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   Table of Contents - Current issue
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July-September 2015
Volume 58 | Issue 3
Page Nos. 273-417

Online since Friday, August 14, 2015

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EDITORIAL  

From Editor's desk p. 273
Vatsala Misra
DOI:10.4103/0377-4929.162829  PMID:26275244
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ORIGINAL ARTICLES Top

Matrix metalloproteinase 7 expression in ampullary carcinoma p. 274
Niraj Kumari, Rajneesh Kumar Singh, Narendra Krishnani, Pooja Shukla
DOI:10.4103/0377-4929.162830  PMID:26275245
Background: Matrix metalloproteinase 7 (MMP7) has largely been studied in pancreatic cancer which is the most common component of periampullary cancer in the western population. In India, the ampullary carcinoma is seen as the most common periampullary cancer in resected pancreaticoduodenectomies. We aimed to study the expression of MMP7 and its correlation with clinicopathological features in ampullary cancer. Materials and Methods: Consecutive cases of all ampullary cancer in a 3-year period were reviewed for histological differentiation (intestinal and pancreatobiliary) by morphology and immunohistochemistry (CDX2, MUC2, cytokeratin 20 [CK20], MUC1, cytokeratin 7 [CK7], and cytokeratin 17 [CK17]). All cases were stained for MMP7 and expression was correlated with histological variables, differentiation, and overall survival. Results: There were a total of 91 ampullary carcinomas (36 intestinal, 44 pancreatobiliary and 6 other types). Ampullary carcinoma showed MMP7 expression in 63.7% cases. Two-third of intestinal type and half of the pancreatobiliary type cancers showed MMP7 expression. MMP7 expression was significantly higher in low pathological T-stage of total ampullary carcinomas; however, it was seen more commonly in higher overall stage of the pancreatobiliary type compared to intestinal type of ampullary carcinoma. Overall survival in patients with MMP7 expression was lower compared to MMP7 negative patients. Conclusions: This is the first study on MMP7 expression in ampullary cancer. MMP7 expression was seen in nearly 64 % of ampullary cancer and showed a significant correlation with low pathological (T-) stage and high overall stage with a shorter survival. MMP7 can be explored as a target for MMP inhibitor therapy in the future.
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BRAF, KIT, NRAS, GNAQ and GNA11 mutation analysis in cutaneous melanomas in Turkish population p. 279
Ismail Yilmaz, Mehmet Gamsizkan, Zafer Kucukodaci, Ufuk Berber, Dilaver Demirel, Aptullah Haholu, Gizem Narli
DOI:10.4103/0377-4929.162831  PMID:26275246
Background: KIT and mitogen-activated protein kinase cascade are important for melanomagenesis. In the present study, we analyzed the frequency of BRAF, NRAS, KIT, GNAQ and GNA11 gene mutations and investigated their association with clinicopathological features of melanomas in Turkish population. Materials and Methods: Forty-seven primary cutaneous melanomas were included in our study. Sanger sequencing method was used for mutation analysis in all cases. Results: Mean age was 62.1 (29-101) years. Female:male ratio was 17:30. Among 47 melanomas, 14 (29.8%) BRAF, 10 (21.3%) NRAS, 4 (8.5%) KIT and 1(2.1%) GNAQ gene mutations were detected. Two of the KIT mutations were found in acral lentiginous melanoma (ALM). In the head and neck region, mutation frequency was significantly lower than in other locations (P = 0.035). The only GNAQ gene mutation (p.Q209L) was detected in a melanoma arising from blue nevus located on the scalp. None of the melanomas harbored NRAS exon 2, KIT exon 13/17/18, GNAQ exon 4 and GNA11 exon 4/5 mutations. Overall mutation frequency did not show significant difference between metastatic (8/14, 57.1%) and nonmetastatic (18/33, 54.5%) patients. We did not observe any significant association between mutation status and gender or age of various patients. Conclusions: Our results support that BRAF and NRAS gene mutations are common in cutaneous melanomas. The activating mutations of KIT gene are rare and especially seen in ALM. GNAQ and GNA11 mutations are infrequent in cutaneous melanomas and may be associated only with melanomas arising from blue nevus.
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Risk factors, organ weight deviation and associated anomalies in neural tube defects: A prospective fetal and perinatal autopsy series p. 285
Asaranti Kar, Tushar Kar, Shyama Kanungo, Lilavati Guru, Jayasree Rath, Priyadarshini Dehuri
DOI:10.4103/0377-4929.162832  PMID:26275247
Introduction: Neural tube defects (NTD) are a group of serious birth defects occurring due to defective closure of neural tube during embryonic development. It comprises of anencephaly, encephalocele and spina bifida. We conducted this prospective fetal autopsy series to study the rate and distribution of NTD, analyze the reproductive factors and risk factors, note any associated anomalies and evaluate the organ weights and their deviation from normal. Materials and Methods: This was a prospective study done over a period of 6 years from August, 2007 to July, 2013. All cases of NTDs delivered as abortion, still born and live born were included. The reproductive and risk factors like age, parity, multiple births, previous miscarriage, obesity, diabetes mellitus, socioeconomic status and use of folic acid during pregnancy were collected.Autopsy was performed according to Virchow's technique. Detail external and internal examination were carried out to detect any associated anomalies. Gross and microscopic examination of organs were done. Results: Out of 210 cases of fetal and perinatal autopsy done, 72 (34.28%) had NTD constituting 49 cases of anencephaly, 16 spina bifida and 7 cases of encephalocele. The mothers in these cases predominantly were within 25-29 years (P = 0.02) and primy (P = 0.01). Female sex was more commonly affected than males (M:F = 25:47, P = 0.0005) There was no history of folate use in majority of cases. Organ weight deviations were >2 standard deviation low in most of the cases. Most common associated anomalies were adrenal hypoplasia and thymic hyperplasia. Conclusion: The authors have made an attempt to study NTD cases in respect to maternal reproductive and risk factors and their association with NTD along with the organ weight deviation and associated anomalies. This so far in our knowledge is an innovative study which was not found in literature even after extensive search.
