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   Table of Contents - Current issue
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April-June 2017
Volume 60 | Issue 2
Page Nos. 155-307

Online since Monday, June 19, 2017

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EDITORIAL  

From Editor's desk p. 155
Vatsala Misra
DOI:10.4103/IJPM.IJPM_323_17  PMID:28631626
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ORIGINAL ARTICLES Top

Ameloblastoma: A 16-year clinicopathological study on Goan population p. 157
Karla Maria Carvalho, Anita Dhupar, Anita Spadigam, Shaheen Syed
DOI:10.4103/0377-4929.208374  PMID:28631627
Background: Ameloblastoma is a benign slow growing tumor of odontogenic origin composed of epithelial cells that resemble enamel forming cells namely the ameloblasts however these lesional cells do not differentiate to produce enamel. They are locally aggressive and can cause severe abnormalities of the face and jaw. Aim: This study aimed to correlate the incidence and recurrence rates of ameloblastoma to the different clinical and histopathological parameters. Methods: A study on ameloblastomas in the Goan population for 16 years (1999–2014) was carried out. Archived documented data of surgically treated cases of ameloblastomas were used in this study. Results: It was revealed that out of 52 cases of ameloblastomas, a male preponderance was seen. Age predisposition was seen to favor the third-fourth decade, the most common site was the posterior aspect of lower jaw for new and recurrent cases. Conclusion: The study highlights, the possible etiological role of location influencing the incidence and recurrence rates of ameloblastomas.
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The absence of CD56 expression can differentiate papillary thyroid carcinoma from other thyroid lesions Highly accessed article p. 161
Ioana Golu, Mihaela Maria Vlad, Alis Dema, Lavinia Cristina Moleriu, Anca Tudor, Mihaela Iacob, Oana Popa, Marioara Cornianu
DOI:10.4103/0377-4929.208378  PMID:28631628
Context: The neural cell adhesion molecule CD56 is an antigen important for the differentiation of the follicular epithelium. Recent studies have reported low or absent expression of CD56 in papillary thyroid carcinoma (PTC) and its presence in normal thyroid tissue, benign thyroid lesions, and most follicular non-PTC tumors. Aim: We wish to estimate the value of CD56 in the differentiation of PTC (including follicular variant-PTC [FV-PTC]) from other nontumoral lesions and follicular thyroid neoplasias. Settings and Design: This was a retrospective, case–control study. Subjects and Methods: We analyzed the expression of CD56 in normal thyroid follicular tissue, 15 nonneoplastic thyroid lesions (nodular hyperplasia, Graves' disease, and chronic lymphocytic thyroiditis/Hashimoto), and 38 thyroid follicular cell neoplasms (25 cases of PTC). The immunohistochemical reactions were performed on sections stained with anti-CD56 antibody. Statistical Analysis Used: We used the Chi-square test, values of P< 0.05 being considered statistically significant. Risk analysis was applied on these studied groups, by calculating the odds ratio (OR) value. Results: Our results indicated that CD56 immunoexpression had differentiated PTC from benign nonneoplastic lesions (P = 0.002), as well as from follicular neoplasias (P = 0.046). There were no significant differences regarding CD56 expression between FV-PTC and classical PTC (P = 0.436). The immunoexpression of CD56 has differentiated PTC from other thyroid non-PTC lesions (P < 0.001), with 26.4 OR value. Conclusions: CD56 has been proved to be a useful marker in the diagnosis of PTC, including FV-PTC. Its absence can help differentiate FV-PTC from other thyroid nodules with follicular patterns.
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Poorly differentiated thyroid carcinoma: A hospital-based clinicopathological study and review of literature p. 167
Thin Thin Win, Nor Hayati Othman, Irfan Mohamad
DOI:10.4103/IJPM.IJPM_457_16  PMID:28631629
Introduction: Poorly differentiated thyroid carcinoma (PDTC) is a rare aggressive malignancy of thyroid follicular cells and has unique features in morphology and behavior. This study was aimed to describe the experience of a tertiary medical center with PDTC within a 10-year period. Materials and Methods: This is a descriptive retrospective study of eight cases of PDTC among 418 various thyroid carcinomas. All cases of PDTC were retrieved along with the clinicopathological information. Results: Only eight cases (1.9%) of PDTC were diagnosed among 418 thyroid carcinomas. Mean age was 48.12 with 3:5 (male:female) and tumor size ranged 3–12 cm. PDTC were diagnosed coexisting with one or more other pathologies; nodular hyperplasia (four cases), papillary carcinoma (one case), follicular carcinoma (three cases), and Hashimoto thyroiditis (two cases); with ≥60% PDTC component. Six cases associated with high-grade features died within 3 years after diagnosis. Discussion: Mean age in this study was younger including a 20-year-old girl. Younger age was associated with better prognosis. Most of the cases had underlying benign thyroid lesions and differentiated thyroid carcinoma. Most of the PDTC had poor prognosis associated with PDTC component ≥60%, tumor necrosis, high mitotic count, lymph node involvement, vascular invasion and distant metastasis; and these cases died within 3 years after diagnosis. Conclusion: Although treatment of PDTC remains surgery followed by radioiodine therapy, correct histopathological diagnosis is important for clinicians and oncologists to predict the prognosis. All thyroid carcinoma should be sampled thoroughly not to miss small foci of PDTC component.
