Background: Several systems including pathologic criteria alone or in combination with clinical features have been proposed to differentiate between benign and malignant adrenocortical tumors and assess their prognosis. The Weiss system appears to be the most commonly used method for assessing malignancy but there are only a few studies which have evaluated its diagnostic power. Since we see large adrenocortical carcinoma (ACC), we attempt to evaluate the diagnostic power of Weiss system in large ACC. Materials and Methods: In this study clinicopathological characteristics of 42 adrenocortical neoplasms are studied and classified into adrenocortical adenoma (ACA) and ACC based on Weiss score of less than or equal to three or greater than three. Results: The histological criteria of Weiss appeared to predict tumor prognosis accurately. Five year survival of patients with Weiss scores of less than or equal to three was 100% compared to 0% of those with Weiss scores greater than three. The average weights of ACA and ACC were 13.0 plus/minus 8.4 grams and 621.1 plus/minus 335.2 grams respectively; average sizes of ACA and ACC were 2.8 plus/minus 1.0 cmsand 13.6 plus/minus 3.7 cms respectively. Conclusion: Weiss score was found to be a good prognostic factor for tumors of the adrenal cortex.

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Eight cases of a histological entity that we name 'acute eosinophilic appendicitis' (AEA) are described and compared with classical acute appendicitis and appendices, which turned out to be normal after emergency appendicectomy. These 8 cases formed part of a dataset of 128 emergency appendicectomies, which also included 78 cases of classical acute appendicitis and 42 cases of normal appendix. The clinical and pathological variables were compared between these three. Acute eosinophilic appendicitis is characterized by acute presentation and a grossly inflamed appendix, but with absence of neutrophils in the muscle layer. The histological hallmark of the entity is eosinophil infiltration of the muscularis propria with accompanying edema separating muscle fibers (the Eosinophil - Edema lesion). The duration and prevalence of symptoms, the male female ratio and the gross maximum circumference of the appendix in these 8 cases resembled classical acute appendicitis rather than those cases in which the morphology of the appendix was normal. The Eosinophil-Edema lesion was also seen in many cases of classical appendicitis in non-suppurative areas where neutrophils were sparse or absent. We hypothesize that this lesion is an allergic response and is probably an early event in the evolution of acute phlegmonous appendicitis. Acute eosinophilic appendicitis may merely be those cases that do not proceed on to suppuration.

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Background / Aims: The eye may be infected from external sources or through intra-ocular invasion of micro-organisms carried by the blood stream. This study was undertaken to isolate and identify the specific bacterial pathogens causing ocular infections and to determine their in-vitro antibacterial susceptibilities to commonly used antibacterial agents. Materials and Methods: A retrospective analysis of all patients with clinically diagnosed bacterial ocular infections such as blepharitis, conjunctivitis, internal and external hordeolum, suppurative scleritis, canaliculitis, keratitis, dacryocystitis, preseptal cellulitis, endophthalmitis and panophthalmitis presenting between January 2005 and December 2005 was performed. Extra-ocular and intra-ocular specimens were collected and were subjected to direct microscopy and culture. Results: A total of 756 patients with bacterial ocular infections were analyzed, of which 462(61%) eyes had adnexal bacterial infection, 217(28.7%) had corneal infection, 6 (0.8%) had scleral involvement and the remaining 71(9.39%) eyes had infection of the intra-ocular tissues. The predominant bacterial species isolated was S. aureus (195 of 776; 25%) followed by S. pneumoniae (169 of 776; 21.78%) and coagulase negative staphylococci (142 of 776; 18.3%). The largest number of gram-positive isolates were susceptible to cefazolin (545 of 624; 87.34%), chloramphenicol (522 of 624; 83.65%) and gatifloxacin (511 of 624; 81.89%) and gram-negative isolates were to amikacin (127 of 136; 93.38%), gatifloxacin (125 of 136; 91.91%) and ofloxacin (119 of 136; 87.5%), while aerobic actinomycetes were to amikacin (100%), gatifloxacin (14 of 16; 87.5%), chloramphenicol (14 of 16; 87.5%) and ofloxacin (13 of 16; 81.25%). Conclusions: S. aureus frequently causes infections of eyelids and conjunctiva, S. pneumoniae of lacrimal apparatus and cornea and coagulase negative staphylococci causes intra-ocular infections. Of all routinely used antibacterials tested, flouroquinolones, especially gatifloxacin and ofloxacin represented a good choice for treating bacterial ocular infections.

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Clinical microbiology is a specific combination of knowledge, attitude and practice aimed at direct clinical involvement in infectious disease management using the core principles of medical microbiology and clinical medicine. In this article certain areas in microbiology, where a more proactive approach could make a significant difference in clinical outcome has been delineated. The article reiterates the role of a medical microbiologist in a hospital setting. The practices described are the norm in well-organized hospitals. These areas include management of positive blood cultures, management of patients in intensive care units (ICUs), hospital infection control and public health microbiology, development of hospital and community anti-infective policy, organization of clinical-microbiological meetings and provision of emergency out-of-hours service. The implementation of this clinical approach and increased engagement with direct patient care would require changes in existing training structure and working patterns of medical and technical staffs in microbiology.