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Solid-pseudopapillary neoplasm of the pancreas: Clinicopathologic and immunohistochemical analysis of nine cases p. 292
Banu Yilmaz Ozguven, Deniz Tuncel, Nedim Polat, Damlanur Sakiz, Fevziye Kabukcuoglu, Hakan Koksal, Huseyin Kaya
DOI:10.4103/0377-4929.162833  PMID:26275248
Background: Solid-pseudopapillary neoplasm (SPPN) of the pancreas is a distinctive tumor of low malignant potential with a predilection for female patients in the second and third decades of life. We studied nine cases of SPPN of the pancreas and reviewed the literature concerning these uncommon tumors. Materials and Methods: A total of 7 cases of SPPN located in the tail of the pancreas and two located in the head of the pancreas were presented. Distal pancreatectomy in three patients and distal pancreatectomy with splenectomy in two patients Whipple's operation in four patients were performed. Histological diagnosis was made by performing hematoxylin-eosin and periodic acid-Schiff staining, immunohistochemical staining. Follow-up of the patients was between 2 months and 12 years. Results: Computed tomography and magnetic resonance imaging were found as equivocal for diagnosis. Mass containing cystic and solid areas were not characteristic but raised suspicion of SPPN. Pathologic examination showed SPPN in all patients. No metastasis or recurrence was detected during follow-up. Conclusions: Solid-pseudopapillary neoplasm is a relatively rare tumor, and patients tend to survive for a long period. Preoperative imaging is not characteristic. Pathologic examination is the mainstay in the diagnosis. Complete surgical removal is the best choice of treatment.
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Primary extranodal non-Hodgkin lymphoma: A 3-year record-based descriptive study from a tertiary care center in Southern India p. 296
Pritinanda Mishra, Sreeya Das, Rakhee Kar, Sajini Elizabeth Jacob, Debdatta Basu
DOI:10.4103/0377-4929.162834  PMID:26275249
Introduction: Primary extranodal lymphoma (pENL) refers to group of disorders arising from tissues other than lymph nodes and even from sites, which normally do not contain lymphoid tissue. This study was undertaken to ascertain the prevalence, anatomical distribution, and histological subtypes of extranodal non-Hodgkin lymphoma (NHL) from a tertiary care institute in Southern India. Materials and Methods: This was a cross-sectional study conducted in the Department of Pathology over a period of 3-years. Detailed clinical history, routine complete blood count, microbiological status was obtained from the medical records. Hamatoxylin and eosin slides were reviewed and immunohistochemistry was performed using a panel of antibodies depending on the morphology. All cases were classified based upon morphologic and immunophenotypic criteria according to World Health Organization 2008 classification. Results: Primary extranodal NHL constituting 22.6% (68/300) of all NHL and the majority of patients were from higher age group with peak incidence seen in fourth to fifth decade of life. In the pediatric population, the most common site is ileo-caecal region (42.8%) and the most common morphology is lymphoblastic lymphoma (42.8%). Similarly in the adult population head and neck was the most common site constituting 36% and diffuse large B-cell lymphoma is the most common morphological subtype comprising 54% of all extranodal lymphomas. Conclusion: Although the reported incidence of pENL is low in India compared to other parts of the world, the possibility of pENL should always be kept in mind even though it arises in an extranodal site.
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Malignant transformation of mature T cells after gammaretrovirus mediated transfer of nucleophosmin-anaplastic lymphoma kinase oncogene p. 301
Ashok Kumar
DOI:10.4103/0377-4929.162835  PMID:26275250
Background: Gene therapy has been in use to cure hereditary and acquired diseases by incorporating the desired gene into the cells with the help of gammaretroviral vectors. Despite the success of this therapy in X-linked severe combined immunodeficiency syndrome, few patients developed leukemia as a major adverse event due to retroviral insertional mutagenesis within stem cells. In experimental animals also, retroviral-mediated gene transfer technique resulted in the development of leukemia. On the other hand, evidence suggests that mature T cells (TC) are relatively resistant to transformation even after retroviral-mediated transfer of potent oncogenes Tcl1, ΔTrkA and LMO2 with no reported side effects yet. Aims: To further address the safety issue for TC use in gene therapy, this study investigated susceptibility of mature polyclonal TC to malignant transformation by the retroviral-mediated transfer of nucleophosmin-anaplastic lymphoma kinase (NPM-ALK) oncogene. Materials and Methods: Wild-type mature TC, isolated from C57BL/6 donor mice (genetic background Ly5.1) were transduced with gamma-retroviral vectors encoding the potent TC oncogene NPM-ALK or the control vector enhanced green fluorescent protein eGFP. The cells were then transplanted into RAG-1 deficient recipient mice (genetic background Ly5.2). Results: Two out of five mice from NPM-ALK oncogene group developed leukemia/lymphoma after latency periods (153 and 250 days, respectively). None of the mice from the control group developed any malignancy throughout the observational period. Conclusion: Mature polyclonal TC are relatively susceptible to malignant transformation after gamma-retroviral mediated transfer of NPM-ALK oncogene; hence safety of TC use in gene therapy should be further investigated to avoid the possible side-effect of development of leukemia/lymphoma.
