = 0.95), depth of invasion (SMP: r = 0.77; SE: r = 0.87; and OR: r = 0.97), lymph node metastasis (N0: r = 0.82; N1: r = 0.92; and N2: r = 0.96), and tumor size (<3 mm ³ : r = 0.76 versus ≥3 mm3: r = 0.94). Conclusions: Overexpression of MMP-2 and MMP-9 are often associated with increased invasive metastatic potential of colorectal adenocarcinoma. However, their activities are essential during the early stages of tumor progression.

Background: Toxemia of pregnancy is the leading cause of maternal mortality and is an important factor in fetal wastage. The incidence is high in developing countries with malnutrition, hypoproteinemia, and poor obstetric facilities. Objectives: The present study was undertaken to analyze placental changes in the preeclampsia-eclampsia syndrome with a view to assess the significance of villous abnormalities by histopathological methods because these changes serve as a guide to the duration and severity of disease. Gross abnormalities noted were the placental infarcts, retroplacental hematoma, and calcification. Results: The striking villous abnormalities observed in the study group were cytotrophoblastic proliferation (86%), thickening of the villous basement membranes (95.23%), increase in syncytial knots (90.4%), villous stromal fibrosis (92%), fibrinoid necrosis (97.82%), endarteritis obliterans (53.96%), decreased villous vascularity, and paucity of vasculosyncytial membranes (93.65%). Conclusions: The gross abnormalities and villous lesions in the preeclampsia (P < 0.001) and eclampsia syndrome (P < 0.05) were significant.

Background and Objective: The study was conducted to evaluate the diagnostic accuracy of imprint cytology in ovarian neoplasms, and to investigate the biological significance of Ki-67 antigen expression in benign and malignant ovarian tumors and correlate it with histological type, grade, and stage of malignant tumor. Materials and Methods: A total of 50 cases including 25 prospective and 25 retrospective cases were studied. Imprint cytology was performed on 25 ovarian tumors and compared with histopathological diagnosis. Ki-67 immunohistochemistry was performed on all 50 cases. Results: On immunohistochemistry, benign tumors had a mean Ki-67 index of 3.2 ± 3.7 while malignant tumors had a mean Ki-67 index of 33.1 ± 16.7, the difference being statistically significant. Significant correlation was observed between the Ki-67 index and stage of the tumor; however, there was no correlation between the grade of differentiation and histological type of tumor with the Ki-67 index. Conclusions: In the present study, the Ki-67 index was higher in advanced stage tumors; hence a higher Ki-67 index points toward the aggressive behavior and poorer clinical outcomes.

Background: Collagen vascular disorders (CVDs) are autoimmune disorders with multisystem involvement. Clinical liver involvement is not a characteristic feature though histological involvement could be frequent. Liver disease in CVDs could be the consequence of various factors. Aim: The aim was to analyze the histological spectrum of liver in collagen vascular disorders (CVDs) at autopsy. Materials and Methods: Thirty-six autopsy livers negative for hepatitis B or C virus were studied in CVD cases with no known association with chronic liver disease or vascular thrombosis or hematological disorder. Cirrhotic and normal livers were used as controls. The paired t-test, one-way ANOVA, and two-sided Dunnett t-test were used for comparison (< 0.05). None of the control cases showed any abnormal vessels. Results: There were 21 systemic lupus erythematosus (SLE), 7 rheumatoid arthritis (RA), 5 systemic sclerosis (SSc), and 3 polyarteritis nodosa (PAN) cases (M:F = 11:25, age range 23-60 years). Histology: Diffuse nodular regenerative hyperplasia of liver (NRHL) was seen in 10 cases, and 6 (5 SLE and 1 RA) had numerous abnormal thin-walled vessels in intermediate- and small-sized portal tracts with no vascular occlusion or inflammation. Moderate sized portal tracts showed more interface and lobular inflammation. The main portal vein and its major branches were normal. None of these six cases had increased transmainases (P>0.05). Most SLE cases had increased transaminases (P<0.05). No evidence of portal hypertension was seen in all except in one RA. Septicemia is known to be associated with raised transaminases. Conclusion: A rare pathology of conglomerate of abnormal vessels in intermediate- and small-sized portal system was observed co-existing with NRHL in CVDs. Raised liver enzyme with interface hepatitis in CVD may not necessarily warrant an overlap, as a similar feature could be observed in septicemia.

Background: The over expression of fascin, extracellular matrix metalloproteinase inducer (EMMPRIN), and ezrin proteins has been associated with poor prognosis in various carcinomas and sarcomas. However, very few studies have reported the relationship between the expression of fascin, EMMPRIN, and ezrin proteins and the clinico-pathologic parameters of colorectal carcinomas. Aims: The aim was to investigate the relationship between fascin, EMMPRIN, and ezrin proteins in colorectal adenocarcinomas and their correlation with clinico-pathologic parameters. Settings and Design: The expression of fascin, EMMPRIN, and ezrin proteins was studied in 210 colorectal adenocarcinoma patients through immunohistochemical staining. Materials and Methods: Immunohistochemical staining by the avidin-biotin peroxidase method was done. The scoring of each protein expression was done and divided into three groups (negative, low-, and high-expression groups). Statistical Analysis: A chi-square test, and Kendall's tau-b correlation test were used for comparing. Survival analysis was performed using the Kaplan-Meier method with log-rank tests and the Cox proportional hazard model. Results: The percentages of the high-expression group of fascin, EMMPRIN, and ezrin proteins in colorectal adenocarcinomas were 24%, 73%, and 62%, respectively. Weak positive correlations were observed among these protein expressions. An increased expression of the fascin protein was significantly associated with advanced tumor depth and shorter survival times, and a high expression of fascin protein was an independent prognostic factor in univariate and multivariate survival analyses. EMMPRIN and ezrin protein expressions were not associated with the clinico-pathologic parameters. Conclusions: The high expression of fascin protein may be an unfavorable prognostic marker for individual colorectal cancer patients.