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Carcinoma en cuirasse is a form of cutaneous metastasis. Although this condition is rare, it is most commonly associated with breast carcinoma with local recurrence after mastectomy. Cutaneous metastasis presents most commonly a few months or years after the primary has been diagnosed. Less frequently a metastasis is diagnosed at the same time as the primary tumor or presents as the first manifestation of the disease. We report a case of carcinoma en cuirasse in a 50-year-old female who presented with elevated, finely nodular, indurated skin lesions on left anterior chest wall, axillary region and keloid - like patch on left upper arm. On further examination a breast mass was detected. Fine needle aspiration of all the lesions was performed. Cytodiagnosis was given as infiltrating duct carcinoma of breast with metastatic carcinoma involving left anterior chest wall, axilla and left upper arm. We should not disregard keloid-like or indurated patches on skin which should be investigated thoroughly.

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Studies from developed countries have reported that extra-pulmonary tuberculosis (EPTB) is on the rise due to the human immunodeficiency virus (HIV) epidemic. However, similar studies from high-burden countries with low prevalence of HIV like Saudi Arabia are lacking. Therefore, we conducted this study to investigate demographic and clinical characteristics of patients with pulmonary and extra-pulmonary tuberculosis. A retrospective analysis was carried out on all patients (n=431) with a culture - proven diagnosis of tuberculosis seen at University teaching hospital, Riyadh, Saudi Arabia from January 2001 to December 2007. A total of 183 (42.5%) pulmonary tuberculosis (PTB) and 248 (57.5%) extra-pulmonary TB (EPTB) cases were compared in terms of age, sex, and nationality. There were 372 Saudis (SA) (86.3%) and the remaining non-Saudis (NSA) 59 (13.7%). The age distribution of the PTB patients had a bimodal distribution. EPTB was more common at young age (20-29 years). The proportion of EPTB cases was significantly higher among NSA patients (72.9%) compared to SA patients (55.1%). Females had higher proportion (59.5%) of EPTB than males (55.6%). The most common site was lymph node tuberculosis (42%). In conclusion, our data suggest that EPTB was relatively common in younger age, female gender and NSA. Tuberculosis (TB) control program may target those populations for EPTB case-finding.

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Blood transfusion is an important mode of transmission of infections to recipients. The aim of the study was to assess the prevalence of transfusion-transmissible infections among blood donors. For this, a 3.5-year retrospective study, from October 2002 to April 2006 was conducted at the blood transfusion centre of Maharaja Agrasen Medical College, Agroha (Hisar) Haryana. Donors were screened for seroprevalence of HIV, HBV, HCV and syphilis. A total of 5849 donors were tested, out of which 4010 (68.6%) were replacement donors and 1839 (31.4%) were voluntary donors. The seroprevalence of HIV was 0.3% in the donors. No voluntary donor was found to be positive for HIV. The low sero-positivity among donors is attributed to pre-donation counseling in donor selection. The seroprevalence of HBV, HCV and syphilis was 1.7%, 1.0% and 0.9% respectively in total donors. The seroprevalence of hepatitis and syphilis was more in replacement donors as compared to voluntary donors.

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Lymphoid infiltrates of the salivary gland can be either reactive or neoplastic. The reactive lesion, lymphoepithelial sialadenitis (LESA) may be associated with Sjogren's syndrome (SS) or may occur as an isolated salivary gland enlargement. Patients with LESA/SS have a particularly high risk of subsequently developing lymphoma, which is a low-grade mucosa-associated lymphoid tissue (MALT) type lymphoma of the salivary gland. We document a rare case of primary non-Hodgkin's lymphoma of the parotid gland arising in the background of LESA and with a rare example of transformation from low grade to high-grade B cell lymphoma of MALT type.

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En plaque meningioma is a rare type of meningioma characterized by infiltrative nature, sheet-like growth and at times invading the bone. We report here a case of en plaque meningioma with typical grade I histomorphology along with unusual feature of angioinvasion. The patient was a 55-year-old man presenting with headache and painful proptosis of right eye. Imaging modalities revealed an en -plaque meningioma extending into the right sylvian fissure, with thickening of right temporal calvarium, greater wing of sphenoid and extension into the orbit. Magnetic resonance angiography showed medial displacement of right middle cerebral artery. The tumor was removed from the sylvian fissure and right temporal convexity. However, only subtotal removal of the intraorbital part was possible. Histology showed a meningothelial meningioma with low tumor cell proliferation, but infiltration into the bone, skeletal muscle and angioinvasion. Recognition of meningiomas en plaque is useful, as these tumors are difficult to resect completely, and are more prone to undergo recurrence or malignant change. In addition, angioinvasion seen in this tumor may have additional prognostic significance.