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Diagnostic value of immunohistochemistry staining of Bcl-2, CD34, CD20 and CD3 for distinction between discoid lupus erythematosus and lichen planus in the skin p. 172
Mazaher Ramezani, Bita-Sadat Hashemi, Sedigheh Khazaei, Mansour Rezaei, Ali Ebrahimi, Masoud Sadeghi
DOI:10.4103/0377-4929.208381  PMID:28631630
Background: Cluster of differentiation (CD) markers is a classification system for monoclonal antibodies against cell surface molecules on leukocytes and antigens from other cells. Aims: The aim of this study is to evaluate immunohistochemical markers in patients with discoid lupus erythematosus (DLE) and lichen planus (LP) and correlation of these markers in two groups and with the normal group in the West of Iran. Settings and Design: Analytical cross-sectional study. Materials and Methods: This study was performed on paraffin blocks of DLE and LP patients with normal group (21, 21 and 16 cases, respectively) between 2009 and 2012. Formalin-fixed, paraffin-embedded tissue sections from each DLE, LP, and normal skin biopsy specimen were cut into 4-μ thick sections and mounted on glass slides. Initial sections were stained with hematoxylin and eosin. Primary antihuman antibodies against CD3, CD20, CD34, and Bcl-2 were applied. Positive control samples for CD3, CD20, and Bcl-2 were received from lymph nodes and for CD34 from dermal microvessels. Statistical Analysis Used: SPSS version 19 (SPSS, Inc., Chicago, USA) and Microsoft Excel 2007. Results: The mean staining for four markers was more significant in DLE and LP groups compared to normal group and for CD34 and CD3 was more significant in LP groups versus DLE group. Conclusions: CD3+, CD34+, Bcl-2+, and CD20+ cells are significantly higher in DLE and LP lesional skins versus normal skin. In addition, there were higher expressions of CD3 and CD34 in LP lesional skin versus DLE lesional skin.
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Ki-67 evaluation in breast cancer: The daily diagnostic practice p. 177
Lukasz Fulawka, Agnieszka Halon
DOI:10.4103/IJPM.IJPM_732_15  PMID:28631631
Context: Breast cancer is the most common malignancy in females. It is routinely classified according to the WHO histological typing. However, there is also a molecular classification of breast cancer which is routinely substituted with surrogate subtypes based on expression of estrogen, progesterone, and human epidermal growth factor receptor 2 receptors and proliferation index (PI). PI is defined as the percentage of Ki-67-positive cells among overall cell population. The method commonly applied by pathologists to determine PI is visual scoring of the sample. Strict recommendations for PI assessment do not exist. Thus, the mode of PI evaluation differs significantly between pathologists. Aims: The aim of our study was to evaluate the daily approach to defining the PI. Settings and Design: Four practicing nonscholar pathologists were asked to evaluate PI in cases of invasive breast carcinoma. Subjects and Methods: The study was performed on a group of 98 patients diagnosed with invasive breast carcinoma. Immunohistochemical reaction was performed with monoclonal antibody against human Ki-67 antigen using Ventana BenchMark XT. Statistical Analysis Used: Results were compared using Pearson's and Spearman's rank correlation coefficients and Fleiss and Cohen's kappa values. Results: Statistical analysis showed pairwise Pearson's coefficients ranging between 0.77 and 0.84 (P < 0.001) and Spearman's rank correlation coefficients ranging between 0.68 and 0.83 (P < 0.001). The Fleiss kappa value for the 14% cutoff point was 0.58 whereas for the 20% cutoff point was 0.60. The pairwise Cohen's kappa values ranged from 0.45 to 0.69 for the 14% cutoff point and 0.53 to 0.67 for the 20% cutoff point. Friedman's rank ANOVA test showed significant differences among the four pathologists (P < 0.001). Conclusions: Our study shows a significant difference in results and methods of evaluation of PI between pathologists.
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Risk of cardiac pacemaker pocket infection in a tertiary care hospital p. 185
Jaswinder Singh Gill, Navreet Singh, SP Khanna
DOI:10.4103/IJPM.IJPM_190_16  PMID:28631632
Background: The risk of pacemaker pocket infections (PPIs) is rare with good antisepsis techniques and use of advanced antibiotics. However, injudicious antibiotic usage leads to the rise of multidrug-resistant bacteria, which may cause PPI. Few reports exist about the microbial spectrum of the PPI from our country, prompting us to study the same. Methods: We conducted this retrospective observational study for 3 years (January 2013–February 2016) from all the patients with PPI. We collected the relevant clinical samples (blood and pus) for the microbial culture using a standard protocol. We included 100 samples collected from the medical staff and the hospital environment as a control sample. The data were analyzed using appropriate statistical methods and a P< 0.05 was considered statistically significant. Results: Our data showed that 17 out of 160 (10.6%) patients had PPI. Coagulase negative Staphylococcus sp. was isolated in 7 (41.2%) patients, followed by Staphylococcus aureus in 4 patients (23.5%). Other isolated bacteria include multidrug-resistant Burkholderia cepacia (n = 3), Mycobacterium abscessus (n = 2) and polymicrobial infection in a single patient. One out of hundred surveillance samples grew B. cepacia. Conclusion: Our data revealed a high incidence of Gram-positive cocci causing PPI. Every hospital should formulate their antibiotic policy based on the pattern of the hospital flora and their drug sensitivity.
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Significance of vascular endothelial growth factor and CD31 and morphometric analysis of microvessel density by CD31 receptor expression as an adjuvant tool in diagnosis of psoriatic lesions of skin p. 189
Nitika Chawla, Sant Prakash Kataria, Kamal Aggarwal, Pardeep Chauhan, Dinesh Kumar
DOI:10.4103/IJPM.IJPM_862_15  PMID:28631633
Background: Pathogenesis of psoriasis is a debated issue. Several mechanisms have been proposed to identify the etiology and pathogenesis so that specific treatments can be given to patients with psoriasis. Aims: (1) To compare pattern and distribution of vascular endothelial growth factor (VEGF) and CD31 in patients with psoriasis and other psoriasiform lesions of skin. (2) To study the correlation between VEGF and CD31 expression, clinical severity, and histopathology of psoriasiform lesions of skin. (3) Evaluation of microvessel density (MVD) by using computer-assisted quantitative image analysis in psoriatic skin lesions. Materials and Methods: This study was conducted on eighty cases, out of which forty were diagnosed cases of psoriasis and forty cases of clinically suspected psoriasiform lesions, submitted in the Department of Pathology, Pt. B.D. Sharma, University of Health Sciences, Rohtak, for histopathological examination. Histopathological sections were stained by routine hematoxylin and eosin staining, and these biopsies were further subjected to immunohistochemical staining with VEGF and CD31 as per standard technique. Results: Assessment of various histopathological features revealed strong correlation between epidermal hyperplasia, suprapapillary thinning, and elongation of rete ridges. Suprabasilar keratinocytes in psoriatic lesions stained intensely for VEGF. The difference for number of microvessels and MVD in psoriasis and psoriasiform lesions was statistically significant. Correlation between intensity of VEGF staining by suprabasilar keratinocytes and MVD was found to be highly significant in psoriatic lesions. Conclusion: The present study concluded that psoriatic lesions exhibit potent angiogenic activity. Early lesions show increased MVD along with other histomorphological parameters such as hypogranulosis, parakeratosis and Munro's microabscesses. Overexpression of VEGF by suprabasilar keratinocytes correlated with increased MVD in papillary dermis.