Background: Salivary duct carcinoma (SDC) is a highly aggressive primary salivary gland neoplasm that resembles intraductal and infiltrating breast carcinoma. Objectives: To review cytomorphologic features of histology proven SDC and evaluate potential pitfalls in cytologic diagnosis. Materials and Methods: Fine needle aspiration cytology (FNAC) of five histologically proven SDCs were reviewed. Results: One patient was an elderly male (61 years), while the other four patients were younger, in their fourth decade (average age: 38 years). The initial cytologic diagnoses in two of the cases were poorly differentiated carcinoma with differential diagnosis of SDC and high grade mucoepidermoid carcinoma, while in the third case, a possibility of malignant mixed tumor was suggested. In fourth and fifth cases, the diagnosis was suggestive of pleomorphic adenoma with cystic change. The spectrum of cytologic changes included flat sheets and cohesive papillary and three-dimensional clusters. There was moderate to severe nuclear pleomorphism and atypia. Cribriform pattern and necrosis were occasionally identified. Prominent bright granular metachromatic stroma was seen in two of the cases interpreted as pleomorphic adenoma with cystic change and in the tumor reported as suggestive of malignant mixed tumor. The fifth case showed numerous cyst macrophages and apocrine cells with mild nuclear atypia. Conclusion: FNAC of SDC is difficult to interpret because of overlapping cytomorphologic features. Bland cytomorphologic features in some cases and several clinical pitfalls are demonstrated in our series.

Context: Fibrosis is universally accepted as a poor prognostic finding in renal pathology. Semi-quantitative assessment is widely used for prognostication in pathology. Aims: We propose a semi-quantitative method to prognosticate primary nonproliferative glomerular diseases. Settings and Design: A semi-quantitative method based on Banff schema, 97 classification has been modified to suit the requirements. Glomerular, tubulointerstitial, and vascular compartments were scored independently, and the scores were totaled to obtain total scores. Materials and Methods: Seventy-six renal biopsies were assessed by semi-quantitative scores and the individual compartmental and total scores were correlated with serum creatinine levels. Follow-up was available in 24 cases. Statistical Analysis: Pearson correlation coefficient, two-tailed t test, to determine the P value. Results: P values were significant for the total scores as well as individual compartments. There is a linear correlation between the scores and serum creatinine levels. A total score of ≥5 was significant. Conclusions: The semi-quantitative scoring system based on modified Banff schema, 1997 is useful in prognosticating renal biopsies in primary nonproliferative glomerular diseases.

Context: To identify various causes, risk factors, age and sex distribution associated with sudden and unexpected natural deaths (SUNDs) in young adults of age between 18 and 35 years. Materials and Methods: Retrospective analysis of autopsy reports and medical records of all SUNDs that occurred instantaneously or within 24 hours of onset of symptoms in young adults, between 2001 and 2009. Result: Of the total 6453 deaths autopsied during 2001-2009, 64 (0.99%) were SUNDs in young adults, chiefly in males between 30 and 35 years of age. Non-cardiac causes significantly predominated (73.4%) over cardiac causes (7.8%). Most of the SUND cases were due to preventable causes, including infections (54.6% cases), cerebrovascular accidents (9.37%) and ischemic cardiac causes (6.25%). Sudden adult death syndrome (SADS) accounted for 18.75% deaths. Conclusion: SUND in young adults is preventable. A meticulous post-mortem examination with special attention to the conduction system of heart and detailed toxicological analysis can pinpoint the cause of death in SADS.

Background and Aim: Gliosarcoma (GS) is an uncommon malignant tumor of the brain, consisting of malignant glial, usually a glioblastoma (GB), as well as sarcomatous component; the latter is usually in the form of fibrosarcoma. We report a series of 10 GSs with prominent smooth muscle component, which is a rare occurrence. Settings and Design: Out of a series of 225 cases of GB admitted in our hospital, 10 were diagnosed as GS with prominent smooth muscle component, gliomyosarcoma (GMS). Materials and Methods: This is an observational study based on the experience with 225 cases of GB, encountered between 1995 and 2008, in our hospital. The tumors showing prominent spindle cell component were stained with reticulin and 20 with strongly positive reticulin stain were diagnosed as GS. They were further studied by immunohistochemical staining for glial fibrillary acidic protein (GFAP), smooth muscle actin (SMA), desmin and factor VIII antigen. Results: Out of 225 cases of GB, 20 were diagnosed as GS. Ten of these showed prominent smooth muscle component and were diagnosed as GMS. They revealed varying degrees of SMA and factor VIII Ag positivity. In the sarcomatous component, SMA and factor VIII positive cells were seen close to the vessel walls as well as away from them. Conclusion: GMS containing prominent smooth muscle component may not be as rare as has been reported in the literature. Both GS and GMS appear to arise from the vessel wall at least in some cases, suggesting their possible vascular origin.