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Acinetobacter baumannii is a ubiquitous pathogen that has emerged as a major cause of healthcare-associated infections. Acinetobacter baumannii usually causes respiratory tract, urinary tract, blood stream and surgical site infections. They are of increasing importance because of its ability to rapidly develop resistance to the major groups of antibiotics. There are few data available on the antimicrobial susceptibility of A. baumannii in Iran. During the period of study from July 2005 to November 2006, a total of 88 strains of A. baumannii were isolated from clinical specimens obtained from patients hospitalized in an Iranian 1000-bed tertiary care hospital. Conventional bacteriological methods were used for identification of A. baumannii. Susceptibility testing was performed by the method recommended by Clinical Laboratory and Standards Institute (CLSI). The majority of isolates were from respiratory tract specimens. The organism showed high rate of resistance to ceftriaxone (90.9%), piperacillin (90.9%), ceftazidime (84.1%), amikacin (85.2%) and ciprofloxacin (90.9%). Imipenem was the most effective antibiotic against A. baumannii and the rate of resistance for imipenem was 4.5%. The second most effective antibiotic was tobramycin, and 44.3% of A. baumannii isolates were resistant to this antibiotic. In conclusion, our study showed that the rate of resistance in A. baumannii to imipenem was low. There was a significant relationship between demographic features of patients such as age, undergoing mechanical ventilation, length of hospital stay and drug resistance.

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Objective: To study the prevalence and characterization of primary non Hodgkin's lymphoma of bone in a major referral center of Pakistan. Methodology: All cases of primary non Hodgkin's lymphoma of bone, diagnosed at a referral center in Pakistan from January 1998 to July 2008 have been included. Patients with diagnosis of lymphoma at some other site prior to diagnosis in bone biopsy were excluded from the study. Results: Sixty cases of primary non Hodgkin's lymphoma of bone were received, with a male to female ratio of 7: 3 (42 males and 18 females). Overall, 52/60 (86.6 %) patients were diagnosed with Diffuse large B-cell non-Hodgkin's lymphoma. The largest fraction of patients was found in the pediatric group i.e. 33/60(55%) followed by elderly group i.e.15/60 (15%) and adults i.e. 12/60 (20%). The commonest sites of involvement were femur (28.3 %), hip bone (16.6%) and humerus (10%). Conclusion: Diffuse large B-cell lymphoma is the commonest type of primary non Hodgkin's lymphoma of bone in the Pakistani population. It is common in all ages. The sites most often involved are femur followed by hip bone. Primary non Hodgkin's lymphoma of bone appears to be more common in males. Our results are comparable to international data with various studies also showing that diffuse large B cell non Hodgkin lymphoma is the commonest primary bone lymphoma. However, primary Bone Lymphoma is more common in children and young adults.

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Pilomyxoid astrocytoma (PMA) is a recently described brain tumor. PMA shares similar features with pilocytic astrocytoma (PA), the most common central nervous system (CNS) tumor in the pediatric population, yet displays subtle histologic differences. We describe a case of PMA in a six-year-old male involving sellar and suprasellar region presenting with failure to thrive and delayed developmental milestones. The histological findings revealed a tumor composed of a monotonous population of loosely arranged cells with delicate piloid like processes, within a prominent myxoid background. The tumor lacked biphasic appearance, Rosenthal fibers, eosinophilic granular bodies and calcification that are commonly observed in classical PA. Previous studies have shown PMA to behave more aggressively than PA, with shorter progression-free survival as well as a higher rate of recurrence and CNS dissemination. Thus, recognition of PMA and its distinction from classical PA is very important.

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Human polyoma virus causes renal dysfunction and graft loss as a result of tubulo-interstial nephritis in renal transplant recipients after reactivation of latent virus in renal epithelium. The infected cells in the urinary sediments are characterized by large homogenous inclusions, which may cause diagnostic error in urine cytology. The epithelial cells with polyoma viral inclusions in urine cytology specimens are termed Decoy cells to caution pathologists not to misdiagnose these cells as cancer cells. We present a case of polyoma viral changes detected the first time in our laboratory in the urine of a 46year old male who underwent renal transplantation six months back and followed by immunotherapy. Urine cytological examination showed decoy cells and subsequently revealed on histopathology. Immunoperoxidase staining for SV-40 LT antigen (LT ag), expression of proliferating cell nuclear antigen (PCNA), p53 and Rb genes were also studied in the tissue sections for further observation. The expression of SV40 LT ag was negative, while PCNA showed strong positivity; p53 and Rb were expressed moderately in the nuclei of cells in the tubules. The report of a case of decoy cells in the urine of a patient with renal transplantation focuses the importance of cytologic analysis of urine as a diagnostic tool for screening renal transplant recipients at risk of polyoma viral infection.