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Mean reticulocyte volume enhances the utility of red cell mean sphered cell volume in differentiating peripheral blood spherocytes of hereditary spherocytosis from other causes p. 307
Sukesh C Nair, Neeraj Arora, Sachin Jain, David Inbakumar, Joy Mammen, Usha Sitaram
DOI:10.4103/0377-4929.162836  PMID:26275251
Context: Mean sphered cell volume (MSCV) and mean reticulocyte volume (MRV) are additional reticulocyte parameters generated while processing the blood samples on Beckman coulter LH 755 in the reticulocyte mode using the volume, conductivity and scatter technology. It has been observed that the difference between mean corpuscular volume (MCV) and MSCV is higher in the cases of hereditary spherocytosis (HS) and this difference is increasingly being utilized as a screening tool for spherocytes. In addition now there have been new observations that reticulocyte volume in cases of HS is less as compared to normal reticulocyte. Aims: Our aim was to test the usefulness of reticulocyte parameters like MSCV and MRV in distinguishing cases of HS and autoimmune hemolytic anemia (AIHA). Materials and Methods: This is a retrospective and partly prospective study where peripheral blood ethylenediaminetetraacetic acid samples from cases of HS (n = 57) and AIHA (n = 29) were processed on LH 755 in both the differential and the reticulocyte mode. The data generated were analyzed and compared with data from normal healthy donors (n = 46). Results: Using an algorithm of MCV - MSCV >10 and MRV - MSCV <25, a sensitivity of 84.2% and specificity of 94.7% was observed in cases of HS. Conclusions: With the reticulocyte analysis, we may now have a simple and cheap additional tool for screening of HS.
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Sehgal index: A new index and its comparison with other complete blood count-based indices for screening of beta thalassemia trait in a tertiary care hospital p. 310
Kunal Sehgal, Preeti Mansukhani, Tina Dadu, Meher Irani, Shanaz Khodaiji
DOI:10.4103/0377-4929.162862  PMID:26275252
Introduction: Beta thalassemia trait (BTT) must be differentiated from iron deficiency anemia to avoid unnecessary iron therapy and for the prevention of thalassemia major by genetic counseling. In a tertiary care hospital, it is vital that the screening tool is not only sensitive but also specific so as to be cost effective and save time. Aim: The aim of this study was to evaluate the new Sehgal index and compare it to existing complete blood count-based indices for the best combination of sensitivity and specificity to predict BTT. Materials and Methods: Study was done in 2 phases - Phase 1: A retrospective analysis of 1022 consecutive high-performance liquid chromatography (HPLC) cases from July 2008 to June 2011. Phase 2: A prospective analysis of 973 consecutive HPLC cases from July 1, 2011 to June 10, 2013 was done to confirm the results of Phase 1 and the applicability of the new Sehgal index. Results: Prevalence of BTT was 28.8% (294/1022) and 25.39% (247/973) in Phase 1 and Phase 2, respectively. Receiver operating characteristic-area under the curve and Youden index was highest for new Sehgal index, followed by Mentzers index <14. The prospective study shows results similar to those in Phase 1 confirming the superiority of the above two indices. Conclusion: Sehgal index and Mentzers index <14 showed the best combination of sensitivity and specificity in predicting BTT. The best indices or combination can be used as a "validated flag rule" in the analyzer middleware program in a hospital for identifying suspected cases of BTT.
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Accelerated staining technique using kitchen microwave oven p. 316
Archana Mukunda, TV Narayan, Balasundhari Shreedhar, R Shashidhara, Leeky Mohanty, Sadhana Shenoy
DOI:10.4103/0377-4929.162863  PMID:26275253
Introduction: Histopathological diagnosis of specimens is greatly dependent on good sample preparation and staining. Both of these processes is governed by diffusion of fluids and dyes in and out of the tissue, which is the key to staining. Diffusion of fluids can be accelerated by the application of heat that reduces the time of staining from hours to the minute. We modified an inexpensive model of kitchen microwave oven for staining. This study is an attempt to compare the reliability of this modified technique against the tested technique of routine staining so as to establish the kitchen microwave oven as a valuable diagnostic tool. Materials and Methods: Sixty different tissue blocks were used to prepare 20 pairs of slides for 4 different stains namely hematoxylin and eosin, Van Gieson's, 0.1% toluidine blue and periodic acid-Schiff. From each tissue block, two bits of tissues were mounted on two different slides. One slide was stained routinely, and the other stained inside a microwave. A pathologist evaluated the stained slides and the results so obtained were analyzed statistically. Results: Microwave staining considerably cut down the staining time from hours to seconds. Microwave staining showed no loss of cellular and nuclear details, uniform-staining characteristics and was of excellent quality. Interpretation and Conclusion: The cellular details, nuclear details and staining characteristics of microwave stained tissues were better than or equal to the routine stained tissue. The overall quality of microwave-stained sections was found to be better than the routine stained tissue in majority of cases.
