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   Table of Contents - Current issue
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January-March 2015
Volume 58 | Issue 1
Page Nos. 1-137

Online since Wednesday, February 11, 2015

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EDITORIAL  

From Editor's desk p. 1
Vatsala Misra
DOI:10.4103/0377-4929.151152  PMID:25673581
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ORIGINAL ARTICLES Top

Invasive micropapillary carcinoma of urinary bladder: A clinicopathological study p. 2
Debajyoti Chatterjee, Ashim Das, Bishan D Radotra
DOI:10.4103/0377-4929.151153  PMID:25673582
Context: Micropapillary variant of urothelial carcinoma (MPUC) is a rare but well-recognized tumor of the urinary bladder. Tumors with micropapillary areas accompanying conventional urothelial carcinoma are more aggressive compared to conventional urothelial carcinoma and show variable keratin 7, keratin 20 and human epidermal growth factor receptor 2 (Her 2)neu expression. Aim: The aim of the study was to analyze the clinical, morphological and immunohistochemical profile of MPUC. Materials and Methods: Transurethral resection of bladder tumor (TURBT) chips of seven cases of invasive MPUC with subsequent cystoprostatectomy specimens of five patients was reviewed. Epithelial membrane antigen (EMA), Keratin 7, Keratin 20, and Her 2 immunohistochemistry were performed in all cases. Follow-up information was available for all patients (2-36 months). Results: All seven patients were male, and their ages ranged from 50 to 62 years. All cases presented with hematuria. The micropapillary pattern was seen in 20-95% of the tumor. All cases showed extensive lymphatic emboli with detrusor muscle invasion. Lymph node metastasis was present in all cases undergoing cystoprostatectomy except one. Keratin 7 and abluminal pattern of EMA positivity were seen in all cases. Keratin 20 was positive in five cases (71%), and Her 2neu positivity was seen in four cases. Three patients died 2, 3, and 6 months after initial diagnosis, among which two were Her 2 positive and one was Her 2 negative. There was no clear prognostic significance of Her 2 positivity. Conclusion: (1) MPUC is a rare but highly aggressive tumor. (2) Micropapillary is usually the predominant pattern. (3) Keratin 7 is expressed universally, whereas Keratin 20 expression is variable. (4) Her 2 expression has no clear influence on the survival.
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Warthin's tumor: An unknown pathogenesis: A neoplasm or a reactive hyperplasia? p. 7
Arpaci Bozdogan Rabia, Linke Serınsoz Ebru, Kara Tuba, Gursoy Didar, Orekici Gulhan, Ozcan Cengiz
DOI:10.4103/0377-4929.151154  PMID:25673583
Background and Aims: To examine the probable role of angiogenesis and lymphangiogenesis in the pathogenesis of Warthin's tumor. Materials and Methods: Sixty-one patients with Warthin's tumor (n = 40), branchial cysts (n = 6), thymic cysts (n = 3), or tonsillar lymphoepithelial cysts (n = 12) were included. Forty Warthin's tumors were used as the lesion group, and 21 lymphoepithelial cysts were used as a control group. 29 lymph nodes around the Warthin's tumor, four of which showed salivary duct inclusions, were also evaluated. Blood vessel density was defined as an indicator of angiogenesis by examining CD31 and FVIII Ag expression, and lymphatic vascular density was defined as an indicator of lymphangiogenesis by evaluating LYVE-1 and podoplanin expression by immunohistochemical analysis. Statistical Analysis Used: Data are expressed with descriptive statistics. Comparative analysis was performed using Shapiro-Wilks, Mann-Whitney U, and Kruskal-Wallis tests. A P < 0.005 was considered to indicate statistical significance. Statistical analysis was performed using the MedCalc ® v.10.3.0 software. Results: The lesion group had higher mean values of age (58 vs. 11 years, P = 0.001), smoking rate (92.3% vs. 19%, P < 0.001), stromal degeneration (100% vs. 42.9%, P < 0.001), lymph node involvement around the lesion (87.9% vs. 12.1%, P < 0.001), salivary duct inclusion (25% vs. 0%, P = 0.0001), than those of lymphoepithelial cysts. Blood vessel density (51.92 ± 25.64 vs. 8 ± 5.35, number/5 high power fields (HPF), P < 0.001) and lymphatic vascular density (68.95 ± 21.32 vs. 21.10 ± 4.05 number/5 HPF, P < 0.001) were higher in Warthin's tumors than lymphoepithelial cysts. Warthin's tumors, and lymph nodes with inclusions had similar levels of blood and lymphatic vascular density, which was higher than those of lymph nodes (P < 0.0001). Conclusions: Warthin's tumor is a true neoplastic epithelial proliferation associated with increased angiogenesis and lymphangiogenesis and induces reactive lymph node hyperplasia.