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Rhino-orbito-cerebral zygomycosis is a rapidly progressive opportunistic fungal infection characterized by a set of clinical and radiological findings that help in prognostication. The present study is aimed to evaluate its histopathologic features as an aid to prognosis in order to guide the physician at the stage of tissue diagnosis to optimize surgery, chemotherapy and immunosuppression. The study comprises of a microscopic analysis of specific histopathologic variables on 33 cases of zygomycosis that were diagnosed and treated in a seven-year period. Fungal load in the tissue (graded as mild, moderate and marked), mean diameter of fungus, degree of neutrophilic and granulomatous response, tissue invasion and necrosis were graded and assessed for their prognostic significance. Seasonal variation, signs and symptoms, extent of involvement and laboratory parameters were also analyzed to examine the trend of occurrence of the disease and to associate these with patient's outcome, which was categorized as either survived or expired. The follow-up ranged from 1 month to 7 years. Of all the histological variables, angioinvasion was directly related to the mortality rate. Diameter of the fungal hyphae and its intraorbital or intracranial invasion also proved to be significant indicators of poor prognosis. (P = 0.04 and 0.0037, respectively) though angioinvasion was directly related to the mortality rate. Thus, histopathology could assist the clinician in assessing patient's progress and thus optimize the treatment in such patients.

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Background and Aims: Castleman's disease (CD) is a rare disease of lymph node with two identified forms - the hyaline vascular (HV) type or angiofollicular type and plasma cell (PC) type. It usually presents as localized or systemic lymphadenopathy or even as extra nodal mass and may give rise to several differential diagnoses. Fine needle aspiration cytology (FNAC), as the initial investigation, may be misleading. Excision biopsy usually gives the diagnosis. This study analyzes the clinical, cytological and histological features of CD of HV type Materials and Methods: All the cases of CD reported between 2001 and March 2008 have been reviewed. Cytology and histopathology slides of all cases were reviewed by two reporting pathologists independently and the clinical records were analyzed. Result: We had five cases of CD all of which presented as cervical lymphadenopathy of 1 to 5 cms in young patients. Patients were mostly asymptomatic with all relevant investigations within normal limits. The cytology findings mostly showed a predominance of small lymphocytes with capillary fragments. On excision biopsy, all cases were diagnosed as CD of HV type. Conclusion: CD should be kept as a differential of lymphadenopathy, especially in asymptomatic and young patients.

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Objective: To study the variation in the cytologic features of gastrointestinal stromal tumors (GISTs) at different sites targeted by different modalities. Study design: Cytologic smears of 9 cases of gastrointestinal stromal tumors were reviewed with their histopathologic follow-up. Immuno-cytochemistry was performed where possible. Results: The study includes eight males and one female patient with an age range of 42 to 71 years. There were four classical cases of gastrointestinal stromal tumors that showed tight cellular bundles and fascicles of slender spindle cells with scant cytoplasm. The cytological features of three recurrent and one malignant case included moderately to markedly pleomorphic, plump spindle to ovoid cells with variable chromatin pattern and variable pale blue to vacuolated cytoplasm, present in loose clusters and singly. There was one case with classical gastrointestinal stromal tumor cytology but myxoid stroma. All other cases were confirmed with either CD117 immunostain and/or histopathology. Benign mucosal fragments from stomach or duodenal mucosa were observed in smears obtained by endoscopic ultrasound - fine needle aspiration (EUS FNA). Conclusion: The variability in cytologic features in GIST implies that a diagnosis of gastrointestinal stromal tumor should be rendered on cytology only in conjunction with immune-cytochemistry result of CD117.

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Mixed gonadal dysgenesis (MGD) presents as a unilateral testis, usually intraabdominal, a streak gonad on contralateral side, and persistent mullerian structures. 45X/45XY karyotype is most frequent in such cases with predominance of 45X cells in both peripheral lymphocytes and gonads. We present a rare case of a left undescended testis, normally descended right testis, with penoscrotal hypospadias, who had a normal karyotype and whose histopathological findings were endometrial tissue and fallopian tube in left testicular biopsy. Gonadal dysgenesis should always be kept a possibility in patient with undescended testis and proximal hypospadias. If karyotype reveals a 46XY gonadal dysgenesis, these patients need all the more careful follow-up to screen for gonadoblastoma in remaining normal testis. Subjecting the patients to prophylactic orchidectomy with hormone replacement can be an additional option in such patients.

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Incontinentia pigmenti (IP) or Bloch-Sulzberger syndrome is a rare X-linked dominant genodermatosis related to the NF kappa B essential modulator (NEMO) gene with approximately 800 cases reported worldwide. It usually occurs in females characterized by cutaneous, skeletal, neurological, ocular and dental abnormalities as well as an increased risk of childhood malignancies. Herein, we report a case of IP in a 14-year-old girl emphasizing early diagnosis and adding to the current literature on the subject.