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Molecular characterization and clinical significance of New Delhi metallo-beta-lactamases-1 producing Escherichia coli recovered from a South Indian tertiary care hospital p. 323
Arindam Ckakraborty, Prabha Adhikari, Shalini Shenoy, Shrikala Baliga, Gopalkrishna Bhat, Satish Rao, Dhanashree Biranthabail, Vishwas Saralaya
DOI:10.4103/0377-4929.162864  PMID:26275254
Context: The increased rate of infection by New Delhi metallo-beta-lactamases-1 (NDM1) producing Escherichia coli is a major concern since they show a high rate of drug resistance and are responsible for mortality and morbidity. Aims: To characterize the NDM1 producing E. coli isolates and their impact on patients' clinical outcome. Settings and Design: This descriptive study was carried out in a multi-specialty tertiary care hospital. Materials and Methods: Three hundred nonrepeat strains of E. coli from inpatients were included in the study. Modified Hodge test and metallo-beta-lactamases (MBL) e-test were performed to detect carbapenemase and MBL activity. Polymerase chain reaction (PCR) technique was performed to detect NDM1. NDM1 positive isolates were further tested for plasmid mediated AmpC, blaCTX , blaSHV , blaTEM genes and also for phylogrouping by PCR methods. Treatment and patients' clinical outcome were also analyzed. Results: Out of 300 isolates, 21 (7%) were MBL producers by phenotypic methods. Of this, 17 (81%) were NDM1 positives, among the NDM1 producers 6 (35%) isolates were belongs to phylogroups D followed by A 5 (29%), B1 4 (24%) and B2 2 (12%), 15 (88%) isolates were blaCTX-M positive suggestive of extended-spectrum beta lactamase producing strain and 7 (47%) were positive with CIT type of AmpC. With the follow-up of the patients, it was found that 12 (71%) recovered and 3 (18%) developed relapses, and mortality was seen in 2 (12%) patients. Conclusions: NDM1 producing isolates showed a high degree of drug resistance but can be treated with suitable antimicrobials, in the majority. Early detection and choice of appropriate antibiotics may help in reducing mortality and morbidity.
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Dengue virus infection: Need for appropriate laboratory tests for diagnosis and management of the condition in children during an outbreak p. 328
Harshavardhini Palanivel, Shashikala Nair, Anandhalakshmi Subramaniyan, Philip Vivian Joseph Ratnam, Reba Kanungo
DOI:10.4103/0377-4929.162865  PMID:26275255
Background: Outbreaks of dengue infection occur in several parts of India with clockwork precision closely related to changing seasons. Most recent outbreak in Puducherry occurred between October 2012 and January 2013, affected a sizable pediatric population. A prospective study was done to characterize the demographic, diagnostic and clinical profile of pediatric patients in a tertiary care center in Puducherry. Materials and Methods: Data of patients serologically positive for either dengue NS1 antigen or anti-dengue IgM antibodies were analyzed. Duration of fever, platelet count, complications, risk factors, morbidity and mortality were analyzed. Results: Among pediatric cases with fever who were screened for NS1/IgM antibody during the recent outbreak, 161 (37.5%) tested positive. NS1 was detected in 85% while 5.5% tested positive for IgM and 3% for IgG. Few (4.9%) tested positive for both NS1 and IgM and 1.2% were positive for both NS1 and IgG. The mean age was 6 years of which 9% were <1-year, the youngest being 1-month old infant. Mean duration of fever was 4 days. Vomiting was associated in 42% of cases. Thrombocytopenia (51%) and hepatomegaly (41%) were two major observations. Among the NS1 positive cases, 49% had thrombocytopenia. IgM alone and NS1 with IgM were associated with thrombocytopenia in 67% and 78% respectively. 14 children had complications of dengue shock syndrome, and four had dengue hemorrhagic fever. Totally, 22 of the children had platelet transfusion. There was no mortality reported among any of these children. Conclusion: Combination of clinical findings and rapid NS1, IgM detection helped in confirming the diagnosis for appropriate management of dengue in children.
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BRIEF COMMUNICATION Top

Subconjunctival dirofilariasis caused by Dirofilaria repens: A case report with short review p. 332
Archana Chintaman Choure, Meghna Satish Palewar, Vaishali Babanrao Dohe, Swati Shankarrao Mudshingkar, K Madhuri, Renu Satish Bharadwaj
DOI:10.4103/0377-4929.162866  PMID:26275256
Human dirofilariasis is a rare infection caused by filarial worms of genus Dirofilaria. Subconjunctival dirofilariasis has been reported from Asia, Europe, Italy and Africa. In India majority cases are from Kerala, Karnataka and very few from Maharashtra. We report the rare case of subconjunctival dirofilariasis caused by Dirofilaria repens from Maharashtra, western India.
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CASE REPORTS Top

Sclerosing rhabdomyosarcoma presenting on the knee-joint p. 335
Yuanyin Zheng, Xiaobin Liu, Yingyu Mao, Maohua Lin, Ting Li
DOI:10.4103/0377-4929.162867  PMID:26275257
Sclerosing rhabdomyosarcoma is a rare pathological diagnosis that easily misdiagnosed. The majority of cases reported the tumor increased rapidly in size and the Ki-67 proliferation index ranged from 10% to 60%. Here, we report the first case of the tumor increased very slowly for 20 years and the Ki-67 proliferation index was lower than 2%, and discuss its histological features and immunohistochemical reactivity with Desmin and Ki-67 and so on.
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Primary pulmonary leiomyosarcoma of lung: An unusual entity with brief review p. 338
Devajit Nath, Sudheer Arava, Prashant Joshi, Karan Madan, Sandeep Mathur
DOI:10.4103/0377-4929.162868  PMID:26275258
Primary pulmonary leiomyosarcomas are rare and diagnostically challenging group of neoplasms approximately constituting 0.2-0.5% of all primary lung malignancies. They originate from the smooth muscle cells of the bronchial wall, blood vessels or from the pulmonary interstitium. Here we present a case of 45 year old male with history of chronic cough, breathlessness and chest pain for few months. Clinical and radiological workup showed a left upper lobe lung mass. Endobronchial ultrasound guided (EUS) needle biopsy of the mass on histopathology confirmed leiomyosarcoma. Further through evaluation ruled out the possibility of metastasis. A final diagnosis of primary leiomyosarcoma of lung was made and patient was planned for surgical management.