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Improvised double-embedding technique of minute biopsies: A mega boon to histopathology laboratory p. 12
Lokendra Yadav, Sarega Thomas, Usha Kini
DOI:10.4103/0377-4929.151156  PMID:25673584
Introduction: Optimal orientation of minute mucosal biopsies is essential for a definite diagnosis in gastrointestinal pathology or to visualize neural plexuses in Hirschsprung disease. The problem of minute size of the biopsy and its orientation gets compounded when they are from neonates and mandates exhaustive strip cuts, thus delaying reporting. Aim: A modified agar-paraffin technique is aimed to make tissue embedding efficient and user-friendly by inking mapping biopsies (one or more) either fresh or fixed with surgical coloring inks followed by embedding first in agar after orientation and followed thereafter by processing, re-embedding in paraffin wax, sectioning and staining. Results: The tissues in agar paraffin block were found to be well processed, firm, held secure and well preserved. The blocks were easy to cut, with serial sections of thickness 2-3 μ and easy to spread. The colored inks remained permanently on the tissues both in the block as well as on the sections which helped in easy identification of tissues. Agar did not interfere with any stain such as Hematoxylin and Eosin or with histochemical stains, enzyme histochemistry or immunohistochemistry. Inking biopsies and pooling them in a block when obtained from the same patient reduced the number of tissue blocks. Conclusion: The modified agar-paraffin embedding technique is a simple reliable user friendly method that can greatly improve the quality of diagnostic information from minute biopsies by optimal orientation, better quality of sections, faster turnaround time and cost-effectiveness by economizing on the number of paraffin blocks, manpower, chemical reagents and laboratory infrastructure.
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Liquid-based cytology versus conventional cytology for evaluation of cervical Pap smears: Experience from the first 1000 split samples p. 17
Vikrant Bhar Singh, Nalini Gupta, Raje Nijhawan, Radhika Srinivasan, Vanita Suri, Arvind Rajwanshi
DOI:10.4103/0377-4929.151157  PMID:25673585
Context and Aim: Screening programs using conventional cytology conventional Pap smear (CPS) have successfully reduced cervical cancer, but newer tests like liquid-based cytology (LBC) and human papillomavirus testing might enhance screening. The main aim of the present study was to assess the diagnostic accuracy of LBC versus CPS using "split samples." Materials and Methods: This was a prospective study comprising of 1000 consecutive cervical "split samples" over a period of 1 year. Split sample was obtained using cervex-brush. CPS was prepared from the brush and the brush head was suspended in the LBC vial and processed by SurePath™ LBC. Results: There were 4.3% unsatisfactory (U/S) cases in CPS and 1.7% in LBC; the main cause is insufficient cells, and excess of blood in CPS. About 25/100 (2.5%) split samples had epithelial abnormalities both in CPS and LBC (1.2%-atypical squamous cells of undetermined significance; 0.4%-low grade squamous intraepithelial lesion; 0.2%-high grade squamous intraepithelial lesion; 0.5%-squamous cell carcinoma; 0.1%-atypical glandular cells favouring neoplasia; 0.2%-adenocarcinoma). Inflammatory organisms were almost equally identified in both techniques but were better seen in LBC samples. Conclusions: LBC technique leads to significant reduction of U/S rate. LBC samples offered better clarity, uniform spread of smears, less time for screening and better handling of hemorrhagic and inflammatory samples. LBC had equivalent sensitivity and specificity to CPS.
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Genomic analysis and clinical importance of Escherichia coli isolate from patients with sepsis p. 22
Arindam Chakraborty, Prabha Adhikari, Shalini Shenoy, Vishwas Saralaya
DOI:10.4103/0377-4929.151161  PMID:25673586
Context: Escherichia coli is a major cause of bloodstream infections and death due to sepsis. Bacteremic isolates harbor a significantly greater repertoire of virulence factors (VFs) in contrast with commensal E. coli isolates. Aims: The aim was to determine the relationships between E. coli VFs, phylogenetic groups, and their clinical importance. Settings and Design: This descriptive study was carried out in a multi-specialty tertiary care hospital. Materials and Methods: Escherichia coli isolates from consecutive episodes of bacteremia in 100 patients were screened for their VFs, phylogenetic group, and their effect on patient's clinical outcome. Virulence genes of all isolates were determined by multiplex polymerase chain reaction (PCR). Phylogenetic analysis was performed by triplex PCR methods. Estimation of risk of death was calculated using APACHE score II calculator. Results: Of the 100 patients, the most common predisposing factors were diabetes (42%), followed by carcinoma (23%). On analysis of the VF genes of the isolates, a majority of strains (88%) were possessing the fimH gene followed by iutA (76%), papC (44%), cnf1 (16%), hlyA (16%) and neuC (5%) respectively. Phylogenetic analysis revealed that 25 (25%) isolates belonged to phylogroup A, 8(8%) strains to group B1, 30 (30%) were from group B2 and 37 (37%) were from group D. The incidence of iutA gene was significant in higher APACHE II score group. Conclusions: Our findings indicate that virulent as well as commensal strains are capable of causing sepsis. Host related predisposing factors, adherence factors, and iron uptake are essential for the survival of the sepsis inducing strains.
