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   Table of Contents - Current issue
October-December 2015
Volume 58 | Issue 4
Page Nos. 421-575

Online since Wednesday, November 04, 2015

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From Editor's desk p. 421
Vatsala Misra
DOI:10.4103/0377-4929.168891  PMID:26549059
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Expression of apoptosis regulating proteins p53 and bcl-2 in psoriasis p. 423
Nikhil Moorchung, Biju Vasudevan, S Dinesh Kumar, Archit Muralidhar
DOI:10.4103/0377-4929.168861  PMID:26549060
Background: Dysfunctional apoptosis has an important role in the development of several skin diseases. Psoriatic keratinocytes possess an enhanced ability to resist apoptosis, which might be one of the key pathogenetic mechanisms in psoriasis. P53 and bcl-2 are two proteins which control apoptosis. Several studies have evaluated the expression of these two proteins in the psoriatic skin, but the results are controversial. Methods: Fifty-eight cases of psoriatic skin biopsies were studied, and the grade of p53 and bcl-2 immunostaining was correlated with the histopathological indices of severity. Results: Bcl-2 expression in the epidermis strongly correlated with the expression in the basal cells and lymphocytes (P – 0.001 and 0.035). There was no correlation with epidermal hyperplasia or with p53 expression in the three compartments. Bcl-2 expression in the basal layer correlated with the p53 expression in the epidermis (P – 0.027), basal layer (P – 0.015) and the lymphocytes (P – 0.034). There was a strong correlation among the p53 expression in all the compartments. There was also a weak correlation of the p53 expression in the epidermis with the epidermal hyperplasia (P – 0.042). Conclusions: Bcl-2 does not appear to play an important role in the apoptotic process in psoriasis. In contrast, it is likely that p53 has a far more important role to play. Mutation analysis of the p53 protein is necessary to evaluate if the protein has mutated or if it is of the wild type.
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The differentiation of amebic colitis from inflammatory bowel disease on endoscopic mucosal biopsies Highly accessed article p. 427
Reecha Singh, Avinash Balekuduru, Ebby George Simon, Manika Alexander, Anna Pulimood
DOI:10.4103/0377-4929.168880  PMID:26549061
Background: Intestinal amebiasis is one of the important differential diagnoses of Inflammatory Bowel Disorders in areas where it is highly prevalent. Aim: Studies comparing the clinical, endoscopic and histological features of these disorders have never been done, so we undertook this study. Materials and Methods: A retrospective study comparing mucosal biopsies of 14 consecutive cases of intestinal amebiasis with 14 cases of Ulcerative colitis and 12 cases of Crohn's disease. A total of 65 biopsies from patients with amebiasis, 56 biopsies from patients with Crohn's disease and 65 biopsies of patients with Ulcerative colitis were reviewed. Results and Conclusions: Discrete small ulcers less than 2 cm in diameter in the cecum or rectosigmoid, with intervening normal mucosa, were the most common finding on endoscopy in patients with amebiasis. On histology, necrotic material admixed with mucin, proteinaceous exudate and blood clot lining ulcers, significant surface epithelial changes such as shortening and tufting adjacent to sites of ulceration, mild chronic inflammation extending into the deep mucosa and mild architectural alteration were features of amebiasis. Trophozoite forms of ameba were seen in the necrotic material lining sites of ulceration or lying separately, as well as over intact mucosa. Necrotic material lining ulcers was less common in IBD, but chronic inflammation, crypt abscess formation and architectural alteration were more severe.
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1p/14q co-deletion: A determinant of recurrence in histologically benign meningiomas p. 433
Aanchal Kakkar, Anupam Kumar, Amitabha Das, Pankaj Pathak, Mehar C Sharma, Manmohan Singh, Ashish Suri, Chitra Sarkar, Vaishali Suri
DOI:10.4103/0377-4929.168852  PMID:26549062
Background: Meningiomas are the most common benign central nervous system tumors. However, a sizeable fraction recurs, irrespective of histological grade. No molecular marker is available for prediction of recurrence in these tumors. Materials and Methods: We analyzed recurrent meningiomas with paired parent and recurrent tumors by fluorescence in situ hybridization for 1p36 and 14q32 deletion, AKT and SMO mutations by sequencing, and immunohistochemistry for GAB1, progesterone receptor (PR), p53, and MIB-1. Results: 18 recurrent meningiomas (11 grade I, 3 grade II, 4 grade III) with their parent tumors (14 grade I, 2 grade II and 2 grade III) were identified. Overall, 61% of parent and 78% of recurrent meningiomas showed 1p/14q co-deletion. Notably, grade I parent tumors showed 1p/14q co-deletion in 64% cases while 82% of grade I recurrent tumors were co-deleted. AKT mutation was seen in two cases, in both parent and recurrent tumors. SMO mutations were absent. GAB1 was immunopositive in 80% parent and 56.3% recurrent tumors. MIB-1 labeling index (LI), PR and p53 expression did not appear to have any significant contribution in possible prediction of recurrence. Conclusion: Identification of 1p/14q co-deletion in a significant proportion of histologically benign (grade I) meningiomas that recurred suggests its utility as a marker for prediction of recurrence. It appears to be a better predictive marker than MIB1-LI, PR and p53 expression. Recognition of AKT mutation in a subset of meningiomas may help identify patients that may benefit from PI3K/AKT pathway inhibitors, particularly among those at risk for development of recurrence, as determined by presence of 1p/14q co-deletion.