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Primary Ewing sarcoma of vulva, confirmed with molecular cytogenetic analysis: A rare case report with diagnostic and treatment implications p. 341
Bharat Rekhi, Girish Chinnaswamy, Tushar Vora, Sneha Shah, Venkatesh Rangarajan
DOI:10.4103/0377-4929.162869  PMID:26275259
Primary vulvar Ewing sarcoma (ES)/PNET is an uncommonly documented tumor, especially with molecular results. A 10-year-old girl presented with left vulvar swelling, a year ago. Her abdominopelvic ultrasound revealed a 12 cm × 8 cm sized, mixed echogenic blood-filled lesion in the left vulva; radiologically considered as a hematoma. Vulvectomy revealed a multinodular grey-brown tumor, microscopically comprising malignant round cells. Immunohistochemically, tumor cells diffusely expressed MIC2/CD99 and Fli1 and subsequently displayed EWSR1 rearrangement, confirming diagnosis of ES/PNET. Subsequently, PET-CT scan revealed residual local lesion with lung metastases. The patient was induced on EFT 2001 chemotherapy protocol. Three months after chemotherapy completion, there was no metabolically active disease on PET scan. Four months later, MRI disclosed recurrent primary and metastatic pulmonary lesions. She was planned for scar excision and adjuvant radiotherapy, but unfortunately defaulted further treatment. This forms the eighth case of primary vulvar ES/PNET confirmed with molecular cytogenetic result, underscoring therapeutic value of objective diagnosis in such cases.
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Primary cardiac sarcoma with metastases to thyroid and brain p. 345
Jyotsna Yesodharan, Subitha Kandamuthan, Usha Poothiode
DOI:10.4103/0377-4929.162870  PMID:26275260
Primary cardiac sarcomas are extremely rare with only a few large case series and isolated case reports in the literature. In spite of their aggressive nature with high chances of local recurrence and distant metastases, these tumors and their treatment strategies remain incompletely defined. We report an unsuspected case of primary cardiac pleomorphic undifferentiated sarcoma in a 52-year-old female who presented with progressive dyspnea and palpitation. In the postoperative period, she was detected to have secondaries in brain and thyroid, confirmed thereafter, by fine-needle aspiration cytology.
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Diffuse lipomatosis of the thyroid gland with papillary microcarcinoma: Report of a rare entity p. 348
Hariharanadha Sarma Nandyala, Srinivasulu Madapuram, Megha Yadav, Sudheer Kumar Katamala
DOI:10.4103/0377-4929.162890  PMID:26275261
Presence of lobules of adipose tissue either focally or diffusely is very rare in the thyroid gland. Fat accumulation can be macroscopic or microscopic. Focal infiltrates of fat have been reported in conditions such as adenolipoma, intrathyroid lipoma, and encapsulated papillary carcinoma. Diffuse lipomatosis has been reported in conditions such as amyloid goitre, heterotopic fat nests, thyrolipoma and liposarcoma. The exact mechanism of fat accumulation is not known although there are many theories postulated. Investigations such as ultrasound, computed tomography scan, and magnetic resonance imaging can detect the presence of macroscopic fat in the thyroid gland. Accurate diagnosis of the type of fat accumulation is necessary because tumorous and nontumorous conditions fall into the differential diagnosis. Only nine cases of papillary carcinoma associated with lipomatosis of thyroid are reported so far. We report possibly the first case of diffuse lipomatosis of the thyroid gland with a focus of papillary microcarcinoma.
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Large lipid-rich mammary analogue secretory carcinoma of parotid gland: An unusual case p. 351
Prashant Joshi, Asit Ranjan Mridha, Shuchita Singh, Prateek Kinra, Ruma Ray, Alok Thakar
DOI:10.4103/0377-4929.162897  PMID:26275262
Mammary analogue secretory carcinoma (MASC) of the salivary gland is a malignant tumor which bears morphologic, immunohistochemical and molecular features similar to those of mammary secretory carcinoma. The tumor is considered as a low-grade malignancy perhaps slightly more aggressive than acinic cell carcinoma. High-grade transformation with recurrences, regional nodal involvement, metastases, and cancer-related death has been reported in a few cases. We report an unusual case of large MASC of the parotid gland in a young patient without regional lymph node involvement. To the best of our knowledge till date such a large MASC of the salivary gland has not been reported in the English literature.
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Clear cell renal cell carcinoma with hemangioblastoma-like features: A recently described pattern with unusual immunohistochemical profile p. 354
Sankalp Sancheti, Santosh Menon, Satyadip Mukherjee, Indu Arun
DOI:10.4103/0377-4929.162898  PMID:26275263
The diagnosis of clear cell renal cell carcinoma may sometimes pose challenges because of the presence of uncharacteristic morphology, varied immunophenotypic patterns and due to lack of molecular or genetic determinants. More often, the morphological variations can be easily overlooked in routine practice and a more common diagnosis is usually put forward. Solid, acinar and alveolar are the common patterns described in the literature. We report a recently described pattern of clear cell renal cell carcinoma which has hemangioblastoma-like morphology and an unusual immunoprofile. In our case, the tumor showed a diffuse hemangioblastoma-like pattern and diffuse positivity for Alpha-inhibin on immunohistochemistry. A thorough literature search, extensive sampling and an expanded immunohistochemistry panel revealed a clear cell renal cell carcinoma component. Presence of renal vein thrombosis and focal necrosis were other helpful features in discerning the malignant nature of tumor.