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Phenotypic and molecular characterization of cefotaximases, temoniera, and sulfhydryl variable β-lactamases in Pseudomonas and Acinetobacter isolates in an Indian tertiary health-care center p. 196
Sana Jamali, Mohammed Shahid, Farrukh Sobia, Anuradha Singh, Haris M Khan
DOI:10.4103/0377-4929.208377  PMID:28631634
Background: Cefotaximases (CTX-M), temoniera (TEM), and sulfhydryl variable (SHV) constitute a rapidly growing cluster of enzymes that have disseminated geographically. They are spreading to species other than Enterobacteriaceae and might be responsible for the presence of blaCTX-M,blaTEM, and blaSHVgenes in Pseudomonas and Acinetobacter spp. The present study was designed to characterize CTX-M, TEM, and SHV phenotypically and genotypically in Pseudomonas and Acinetobacter spp. Materials and Methods: A total of 90 isolates (73 Pseudomonas and 17 Acinetobacter spp.), resistant to any of the third-generation cephalosporins, were randomly selected from clinical samples. Results: Of 90 isolates, 64 (71.11%) were tested positive for extended-spectrum β-lactamase (ESBL) production. Among phenotypically tested ESBL producers, forty isolates were randomly selected for molecular characterization. The prevalence of CTX-M, TEM, and SHV was found to be 57.5%, 15%, and 75%, respectively. Multiplex polymerase chain reaction assay categorized blaCTX-Mgenes into Groups 1 and 26 where Group 1 was present in only 5 isolates and Group 25 was present in rest of the 18 isolates. Conclusion: This is among the premier systemic reports from India documenting phenotypic and molecular characterization of CTX-M, TEM, and SHV β-lactamases in Pseudomonas and Acinetobacter spp. With judicious use of antibiotics and strict infection control procedures, it may be possible to limit the effects of these newer β-lactamases.
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Cytocentrifuged biopsy fixative preparation: A simple cost-effective technique facilitating microscopic diagnosis of lumen-dwelling intestinal parasites p. 202
Prashant Joshi, Prasenjit Das, Venkateswaran Iyer, Siddharth Datta Gupta
DOI:10.4103/IJPM.IJPM_417_16  PMID:28631635
Objective: Direct microscopic visualization is the most specific method for detecting intestinal parasites and is commonly achieved by stool examination or mucosal biopsy. However, postfixation, the intestinal biopsy fragment is often curled, and the entire surface of the biopsied mucosa is seldom viewed microscopically. Tissue processing further distorts morphology of the organisms and causes diagnostic difficulties. Examining multiple sections for parasite detection is time-consuming and often requires aid of special stains and/or immunohistochemistry. To overcome these disadvantages, we hypothesized that the fixative in which biopsies are transferred may provide a valid representation of the biopsied mucosal surface and therefore aid in the identification of mucosal surface parasites.Materials and Methods: Formalin in which biopsies were transferred was retained, stored at 4°C and processed with a cytocentrifuge. Totally, 120 consequent duodenal biopsy fixatives were processed in this way and the cytocentrifuged smears visualized after May-Grunwald-Giemsa staining. Findings of these smears were correlated with their corresponding formalin fixed paraffin embedded tissue sections.Results: Cytocentrifuged formalin preparations were found to be representative of the mucosal surface contents. Giardia trophozoites were visualized in 10/120 preparations with distinct morphological characteristics which were seldom appreciable in tissue sections, eliminating the need for special stains. Furthermore, two of the corresponding histology sections did not demonstrate the parasites despite step sections, while in one case few parasites could be identified in the step sections. Conclusions: Cytocentrifuged fixative preparation is a simple and cost-effective technique which can be routinely employed for intestinal parasite characterization.
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Profiling of peripheral T-cell lymphomas in Kerala, South India: A 5-year study p. 206
Rekha A Nair, Jayasudha Arundhathi Vasudevan, Priya Mary Jacob, Renu Sukumaran
DOI:10.4103/IJPM.IJPM_762_16  PMID:28631636
Background: Peripheral T-cell lymphomas (PTCLs) are non-Hodgkin's lymphomas (NHLs) with considerable variation in incidence across the world. They show a wide variety of clinicopathological features and generally associated with poor clinical outcome. Lymphoma data from different geographic regions will definitely aid in routine clinical practice and research work. PTCLs are reported with a higher frequency in Asia as compared to Western countries. Objective: The objective of this study was to analyze the frequency and distribution of PTCLs diagnosed in a tertiary care cancer center in Kerala. Materials and Methods: This was a retrospective study carried out in the Division of Pathology, Regional Cancer Centre, Thiruvananthapuram, for 5 years from January 1, 2011, to December 31, 2015. All PTCLs diagnosed during this period were reviewed and then classified according to the 2016 revision of the World Health Organization classification of lymphoid neoplasms. Statistical significance of the results was evaluated using Chi-square test. Results: Among the total 3108 cases of lymphomas diagnosed at our center, 2404 cases were NHLs (77.35%). PTCLs (n = 333) contributed 13.85% of all NHLs. Among these, PTCL, not otherwise specified, constituted the most common subtype (92 cases, 27.63%), followed by angioimmunoblastic T-cell lymphoma (79 cases, 23.72%), anaplastic large cell lymphoma (75 cases, 22.52%), mycosis fungoides (28 cases, 8.40%), and adult T-cell leukemia/lymphoma (ATLL) (28 cases, 8.40%). Conclusion: This is the largest study on PTCLs reported from Kerala. We document that the frequency of PTCLs is higher than that reported from Western studies. The frequency of ATLL reported from Kerala is much higher than that reported from other states.