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Histopathological yield in different types of bronchoscopic biopsies in proven cases of pulmonary tuberculosis p. 439
Nalini Gupta, Gurmeet C Singh, Manoj K Rana
DOI:10.4103/0377-4929.168881  PMID:26549063
Background: Diagnosis of pulmonary tuberculosis (TB) is difficult and often requires a lung biopsy. The goal of this retrospective study was to determine the histopathological parameters useful for diagnosis of pulmonary TB in different types of bronchoscopic biopsies (transbronchial lung biopsy [TBLB], transbronchial needle aspiration [TBNA], and bronchial biopsy [BB]). Materials and Methods: The records of patients diagnosed to have pulmonary TB, over a period of 1-year were evaluated. Patients with positive acid-fast bacilli (AFB) culture and with three bronchoscopic biopsies including TBLB, TBNA, and BB were included in the study. Selected (14) histological parameters were evaluated retrospectively in a total of 27 biopsies from 9 patients with TB after hematoxylin-eosin and Ziehl-Neelsen staining. Results: Diagnostic yield in TBLBs and TBNA was similar for granulomas detection (66.6% each). Granulomas in TBNA were larger, caseating and confluent as compared to small interstitial granulomas seen in TBLB. AFB was demonstrated in only one patient in TBNA. Lymphocytic cell cuffing was seen around most TBLB granulomas. One patient also showed microfilaria in blood vessel in TBLB. BBs in all patients showed the presence of goblet cell metaplasia and increased peribronchial plasma cell infiltrate with or without eosinophils may be indicative of chronic injury. The yield of granulomas was low in BBs seen in only 2 patients (22.2%). Conclusion: Diagnostic yield of TBNA and TBLB for granulomas was similar; however, caseation was seen more frequently in TBNA than on TBLB. Of other histological parameters, bronchial metaplastic changes and peribronchial plasma cells infiltrate were constant findings in all tubercular biopsies indicative of chronic injury.
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Fluorescent microscopy and Ziehl-Neelsen staining of bronchoalveolar lavage, bronchial washings, bronchoscopic brushing and post bronchoscopic sputum along with cytological examination in cases of suspected tuberculosis p. 443
Vijay Kumar Bodal, Manjit S Bal, Sunita Bhagat, Jai Kishan, Deepika , Rupinder K Brar
DOI:10.4103/0377-4929.168849  PMID:26549064
Objectives: Ever since the discovery of Mycobacterium tuberculosis in 1882, many diagnostic methods have been developed. However "The gold standard" for the diagnosis of tuberculosis (TB) is still the demonstration of acid fast Bacilli (AFB) by microscopic examination of smear or bacteriological confirmation by culture method. Materials and Methods: In suspected 75 patients with active pulmonary TB, the materials obtained bronchoscopically, were bronchoalveolar lavage (BAL), bronchial brushings, bronchial washings and post bronchoscopic sputum. Four smears were made from each of the specimen. Fluorescent Staining, Ziehl–Neelsen (ZN), Pap and May Grunwald-Giemsa (MGG) stains were carried out for cytological examination. Results: Fluorescent stain yielded maximum AFB positivity in all the methods, that is 36 (48%) in post fibre-optic bronchoscopy (FOB) sputum and 19 (25.33%) by fluorescence microscopy in both bronchial brushings and bronchial washings. Maximum yield of AFB with ZN staining 12 (16%) was equal to the post FOB sputum and bronchial brushings samples. It was followed by 6 cases (8%) in BAL and 4 (5.3%) in bronchial washings. The cytological examination was suggestive of TB in only 8 (10.66%) cases in bronchial washings and 6 (8%) cases in post FOB collection. It was equal in BAL and Bronchial brushings each that is 5 (6.67%). Conclusion: Bronchoscopy is a useful diagnostic tool and fluorescent microscopy is more sensitive than ZN and cytology. On X-ray examination, other diseases like malignancy or fungus can also mimick TB. So apart from ZN staining or fluorescence microscopy, Pap and MGG stain will be worthwhile to identify other microorganisms.
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Cytologic diagnosis of gastric submucosal lesions by endoscopic ultrasound-guided fine-needle aspiration: A single center experience in Saudi Arabia p. 448
Emad Raddaoui, Majid A Almadi, Abdulrahman M Aljebreen, Faisal Alsaif
DOI:10.4103/0377-4929.168868  PMID:26549065
Background and Aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) sampling has become standard practice for the diagnosis of submucosal gastrointestinal (GI) lesions. The aim of this study was to determine the utility of EUS-guided FNA cytology in the diagnosis of deeply seated gastric mass lesions. Materials and Methods: Thirteen patients with deeply seated gastric mass lesions were diagnosed by EUS-FNA. Adequate cytology material was present in all cases. Cell blocks were available in 10 cases. Surgical resections were performed in 8 cases. Immunohistochemical (IHC) studies were done on cell blocks in 9 cases and on 6 resected specimens. Seven cases has proved to be GI stromal tumors (GIST), in four of them, cell blocks were available, and resection for GIST was performed in 5 cases. IHC stains that were performed in cytology, as well as resection specimens, revealed similar results in each patient. Conclusion: EUS-FNA cytology, when combined with a histologic assessment of cell blocks provides accurate and efficient tissue diagnosis of a wide variety of deeply seated gastric mass lesions.