Context: Light chain immunofluoresence (IF) in renal biopsy is routinely used in the diagnosis of light chain deposition disease (LCDD), amyloidosis and cast nephropathy. Light chain predominance has also been reported in certain glomerulopathies like IgA nephropathy. However, pathogenesis of this pattern of deposition in various glomerulopathies is uncertain. Aim: To discuss the pathogenesis and utility of light chain IF in nephropathies. Setting and Design: Retrospective study. Materials and Methods: The pattern of light chain IF and light microscopic diagnosis in 306 cases of various nephropathies was reviewed. Direct IF was done in all these cases with commercial fluorescence (Fluoresciene Isothiocynate ) conjugated polyclonal rabbit anti-human antisera against IgM, IgG, IgA, C3, C1q, kappa and lambda light chains. Results: Light chain deposits were seen in 240 (78.43%) cases. In IgA nephropathy, lupus nephritis and post-infectious glomerulonephritis (PIGN), lambda positivity was more as compared to kappa. Light chain deposits in LCDD and membranous nephropathy were more kappa type. The IF pattern in amyloidosis was not consistent. Conclusion: The pathogenesis of light chain predominance in glomerulopathies is not clear and it depends on isoelectric point and size of the immune complex. Light chain IF should be performed routinely in all the renal biopsies.

Background: Prostatic adenocarcinoma and urothelial carcinoma of the urinary bladder are common cancers in men. High grade forms of these tumors may present ambiguous morphologic features that do not permit a definite diagnosis. This distinction between the two tumors has significant staging and therapeutic implications. Hence, an accurate diagnosis is essential for optimal patient care. p63 is a new marker which can be used in this context. It is expressed in most of the urothelial carcinomas and negative in majority of prostatic adenocarcinomas. Aim: To compare the expression of p63 in urothelial carcinomas and adenocarcinomas of prostate. Materials and Methods: Comparative cross--sectional study was carried out at a tertiary cancer hospital from 15 June 2006 to 15 December 2006. Immunohistochemical stain p63 was performed on 50 cases of urothelial carcinoma and 50 prostatic adenocarcinomas. Patients' name, age, histology numbers, grade of tumor, and expression of p63 were recorded. p63 expression was seen in 44 of 50 urothelial carcinomas (88%). None of the prostatic adenocarcinomas expressed p63. The ages of patients with prostatic adenocarcinoma ranged from 49 to 86 years with a median age of 71 years and 41 to 83 years for urothelial carcinomas with a median age of 60.5 years. Conclusion: p63 can be used as a reliable marker to distinguish prostatic adenocarcinomas from urothelial carcinomas in difficult cases in conjunction with other markers like PSA.

A simple slide test and image analysis were used to reveal the presence of an acute-phase response and to determine its intensity in subjects of acute myocardial infarction and acute ischemic stroke. Erythrocytes tend to aggregate during an inflammatory process. Evaluation of erythrocyte adhesiveness/aggregation is currently available to the clinicians indirectly by erythrocyte sedimentation rate (ESR), but ESR correlates poorly with erythrocyte aggregation, hence a simple slide technique using citrated blood was used to evaluate erythrocyte aggregation microscopically and also by using image analysis. Aims: (1) To study erythrocyte aggregation/adhesiveness by a simple slide test in subjects with acute ST-elevated myocardial infarction (STEMI), acute ischemic stroke and healthy controls. (2) To study the prognostic significance of ESR and erythrocyte aggregation/adhesiveness test (EAAT) in predicting the outcome after 1 week in subjects of acute myocardial infarction and acute ischemic stroke. Patients and Methods: Three groups of subjects were included in the study; 30 patients of acute STEMI, 30 patients of acute ischemic stroke, and 30 subjects with age- and gender-matched healthy controls. Citrated blood was subjected to simple slide test and ESR estimation by Westergren's method. Stained smears were examined under 400Χ and graded into four grades. Images were taken from nine fields; three each from head, body, and tail of the smear. The degree of erythrocyte aggregation was quantified using a variable called erythrocyte percentage (EP), by using the software MATLAB Version 7.5. A simple program was used to count the number of black and white pixels in the image by selecting a threshold level. Results: The mean ESR of the subjects with acute myocardial infarction (29 + 17.34) was significantly higher (P = 0.001) than the mean ESR of the control group (15.5 + 12.37). The mean EP of the subjects with acute myocardial infarction (69.91 + 13.25) was significantly lower (P < 0.001) than the mean EP of the control group (85.16 + 8.41). The mean ESR of the subjects with acute stroke (40.46 + 33.75) was significantly higher (P = 0.0005) than that of the controls (15.5 + 12.37). The mean EP of the stroke patients (70.59 + 11.30) was significantly lower (P < 0.001) than the mean EP of the controls (85.16 + 8.41). In subjects with acute myocardial infarction there was a significant negative correlation (r = −0.623) between ESR and EP. In acute stroke patients there was a significant negative correlation (r = −0.69) between ESR and EP. On performing standard error of proportions, P value was < 0.05. Conclusion: EAAT is a simple bedside test for erythrocyte aggregation, which indirectly reveals the presence and proportion of inflammation. This test has the potential to assess the prognosis of acute myocardial infarction and acute stroke. It can also be used as a screening test for high-risk individuals, so that necessary interventions could be adopted. However, further studies need to be conducted to establish standard protocols.

Context: Monitor 100^® (Electa Lab, Italy) is a newly developed automated method for measurement of erythrocyte sedimentation rate (ESR). Aims: The aim of our study was to compare the ESR values by Monitor 100^® against the standard Westergren method. Patients and Methods: This cross-sectional study was conducted at a Level I trauma care center on 200 patients. The samples taken were as per the recommendations charted out by International Council for Standardization in Hematology (ICSH) for comparing automated and manual Westergrens method. Statistical Analysis Used: Bland and Altman statistical analysis was applied for evaluating Monitor 100^® against the conventional Westergren method. Results: The analysis revealed a low degree of agreement between the manual and automated methods especially for higher ESR values, mean difference -11.2 (95% limits of agreement, -46.3 to 23.9) and mean difference -13.4 (95% limits of agreement-58.9 to 32.1) for 1 and 2 hours, respectively. This discrepancy which is of clinical significance was less evident for ESR values in the normal range <25 mm/hour (-7.7 mean of difference; -18.9 to 3.5 limits of agreement). Conclusions: The fully automated system Monitor 100^® for ESR measurement tends to underestimate the manual ESR readings. Hence it is recommended that a correction factor be applied for the range of ESR values while using this equipment. Further studies and validation experiments would be required.