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Metaplastic carcinomas of the breast are malignant breast neoplasms composed of a mixture of both epithelial and mesenchymal elements. The rarity of this tumor is exemplified by the fact that it accounts for only about 0.2% of all breast carcinomas. It can present histologically with diverse differentiation and the exact histogenesis of these tumors is unknown. The present case is reported for its rarity and for the presence of transitional cell differentiation along with the other usual components of metaplastic carcinoma. Transitional cell differentiation in a metaplastic carcinoma has not been documented in the literature. Besides this, it highlights the importance of special stains and immunohistochemistry in evaluating these carcinomas and the need for early diagnosis and excision of these tumors as these carcinomas generally have a poorer prognosis as compared to breast carcinomas without metaplasia, with the tumor size having an important bearing on the outcome of this condition.

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Congenital cystic adenomatoid malformation (CCAM) of the lung, Stocker's type III is a rare anomaly characterized by replacement of normal pulmonary tissue with cysts of variable size and distribution. We report here a 16-week stillborn fetus with Stocker's type III bilateral CCAM involving the entire lungs. The additional associated malformations included collapsed nasal bridge, low set ears, malformed ears, absence of neck folds, absence of nipples and areolas, tracheal stenosis, fetal hydrops and small heart. The pathogenesis, radiological findings, pathological findings and prognosis of CCAM are discussed along with review of literature.

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Molecular diagnostic tools form a necessitity in the modern practice of pathology. This review aims to introduce some basic principles of molecular diagnostics to a pathologist involved in the practice of histology. Some common clinical scenarios and the application of molecular techniques in those settings to obtain an accurate diagnosis is discussed.

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Ectopic cervical thymomas are often confused with thyroid or parathyroid swellings due to their anatomical positioning. Predominant epithelial thymoma can be misdiagnosed as papillary thyroid carcinoma on fine needle aspiration and lymph node metastasis of epithelial tumor on frozen section. Predominantly lymphocytic thymomas have often been misinterpreted as Hashimoto's thyroiditis or malignant lymphoma, either by fine needle aspiration or on frozen section analysis. If cytology is doubtful and is not correlating with clinical, anatomical and surgical findings; immunohistochemistry is a very important tool in such cases to give final answer. Thyroid cell specific proteins such as thyroglobulin, thyroid transcription factor-1, thyroperoxidase and dipeptidyl aminopeptidase-4, neuroendocrine markers chromogranin, calcitonin and parathyroid hormone could be used to rule out thyroid or parathyroid origin. We present such rare case of ectopic cervical thymoma mimicking as papillary thyroid carcinoma.

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Staphylococcus aureus is a rare cause of pneumonia, though in recent times methicillin-resistant strains are emerging increasingly as causative pathogens. Methicillin resistant Staphylococcus aureus (MRSA) has been reported to cause rapidly fatal hemorrhagic pneumonia. Most of these strains have been found to produce a lethal exotoxin called Panton-Valentine leukocidin. The finding of an underlying asymptomatic multisystem sarcoidosis was unusual in the case being reported here.

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A dedifferentiated liposarcoma of the retro-peritoneum of a 45-year-old female is described in this case report. It showed dedifferentiation into a histological low-grade type and thus defies the traditional definition of dedifferentiated liposarcoma. The excised specimen was a huge, multi-nodular encapsulated mass surrounding the kidney and infiltrating into it. The mass showed a dedifferentiated focus different in color from the surrounding tumor and containing areas of necrosis and hemorrhage. The sections from the dedifferentiated part of the tumor appeared predominantly as benign spindle cell component on histology but the tumor was infiltrating into the kidney. Hence, a close and long-term follow-up is expected in such cases though they look benign. In the retro-peritoneum, a lipoma-like well-differentiated liposarcoma with spindle cell component, like the present tumor, which shows dedifferentiation, should not be overlooked.

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Various combinations of thyroid carcinomas have been reported including those between different cancers of follicular cell origin and those between follicular and C-cell histogenesis. Accordingly, anaplastic carcinomas have been seen to coincide with simultaneous papillary and follicular cancers. We report a case of composite anaplastic and papillary cancer on one thyroid lobe with a follicular carcinoma in the other lobe in a female patient aged 64 years. The patient also had a separate and independent follicular adenoma in the same lobe as the composite anaplastic and papillary carcinoma. The papillary carcinoma was continuous with the anaplastic carcinoma. The findings were supported by immunohistochemistry. The patient was managed by a total thyroidectomy with bilateral modified radical neck dissection followed by chemotherapy. However, she died two months after surgery. The common follicular cell origin will explain the concurrent presence of all these cancers. This could result from the dedifferentiation of a pre-existing differentiated carcinoma.