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Evaluation of immunohistochemical subtypes in diffuse large B-cell lymphoma and its impact on survival p. 453
Anamika Dwivedi, Anurag Mehta, Poonam Solanki
DOI:10.4103/0377-4929.168886  PMID:26549066
Background and Aim: Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma in Indian population. The disease could be divided into the prognostically important subtypes, germinal center B-cell (GCB)-like and activated B-cell-like, using gene expression profiling (GEP). The molecular subtype as defined by GEP could also be predicted by using immunohistochemistry (IHC) based algorithms using three biomarkers CD10, BCL-6, and multiple myeloma oncogene-1 (MUM1). It has been confirmed that patients belonging to the GCB subtype have a better outcome and survival than those belonging to the second subtype. The present study was conducted to study the prevalence of these two subgroups and their correlation with survival of the patients. Materials and Methods: A total of 83 patients of DLBCL were included in the study. Hematoxylin- and eosin-stained sections were prepared from the paraffin-embedded tissue blocks. The staining for all the three antibodies was considered positive when more than 30% cells were stained with the respective antibody. Results: The results showed that 44 patients (53%) had GCB immunophenotype and 39 patients (47%) had non-GCB phenotype. However, no statistically significant difference in overall and disease-free survival was noted between the subgroups. Conclusion: This study demonstrated that frequency of GCB subtype of DLBCL is significantly higher than the non-GCB subtype, and the non-GCB immunophenotype has better relapse-free survival 78% (standard error = 0.10) at the end of 3 years, while GCB has 56% (standard error = 0.23). Further studies should be performed with larger number of patients to show difference in clinical outcome between GCB and non-GCB subgroups.
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Volume, conductivity, and scatter parameters as diagnostic aid to bacterial sepsis: A tertiary care experience p. 459
Abhishek HL Purohit, Praveen Kumar, Subhadra Sharma, Arti Kapil, Ayush Gupta, Ashok K Mukhopadhyay
DOI:10.4103/0377-4929.168853  PMID:26549067
b>Introduction and Materials and Methods: Early diagnosis of sepsis is extremely important to reduce high mortality and morbidity. In this study, clinical usefulness of the volume, conductivity and scatter parameters (mean channels of cell volume, conductivity, and light scatter) in neutrophils was analyzed for predicting acute bacterial infection, which are obtained by the Coulter LH 750 Hematology Analyzer (Beckman Coulter, Fullerton, CA, USA) during automated differential counts. Results: Peripheral blood samples from 162 patients with positive blood cultures for bacteria and 40 healthy controls were studied. We observed a significant increase in the mean channel of neutrophil volume (MNV) from septic patients compared with control subjects (156 ± 13.5 vs. 143 ± 4.8; P < 001). Discussion and Conclusion: An elevation of the MNV was associated with a higher white blood cell count and percentage of neutrophils and was present even in patients who did not have leukocytosis or neutrophilia. With a cut-off of 149 for the MNV, a specificity of 91.4% and sensitivity of 88.7% were achieved. As a quantitative, objective, and more sensitive parameter, we propose that the MNV has a potential to be an additional indicator for acute bacterial infection.
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Association of virulence genes with mecA gene in Staphylococcus aureus isolates from Tertiary Hospitals in Nigeria p. 464
Oyebode Armstrong Terry Alli, David O Ogbolu, Adebayo O Shittu, Anthony N Okorie, John O Akinola, John B Daniel
DOI:10.4103/0377-4929.168875  PMID:26549068
Introduction: Staphylococcus aureus is the etiological agent for a wide range of human infections, and its pathogenicity largely depends on various virulence factors associated with adherence, evasion of the immune system and damage of the host. This study determined the prevalence of methicillin-resistant S. aureus (MRSA) and some selected virulence genes in clinical isolates of S. aureus from South-Western Nigeria. Materials and Methods: The antibiotic susceptibility of 156 S. aureus isolates to various antibiotics was determined. Moreover, polymerase chain reaction detection of the mecA gene was performed including SCCmec typing, and the isolates were screened for selected genes (alpha hemolysin [hla], intracellular adhesion A [icaA], Panton-Valentine leukocidin [PVL], fibronectin binding protein A [fnbA], bone sialoprotein binding protein [bbp], exfoliative toxin A [eta], exfoliative toxin B [etb], and collagen binding adhesion [cna]) associated with virulence. Results: The prevalence of mecA gene was 42.3% (66 out of 156 S. aureus), and SCCmec typing showed that 24 (36.4%) carried the SCCmec II element, 4 (6.1%) with type III, 10 (15.2%) with SCCmec IV, and 28 (42.4%) harbored type V. The proportion of S. aureus with the following genes was ascertained: Hla (55.1%), icaA (42.3%), PVL (34.6%), fnbA (8.3%), bbp (4.5%), and eta (3.8%). All the isolates were etb and cna negative. The prevalence of the PVL gene in methicillin susceptible Staphylococcus aureus (MSSA) was 53.3% compared with 9.1% of MRSA. An association between virulence genes (eta and icaA) and mecA positive S. aureus; and significant difference in the distribution of virulence genes in in-patients and out-patients were found. The MRSA strains in South-Western Nigeria were dominated by SCCmec II and SCCmec V. Conclusion: The study concluded that there is a high prevalence of MRSA in Nigeria with association of eta and icaA genes with mecA gene in S. aureus isolates.
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Study of clinical spectrum and risk factors of neonatal candidemia p. 472
Rahul Gopichand Wadile, Viraj Madhusudan Bhate
DOI:10.4103/0377-4929.168888  PMID:26549069
Context: Candida colonization in neonates results in significant morbidity and mortality. The prevalence and clinical significance of neonatal candidemia are poorly understood. Aims: This study aimed to study clinical spectrum and risk factors of neonatal candidemia. Settings and Methods: 108 cases of septicemia were studied. Blood samples were collected into Glucose broth and Bile broth, which are inoculated on Blood agar and MacConkey's agar and incubated at 37° C for 7 days. Candida species were isolated were confirmed by standard techniques. Statistical Analysis Used: The data was collected and analyzed using by using SPSS IBM Company, Chicago, Version 16.0. Results: 62 newborn patients who had a positive Candida blood culture. 47 (79.03%) were low birth weight and 37 (59.67%) were male. 19 (30.65%) were died. Candida species was a contributory factor to mortality in 14 (73.68%) patients. Among Candida isolates, Candida albicans was the commonest (65%) followed by Candida parapsilosis (15%) and Candida glabrata (10%). The risk factors like intrapartum use of antibiotics, vaginal delivery, low birth weight are identified in culture positive neonates. Conclusions: Candida species are assuming an increasing role in nosocomial infections in neonates and is associated with an increased risk of mortality.