Background: The etiology of bicytopenia/pancytopenia varies widely in children, ranging from transient marrow viral suppression to marrow infiltration by fatal malignancy. Depending on the etiology, the clinical presentation can be with fever, pallor or infection. Knowing the exact etiology is important for specific treatment and prognostication. Aims: To evaluate the etiological and clinico-hematological profile in children with bicytopenia and pancytopenia. Materials and Methods: A review of bicytopenic and pancytopenic children referred for bone marrow examination from January 2007 to December 2008 was done. Detailed history, clinical examination and hematological parameters at presentation were recorded. Results and Conclusion: During the study period, a total of 990 children were referred for bone marrow examination for different indications. Of these, 571 (57.7%) had either pancytopenia (17.7%) or bicytopenia (40%). Commonest form of bicytopenia was anemia and thrombocytopenia seen in 77.5% cases, followed by anemia and leukopenia in 17.3% and leukopenia and thrombocytopenia in 5.5% cases. Most common etiology was acute leukemia (66.9%) in bicytopenic children and aplastic anemia (33.8%) in pancytopenic children. Children with bicytopenia had a higher incidence of underlying malignancy (69.5% vs. 26.6%), splenomegaly (60.5% vs. 37.4%), lymphadenopathy (41.8% vs. 15.1%) and circulating blasts (64.6% vs. 20.1%) and a lower incidence of bleeding manifestations (12.1% vs. 26.6%) as compared to children with pancytopenia.

Background: Pegylated interferon and ribavirin combination therapy remain the first-line treatment for chronic hepatitis C virus (HCV) infection. In contrast to the large number of studies in treatment-naive patients, the effectiveness of retreatment in patients who have previously failed pegylated interferon based therapy is not much reported. Objectives: The aim of this retrospective study was to focus on the efficacy of pegylated interferon alpha and ribavirin in retreated chronic hepatitis C patients. Patients and Methods: All patients were treated with pegylated interferon alpha either 2a (180 μg) or 2b (1.5μg/kg) subcutaneously once weekly for a 48-week period, plus ribavirin 1000-1200 mg/day. The patient who had a negative HCV RNA at the end of 48 weeks were followed up for 24 weeks, and the patients who relapsed in the post-treatment follow-up period of 24 weeks were treated again with pegylated interferon alpha; but if the first treatment was administered with pegylated interferon alpha 2a, the second was administered with pegylated interferon alpha 2b and if pegylated interferon alpha 2b, then the second with pegylated interferon alpha 2a. Results: We evaluated the outcome of our patients with chronic HCV who achieved a viral response at the end of the therapy, but did not achive sustained virologic response; 54% (38/70) of patients did achieve sustained virologic response, while 46% (32/70) of patients did not (eight patients did not achieve early virologic response, five patients were nonresponders at 24th week of the treatment, the remaining 19 patient had negative HCV at the end of the therapy but did not achieve sustained virologic response). We began from 19 patients to 8 patients, who had negative HCV RNA at the end of the treatment, but did not achieve sustained virologic response, interferon plus ribavirin therapy again. If the patient had interferon alpha 2a, we gave in the second tour alpha 2b; and if alpha 2b, then alpha 2a. The early virologic response of these nine patients were found to be 63% (5/8). These 5 patients who had rapid virologic response and early virologic response at the second therapy achieved sustained virologic response this time. Conclusions: These findings suggest that the standard 48-week treatment is insufficient and that an extended course of treatment may be necessary. Relapse is a poorly understood clinical outcome in the treatment of chronic HCV patients. Retreament can give a chance to some patients specially who have early virologic response and negative HCV RNA at the end of the first therapy.

Background: During the last decade, coagulase-negative staphylococci (CoNS) have emerged as a major cause of nosocomial infections. They constitute a major component of the normal skin and mucosal microflora, and are particularly responsible for catheter- and medical device-related sepsis. They present unique problems in diagnosis and treatment of infections. Purpose: The present study has been designed to evaluate phenotypic and genotypic characteristics of CoNS among nosocomial isolates. Setting and Design: This study was carried out in a tertiary care hospital. Data from 150 samples collected from 73 hospitalized patients and 15 healthy volunteers between October 2003 and May 2005 were analyzed. Patients and Methods: A total of 100 CoNS strains responsible for sepsis or implant-associated infections and 50 saprophytic strains were studied. Invasive CoNS strains were selected on the basis of different colony morphologies, drug resistance patterns, and biofilm formation. The same criteria were used to select saprophytic isolates. Multiplex PCR was used to explore the ica, mecA, and atlE genes, which might contribute to the pathogenicity of CoNS and the formation of biofilms. Results: Most of the invasive strains that formed the biofilm were resistant to multiple antibiotics, with more than 80% resistant to methicillin. ica and mecA genes were detected significantly in pathogenic strains (chi-square test, P<0.0001) whereas atlE was ubiquitously amplified in all the strains. All those strains which had ica and mecA genes were resistant to multiple antibiotics and were positive for biofilm formation. Conclusion: These genetic markers thus appear to discriminate between potential invasive virulent and saprophytic strains of CoNS.