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An integrated genomic profile that includes copy number alterations is highly predictive of minimal residual disease status in childhood precursor B-lineage acute lymphoblastic leukemia p. 209
Nikhil Patkar, PG Subramanian, Prashant Tembhare, Sneha Mandalia, Gaurav Chaterjee, Nikhil Rabade, Rohan Kodgule, Karishma Chopra, Asma Bibi, Swapnali Joshi, Shruti Chaudhary, Russel Mascerhenas, Pratibha Kadam-Amare, Gaurav Narula, Brijesh Arora, Shripad Banavali, Sumeet Gujral
DOI:10.4103/IJPM.IJPM_466_16  PMID:28631637
Introduction: Copy number alterations (CNA) have been described in childhood precursor B-lineage acute lymphoblastic leukemia (B-ALL) which in conjunction with chromosomal abnormalities drive leukemogenesis. There is no consensus on the clinical incorporation of CNA in B-ALL. An integrated genomic classification (IGC) has been proposed which includes CNA and cytogenetics. Methods: We correlated this IGC with immunophenotypic minimal residual disease (MRD) as well as other standard criteria for 245 patients of B-ALL such as National Cancer Institute (NCI) risk, D+8 prednisolone response, cytogenetics, and ploidy status. Results: MRD was detectable in 81 patients (33.1%). The most common abnormalities were seen in CDKN2A/B (25.7%) followed by PAX5(20%), ETV6(16.7%), IKZF1(15.5%), Rb1(5.3%), BTG (3.3%), EBF1(2.0%), and PAR1(0.8%). On integrating CNA into the IGC, 170 patients (69.4%) were classified into good genomic risk (GEN-GR) whereas 75 (30.6%) belonged to the poor genomic risk (GEN-PR) category. The IGC showed a significant correlation with MRD and NCI risk. The presence of CNA predicted MRD clearance in intermediate cytogenetics group. Conclusion: These data seem to indicate that in addition to cytogenetics, CNA should be incorporated into routine clinical testing and risk algorithms for B-ALL. The IGC is of prognostic relevance and offers an additional avenue for prognostication and risk-adapted therapy.
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Clinicomicrobiological profile of endophthalmitis: A 10 year experience in a Tertiary Care Center in North India p. 214
Gita Satpathy, Niranjan Nayak, Meenakshi Wadhwani, Pradeep Venkwatesh, Atul Kumar, Yograj Sharma, Vishnu Sreenivas
DOI:10.4103/IJPM.IJPM_794_15  PMID:28631638
Purpose: To determine the clinicomicrobiological profile of infectious agents and their antibiotic susceptibility in different type of endophthalmitis. Methods: A retrospective review of clinical and microbiological records from January 2001 to December 2010, was performed in 1110 patients diagnosed with different type of endophthalmitis (postoperative, posttraumatic, endogenous and post keratitis) to record the demographic details, clinical presentations; microbiological agents isolated with their antimicrobial sensitivity pattern. Antimicrobial susceptibility testing for various culture positive isolates (bacterial/fungal) was performed by the disc diffusion technique. Results: Out of the 1110 intra-ocular specimens processed, 384 (34.6%) were positive for bacteria. S epidermidis was the most predominant isolate accounting for 42.7% of all bacteria obtained, followed by Pseudomonas aeruginosa (24.5%). Besides Pseudomonas, Acinetobacter spp. were the next common gram negative bacilli detected (8.3%) followed by Klebsiella, E. coli, Enterobacter and Alkaligenes in 2.6%, 0.8%, 0.8% and 0.5% cases respectively. The predominant fungal species were Aspergillus spp., in 36.1%, followed by Fusarium spp. in 26.4% cases. Overall susceptibility pattern in our study showed that gram positive bacteria were most susceptible to glycopeptides like vancomycin (80-100%) and fluoroquinolones (87-91%). The sensitivity pattern of gram negative organisms like Pseudomonas and Klebsiella towards fluoroquinolones ranged between 61% - 82%. Conclusion: S epidermidis was the most common bacteria isolated in postoperative and posttraumatic endophthalmitis, Pseudomonas aeruginosa was the most common bacterial isolated in posttraumatic endophthalmitisAmongst fungi Aspergillus was the most common organism.
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Prevalence of Clostridium difficile infection among the patients attending a tertiary care teaching hospital p. 221
Lavanya Segar, Joshy M Easow, Sreenivasan Srirangaraj, Mohammad Hanifah, Noyal M Joseph, KS Seetha
DOI:10.4103/0377-4929.208383  PMID:28631639
Background: Clostridium difficile, a most important nosocomial enteric pathogen, is recognized globally as responsible for antibiotic-associated diarrhea and colitis. It is associated with considerable morbidity and mortality due to widespread use of antibiotics. Aims: The study was done to determine the prevalence of C. difficile infection (CDI) among the patients attending a tertiary care teaching hospital in Puducherry. Settings and Design: We performed a prospective cohort study in Mahatma Gandhi Medical College and Research Institute. Materials and Methods: Around 150 patients were evaluated along with the patient details. C. difficile toxin detection was done as per the standard algorithm using the C. Diff Quik Chek Complete® assay (TECHLAB, Blacksburg, VA, USA). Statistical Analysis Used: Analysis was done using statistics software (SPSS 16.0, SPSS Inc., Chicago, IL, USA). Results: The prevalence of CDI was found to be 4%. More toxin-positive cases were between 50 and 60 years of age, and there was no difference in gender. Intensive Care Unit showed more toxin-positive cases; however, there was no significant association between the occurrence of CDI and the primary diagnosis of the patients. Conclusions: The prevalence of CDI in our hospital was found to be 4%, which was relatively lower compared to other Indian studies. However, awareness of the risk factors may assist in identifying patients at higher risk for CDI, guide implementation of appropriate preventive measures, and modulate potential intervention measure during management.