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Comparison of biofilm formation in clinical isolates of Candida species in a tertiary care center, North India p. 475
Vivek Agwan, Ruchika Butola, Molly Madan
DOI:10.4103/0377-4929.168873  PMID:26549070
Background and Objectives: Biofilms are colonies of microbial cells encased in a self-produced organic polymeric matrix. The biofilm production is more important for nonalbicans Candida (NAC); as C. albicans possess many other mechanisms to establish infections. Correct identification of Candida species has gained importance due to persistent rise in infections caused by NAC. We sought to isolate, identify Candida species in clinical isolates and study biofilm formation. Materials and Methods: Modified microtiter plate method was performed to study biofilm formation by isolates in Sabouraud's dextrose broth. It was then quantitatively assessed using a spectrophotometer. Biofilm formation was graded as negative, +1, +2, +3 and + 4 on the basis of percentage absorbance. Results: Biofilm formation was observed in 16 of 40 (40.0%) isolates of C. albicans as compared to 39 of 78 (50.0%) of isolates of NAC. Strong (+4) biofilm production was seen in maximum biofilm producers in C. tropicalis (12 of 27) followed by C. albicans (8 of 16). Total biofilm producers were significantly more among high vaginal swab isolates 63.2% (12 of 19) and urine isolates 59.2% (29 of 49), when compared to blood isolates 34.2% (13 of 38) as well as other isolates 27.5% (11 of 40). Interpretation and Conclusions: NAC species are qualitatively and quantitatively superior biofilm producers than C. albicans. Biofilm production is the most important virulence factor of NAC species and compared to other lesions, it is more significantly associated with luminal infections.
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Immunofluorescence profile of discoid lupus erythematosus p. 479
Shreekant Bharti, Sunil Dogra, Biman Saikia, Ranjana Minz Walker, Seema Chhabra, Uma Nahar Saikia
DOI:10.4103/0377-4929.168850  PMID:26549071
The direct immunofluorescence (DIF) of skin in conjunction with histopathology gives the best diagnostic yield. It is invaluable in confirming the diagnosis of small vessel vasculitides and bullous lesions of the skin and can be used as an additional tool to pinpoint the diagnosis of systemic and localized autoimmune diseases involving the skin. This study was undertaken to analyze the strength of DIF vis-à -vis histopathology in the diagnosis of discoid lupus erythematosus (DLE) and at the same time to elaborate the specific immunofluorescence findings in the lesions of DLE. The clinical profile and cutaneous lesions of 75 patients with DLE are described. DIF was positive in 68% and histopathology in 60% of cases. The most common immunoreactant was IgG at the dermoepidermal junction, followed by IgM and IgA. A conclusive diagnosis of DLE could be achieved satisfactorily in 64 cases (85%) by a combination of the two techniques.
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Extensive intestinal metaplasia of renal pelvis: Report of a case and literature review p. 483
Prakriti Shukla, Hanni V Gulwani
DOI:10.4103/0377-4929.168890  PMID:26549072
Transformation of the urothelium to the intestinal type of epithelium is rare in the pelvis with very few cases reported in the literature. The present study reports extensive intestinal metaplasia of the pelvi-calyceal system without residual urothelium in a 35-years-old woman with a 2 years history of renal calculi. Right - sided Nephrectomy was undertaken. Immunohistochemistry of the metaplastic epithelium revealed positive expression of CK20, low Ki-67 index and negative expression of p53. In this patient long standing metaplastic changes did not progress to adenocarcinoma which indicates that extensive intestinal metaplasia is not always associated with malignancy.
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Functional parathyroid cystic adenoma: A rare cause of hypercalcemic crisis with primary hyperparathyroidism p. 487
BS Sumana, M Sabaretnam, Vijaya Sarathi, Akshatha Savith
DOI:10.4103/0377-4929.168847  PMID:26549073
We discuss a case of primary hyperparathyroidism caused by a giant cystic parathyroid adenoma presenting with neck swelling and hypercalcemic crisis. Fine-needle aspiration cytology of presumed thyroid swelling from one of the two sites aspirated yielded clear fluid but was not attributed to parathyroid pathology. Elevated serum calcium and intact parathormone (iPTH) levels suggested preoperative parathyroid pathology. Ultrasound neck and sestamibi scan for parathyroid localization were not conclusive. Due to resistant hypercalcemia, the patient underwent emergency bilateral neck exploration and excision of the identified left superior parathyroid cyst along with total thyroidectomy. Monitoring of intra-operative iPTH helped complete removal of hyperfunctioning parathyroid tissue. Histopathological examination confirmed the parathyroid cyst. Cystic parathyroid adenoma should be considered in the differential diagnosis of cystic neck lesions.