Introduction: While foot infections in persons with diabetes are initially treated empirically, therapy directed at known causative organisms may improve the outcome. Many studies have reported on the bacteriology of diabetic foot infections (DFIs), but the results have varied and have often been contradictory. The purpose of the research work is to call attention to a frightening twist in the antibiotic-resistant Enterococci problem in diabetic foot that has not received adequate attention from the medical fraternity and also the pharmaceutical pipeline for new antibiotics is drying up. Materials and Methods: Adult diabetic patients admitted for lower extremity infections from July 2008 to December 2009 in the medical wards and intensive care unit of medical teaching hospitals were included in the study. The extent of the lower extremity infection on admission was assessed based on Wagner's classification from grades I to V. Specimens were collected from the lesions upon admission prior to the initiation of antibiotic therapy or within the first 48 h of admission. Results: During the 18-month prospective study, 32 strains of Enterococcus spp. (26 Enterococcus faecalis and 06 E. faecium) were recovered. Antibiotic sensitivity testing was done by Kirby-Bauer's disk diffusion method. Isolates were screened for high-level aminoglycoside resistance (HLAR). A total of 65.6% of Enterococcus species showed HLAR. Multidrug resistance and concomitant resistance of HLAR strains to other antibiotics were quite high. None of the Enterococcus species was resistant to vancomycin. Conclusion: Multidrug-resistant Enterococci are a real problem and continuous surveillance is necessary. Today, resistance has rendered most of the original antibiotics obsolete for many infections, mandating the development of alternative anti-infection modalities. One of such alternatives stemming up from an old idea is the bacteriophage therapy. In the present study, we could able to demonstrate the viable phages against MDR E. faecalis.

Context: There are sparse data on herpes simplex virus type 2 (HSV-2) infection in India. HSV-2 is one of the most common sexually transmitted infections and the primary cause of genital ulcer disease worldwide. Aim: The aim of this study is to describe the incidence of HSV-2 infection among young reproductive age women in Mysore, India. Setting and Design: Between October 2005 and April 2006, 898 women were enrolled into a prospective cohort study in Mysore, India, and followed quarterly for 6 months. Materials and Methods: An interviewer administered questionnaire was used to collect demographic and social risk factors, and physical examination was conducted for collection of biological specimens to screen for reproductive tract infections at each visit. Serologic testing was conducted for the presence of HSV-2 antibodies using HerpeSelect HSV-2 enzyme-linked immunosorbent assay. Statistical Analysis Used: Data were analyzed using R. Incidence density rates were calculated using Poisson distributions with person-time of follow-up as denominator. Person-time was calculated as time from enrollment until time of first positive HSV-2 test. Results: There were 107 women with HSV-2 antibodies leaving 700 women with negative results at enrollment. The analysis included 696 out of which, there were 36 HSV-2 seroconversions during the study period. The study cohort accumulated roughly 348 woman-years of follow-up, yielding an HSV-2 acquisition rate of 10.4 cases/100 woman-years. All detected infections were asymptomatic. Conclusions: HSV-2 incidence is moderate in this community sample of young reproductive age monogamous women. More research is needed to establish incidence estimates in different Indian settings.

Objective: To evaluate the serological profile of leptospirosis by microscopic agglutination test (MAT) and dark field microscopy (DFM) and to determine the serovar prevalence rate among patients with pyrexia of unknown origin. Materials and Methods: A total of 3830 blood samples were received from different hospitals and laboratories in and around Chennai. They were screened for leptospirosis by MAT and direct observation of live Leptospira by DFM. Results: A total of 748 (19.5%) Leptospira positive cases were identified; among these, 36.76% were Leptospira australis, 30% were Leptospira canicola, 14.57% were Leptospira autumnalis, 12% were Leptospira icterohaemorrhagiae, 4.68% were Leptospira patoc and 1.87% were Leptospira grippotyposa. Patients were in the age group of 1-86 years, with a median age of 43.5 years. 50% positive cases were in the age group of 10-35 years. Majority of the Leptospira infected cases were males (62.98%) than females (37.02%). Conclusion: Leptospirosis occurs in Chennai throughout the year although the number and positivity of cases increased during the monsoon season.

Backgrounds: Helicobacter pylori infect more than half of the global population. It is suggested to be related with gastritis, peptic ulcer disease (PUD), and gastric cancer. Aims: The aim of this present study was to evaluate proinflammatory cytokines including interleukin 1, 6, 8, 10, and thrombomodulin in H. pylori-infected patients with PUD and gastric cancer. Patients: This cross-sectional study was conducted in Taleghani Hospital on 111 patients with H. pylori infection. Materials and Methods: Patients were divided into three groups of PUD, cancer, and control (normal on endoscopy), according to the results of endoscopy. The serum levels of interleukins 1, 6, 8, and 10 and thrombomodulin was determined using enzyme-linked immunosorbent assay (ELISA) technique. H. pylori infection was diagnosed by histological examination of the endoscopic biopsy. Results: One hundred eleven patients were included in the study; 30 as PUD group, 30 as gastric cancer group, and 51 as controls. There was no significant difference between the means of IL-1 and IL-10 levels among the three groups (P = 0.744 and 0.383, respectively). IL-6, IL-8, and thrombomodulin levels were found to be statically different among the three groups (P < 0.05). The level of IL-6, IL-8, and thrombomodulin in cancer group was significantly higher than PUD and control groups (P < 0.05). Conclusion: There is a significant association between H. pylori infection and serum IL-6, IL-8, and thrombomodulin but such relation is not present between H. pylori and IL-1 and IL-10. Immunity response (IL-6, IL-8 and thrombomodulin) is more severe in cancer patient than PUD.