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Concept map as an adjunct tool to teach pathology p. 226
Shivayogi R Bhusnurmath, Bharti Bhusnurmath, Shefali Goyal, Safina Hafeez, Ashraf Abugroun, John Okpe
DOI:10.4103/0377-4929.208410  PMID:28631640
Context: Concept maps (CMs) were tested for their effectiveness in teaching pathology in a conceptual manner. Aims: To correlate the quality of CMs drawn by students with their performance on tests involving clinical problem-solving. Subjects and Methods: Students were taught “how, why, and so what” about CMs at the start of the course. Each student drew one CM every week and a minimum of ten throughout the course and submitted them for evaluation and corrections. The course which is offered twice a year (approximately 600 students in each class) generates approximately 12,000–13,000 CMs each year. Two thousand nine hundred CMs from 290 students in one class were included in the study. Each CM was scored by three authors independently. The students' scores on the CMs were correlated with their scores on the midterm and final examinations. Statistical Analysis Used: Wilcoxon signed-rank test and Spearman's rank-order correlation. Results: The mean scores for the CMs at the course's midterm and final were 59% and 69.7%, and the mean scores for the examinations were 76% and 84.2% on the midterm and finals, respectively. There was a highly significant correlation between the CM scores and examination scores (P < 0.0001). Conclusion: CMs proved to be a great tool to teach pathology effectively.
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BRIEF COMMUNICATIONS Top

Placental histopathological findings in preterm/term and early/late onset small for gestation age: Are they significant? p. 232
Rachna Agarwal, Akanksha Tiwari, Neelam Wadhwa, Gita Radhakrishnan
DOI:10.4103/IJPM.IJPM_390_16  PMID:28631641
We undertook a prospective comparison of placental histopathological findings in preterm versus term and early onset versus late onset small for gestation age (SGA) to find more information on the etiological aspects of this disorder. A total of 130 women with nonanomalous SGA were allocated into preterm (n = 60); term (n = 70); early onset (n = 9) and late onset (n = 121) groups. The blinded intergroup placental histopathology comparison was performed both qualitatively (type of lesion) and quantitatively (number of the lesion). All SGA placentae showed varying number of maternal underperfusion (MUP), fetal under perfusion, inflammatory, and others lesions. There was a slight higher percentage of placenta having MUP in preterm and early onset SGA. Perivillous fibrin deposition was peculiar for placenta of preterm SGA (P = 0.043). Both preterm and early onset SGA had a higher number of placental lesions, but there was no statistical difference either in type or number of the placental lesion in any of the examined groups.
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Sporadic occurrence of cryptococcal meningitis in HIV-seronegative patients: Uncommon etiology? p. 236
Shukla Das, Shyama Datt, Priyamvada Roy, Rumpa Saha, Immaculata Xess
DOI:10.4103/IJPM.IJPM_599_16  PMID:28631642
Cryptococcosis in HIV-seronegative patients is rarely reported from India. This prospective study was conducted to look for cryptococcal meningitis in HIV-seronegative individuals and compare their laboratory features to cryptococcal meningitis in HIV-seropositive patients. Cerebrospinal fluid was collected from 153 suspected cases of meningitis and subjected to India ink preparation, antigen detection, and culture. Nineteen samples tested positive for Cryptococcus neoformans infection. Seventeen and two patients were HIV reactive and nonreactive, respectively. In vitro susceptibility of C. neoformans isolates to fluconazole and amphotericin B was performed using standard broth microdilution method and E-test. Eighteen strains were susceptible to amphotericin B, while fluconazole was reported susceptible in 15 strains. Hence, index of suspicion of C. neoformans infection as possible cause of meningitis must be maintained even in HIV-negative patients. Use of amphotericin B for treating C. neoformans meningitis should be restricted to prevent any increase in resistance.
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Multidrug-resistant tuberculosis detection and characterization of mutations in mycobacterium tuberculosis by genotype MTBDRplus p. 239
Rajneesh Tripathi, Shampa Anupurba
DOI:10.4103/IJPM.IJPM_53_16  PMID:28631643
Detection of drug resistance in Mycobacterium tuberculosis by conventional phenotypic drug susceptibility testing methods requires several weeks. Therefore, molecular diagnostic tests for rapid detection of multidrug resistance tuberculosis (MDR-TB) are urgently needed. Early diagnosis helps in initiating optimal treatment which would not only enable cure of an individual patient but also will curb the transmission of drug resistance in the community. Line probe assay (LPA) has shown great promises in the diagnosis of MDR-TB. All MDR suspect patients from ten-linked districts were asked to deposit sputum samples at peripheral designated microscopy centers. The district TB officers facilitated the transport of samples collected during February 2014–December 2014 to our laboratory. The detection of rpoB gene mutations for rifampicin (RIF) and katG and inhA genes for isoniazid (INH), respectively, was performed on 663 samples by LPA. A total of 663 sputum samples from MDR suspects were received of which 321 (50.8%) were found to be MDR. Missing of WT8 along with mutation in codon S531 L was the most common pattern for RIF-resistant isolates (80.8%) and missing WT along with mutation in codon S315T1 of k atG gene was the most common pattern for INH-resistant isolates (91.3%).The MDR-TB in Eastern Uttar Pradesh, India, was found to be 50.8%. The common mutations obtained for RIF and INH in the region was mostly similar to those reported earlier.