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Bilateral pseudoangiomatous stromal hyperplasia in a human immunodeficiency viral-infected patient p. 356
Noppadol Larbcharoensub, Duangkamon Wattanatranon, Suda Sanpaphant, Nithid Sri-utenchai, Cholatip Wiratkapun, Youwanush Kongdan
DOI:10.4103/0377-4929.162899  PMID:26275264
Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon mesenchymal neoplasm of the breast demonstrating stromal myofibroblastic proliferation and having the appearance of anastomosing slit-like pseudovascular spaces lined by spindle-shaped cells. A case of nodular PASH of the bilateral breasts in a 40-year-old woman with clinically presenting with a progressive enlarged breast lump is reported. Mammographic and ultrasonographic features of the right and left breasts showed a large solid lump with well-circumscribed border measuring 4 cm × 1.7 cm × 3.4 cm and 13.8 cm × 10.9 cm × 12.1 cm, respectively. Wide excision of the right breast and quadrantectomy of the left breast were performed. The histopathological examination of the lesion showed anastomosing slit-like pseudovascular spaces. The stromal cells were immunoreactive for muscle actin (HHF35), smooth muscle actin, and progesterone receptor. Clinical and pathological findings with briefly reviewed relevant literatures are discussed. This is the first clinicopathological and radiological report of bilateral mammary nodular PASH in a human immunodeficiency viral-infected patient.
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Sclerosing angiomatoid nodular transformation of spleen masquerading as a splenic abscess p. 359
Kunal Ashok Bagul, Arijit Sen
DOI:10.4103/0377-4929.162900  PMID:26275265
Here we report an incidental case of sclerosing angiomatoid nodular transformation (SANT) in an open splenectomy specimen from a young man who presented with insidious abdominal pain. The condition was mimicking as a splenic abscess. Histopathological and immunohistochemical analysis confirmed this to be SANT. SANT presents a diagnostic challenge to clinicians, radiologists, as well as pathologists because of its extreme rarity. Therefore, it must be included as a differential diagnosis in cases with nonspecific pain or radiological splenic mass. This case highlights that SANT can present with varied clinical features and at a wide range of ages. A high index of suspicion is required for its diagnosis.
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Sarcoidosis detected due to tattoo swellings in an Indian female p. 362
Ashok Ghorpade
DOI:10.4103/0377-4929.162901  PMID:26275266
A female patient presented with asymptomatic swellings in old blue-black tattoo marks of her forearms. On careful skin examination, few raised erythematous, circular plaques were also found on the non-tattooed skin on her back, about which she was unaware. The diagnosis of cutaneous and systemic sarcoidosis was confirmed after classical histopathological findings from skin lesions from her non tattooed back and from papulonodular tattooed lesions, ruling out other causes of granulomas and supported by a negative Mantoux test, raised serum angiotensin converting enzyme level, high resolution computed tomography thorax, etc. She responded well to oral steroid therapy. The importance of a careful skin examination, easy access provided by skin lesions in suspected cases of cutaneous/systemic sarcoidosis, the value of sudden tattoo changes in the diagnosis here and the possible contribution of tattoos toward the causation of cutaneous and/or systemic sarcoidosis are highlighted.
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Solid-pseudopapillary neoplasm of the pancreas: A classical presentation with unique paranuclear dot like immunostaining with CD 99 p. 365
Kunjulekshmi Amma Raveendran Nair Anila, Nileena Nayak, Madhu Muralee, Bhaskaran Pillai Venugopal, Rari P Mony
DOI:10.4103/0377-4929.162902  PMID:26275267
A 32-year-old lady presented with a history of abdominal pain and upper abdominal discomfort of 3 months duration. Her imaging studies done at a local hospital showed a solid-cystic mass involving head of the pancreas. The patient was referred to our surgical oncology department. On examination, there was a nontender mass in the epigastrium. An ultrasound scan guided fine-needle aspiration (FNA) was done which was showing classical features of solid-pseudo papillary neoplasm of the pancreas. With this preoperative diagnosis patient was taken up for surgery. Per operatively, there was a solid-cystic mass in the head of the pancreas. Pancreaticoduodenectomy was done. Histopathology and immunohistochemistry (IHC) confirmed the diagnosis of solid-pseudo papillary neoplasm of the pancreas. Apart from the routine IHC panel, CD 99 immunostain was also done which demonstrated the characteristic paranuclear dot-like staining observed in previous studies in the literature.
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Psammomatous melanotic schwannoma as a component of Carney complex p. 368
Salapathi Shanmugam, Mitra Ghosh, Sadiya Niamathullah, Siddhartha Ghosh
DOI:10.4103/0377-4929.162903  PMID:26275268
Melanotic schwannoma is a rare form of pigmented neural tumor commonly arising from the posterior spinal nerves and ganglia. Two variants have been described, psammomatous and nonpsammomatous. 50% of psammomatous tumors are associated with Carney complex. The biologic behavior of the tumor is difficult to predict and slightly over 10% of the tumors follow malignant course. We present a case of psammomatous melanotic schwannoma as part of Carney complex in a 67-year-old male. Clinical examination revealed oral mucosal and abdominal skin pigmentation. Magnetic resonance imaging showed an intradural extramedullary lesion at D8-D12 level. Intraoperative squash smear study showed sheets of spindle cells with abundant intracytoplasmic melanin pigmentation and few psammoma bodies. Based on clinical, radiologic, and histopathological findings with immunohistochemistry correlation a final diagnosis of psammomatous melanotic schwannoma was rendered.