Aim: Depletion of CD4 cell count is a hallmark of disease progression in AIDS. CD4 cell count is essential for physicians to decide about the timing of initiation of antiretroviral therapy (ART) and for prophylaxis of opportunistic infections. WHO has recommended that, absolute lymphocyte count (ALC) of ≤1200/μL can substitute CD4 cell count of ≤200/μL in resource-constrained countries throughout the world. Materials and Methods: This study was undertaken to know whether there is a correlation between CD4 cell count and ALC in HIV-infected individuals. A single sample of blood was withdrawn for ALC and CD4 cell count. The samples received from December 1, 2004 to December 31, 2005 were analyzed. Results: A total of 196 samples were collected from 185 patients. After exclusion, a total of 182 samples were analyzed. Results revealed that male:female ratio was 126:56 and their age ranged from 13 to 67 years. The median ALC was 1747 cells/μL, whereas the CD4 cell count ranged from 5 to 2848. The correlation coefficient between ALC and CD4 cell count was significant (0.714). There were 49 patients with an ALC of ≤1200/μL of whom 77.6% patients had CD4 cell count ≤ 200/μL (true positive) and 22.4% had CD4 cell count > 200/μL (false positive). There were 133 patients with an ALC of >1200/μL of whom 84.2% had CD4 cell count > 200/μL (true negative) and 15.8% had CD4 cell count ≤ 200/μL (false negative). Taking ALC of ≤1200/μL as a predictor of CD4 cell count ≤ 200/μL ,the sensitivity of the test was 64.4% and specificity was 91.1%. The positive predictive value was 77.6%, negative predictive value was 84.2%, and accuracy was 82.4%. Conclusion: We found that an ALC of ≤ 1520/μL has higher sensitivity (78%) for a CD4 cell count of ≤ 200/μL. The ALC was found to be significantly cost-effective in our setup but chances of missing out patients requiring ART was 1 in 5 using the WHO guidelines.

Background: Invasive fungal infections are a significant cause of morbidity and mortality in immunocompromised populations. Aims: To evaluate the susceptibility pattern of our isolates against amphotericin B, itraconazole, and voriconazole and to compare the antifungal activities of these agents with each other against the Aspergillus species tested. Settings and Design: A prospective study was designed to include clinical and environmental isolates of Aspergillus species. Materials and Methods: 420 sputum samples, 70 bronchoalveolar lavage fluids, 160 oral washings, and 47 environmental samples were collected. Direct microscopy by potassium hydroxide and lactophenol cotton blue mounts followed by culture on Sabourad`s dextrose agar (SDA) was done. Susceptibility testing was performed by the broth microdilution technique as per Clinical Laboratory Standards Institute standards (M-38A). Additionally, all the isolates were also tested by the colorimetric microdilution technique using Alamar Blue dye. Statistical Analysis: It was done by the Chi-square test and Z-test using SPSS statistical software version 12.0. Results and Conclusion: Twenty-seven isolates (47.3%) were recovered from patients with chronic bronchial asthma followed by fibrocavitary pulmonary tuberculosis in 9 (15.7%), allergic bronchopulmonary aspergillosis (ABPA) in 6 cases (10.5%), bronchiectasis in 3 (5.2%), bronchogenic carcinoma in 5 (8.7%) and those receiving radiotherapy for head and neck cancer 7 (12.2%). Thirteen environmental isolates were also included in the study. The most common isolate was A. fumigatus 28 (40%), followed by A. niger 22 (31%), A. flavus 13 (19%), and A. terreus 7(10%). All isolates were susceptible to amphotericin B, itraconazole, and voriconazole. Among the three agents tested, voriconazole exhibited lowest MICs (≤1 μg/ml) against all Aspergillus species.

The recent discovery of the JAK2 mutations has rekindled interest in the approach to classic BCR/ABL-negative myeloproliferative neoplasms (MPNs) in terms of both diagnostic evaluation and treatment. However, additional clinical, laboratory and histological parameters play a key role to allow diagnosis and subclassification, regardless of whether JAK2 V617F mutation is present or not. Here are two cases which incidentally presented with splenomegaly and moderate leukocytosis, and were diagnosed as MPN-primary myelofibrosis (PMF) in prefibrotic phase and polycythemia vera (PV), respectively, using revised World Health Organization (WHO) 2008 criteria.

Parasitic gastrointestinal infections are a major cause of morbidity and mortality in the developing world, with stool microscopy being the mainstay of diagnostic practice. Both direct microscopy and concentration techniques can be utilized; direct microscopy may be time consuming and tedious; however clinical laboratories in developing countries lack trained staff who can effectively use concentration methods. In our practice we used the Parasep O and P filter concentrator tubes (manufactured by DiaSys Ltd, Berkshire, England. Product Code 146000) along with direct microscopic techniques and found that Parasep filters enhanced the ability to detect intestinal parasites that would have been missed on routine microscopy. We found the Parasep filter concentration method to be easy, cost-effective and reliable for routine stool examinations.

Sarcoma of the breast constitutes less than 1% of all malignant breast tumors and liposarcoma of the breast has an incidence of 0.3% of all the mammary sarcomas. A 47-year-old woman presented with a mass in the right breast and mammography was suggestive of a malignant lesion. Modified radical mastectomy was performed. The tumor was diagnosed histologically as a pleomorphic liposarcoma. The patient was discharged and her postoperative recovery was uneventful.