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Context: Nipple areola (NA) sparing mastectomy has an acceptable complication rate, is oncologically safe and facilitates an improved cosmetic result, aiding greatly in reducing psychological trauma associated with breast loss. Questions regarding preoperative case selection for NA sparing mastectomy are pertinent. Aims: The principle objective was to develop a simple model based on correlation of malignant involvement of NA with morphological factors in breast cancer cases to accurately predict the cancerous involvement of nipple areola preoperatively. Settings and Design: The present cross-sectional study was carried out on 136 patients of breast cancer. The period of study spanned 3 years from 2004 to 2007. Materials and Methods: We evaluated 17 different morphological parameters which had proven prognostic significance in breast cancer cases for their relationship with NA involvement. Data regarding cytological parameters were available in 120 cases out of the total number of 136 cases. Simple and conventional methods appropriate for any under-resourced set-up were employed to enhance the economic viability and acceptability of the project. Statistical Analysis used: Statistical analysis in this study was mostly done using SPSS version: 14 software. P-value < 0.05 was considered significant when assessing correlation between two parameters. Results: The frequency of NA involvement detected in this study was 19.1%. In univariate analysis, 13 of the 17 morphological parameters were found to have strong statistical association (P<0.05) with NA involvement. In multivariate analysis, only four parameters-macroscopic NA changes, tumor-NA distance (<1.5cm), histological lymph node grade and extra capsular extension in lymph node were found to have independent role for NA involvement prediction. This multivariate Cox and Snell Regression model with Cox and Snell Regression Square of 0.551 can predict accurately 98.5% cases of nipple involvement using the 4 parameters as variables. Conclusions: By application of this simple multivariate model, accurate prediction of NA involvement would be possible preoperatively. NA sparing mastectomy may be performed on those cases predicted to have no NA involvement thus substantially reducing the burden of psychological morbidity.

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Adenomyoepithelioma of the breast is a rare tumor. Malignant change arising in this lesion is infrequent and only a few cases have been reported. We discuss a case of a 56-year-old female presenting with a firm breast mass, which was interpreted as myoepithelial carcinoma arising in a background of adenomyoepithelioma, based on morphological and immunohistochemical studies. This case is being highlighted for its rarity and distinct morphological spectrum.

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Background and Objectives: The advent of new fluoroquinolones has drawn the attention for reliable methods on the in-vitro susceptibility testing of Streptococccus pneumoniae. This study attempts to determine the minimum inhibitory concentration (MIC) of second-generation (ciprofloxacin and ofloxacin), third-generation (levofloxacin) and the fourth-generation (moxifloxacin and gatifloxacin) fluoroquinolones against S. pneumoniae recovered from bacterial keratitis. Materials and Methods: In retrospect, the MICs of 50 strains of S. pneumoniae isolated from the corneal scrapes of patients with bacterial keratitis were determined against ciprofloxacin, ofloxacin, levofloxacin, gatifloxacin and moxifloxacin using E-tests. The National Committee of Clinical Laboratory Standards (NCCLS) susceptibility patterns and the potencies of the MICs were statistically compared. Results: The median MIC of ciprofloxacin (0.25μg/ml) was found to be lower than the median MICs of ofloxacin (0.5μg/ml) (P<0.449) and levofloxacin (1.0μg/ml) (P<0.001). The median MICs of gatifloxacin (0.1μg/ml) was lower than the median MICs of ciprofloxacin (0.25μg/ml) (P<0.001), ofloxacin (0.5μg/ml) (P<0.001) and levofloxacin (1.0μg/ml) (P<0.001). Moxifloxacin (0.06μg/ml) had showed lower median MICs than gatifloxacin (0.1μg/ml) (P<0.001) levofloxacin (1.0μg/ml) (P<0.001), ofloxacin (0.5μg/ml) (P<0.001) and ciprofloxacin (0.25μg/ml) (P<0.001). Moxifloxacin (0.06μg/ml) had a lower MIC50 (μg/ml) than gatifloxacin (0.1μg/ml), levofloxacin (1.0μg/ml), ciprofloxacin (0.25μg/ml) and ofloxacin (0.5μg/ml). MIC90 (μg/ml) of moxifloxacin (0.06μg/ml) was found to be lower than the MIC90 (μg/ml) of gatifloxacin (0.5μg/ml), levofloxacin (1.0μg/ml), ofloxacin (0.5μg/ml) and ciprofloxacin (0.5μg/ml). Conclusion: Based on in-vitro testing, the five portrayed fluoroquinolones 100% sensitivity to S. pneumoniae. However, the fourth-generation fluoroquinolone, moxifloxacin appeared to be more effective against S. pneumoniae than gatifloxacin, levofloxacin, ofloxacin and ciprofloxacin.

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An eight-month-old female, delivered to consanguineous parents, presented with acute liver cell failure. Her investigations showed progressive cholestatic jaundice, high liver enzymes and high gamma-glutamyl transferase. Hepatitis and inborn errors of metabolism were excluded. The liver biopsy showed a prominent parenchymal bile stasis without features of bile obstruction or paucity of bile ducts. These findings wee suggestive of Byler disease or progressive familial intra hepatic cholestasis type III (PFIC III) which begins in infancy and usually progresses to cirrhosis and hepatic failure in the first few years of life.