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Evaluation of a new rapid kit, BD MGIT TBc identification test for confirmation of Mycobacterium tuberculosis complex p. 243
Gandhi Kandhakumari, Selvaraj Stephen
DOI:10.4103/IJPM.IJPM_695_15  PMID:28631644
At present, three rapid kits are available globally for the confirmation of Mycobacterium tuberculosis complex (MTBC) in cultures by MPT64 antigen (MPT64 Ag) detection. These include Capilia TB, SD Bioline, and BD MGIT TBc Identification (TBcID). The third kit is yet to be validated in India. We have tested this kit and compared with SD Bioline using conventional tests as gold standard. Seventy-one MTBC (70 M. tuberculosis and one Mycobacterium bovis) and four nontuberculous mycobacteria (NTM) were isolated from 649 clinical specimens in MGIT 960 and/or Lowenstein–Jensen slants (LJ). MPT64 Ag was detected by both TBcID and SD Bioline kits in all the 71 clinical isolates and the reference strain M. tuberculosis H37Rv. All NTM species tested were negative by the two different kits. Thus, TBcID kit showed 100% concordance in terms of sensitivity and specificity. Rapid kits confirm MTBC cultures within 15 min in contrast to several weeks' time required by conventional techniques.
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CASE REPORTS Top

Primary leptomeningeal primitive neuroectodermal tumor: A difficult entity to diagnose p. 247
Jyothy Sehgal, Murthy Murali Krishna Jagarlapudi, Murthy V.R.K. Tenneti, Syed Ameer Basha, Sundaram Challa
DOI:10.4103/0377-4929.208376  PMID:28631645
A 25-year-old male presented with difficulty in walking, loss of vision, and seizures. A clinical possibility of craniospinal meningeal pathology was considered. On computed tomography (CT) scan and magnetic resonance imaging, there was an enhancement of leptomeninges with few ring-enhancing lesions in both frontal lobes and right frontoparietal region. He was evaluated for low backache and occipital headache 2½ years earlier and was found to have communicating hydrocephalus on CT scan. He underwent ventriculoperitoneal shunt and was followed up with CT scans. Meningeal biopsy was done in the present admission, and there was a diffusely infiltrating small round cell tumor. Immunohistochemistry was done, and the tumor cells were found to be negative for glial, mesenchymal, melanotic, and lymphoid markers. The cells were positive for neuron-specific enolase, chromogranin, and vimentin. A diagnosis of primitive neuroectodermal tumor involving the meninges was made. A possibility of primary leptomeningeal tumor extending to parenchyma was considered based on the clinical progression. Patient was treated with chemotherapy and radiotherapy. He improved partially and was stable at 3-year follow-up.
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Primitive neuroectodermal tumor presenting as a presacral mass: A rare case report with review of literature p. 250
Pradnya S Bhadarge, Sonali S Datar, Pradeep S Umap, Alok C Shrivastava
DOI:10.4103/IJPM.IJPM_445_16  PMID:28631646
Primitive neuroectodermal tumors (PNETs) are a group of highly malignant small round cell tumor (SRCT) of neuroectodermal origin. They exhibit a great diversity in their clinical manifestations and pathologic similarities with other SRCTs. PNET commonly occurs in the central nervous system, head and neck region, paravertebral region, pelvis, and lower extremities. PNET presenting as a presacral mass is very rare. We present a case of 65-year-old female patient presented with a mass in the abdomen. Exploratory laparotomy with excision of mass was carried out. Histopathology revealed the diagnosis of PNET. The rarity of PNET at presacral region prompted the description of this case.
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Intrahepatic biliary cystadenoma with ciliary metaplasia: Report of a rare morphological variant p. 253
Gaurav Khanna, Pragya Sharma, KS Madhusudhan, Adarsh Barwad, Piyush Ranjan, Biplab Mishra, Prasenjit Das
DOI:10.4103/0377-4929.208394  PMID:28631647
Histological diagnosis of biliary cystadenoma is based on the type of epithelial cells lining the cyst and radiological features. The cyst-lining cells are not usually ciliated. We herein report a very rare example of an intrahepatic biliary cystadenoma with ciliated epithelial lining, which had taken us away from this diagnosis toward an intrahepatic foregut duplication cyst. Radiologically, also the lesion was deceptive, and a possibility of hydatid cyst was considered. However, immunohistochemical workup finally led us to this diagnosis. This report would document this rare morphological variant, which may pose diagnostic difficulty.
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Leiomyosarcoma of inferior vena cava with intracardiac extension presenting as Budd-Chiari syndrome: Report of a rare case p. 256
Kaniyappan Nambiyar, Arvind Ahuja, Minakshi Bhardwaj
DOI:10.4103/IJPM.IJPM_782_15  PMID:28631648
Primary leiomyosarcoma of vascular origin is a rare malignant smooth muscle tumor. This report describes a case of primary leiomyosarcoma of the inferior vena cava (IVC) in a 52-year-old male who presented with complaints of abdominal pain, chest pain, and bilateral lower limb swelling for 4 months. Imaging of the chest and abdomen revealed a mass in the IVC extending into right atrium, heterogeneous enhancement of liver, hepatosplenomegaly, and ascites. Histopathological examination showed a malignant spindle cell tumor with cells arranged in fascicular and hemangiopericytomatous pattern. Immunohistochemistry for smooth muscle actin and desmin confirmed smooth muscle origin of the tumor. Recognition of this tumor in this rare location and Budd-Chiari syndrome-like presentation is imperative for proper management of the patient.
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Chlamydia trachomatis proctitis masquerading as carcinoma rectum: First case report from India p. 259
Benu Dhawan, Govind Kumar Makharia, Deepak Juyal, Sujeesh Sebastian, Riti Bhatia, Neena Khanna
DOI:10.4103/IJPM.IJPM_114_16  PMID:28631649
While proctitis is caused both by infectious and noninfectious causes, infectious causes are acquired typically sexually. Chlamydia trachomatis, which is the most frequent bacterial pathogen causing sexually transmitted infections worldwide, is one of the causative agents of proctitis. We report a case history of a bisexual male who presented to us with rectal bleeding. The colonoscopy showed a nodular ulcerated lesion in the rectum suggestive of rectal malignancy, but biopsies from rectal mass did not reveal malignancy. A rectal biopsy was positive for C. trachomatis by polymerase chain reaction assay, and a diagnosis of C. trachomatis proctitis was made. Considering the invasive anorectal disease and patient's sexual history, he was treated with prolonged doxycycline therapy as per Centres for Disease Control and Prevention's treatment recommendation for lymphogranuloma venereum. A high index of clinical suspicion along with appropriate microbiological testing can clinch the diagnosis of C. trachomatis infection.