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Mismatch repair protein deficient endometrioid adenocarcinomas, metastasizing to adrenal gland and lymph nodes: Unusual cases with diagnostic implications p. 491
Bharat Rekhi
DOI:10.4103/0377-4929.168859  PMID:26549074
Recently, certain endometrial carcinomas have been found to be associated with mismatch repair (MMR) protein defects/deficiency. A 39-year-old female presented with cough, decreased appetite and significant weight loss since 2 months. Earlier, she had undergone total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) for endometrioid adenocarcinoma. Imaging disclosed an 8 cm-sized adrenal mass that was surgically excised. Histopathology of the adrenal tumor, endocervical tumor, and endometrial biopsy revealed Federation of Gynecology and Obstetrics (FIGO) Grade II to III endometrioid adenocarcinoma. By immunohistochemistry, tumor cells were positive for cytokeratin 7, epithelial membrane antigen, PAX8, MLH1 and PMS2 while negative for estrogen receptor (ER), progesterone receptor (PR), MSH2 and MSH6. She underwent adjuvant radiotherapy and chemotherapy. A 34-year-old lady presented with vaginal bleeding since 9 months. She underwent TAH-BSO, reported as FIGO Grade III endometrioid adenocarcinoma. By immunohistochemistry, tumor cells were negative for ER, PR, MLH1, and PMS2 while positive for MSH2 and MSH6. She underwent adjuvant radiotherapy and chemotherapy. However, she developed multiple nodal and pericardial metastases and succumbed to the disease within a year post-diagnosis. Certain high-grade endometrioid adenocarcinomas occurring in younger women are MMR protein deficient and display an aggressive clinical course. Adrenal metastasis in endometrial carcinomas is rare.
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Extracavitary primary effusion lymphoma: A case report from India p. 496
Rajalakshmi Sampath, Marie Therese Manipadam, Sheila Nair, Inian Samarasam
DOI:10.4103/0377-4929.168851  PMID:26549075
We present a case of extracavitary primary effusion lymphoma presenting, as jejunal polyps in a 38-year-old man. This is the first report of this entity from India. Although rare in our country, the diagnosis should be suspected in cases of CD20 negative large cell lymphoma with plasmablastic or immunoblastic differentiation in seropositive patients. Immunostaining for latency-associated nuclear antigen-1 and in situ hybridization for Epstein-Barr virus-associated RNA will confirm the diagnosis.
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A 36-year-old man with vomiting, pain abdomen, significant weight loss, hyponatremia, and hypoglycemia p. 500
Deepti Mutreja, Kartik Sivasami, Vanmalini Tewari, Bhaskar Nandi, G Lakhsmi Nair, Sunita D Patil
DOI:10.4103/0377-4929.168871  PMID:26549076
Diagnosis of Strongyloides stercoralis hyperinfection can be a challenge. The key to a timely diagnosis is to have a high index of suspicion. We present a rare case of a 36-year-old human immunodeficiency virus negative male patient, who was on multidrug therapy for lepromatous leprosy and was treated for type 2 lepra reactions with steroids in the past. The patient presented with vomiting and pain abdomen, persistent hyponatremia, and terminal hypoglycemia. He had features of malnutrition and had a rapid downhill course following admission. A diagnosis of S. stercoralis hyperinfection with sepsis and multiorgan failure, adrenal hemorrhage, and syndrome of inappropriate antidiuretic hormone secretion was established on a postmortem examination.
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Epithelial inclusion cyst of the cecum: A rare entity p. 506
Shweta Mittal, Manisha Makkar, Vijay Suri
DOI:10.4103/0377-4929.168870  PMID:26549077
Epithelial inclusion cyst of the cecum (EICC) or epidermoid cyst of the cecum is extremely rare. Only seven cases of EICC have been reported in the English literature until now. A case of EICC is being reported in a 25-year-old female who presented with a pelvic mass associated with lower abdominal pain radiating to back. Abdominal contrast-enhanced computed tomography scan showed a well-defined mass juxtaposed to cecum. During operation, a subserosal cystic mass was found adherent to the anterior wall of the cecum and confirmed to be an epithelial inclusion cyst histopathologically. It is being reported due to its extreme rarity.
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Anaplastic lymphoma kinase-positive pulmonary inflammatory myofibroblastic tumor with sarcomatous morphology and distant metastases: An unusual histomorphology and behavior p. 509
Bhawna Sethi, Trupti Pai, Abhishek Allam, Sridhar Epari
DOI:10.4103/0377-4929.168866  PMID:26549078
Inflammatory myofibroblastic tumor (IMT), an intermediate-grade neoplasm of myofibroblastic/fibroblastic differentiation, occurs commonly in children and young adults. It is characterized by anaplastic lymphoma kinase (ALK) gene rearrangement and overexpression of ALK-protein. However, aggressive behavior is more commonly associated with ALK-negativity rather than ALK-positivity. Pulmonary involvement is most common visceral location and carries minimal potential for distant metastasis. We present a case of 49-year-old female with pulmonary IMT of spindle cell sarcomatous histomorphology. Frequent mitoses and necrosis with characteristic cytoplasmic immunoreactivity for ALK-1 protein and ALK-gene rearrangement on fluorescence in-situ hybridization were noted. This case is unusual for occurrence in higher age-group of fifth decade, sarcomatous histomorphology at presentation (rather than transformation) and metastases to distant sites despite ALK-protein overexpression and gene rearrangement.
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Spindle-cell ameloblastic carcinoma of the maxilla with adenoid cystic carcinoma-like areas: A new variant? p. 513
Hena A Ansari, Prasenjit Sen Ray, Nazoora Khan, Arshad Hafiz Khan
DOI:10.4103/0377-4929.168856  PMID:26549079
Ameloblastic carcinoma is a rare aggressive malignancy of odontogenic epithelial origin. The disease has been reported to afflict people over a wide range of age group without any sex predilection. It is characterized by rapid growth and destruction of overlying bones along with involvement of adjacent soft tissues. The overall prognosis of this cancer is poor despite radical surgery and radiotherapy. Owing to the rarity of this lesion, complete data on the biological behavior and response to different treatment modalities are still lacking. The authors hereby report a case of this uncommon tumor arising from left maxilla in a 60-year-old Indian male. Histopathological examination of the tumor showed foci of spindling intermixed with large areas of tumor cells arranged in cribriform pattern and having luminal eosinophilic material which was reminiscent of adenoid cystic carcinoma. A final diagnosis was achieved after immunohistochemical study. These unusual findings prompted this case report.