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Mesenchymal dysplasia of placenta p. 371
Krishna G Balachandran Nair, Minu Srinish, Preesha Balan, Santha Sadasivan
DOI:10.4103/0377-4929.162904  PMID:26275269
A rare case of placental mesenchymal dysplasia (PMD) in a 26-year-old patient is reported. Ultrasound scan at 17 weeks of gestation showed placenta with multiple cystic spaces and a normal appearing fetus. Following delivery of a term live baby, histological examination of the placenta was suggestive of PMD. The early recognition of this rare condition by characteristic ultrasonographic findings is herein emphasized and hence that PMD is distinguished from molar pregnancy.
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Acute postinfectious glomerulonephritis with a large number of crescents caused by Mycoplasma pneumoniae p. 374
Xinghua Chen, Wanwen Xu, Juan Du, Huiming Wang
DOI:10.4103/0377-4929.162907  PMID:26275270
Mycoplasma pneumoniae-induced acute postinfectious glomerulonephritis has various pathological changes and relatively poor prognosis. It often occurs in children, barely in adults. Currently, no clear treatment guidelines have been established for its treatment using glucocorticoid and immunosuppressive. In this study, we report an adult who admitted to our hospital due to fever and gross hematuria. The patient presented with nephritic syndrome and renal failure and confirmed to have M. pneumoniae infection by serum detection and acute postinfectious glomerulonephritis with a large number of crescents by renal biopsy. He was given glucocorticoid, immunosuppressive agent combined with hemodialysis as well as other supportive treatment. Three months later, his renal function became normal, urine protein level decreased to 0.4 g/24 h, and the C3 complement increased to normal level. In conclusion, glucocorticoid and immunosuppressive treatment should be given to patients with M. pneumoniae-infection induced glomerulonephritis after confirmed to have a large number of crescents by renal biopsy and the treatment could improve the prognosis.
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Blastic plasmacytoid dendritic cell neoplasm presenting as leukemia without cutaneous involvement in a 25 years male patient: Unusual presentation of a rare entity p. 377
Sumaira Qayoom, Garima Durga, Seena George, Khaliqur Rahman
DOI:10.4103/0377-4929.162912  PMID:26275271
Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare, aggressive neoplasm classified under "acute myeloid leukemia (AML) and related precursor neoplasm" by current WHO classification. Elderly male are commonly affected with cutaneous lesion being the hallmark of disease presentation. The disease progresses rapidly and sooner or later involves bone marrow and peripheral blood. Cases presenting primarily as leukemia without cutaneous involvement is a rarity with about 29 cases reported in literature till date. Characteristic immunophenotype of CD4 + /CD56 +/− cells expressing antigens associated with plasmacytoid dendritic cells like CD123, TCL1, BDCA2/CD303, cutaneous lymphocyte-associated and interferon dependent molecule MxA, in absence of any other lineage specific marker confirms the diagnosis. The disease has a poor survival and no standardized therapeutic strategy in the current scenario. A case of 25-year-male presenting with leukemic BPDCN without cutaneous involvement is presented here, who was treated with AML like protocol followed by hematopoietic stem cell transplantation, but succumbed to the disease within 8 months of diagnosis. The present case is being first to be reported from India.
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Early onset mixed cryoglobulinemia in hepatitis C p. 381
Kritika Krishnamurthy, Sudhesna Mohapatra, TK Mishra, Nikhil Jha
DOI:10.4103/0377-4929.162914  PMID:26275272
Cryoglobulinemia is one of the most common forms of extrahepatic manifestation of chronic hepatitis infection. The phenomenon is generally seen after several years of chronicity predominantly in the female population resulting in arthralgias, purpuras, and other symptoms, due to vasculitis. Here we present a case of incomplete mixed cryoglobulinemia Type III (as per Brouet's classification) in a young boy aged 13 years who presented with an unusual symptom of pruritus. Diagnosis was confirmed by cryoprecipitation test followed by immunofixation. We aim to highlight the difficulty in diagnosis of this rare case/presentation, important investigation pitfalls and how to avoid them.
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Brevundimonas diminuta bacteremia in a man with myelodysplastic syndromes p. 384
Huiling Cao, Min Li, Xuewen Yang, Chunbing Zhang
DOI:10.4103/0377-4929.162920  PMID:26275273
Brevundimonas diminuta are ubiquitous in the environment, but are infrequently isolated from clinical samples. Here we report a case of B. diminuta bacteremia in a man with myelodysplastic syndromes (MDS) at a teaching hospital in China and review the previously reported cases. The organism was confirmed by culture and 16s rRNA sequence analysis with highly sensitivity to broad-spectrum antibiotics. Our report and other cases demonstrated that the optimal therapeutic duration for B. diminuta infections in various situations remains to be established.
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Subcutaneous human Dirofilariasis in Vidarbha p. 387
Sarika Prabhakar Kombade, RS Mantri, NA Ambhore, RP Karyakarte
DOI:10.4103/0377-4929.162923  PMID:26275274
Zoonotic filariasis due to Dirofilaria repens is prevalent in several regions of the world. Human dirofilariasis due to D. repens has not been widely recognized in India, but few cases reported from some parts of India. Dirofilaria species are commonly encountered in the subcutaneous tissue of dogs, foxes, and cats and it can accidentally infect humans. Here, we report a case of subcutaneous dirofilariasis, presenting as a subcutaneous nodule on the right leg of a 25-year-old female from Vidarbha region.