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Extraskeletal mesenchymal chondrosarcoma at unusual location involving spleen and kidney with review of literature p. 262
Krushna Chandra Pani, Mahima Yadav, P Valli Priyaa, Niraj Kumari
DOI:10.4103/IJPM.IJPM_16_16  PMID:28631650
Mesenchymal chondrosarcoma (MC) is a rare malignant neoplasm bearing characteristic dimorphic pattern histologically. We describe two rare cases of primary MC involving two different visceral organs (1) a 24-year-old man with solid renal mass and, (2) a 42-year-old man with cystic splenic mass. The histological and immunophenotypical features of both lesions were classical of MC. Although this lesion is uncommon in visceral organs, the possibility of this rare entity must be kept in differential diagnosis with compatible morphology.
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Follicular variant of peripheral T-cell lymphoma p. 265
Archana Lakshmanan, S Annapurneswari, Sheila Nair
DOI:10.4103/IJPM.IJPM_710_16  PMID:28631651
Globally, peripheral T-cell lymphomas (PTCLs) constitute about 12% of all non-Hodgkin lymphomas, of which the unspecified category is the most common subtype (30%). Mostly, the unspecified category shows a diffuse pattern of involvement in the lymph nodes. However, rarely, they may show a follicular/nodular pattern mimicking a follicular lymphoma. We report a case of a follicular variant of PTCL, not otherwise specified. This case displayed a striking nodular/follicular pattern with an admixture of small (centrocyte-like) and large (centroblast-like) cells, thus mimicking a follicular lymphoma. The neoplastic cells were strongly positive for both CD3 and CD20. In addition, they were positive for pan T-cell markers and PD-1. T-cell receptor gene rearrangement studies highlighted a monoclonal T-cell population. Even though this variant of PTCL is very rare, it is important to keep it as a differential for the lymphomas exhibiting nodular pattern.
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Primary cutaneous large B-cell lymphoma of scalp: Case report of a rare variant p. 268
Yasmeen Khatib, Madhura Dande, Richa D Patel, Meena Makhija
DOI:10.4103/0377-4929.208414  PMID:28631652
Primary cutaneous large B-cell lymphoma (Bcl) is defined as a lymphoma composed of large cells constituting more than 80% of the infiltrate and absence of extracutaneous involvement after staging investigations. In the new World Health Organization/European Organization for Research and Treatment of Cancer classification, cutaneous Bcls with large cells are of three types - primary cutaneous large Bcl leg type (PCLBCLLT), primary cutaneous follicle center lymphoma diffuse type (PCFCLDT), and primary cutaneous large Bcls other (PCLBCLO). These three different types are distinct in terms of their clinicopathological features and survival. The PCLBCLO has intermediate features between those of PCLBCLLT and PCFCLDT. We present a case of PCLBCLO in a 57-year-old male who presented with a scalp swelling. Ultrasonography examination was suggestive of a sebaceous cyst. Computed tomography scan revealed the presence of an ill-defined hyperdense region in the soft tissue of the scalp region extending into the deeper layers of the scalp. Fine-needle aspiration cytology (FNAC) revealed the presence of atypical lymphoid cells. Diagnosis was confirmed by biopsy and immunohistochemistry. Patient received rituximab combined with doxorubicin, vincristine, cyclophosphamide, and prednisolone regimen with complete resolution of the lesion. We present this case for its rarity, the utility of FNAC in early diagnosis, and to discuss the differential diagnosis.
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Hodgkin's lymphoma with unusual pulmonary presentations: Reporting two cases p. 272
Brett Matthew Lowenthal, Xiangdong Xu, Meera Subash, Lily J Jih
DOI:10.4103/IJPM.IJPM_687_16  PMID:28631653
Classical Hodgkin's lymphoma (CHL) presenting with exclusively pulmonary symptoms is very unusual. We report two cases of CHL with atypical clinical presentations mimicking pulmonary infections. The first case represents a stage IV CHL with secondary lung involvement, and the second case demonstrates a very rare case of CHL with isolated lung involvement, also known as primary pulmonary Hodgkin's lymphoma. The second patient was initially misdiagnosed and treated with six months of antibiotics before the correct diagnosis was made by a lung biopsy. Both patients received chemotherapy; one patient achieved complete remission and the other achieved near-complete remission.
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Composite lymphoma with coexistence of diffuse large B-cell lymphoma and anaplastic large cell lymphoma: Diagnostic pitfalls p. 275
Meyyappa Devan Rajagopal, Rakhee Kar, Debdatta Basu, Sunu Lazar Cyriac
DOI:10.4103/IJPM.IJPM_139_16  PMID:28631654
Composite lymphoma is a rare tumor composed of two or more distinct lymphomas in the same topographic site or tissue. Several combinations of B-cell non-Hodgkin lymphoma (NHL), T-cell NHL, and Hodgkin lymphoma can occur with different prognoses and treatments. The coexistence of a B-cell NHL and a T-cell NHL is unusual. The exact etiology of composite lymphoma is unknown; however, few mechanisms have been proposed to explain its pathogenesis. The chemotherapeutic protocols are heterogeneous but are essentially targeted against the high-grade component. Most of the cases show worse outcome with a median survival of 12 months. In this article, we report a case of composite lymphoma which was initially diagnosed as diffuse large B-cell lymphoma, and the presence of CD3-positive atypical cells in the bone marrow urged us to re-evaluate the lymph node biopsy following which a focus of Alk-1-positive anaplastic large cell lymphoma was identified.