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Adenoid cystic carcinoma of the trachea p. 516
Heena M Desai, Rohit Thakare, Gayathri P Amonkar, Vinaya Karkhanis, Jyotsna M Joshi
DOI:10.4103/0377-4929.168889  PMID:26549080
Primary salivary gland - type tumors of the lung and airways being unusual, they pose a diagnostic challenge on small biopsies and are usually consigned as non-small cell lung carcinomas. Since the clinical behavior of these tumors is different from the conventional lung tumors, it is important to accurately diagnose them. Among this category of tumors, adenoid cystic carcinoma (ACC) of the lungs and airways is exceedingly rare. Few large studies and maximum case reports have been reported in literature on ACC of the lungs and trachea so far. We herein report a rare case of primary ACC of the trachea diagnosed on bronchoscopic biopsy.
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Malignancy of fallopian tube p. 519
Ranjan Agrawal
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Primary alveolar rhabdomyosarcoma of fallopian tube masquerading as a unilateral adnexal mass: A case report and literature review p. 521
Nisreen Abu Shahin, Amin Alqaisy, Wenxin Zheng
DOI:10.4103/0377-4929.168884  PMID:26549082
Rhabdomyosarcoma (RMS) is a high-grade sarcoma that predominantly affects children, and rarely, the adult population. RMS demonstrates three major histologic variants: Embryonal, alveolar, and pleomorphic. A limited number of documented pure RMS cases of the gynecologic organs in adult women are found in the literature. Of these reports, the fallopian tube (FT) is reported as the primary site in only three cases, those included one of embryonal and two of the pleomorphic histologic variants. Herein, we report the first case of alveolar RMS arising in the FT of an adult woman and presenting as a unilateral adnexal mass.
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Serous papillary cystadenofibroma of the fallopian tube: A case report and short review of literature p. 524
Yasmeen Khatib, Richa D Patel, Anuja S Kashikar, Komal Chavan
DOI:10.4103/0377-4929.168865  PMID:26549083
Serous papillary cystadenofibromas (SPCAFs) of the fallopian tube are very rare benign tumors of the female genital tract. They are usually asymptomatic and are found incidentally. Until now, only 18 cases of this tumor have been reported in the world literature. We report a case of SPCAF of the left fallopian tube in a 30-year-old female who presented with a large abdominal mass and pain. On computed tomography, a diagnosis of ovarian neoplasm was given. However, during surgery the tumor was found to arise from the fallopian tube and was treated with tubal cystectomy with sparing of the ovary. We present this unique case on account of its rarity, unusual presentation, and huge size along with a short review of literature.
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Significance of fibrotic bands in utero - Amniotic band sequence with limb body wall complex: A rare case of fetal autopsy p. 528
P Lekshmi Devi, PJ Cicy, Renu Thambi, Usha Poothiode
DOI:10.4103/0377-4929.168876  PMID:26549084
Amniotic band sequence (ABS) includes a wide spectrum of abnormalities resulting from entrapment of various fetal parts from a disrupted amnion, ranging from a mere constriction ring affecting a finger to a fatal form called limb body wall complex (LBWC). Reported cases of ABS with LBWC are very few. The spectrum of anomalies depends on which part gets entrapped and at what point of gestation. Hence, the clinical presentation can be extremely variable. Early detection of such cases using sonology is really challenging due to the small size of the fibrotic bands. Here, we present a case of amniotic band syndrome with LBWC in a fetus at 24 weeks of gestation, which was referred for an autopsy. The fetus also showed scoliosis, gastroschisis, lumbosacral meningocele, congenital talipes equinovarus, and cleft palate, thus having features of placenta cranial and placenta abdominal phenotype which is very rare.
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Primary intracardiac malignant peripheral nerve sheath tumor: A rare case report p. 531
Sudheer Arava, Saphalta Bagmar, Parul Jain, Muthu Kumaran, Sanjeev Kumar, Ruma Ray
DOI:10.4103/0377-4929.168867  PMID:26549085
Myxomas are the most common benign cardiac tumors constituting approximately 75% of all the cardiac tumors. Rest 25% are malignant and sarcomas being the commonest. Among the sarcomas primary cardiac malignant peripheral nerve sheath tumors are extremely rare. They usually arise in relation to the branches of vagus or phrenic nerves, 5-42% being associated with neurofibromatosis type 1. Clinical signs and symptoms depend on the location and extent of involvement. Complete resection is the treatment of choice but local recurrence is common.
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Nevus sebaceus with basal cell carcinoma, poroma, and verruca vulgaris p. 534
Ali Fuat Cicek, Andac Aykan, Abdulkerim Yapici, Mehmet Gamsizkan, Serdar Ozturk, Murat Demiriz
DOI:10.4103/0377-4929.168885  PMID:26549086
Nevus sebaceus (NS) is a congenital, benign, hamartomatous lesion and it is possible to see several benign or malignant tumors accompanying it. One of these is the poroma, which is very rare, and has only been reported twice before, in the English literature. In this paper, we presented two new cases of NS. One of them was a 40-year-old male who presented with a congenital skin lesion on his temporoparietal region. This lesion was composed of four different lesions, including NS, poroma, basal cell carcinoma (BCC), and verruca vulgaris. The second patient was a 41-year-old male presenting with a yellow-brown patch on the scalp. This lesion was comprised of NS and BCC. In addition to these presentations, we discussed the differential diagnosis between BCC and trichoblastoma, both of which are likely to be seen with NS. For this purpose, we recommended an immunohistological panel, which may be useful for differentiating these two morphologically similar lesions.