Tubulocystic renal cell carcinoma (TCRCC) is a rare variant of renal cell carcinoma, which has distinct histology but there is some controversy about its association with papillary renal cell carcinoma (PRCC) and cell of origin in literature. We report an 18-year-old girl with the rare TCRCC of kidney associated with PRCC with metastases to the para-aortic nodes. The patient presented with hematuria and a right renal mass with enlarged regional nodes for which a radical nephrectomy with retroperitoneal lymph node dissection was done. On gross examination, a solid cystic lesion involving the lower pole and middle pole of the kidney measuring 12x9x9 cm was seen along with an additional cystic lesion in upper pole of kidney. Microscopically the main tumor showed the typical histology of a tubulocystic carcinoma with multiple cysts filled with secretions lined by variably flattened epithelium with hobnailing of cells. The mass in the upper pole was a high-grade PRCC and the nodal metastases had morphology similar to this component. To conclude, at least a small but definite subset of TCRCC is associated with PRCC, and cases associated with PRCC do seem to have a higher propensity for nodal metastasis as in the case we report.

Sebaceous lymphadenoma is a rare benign salivary gland tumor of uncertain histogenesis. We report such a case in a 37-year-old female presenting with a parotid swelling. Recognition of key histological features will readily allow differentiation of this neoplasm from its benign and malignant mimics. The prognosis is excellent following excision.

Malakoplakia of lung is an unusual condition that has been reported to occur in association with immunocompromised state, particularly in those with acquired immunodeficiency syndrome. We present two cases of pulmonary malakoplakia in immunocompetent individuals. The diagnosis was made on histopathological examination of surgically resected specimen.

Embryonal rhabdomyosarcoma is the most common soft tissue sarcoma in children. We report a rare case of embryonal rhabdomyosarcoma of the soft palate in a 32-year-old Caucasian female. Detailed histology of the tumor is described. Positive staining with desmin, myogenin and myoD1 confirmed the tumor to be embryonal rhabdomyosarcoma. A genetic association between rhabdomyosarcoma, polycystic ovary syndrome and the FEM1A gene on the human chromosome is speculated upon.

The presence of sarcomatous element transforms the usually innocuous spermatocytic seminoma into a highly aggressive neoplasm. We report a case of spermatocytic seminoma with undifferentiated sarcomatous component in a 43-year-old male, presented with testicular mass since two and a half years. Orchidectomy was performed and after 9 months, the patient presented with recurrent scrotal mass with bilateral pulmonary metastases.

Xanthogranulomatous salpingitis (XGS) is a rare form of chronic inflammation of the fallopian tubes. A 41-year old woman with a history of secondary infertility for 2 years is presented. The patient underwent bilateral salpingooopherectomy with presumptive diagnosis of adnexal mass with cystic component. Intraoperative pathology consultation was done. The diagnosis of bilateral XGS associated with chronic active follicular salpingitis was made. XGS is reported to be caused by an unsuccesfully treated pelvic inflammatory disease. Its association with chronic active follicular salpingitis has not been previously reported. Chronic active follicular salpingitis with xanthogranulomatous inflammation might give the impression of a cystic adnexal mass with septations on preoperative pelvic computed tomography. Frozen sections are necessary to rule out malignancy as done in our case.

Mesenchymal chondrosarcoma is a rare aggressive variant of chondrosarcoma that frequently occurs in extraskeletal location. A 28-year-old female presented with a history of dyspnea and fever and succumbed to her illness before a conclusive diagnosis was established. An autopsy performed revealed the presence of an extraskeletal mesenchymal chondrosarcoma (ESMC) involving the pleura. Only one case of ESMC of the pleura has been reported previously. Herein, we report the second case of ESMC of the pleura.

Malignant peripheral nerve sheath tumor (MPNST) of the urinary bladder is a very rare clinical entity. The association of such a tumor with urothelial carcinoma is even more unusual. Differential diagnosis between coexisting two distinct primary tumors and carcinosarcoma of the urinary bladder is very important as both the treatment and prognosis vary widely. Herein, we report a case of an MPNST with a concomitant in situ urothelial carcinoma in a 53-year-old man. To our knowledge, this is the first documented case of MPNST of the bladder that is treated by transuretheral resection which is in contrast with the previous reports that used cystectomy.

A 25-year-old woman was seen for a painless subcutaneous mass of 2 years duration. On excisional biopsy, a collapsed cystic structure lined by stratified, ciliated, columnar epithelium was noted. These linning cells did not produce mucin. Immunohistochemical staining for progesterone receptor, estrogen receptor and epithelial membrane antigen was positive, whereas it was negative for carcinoembryonic antigen. Findings were consistent with cutaneous ciliated cyst (CCC). CCCs are rare, predominantly occurring on the lower extremities of young women. Most of them have been regarded as Mullerian remnants. A case of a CCC in the subcutaneous area is reported.

Solid pseudopapillary tumor (SPT) of the pancreas is a rare benign or low-grade malignant epithelial tumor that occurs mainly in young females in second to fourth decades of life. Pathologic and imaging findings include a well-defined, encapsulated pancreatic mass with cystic and solid components with evidence of hemorrhage. We report a 23-year-old female who presented with upper abdominal pain of long duration and epigastric mass on palpation. Multidetector-row CT (MDCT) demonstrated a large well-defined heterogeneous attenuation mass, containing hyperdense areas of hemorrhage mixed with solid enhancing and cystic non-enhancing areas, arising from the pancreatic body and tail. Splenic vein thrombosis was present with dilated splenoportal collateral vessels between splenic hilum and portal/superior mesenteric veins, with dilated vessels seen in the gastric wall, with patent portal vein, compatible with sinistral portal hypertension. Typical imaging features and age and sex of the patient suggested a diagnosis of SPT of pancreas complicated by segmental portal hypertension due to splenic vein thrombosis. Histopathology of the biopsy material was confirmatory.