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Background and Aims: The role of hepatitis C virus (HCV) genotypes in the severity of liver disease is still debatable and there is an occasional published report from India. The aim of this study is to assess the role of HCV genotypes in severity of liver disease in Indian patients. An attempt has also been made to perform a multivariate analysis to identify the predictors of severity of liver disease in chronic HCV infection. Materials and Methods: In this study, 31 newly diagnosed cases of chronic HCV infection over a period of two years were included. Age, sex and serum alanine transaminase (ALT) levels were recorded for each patient. HCV genotypes were identified using Line Probe assay (INNO-LiPA HCV II kit, Innogenetics, Belgium). Histological activity was graded and fibrosis was staged. Univariate and multivariate analysis was done to identify predictors of histological severity and fibrosis. Results: By univariate analysis, age of the patient, serum ALT levels and absence of genotype 3 (i.e., presence of HCV genotype other than genotype 3) showed association with histological activity score; whereas age and histological activity score showed association with fibrosis. However, on multivariate analysis, only serum ALT levels and absence of genotype 3 correlated well with activity score; while only activity score remained a significant predictor of stage of fibrosis. Conclusions: This study emphasizes the significant correlation of HCV genotype with severity of liver disease in chronic HCV infection. The stage of fibrosis showed correlation only with activity score as an independent factor. These results would further help in outlining algorithms for therapeutic stratification of patients with HCV infection.

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Congenital epulis or neonatal granular cell tumor is a tumor whose histogenesis has long been debated. It is dissimilar to other granular cell tumors; the latter having derivation from Schwann cells and hence being S-100 positive. We report a case of congenital granular cell tumor in a newborn female child that was uneventfully operated. The case is reported here because of its rarity.

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Adenosarcoma like tumor of the seminal vesicle is reported herein. A 35-year-old male presented with mass in the pelvis between bladder and rectum, involving the seminal vesicle and prostate. Mass recurred after enucleation in four years. Histologically, the tumor was multicystic with bland ciliated lining epithelium and sarcomatous stroma. A wide excision was performed followed with chemotherapy and radiotherapy. Adenosarcomas have a low grade recurrent malignant potential and should be recognized.

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A 60-year-old woman, a known diabetic and asthmatic, was admitted for acute exacerbation of chronic obstructive pulmonary disease. Physical examination revealed two soft nodules in the left infra axillary region. Fine needle aspiration cytology (FNAC) showed fungal granulomatous reaction suggestive of fungal infection. Periodic acid Schiff stain (PAS stain) revealed PAS positive, acutely branching, septate fungal hyphae. Wet mount of the aspirate revealed plenty of pus cells and branching septate hyphae. Ziehl-Neelsen (ZN) stain showed moderate numbers of acid fast bacilli. Culture yielded Aspergillus flavus and Mycobacterium fortuitum.

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Adrenal myelolipoma is a rare benign tumor composed of adipose and hematopoietic tissue. Most tumors are small in size and incidentally detected. We report a case of giant adrenal myelolipoma weighing 2200 gms which was diagnosed on radiology as a liposarcoma. This case is unusual in view of the large size and presence of bony spicules. To the best of our knowledge, not more than 10 giant adrenal myelolipoma cases have been reported in literature.

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A 45-year-old female presented with loss of vision in the left eye, numbness on left half of face and left-sided hemicrania for two months. On the basis of radiological investigations, provisional diagnosis of basal meningioma was made. Tissue sent for histopathological evaluation revealed a dual tumor-meningioma with metastasis from follicular carcinoma, thyroid. To the best of authors' knowledge, this is the first report of a tumor metastasizing to another tumor, where a follicular carcinoma thyroid metastasized to meningioma.

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Context: Sub-epithelial myofibroblasts are known to influence the biology (proliferation, differentiation and apoptosis) of overlying epithelia. In the intestine, myofibroblasts have been demonstrated to be essential for epithelial differentiation. It is therefore hypothesized that myofibroblasts may also be involved in intestinal metaplasia that is characteristic of Barrett esophagus. Objective: This study endeavors to immunohistologically evaluate epithelial-myofibroblast interaction in Barrett's metaplasia. Materials and Methods: Nineteen archival esophageal endoscopic biopsies of Barrett's metaplasia were immune-phenotyped for the following epithelial and myofibroblast antigens - cytokeratins (CK) 8, 13, 18, CDX2 (Caudal type homeobox 2), a-smooth muscle actin (SMA). Results: α-SMA immunostaining revealed close association between myofibroblasts and metaplastic Barrett's epithelium but not with normal esophageal squamous epithelium. Myofibroblasts were more prominent in dysplastic than in non-dysplastic Barrett metaplasia. CDX2 and CK 8/18, indicators of intestinal differentiation were expressed in Barrett metaplasia but not normal esophageal squamous epithelium, while the reverse was the case for CK 13, which only stained normal esophageal squamous epithelium. Conclusion: Although their precise role is yet to be clearly defined, sub-epithelial myofibroblasts are very likely involved in the pathogenesis of Barrett's metaplasia.