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Concomitant follicular lymphoma and histiocytic sarcoma: A rare progression, trans-differentiation or co-occurrence? p. 537
Anuj Verma, Tanuja Shet
DOI:10.4103/0377-4929.168860  PMID:26549087
Trans-differentiation of follicular lymphoma (FL) into a histiocytic sarcoma (HS) is a rare event and usually occurs as a sequential event. We report a case where in the same node with two distinct areas one of low-grade FL and another with HS was observed. This patient was a 58 years old with generalized lymphadenopathy and Ann Arbor Stage III disease. The cervical node biopsy on histological examination revealed two distinct areas, firstly a FL with nodular architecture and the other a smaller focus of sheets of pleomorphic histiocytic cells diffusely arranged at the edge of the section contiguous with FL with few cells in transiting phase. On immunohistochemistry the FL was positive for CD20, CD10, PU.1, PAX5 and Bcl2, while the large histiocytic cells were positive for CD163, CD68, LCA, and PU.1, weakly for PAX5 and negative for CD20, CD10, CD30, CD3, CD1a, Bcl2, S100, and Alk-1. The therapeutic implications of this diagnosis and postulated theories on trans-differentiation are discussed.
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Pineal parenchymal tumor of intermediate differentiation p. 540
Meena Patil, Manjiri Karandikar
DOI:10.4103/0377-4929.168854  PMID:26549088
The 2007 World Health Organization classification of tumors of the central nervous system identified "pineal parenchymal tumor of intermediate differentiation" (PPTID) as a new pineal parenchymal neoplasm, located between pineocytoma and pineoblastoma as grade II or III. Because of the small number of reported cases, the classification of PPT is still a matter of controversy. We report a case of PPTID. A 25-year-old female patient was admitted to hospital with complaints of a headache, nausea, vomiting since 1-year. Computed tomography/magnetic resonance imaging of the brain showed well-defined, mildly enhancing lesion in the region of the pineal gland with areas of calcification. The tumor was excised. After 3 years, she presented with metastasis in thoracic and lumbosacral spinal region. This is a rare event.
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Mixed adenoneuroendocrine carcinoma of the gallbladder, histopathological features p. 543
Shweta Azad, Deepti Shukla, Ankur Garg, Sanjay Singh Negi, Veena Malhotra
DOI:10.4103/0377-4929.168879  PMID:26549089
An unusual case of mixed adenoneuroendocrine carcinoma is described which posed a diagnostic challenge in view of neuroendocrine component mimicking signet ring cells of adenocarcinoma. Diagnostic criteria for these mixed tumors, their histogenesis and treatment modalities are highlighted.
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Primary Burkitt's lymphoma of the breast without Epstein-Barr virus infection: A case report and literature review p. 546
Jianguo Wei, Caixia Lin, Chunwei Xu, Qun Xi, Cheng Wang
DOI:10.4103/0377-4929.168863  PMID:26549090
Burkitt lymphoma (BL) is a highly aggressive neoplasm, which arising from the germinal center or post germinal center B-cell. Primary breast lymphomas are extremely rare, and the most common histologic type is diffuse large B-cell lymphoma. Primary BL of the breast is much less common than the other types of lymphoma. Here, we report an extremely rare case of a 37-year-old Chinese female with localized bilateral breast, who was referred to our institution for bilateral breast swelling. The left breast tissue ultrasonography showed the short axis measuring 20.3 mm × 18.8 mm and the long axis measuring 22.1 mm × 20.8 mm soft tissue mass. The right breast tissue ultrasonography showed the short axis measuring 30.2 mm × 26.9 mm and the long axis measuring 33.5 mm × 2.18 mm. Coarse needle biopsy of breast masses demonstrated a non-Hodgkin's B-cell lymphoma. The patient underwent a bilateral mastectomy. Histological examination of the tumor showed a characteristic "starry sky" pattern, the medium-sized tumor cells were a monotonous pattern of growth, and there were many abnormal mitotic figures. The neoplastic cells strongly expressed CD20, CD79-μ, MUM-1, PAX-5, CD43 and Bcl-6, Ki-67 were nearly 100% positive, but negative for CD10, Bcl-2 and TdT. By fluorescence in situ hybridization an IGH-MYC gene fusion was detected in the tumor tissue which indicating the presence of a typical BL translocation t(8;14)(q24;q32). The final histopathological diagnosis was primary BL of the breast.
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Lymphoepithelioma-like hepatocellular carcinoma without Epstein-Barr virus infection: A case report and a review of the literature p. 550
Jianguo Wei, Qingmeng Liu, Cheng Wang, Shanlu Yu
DOI:10.4103/0377-4929.168857  PMID:26549091
Lymphoepithelioma-like carcinoma (LELC) of the liver is uncommon, only 20 cases have been reported in the English-language literature so far, and the majority has been identified as cholangiocarcinomas, only four cases were hepatocellular LELC. Here we described a rare case of lymphoepithelioma-like hepatocellular carcinoma (HCC). A 42-year-old Chinese female who was incidentally found to have a liver-occupying lesion during a routine medical examination. Ultrasonography revealed a 47 mm × 33 mm × 36 mm hypoechoic mass in the left lobe. Computed tomography and magnetic resonance imaging displayed a nodular lesions in the left liver lobe. The patient underwent a left-side hepatectomy. Histopathological examination of the resected specimen revealed an undifferentiated carcinoma with a dense lymphocytic infiltrate, predominantly composed of CD3(+) T cells, morphologically similar to nasopharyngeal carcinoma. Immunohistochemically, the tumor cells were positive for CK, EMA, Glypican-3 and hepatocyte, but negative for alpha-fetoprotein, CK19, CK7 and CK20. Epstein–Barr virus (EBV) in situ hybridization was negative. The final histopathological diagnosis was lymphoepithelioma-like HCC without EBV infection.