Deep penetrating nevus (DPN) is a variant of melanocytic nevus which goes unrecognized due to its relative rarity and may be misinterpreted as malignant melanoma. It commonly presents in young adults as a dark pigmented lesion on the face, neck, or shoulder. A 60-year-old lady presented with a mole over the left arm of 8 years duration. A biopsy of the lesion was performed under the clinical impression of a compound nevus with suspicion of malignancy. Based on the histologic features, a diagnosis of DPN was put forward.

Intravenous leiomyomatosis is an example of unusual growth patterns that is sometimes exhibited by uterine leiomyomas, characterized by smooth muscle proliferations within the uterine or pelvic veins. Extension into the heart via the inferior vena cava is even rarer and is designated as intracardiac leiomyomatosis. This is a report of two such cases that had preoperative diagnoses of a thrombus and right atrial myxoma, respectively.

We report a case of 50-year-old male with obstructive jaundice diagnosed as peri-ampullary collision tumor comprising of large cell neuroendocrine carcinoma and signet ring cell carcinoma. The association of neuroendocrine (usually carcinoids) and adenocarcinoma is extremely uncommon with only few case reports available in the reported literature.

Isolated idiopathic right ventricular dilated cardiomyopathy is rare and is a diagnosis by exclusion. There is a distinct male predominance. The usual clinical presentations are syncope, ventricular tachycardia, left bundle branch block on ECG and right heart failure. Diagnosis is usually established based on the clinical and laboratory parameters. Confirmation of the same is done by studying the pathological features of the heart in an endomyocardial biopsy or at post-mortem. Herein we report a case of this rare entity which was diagnosed clinically and was further confirmed at autopsy.

Hyalinizing clear cell carcinoma (HCCC) of tongue is a rare neoplasm originating from minor salivary glands. We present a case of HCCC involving the base of tongue, in a 73-year-old male, clinically diagnosed as fibroma. Laser excision of the mass was done. Histopathological examination showed an infiltrating lesion composed predominantly of clear cells. The differential diagnosis included other salivary gland lesions having a clear cell component and metastatic clear cell renal carcinoma. Immunohistochemistry was useful in ruling out these lesions exhibiting clear cell component from clear cell carcinoma. Imaging studies revealed no lesion in either kidney. Since, HCCC has a better prognosis and the adequate treatment is wide excision, it needs to be differentiated from other carcinomas with clear cells. No further therapy was given to the patient. One year after the surgery, the patient is symptom free without local recurrence and on regular follow up.

Anti M is considered a naturally occurring antibody that is usually active at temperatures below 37°C and is thus of no clinical significance. This antibody, if present in an individual, can lead to a discrepancy between forward and reverse ABO grouping and thus creates diagnostic difficulties for blood bank staff. We report a case of a 58-year-old lady who had an unexpected reaction in reverse grouping due to anti M that posed a problem for us in the interpretation of results of her blood group. We also reviewed the literature to find out the significance of such discrepancy in blood grouping.

Acute erythroid leukemia in children is very rare. Here is a case of erythroleukemia in a child of age 1.5 years, which was diagnosed on peripheral smear, bone marrow examination, cytochemistry but was confirmed on immunophenotyping. CD45 versus side scatter demonstrated blast population (29%) expressing CD45 of variable intensity (dim to negative). The myeloid nature of blast population showed bright expression of cytoplasmic myeloperoxidase (MPO), heterogenous positivity of CD117 and dim expression of CD13, CD33. These blasts also showed bright positivity for CD71 which showed erythroid nature of blasts. Flow cytometry can be comprehensive enough to completely subtype cases of leukemias/myelodysplastic syndromes, polycythemia rubra vera, non-neoplastic conditions like reactive erythroid hyperplasia following immunosuppressive therapy or viral infections or nutritional deficiencies, unlyzed RBCs or thrombocytosis which may mimic acute erythroid leukemia on flow cytometry.

Rearrangements of the mixed lineage leukemia (MLL) gene at 11q23 commonly occur in infants with CALLA negative B lymphoblastic leukemia (B-ALL). Most often, these are detected by conventional karyotyping; however, fluorescent in-situ hybridization (FISH) with the help of a dual-color break-apart probe is used to identify cryptic translocations. When there is an MLL gene translocation, the usual FISH signal pattern is 1 red-1 green-1 yellow fusion signal pattern. We present a case of an infant with CALLA negative precursor B-ALL with a characteristic translocation t(4;11) (q21;q23), however, with an unusual MLL FISH signal pattern.

Acinetobacter baumannii is considered as an emerging nosocomial pathogen and is renowned for its multi-drug resistance. We report a case of community-acquired pan-resistant A. baumannii caused fulminating septicemia. The treatment failure led to death. The A. baumannii strain isolated from blood, pus, urine and tracheal aspirate was confirmed by 16S r-RNA sequence homology and found positive for metallo-β-lactamase IMP-1, and was found to be a strong biofilm producer. The isolate was only susceptible (moderately) to colistin.

Brucellosis is one of the most important zoonotic diseases. Several complications may be seen during its clinical course. Here, we describe a patient who presented with complaints of fatigue, malaise, and intensive lumbar pain. He had been suffering from these complaints for nearly 1 month. It was learned that he lived in rural area, made and ate his own cheese. The Rose Bengal test was positive and Brucella standard tube agglutination was positive at 1/320 titer. Pedro Pons' sign, an osteoarticular complication of brucellosis, was revealed with the aid of radiologic imaging. Osteoarticular involvement is common in the course of brucellosis. Deformation in vertebrae formerly known as Pedro Pons' sign should be thought in brucellosis patients suffering from lumbar pain.