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ERRATUM Top

Erratum: Squash cytodiagnosis of synchronous papillary serous carcinoma of ovary and endometrium with demonstration of serous tubal intraepithelial carcinoma as a precursor lesion p. 278

DOI:10.4103/0377-4929.208417  PMID:28631655
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CASE REPORTS Top

Brevundimonas diminuta infection in a case of nephrotic syndrome p. 279
Abhilash Chandra, Anupam Das, Manodeep Sen, Meenakshi Sharma
DOI:10.4103/IJPM.IJPM_679_15  PMID:28631656
Brevundimonas has rarely been isolated from clinical specimens. We here report a case of Brevundimonas diminuta infection in an 18-year-old male patient with nephrotic syndrome. B. diminuta was identified by the VITEK 2 Compact system, following isolation from his blood sample. To the best of our knowledge, B. diminuta has not been reported in patients with nephrotic syndrome.
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Citrobacter freundii as a cause of acute suppurative thyroiditis in an immunocompetent adult female p. 282
Gursimran Kaur Mohi, Priya Datta, Jagdish Chander, Arjun Das
DOI:10.4103/0377-4929.208400  PMID:28631657
Acute suppurative thyroiditis (AST) is an uncommon condition, in the patients with preexisting thyroid disease or immunosuppression. The most common cause of AST is bacterial, and the most common bacteria are Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli, and Klebsiella species. Due to various complications such as septicemia, septic thrombophlebitis, necrotizing mediastinitis, or pericarditis, prompt diagnosis and treatment are the keys to reduce mortality and morbidity. Here, we describe a case of a 40-year-old female with AST caused by Citrobacter freundii. This is the first case report of isolation of this bacterium from AST in the world. It is important to differentiate AST from subacute thyroiditis, which is far more frequent and runs a more prolonged course. Various risk factors which predispose to this condition include structural abnormality in the thyroid gland or thyroid disease and immunocompromised state. The route of infection may be either hematogenous or lymphatic seeding. With the increase in number of immunocompromised patients, the cases of AST will increase.
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A case of Aspergillus tracheobronchitis in a patient with chronic obstructive pulmonary disease p. 285
Ming-Li Yuan, Gang Yang, Hong-Ling Hu, Wen Yin, Wei-Jun Tan, Su Zhao
DOI:10.4103/IJPM.IJPM_248_16  PMID:28631658
Aspergillus tracheobronchitis (AT) is a unique form of invasive pulmonary aspergillosis, which is commonly found in patients with impaired immunity. Early-stage AT presents in a nonspecific way, both clinically and radiographically, thereby delaying diagnosis and resulting in a high mortality. Owing to impaired mucociliary clearance, previous nonfungal infections, and administration of corticosteroids, among other aspects, patients with chronic obstructive pulmonary disease (COPD) are predisposed to AT, although they are mostly immunocompetent. AT in COPD patients has not been well recognized and the condition is often misdiagnosed or missed. We herein report a case of AT diagnosed in a male with past COPD, with the features of pseudomembranous AT upon bronchoscopy. This contradicts the opinion that pseudomembranous AT is found in severely immunocompromised hosts with hematologic malignancies.
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IMAGES Top

Subcutaneous cysticercosis presenting as cervical swelling: Amazing and unexpected cytological findings p. 288
Punam Prasad Bhadani, Iffat Jamal, Shashikant Kumar, Shuchi Smita
DOI:10.4103/IJPM.IJPM_497_16  PMID:28631659
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Crescentic C3 glomerulopathy with acquired partial lipodystrophy: An unusual cause of rapidly progressive renal failure p. 290
Smita Mary Matthai, Shibu Jacob, Raiyani Palak, K Jagdish, Santosh Varughese, V Tamilarasi
DOI:10.4103/0377-4929.208401  PMID:28631660
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Primary hydatid cyst of femur masquerading as other bone pathologies p. 292
Prachi Nayak, Palak Agarwal, Premala A Singh, Uday B Yadav
DOI:10.4103/0377-4929.208404  PMID:28631661
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LETTERS TO EDITOR Top

Pediatric nasopharyngeal carcinoma with a spectrum of precursor lesions: Cervical lymph node metastasis initially diagnosed by fine needle aspiration cytology p. 294
Dilip Kumar Das, Bahia I Haji, Mohmad Jaragh, Bency John, Kenneth C Katchy
DOI:10.4103/IJPM.IJPM_638_16  PMID:28631662
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T helper 17 cells in atopic dermatitis: Study in a tertiary care center p. 296
Sharma Sudha, Saikia Biman, Handa Sanjeev
DOI:10.4103/IJPM.IJPM_95_16  PMID:28631663
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Fine needle aspiration cytology of thyroid metastasis: An unusual presentation of cervical carcinoma; a case report and review of literature p. 298
Monika Singh, Prajwala Gupta, Minakshi Bhardwaj
DOI:10.4103/IJPM.IJPM_543_16  PMID:28631664
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Antineutrophil cytoplasmic antibody-associated vasculitis and chronic lymphocytic leukemia: A rare association p. 300
Mani Nagarajan, Jeyachandran Dhanapriya, Thanigachalam Dineshkumar, Ramanathan Sakthirajan, T Balasubramaniyan, Natarajan Gopalakrishnan
DOI:10.4103/0377-4929.208387  PMID:28631665
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5q deletion myelodysplastic syndrome p. 301
Preethi S Chari, Smitha Chander, TS Sundareshan, Sujay Prasad
DOI:10.4103/0377-4929.208396  PMID:28631666
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Pediatric plasmablastic lymphoma: Diagnostic and therapeutic dilemma p. 303
Aroonima Misra, Sameer Bakhshi, Rajive Kumar, Anita Chopra
DOI:10.4103/IJPM.IJPM_375_16  PMID:28631667
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Poly immunophenotypic expression in a case of diffuse large B-cell lymphoma p. 304
Neha Singh, Aniruddha Ketkar, Sumeet Gujral
DOI:10.4103/0377-4929.208399  PMID:28631668
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Virtual digital pathology: The future is near p. 306
Saurabh Juneja, Manjushree Juneja
DOI:10.4103/IJPM.IJPM_324_16  PMID:28631669
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