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Glomangiopericytoma of nasal cavity p. 554
Niketa Paras Roy, Devangi Parthiv Desai, Sudha Ajay Jain
DOI:10.4103/0377-4929.168864  PMID:26549092
Glomangiopericytoma/sinonasal type hemangiopericytoma is a rare sinonasal neoplasm arising from the pericytes surrounding capillaries and accounts for less than 0.5% of all sinonasal tumors. This tumor differs from conventional soft tissue hemangiopericytoma in location, biologic behaviour and histologic features. Glomangiopericytoma is a borderline low malignancy tumor with a good prognosis after complete surgical resection. We report a case of 60-year-old woman who presented with progressive nasal obstruction and frequent nasal bleeding and was diagnosed as glomangiopericytoma on histopathological and immunohistochemistry findings. Histological characteristics, differential diagnosis and prognosis of this tumor are discussed in this article. This case has been reported because of its rarity and an array of differential diagnosis.
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Endometrioid like yolk sac tumor of the testis with small teratomatous foci: A case report and review of the literature p. 557
Prabir Hazarika
DOI:10.4103/0377-4929.168869  PMID:26549093
I have reported a case of endometrioid like yolk sac tumor of the testis in a 20-year-old boy. Endometrioid like yolk sac tumor is a rare tumor. A few cases have been reported in ovary. In case of male, a case of pure glandular endometrioid like yolk sac tumor is reported in a 43 years male in right undescended testis and another case of abdominal metastasis showing endometrioid pattern from mixed testicular germ cell tumor comprising of teratoma and embryonal carcinoma. My patient was a 20-year-old male presented with painless enlargement of right testis. Grossly the tumor was glistening creamish white with a multicystic appearance. Histopathological examination showed the tumor to be composed of glandular elements resembling early secretory endometrium, foci of keratinized thin squamous epithelium and a single focus of benign cartilage. The glandular elements show immunohistochemical positivity for AFP, cytokeratin 7 (CK7) and epithelial membrane antigen (EMA).
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An extraneural primary anaplastic ependymoma at the subcutaneous inguinal region: Report of a rare case p. 560
Hamide Sayar, Ayca Ersen, Neslihan Kurtul, Mehmet Fatih Yazar, Ozan Balakan
DOI:10.4103/0377-4929.168883  PMID:26549094
Ependymomas commonly arise in the central nervous system. Extraneural presentation is quite rare. Herein, we describe a primary extraneural ependymoma in a young female. The mass was located in the right inguinal area. The cut surface of the 7.5 mm × 6.5 mm × 4.5 mm sized tumor was brownish-yellow in color. Histologically, it was hypercellular exhibiting pseudorosette or rosette formations and some papillary structures. Mitosis was counted as high as 10 per 10 high power fields. Neither necrosis nor vascular endothelial proliferation within the tumor was observed. Tumor cells showed strong glial fibrillary acidic protein immunoreactivity. On epithelial membrane antigen, intracytoplasmic dot-like immunostaining was observed. This is the first report presenting a primary extraneural anaplastic ependymoma arising in the inguinal subcutaneous region.
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Leishmaniasis in a patient with HIV co-infection: Diagnosis on fine needle aspiration cytology p. 563
Anjali N Bode, Sandhya V Poflee, Nandu P Pande, Pradip S Umap
DOI:10.4103/0377-4929.169020  PMID:26549095
Leishmaniasis is a vector borne parasitic disease caused by obligate intracellular protozoa Leishmania and is transmitted by the bite of sand fly. The disease typically presents in visceral, cutaneous and mucocutaneous forms and is endemic in some states of India. Cases with atypical presentation are seen when patient has co- infection with HIV. We report a case of Leishmaniasis occurring in a HIV seropositive expectant mother diagnosed initially on fine needle aspiration cytology. The patient was resident of non endemic area and had presented with isolated cervical lymphadenopathy and fever without spleenomegaly. Characteristic morphological features of Leishmania seen in the fine needle aspiration smears from the neck nodes were identified and definitive diagnosis of Leishmaniasis could be given. Cytological features were not suggestive of any other disease. Timely diagnosis of the disease facilitated proper management in our patient.
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Cases of bowel schistosomiasis presenting as carcinoma colon p. 566
Biswajit Biswas, Deepak Vedant, Vijay Kaushal, Pooja Chauhan, Tanish Mandal, Nidhi Raina, Brij Sharma
DOI:10.4103/0377-4929.168882  PMID:26549096
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Quiz page p. 568

DOI:10.4103/0377-4929.168897  PMID:26549097
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Discordant and metachronous Non-Hodgkin's lymphomas: Enteropathy-associated T-cell lymphoma, Type II with aberrant expression of CD4 presenting several years after a mucosa-associated lymphoid tissue type B-cell lymphoma p. 569
Fiona Fonseca, Meenal Hastak, Bijal Kulkarni
DOI:10.4103/0377-4929.168848  PMID:26549098
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High grade angiosarcoma of nasal cavity and paranasal sinuses: A rare case with immuno-histopathological study p. 570
Sanjay D Deshmukh, Sinai Khandeparkar Siddhi Gaurish, Netra Pathak, Vidya Rokade, Amruta B Jadhav
DOI:10.4103/0377-4929.168878  PMID:26549099
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Interference of hemoglobin D Punjab on measurements of glycated hemoglobin p. 572
Anju Shukla, Sunil Dabadghao, Surbhi Gupta, Sunil Verma
DOI:10.4103/0377-4929.168874  PMID:26549100
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Quiz Answer page p. 575
Prachi Nayak, Premala Anthony Singh, Vatsala Misra
DOI:10.4103/0377-4929.168892  PMID:26549101
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