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Context: Several attempts have been made to formulate a morphologic classification of focal segmental glomerulosclerosis (FSGS) variants with therapeutic and prognostic implications. Differences in study populations such as racial profile or therapy offered have hampered attempts to define prognostic variables in FSGS. Literature reveals conflicting results regarding the prognostic significance of tip variant of FSGS in different populations. Aims: To study the clinical and pathologic parameters in tip and not otherwise specified (NOS) variants of FSGS, in subjects from the Indian subcontinent with prognostic significance. Materials and Methods: First we performed a retrospective analysis of patients with biopsy proven primary FSGS, diagnosed between January 2004 and December 2008. Twenty cases of tip variant were encountered in adult population and similar numbers of adult cases of NOS variant were randomly selected. Renal biopsies were studied using light and immunofluorescence microscopy. Medical records for clinical data at presentation, biopsy and three monthly follow-up intervals were reviewed and compared between two groups. Results: At presentation, clinical profiles for the two groups were similar; however, significant differences in histological parameters and clinical outcome in tip and NOS variant cases were noted. Interstitial fibrosis and tubular atrophy were significantly higher in NOS variant. Greater response rate to steroid therapy was observed in tip variant cases while higher proportion of NOS variant cases showed renal failure. Conclusion: Analysis of histological parameters is important in assessing the outcome of tip and NOS variants. Tip variant signifies a better prognostic subset for a population of Indian origin affected by FSGS.

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Angiomyolipomata of the kidney are unusual lesions composed of abnormal thick walled blood vessels, smooth muscle and adipose elements. These are asymptomatic and occasionally present with flank pain, a palpable mass or gross hematuria. They may be associated with tuberous sclerosis. The risk of bleeding is increased with size, and lesions greater than 4 cm have more than 50% chance of significant bleeding. An unusual case of multifocal renal angiomyolipoma associated with tuberous sclerosis and presenting as massive intra abdominal hemorrhage is reported.

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Objective: A preliminary opt-out screening study for HIV was conducted in a tertiary care hospital in India according to Center for Disease Control (CDC) guidelines. A total of 876 cases were screened for HIV during August 2007 to December 2007 using tests approved by the National AIDS Control Organization (NACO). Results: Data indicates that the prevalence of HIV in emergency and pre-surgical setting was 21 per thousand at the tertiary care center. Positivity rate in the pediatric population was 20.9 per thousand while in adults it was 21.4 per thousand. Most patients were totally unsuspected. Nearly 40000 patients seek admission annually to the emergency department alone. Thus nearly 700 to 800 patients may be missed every year if one does not resort to such a practice. Conclusion: Since India has the second largest number of HIV cases in the world, opt-out screening program and testing in an emergency setting, as recommended by CDC, is extremely relevant. Logistics of implementation of this policy need to be worked out at a national level.

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Gonodoblastomas with ovarian germ cell tumors other than dysgerminoma coexists very rarely with yolk sac tumor (YST). Because of this rarity, we report a case of gonadoblastoma with YST. An 18-year-old female patient was admitted to our hospital with an abdomino-pelvic mass. Ultrasonographical examinations revealed a 15X14 cm heterogenous pelvic mass with calcific foci in the left adnexal area. Macroscopically, the resected mass was oval and measured 18X15X15 cm and weighed 3150 gm. Histological examination showed both gonadoblastic and YST areas. There were many gonadoblastic nests in the subcapsular areas of the tumor. The gonadoblastic nests were composed of large and small cells. The YST areas showed enteric differentiation and numerous hyaline globules. Immunohistochemical examination may help in the diagnosis of these gonadoblastoma with YST.

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A 30-year-old female, a Myanmar refugee, settled in Mizoram for last three years, reported to our hospital with respiratory symptoms and numerous characteristic skin lesions on multiple sites. Histology and culture of a biopsy from a facial skin lesion established the diagnosis of penicilliosis marneffei. This is first known case of Penicillium marneffei infection from Mizoram state, India to the best of our knowledge. It is possible that several undetected cases of the disease exist in Mizoram, and in the neighboring country, Myanmar and several such cases may be presenting in metropolitan cities.

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Embryonal (undifferentiated) sarcomas arising in mesenchymal hamartoma are on record but cases of hepatic angiosarcoma (AS) arising in mesenchymal hamartoma (MH) of the liver are extremely rare. We report one such case in a 20-year-old male patient. He presented with a lump in the right hypochondriac region and pain of two years duration with rapid increase in size since two months. Ultrasonography (USG) revealed a well circumscribed mass on the undersurface of the right lobe of liver suggestive of hemangioma. The patient underwent resection of the mass. Histopathology revealed AS with areas of MH.

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We report an interesting finding of multiple large drusen in an eviscerated eye with a longstanding retinal detachment. The origin and composition of the drusen is also speculated on the basis of special stains.

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