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Cervical strongyloidiasis in an immunocompetent patient: A clinical surprise p. 389
Sasmita Panda, Asaranti Kar, Upasana Das, Niranjan Rout
DOI:10.4103/0377-4929.162927  PMID:26275275
A 32-year-old lady came for a routine gynecological check up. Her cervical cytologic smear was reported as low grade squamous intraepithelial lesion. As a part of basic routine investigation, cervical punch biopsy was done. Astonishingly it revealed multiple rhabditiform larvae of Strongyloides stercoralis. These were curved thick with pointed end and a short buccal cavity. She did not have any history of immunosuppression including steroid therapy and was otherwise normal. Extensive review of the literature on parasites encountered in cervix yielded few case reports on strongyloides in cytologic smears, but failed to reveal any report till date on S. stercoralis found in histopathology section. Our case is probably the first in the world and the first reported from India to the best of our knowledge. We describe this case of strongyloidiasis of cervix with review of the literature on various parasites encountered in the cervix because of its rarity and also to keep this parasitic infestation as a differential diagnosis of cervical lesions.
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Chlamydia pneumoniae-related hemophagocytic lymphohistiocytosis in an adult patient with clonal karyotype abnormality p. 392
Zheng-Yi Huang, Tzong-Shi Chieuh, Kwei-Shuai Hwang, Tzu-Chuan Huang
DOI:10.4103/0377-4929.162928  PMID:26275276
Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening disease characterized by a severe hyperinflammation caused by uncontrolled proliferation of activated lymphocytes and macrophages. Herein, we report a 58-year-old male who had Chlamydia pneumoniae-related pneumonia, followed by aggressive HLH. An abnormal cytogenetic profile was also detected. To our knowledge, this is the first report of an adult patient with C. pneumonia-associated HLH.
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Uncommon pathogen: Serious manifestation: A rare case of Achromobacter xylosoxidans septic arthritis in immunocompetetant patient p. 395
Kalpana Tikaram Suryavanshi, Sanjay K Lalwani
DOI:10.4103/0377-4929.162929  PMID:26275277
Achromobacter xylosoxidans is a rare opportunistic Gram-negative bacilli and rarer etiology of septic arthritis. We present here the first Indian case of septic arthritis due to A. xylosoxidans in 11-month-old male child confirmed by 16S rRNA sequencing. The child was admitted as suspected case of septic arthritis and underwent arthrotomy. Drained pus revealed Gram-negative bacilli, identified as Serratia odorifera by API (bioMérieux, Marcy l'Ιtoile, France), later subjected to VITEK 2 (bioMérieux, Marcy l'Ιtoile, France) identification revealing it to be A. xylosoxidans. It being a rare etiology of septic arthritis confirmation was done with 16S rRNA Sequencing.
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IMAGES Top

Atypical presentation of Whipple disease with no diarrhea p. 398
Ingrid Perez-Alvarez, Somaye Yekezare, X Frank Zhao, Xiangdong Xu
DOI:10.4103/0377-4929.162930  PMID:26275278
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Myiasis in vulvar carcinoma in a patient with acquired immune deficiency syndrome p. 400
Dhaneshwar Namdeorao Lanjewar, Shubhangi Aagle, Deepti Dongaonkar, Anuradha Murthy
DOI:10.4103/0377-4929.162932  PMID:26275279
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Rhinofacial entomophthoramycosis: A rare fungal infection in an adolescent boy p. 402
Shalini Bhalla, Vipul K Srivastava, Ramesh K Gupta
DOI:10.4103/0377-4929.162933  PMID:26275280
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Vibrant colors of uric acid crystals on polarization p. 404
Kusum D Jashnani, Jyothi B Shetty, Heena M Desai
DOI:10.4103/0377-4929.162935  PMID:26275281
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Subcutaneous infection by Cladosporium sphaerospermum-A rare case report p. 406
Alekhya Maduri, Rashmi Patnayak, Anju Verma, Nagaraja Mudgeti, Usha Kalawat, Thota Asha
DOI:10.4103/0377-4929.162936  PMID:26275282
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QUIZ PAGE Top

Quiz page p. 408

DOI:10.4103/0377-4929.162937  PMID:26275283
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LETTERS TO EDITOR Top

The myofibroblastic sarcoma of retroperitoneum: A diagnostic dilemma p. 409
JP Geetha, MV Rashmi
DOI:10.4103/0377-4929.162938  PMID:26275284
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Is histopathology informative for further characterization of DOTANOC-proven islet cell lesions in infancy? p. 410
Rakesh Kumar Gupta, Ravindra Kumar Saran, Pinaki Ranjan Debnath, Rajiv Chadha
DOI:10.4103/0377-4929.162939  PMID:26275285
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Primary diffuse large B-cell lymphoma of the central nervous system in pineal gland: Report of a rare case with review of literature p. 412
Jayasudha Arundhathi Vasudevan, Rekha A Nair, Sreejith G Nair, Anil Prahlada
DOI:10.4103/0377-4929.162940  PMID:26275286
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Trichosporon asahii as a cause of urinary tract infection: A rare human pathogen p. 413
Ritesh Ranjan, Priti Chowdhary, Anita Pandey, Ritika Adarsh
DOI:10.4103/0377-4929.162941  PMID:26275287
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QUIZ ANSWER PAGE Top

Quiz answer page p. 415
KP Aravindan
DOI:10.4103/0377-4929.162943  
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BOOK REVIEW Top

Fundamentals of pathology of skin p. 416
Premala Anthony Singh
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TRIBUTE Top

Remembering Prof. K. C. Das p. 417
Neelam Varma, Kanjaksha Ghosh
PMID:26275288
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