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Role of multiplex polymerase chain reaction using IS6110 and Protein b for the diagnosis of extra-pulmonary tuberculosis: North India p. 27
Kusum Sharma, Suma B Appannanavar, Manish Modi, Malkit Singh, Aman Sharma, Subhash Varma
DOI:10.4103/0377-4929.151164  PMID:25673587
Background: Prompt and accurate diagnosis of extra-pulmonary tuberculosis (TB) is highly challenging. Current conventional techniques lack sensitivity and are time-consuming. Here, we report our experience with multiplex polymerase chain reaction (MPCR) using two targets namely IS6110 and protein antigen b in the diagnosis of extra-pulmonary TB. Materials and Methods: A total of 150 patients of extra-pulmonary TB visiting tertiary care center in north India between September 2008 and December 2009 were included in the study. Sixty-six biopsy samples and 84 were body fluids from these patients were subjected for microscopy (Ziehl-Neelsen), culture on LJ medium and for Multiplex PCR using IS6110 and Protein b antigen. Results: Smear positivity was noted in 11 samples (7.33%), and LJ culture yielded Mycobacterium tuberculosis in 8 biopsies and 9 body fluids with overall positivity of 11.3%. The multi-targeted PCR could detect M. tuberculosis in a total of 112 samples. Of 112 positive samples, only Protein b band was detected in 7 samples and only IS6110 was detected in 5 samples. Overall Protein b, PCR could detect 71.33% of the cases, whereas IS6110 was positive in 66.6% of the cases. Overall the sensitivities of microscopy, culture, IS6110 PCR, Protein b PCR and MPCR were 7.33%, 11.3%, 66.67%, 71.3% and 74.6%, respectively. Thus by using more than two targets the sensitivity increased from 66.67% of IS6110 to 74.6% in MPCR. Conclusion: Multiplex polymerase chain reaction using IS6110 and Protein b antigen is a highly sensitive and specific tool in the diagnosis of pauci-bacillary conditions like extra-pulmonary TB.
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Evaluation of phenotypic tests for detection of Klebsiella pneumoniae carbapenemase and metallo-beta-lactamase in clinical isolates of Escherichia coli and Klebsiella species p. 31
Kalpana Chauhan, Anita Pandey, Ashish K Asthana, Molly Madan
DOI:10.4103/0377-4929.151168  PMID:25673588
Context: Carbapenemase production is an important mechanism responsible for carbapenem resistance. Aims: Phenotypic detection and differentiation of types of carbapenemase in carbapenem resistant Enterobacteriaceae is important for proper infection control and appropriate patient management. Settings and Design: We planned a study to determine the occurrence of Class A Klebsiella pneumoniae carbapenemase (KPC type) and Class B Metallo-β-lactamase (MBL type) carbapenemase in hospital and community. Materials and Methods: Clinical isolates of Escherichia coli and Klebsiella species and simultaneously evaluate different phenotypic methods for detection of carbapenemases. Results: It was observed that 20.72% clinical isolates of E. coli and Klebsiella spp. were resistant to carbapenem on screening of which, 14.64% were E. coli and 29.69% were Klebsiella spp. Using phenotypic confirmatory tests the occurrence of carbapenemase production was found to be 87.01% in E. coli and 91.51% in Klebsiella spp. using both modified Hodge test (MHT) and combined disk test (CDT) using imipenem-ethylenediaminetetraacetic acid. Conclusions: Both MBL and KPC type carbapenemases were seen among clinical isolates of E. coli and Klebsiella spp. CDT is simple, rapid and technically less demanding procedure, which can be used in all clinical laboratories. Supplementing MHT with CDT is reliable phenotypic tests to identify the class A and class B carbapenemase producers.
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Comparison of four diagnostic techniques for detection of Trichomonas vaginalis infection in females attending tertiary care hospital of North India p. 36
Razia Khatoon, Noor Jahan, Siraj Ahmad, Haris Manzoor Khan, Tamkin Rabbani
DOI:10.4103/0377-4929.151172  PMID:25673589
Background: Trichomonas vaginalis causes a common sexually transmitted disease trichomoniasis, which may lead to increased risk of transmission of human immunodeficiency virus infection and other pelvic inflammatory diseases. Wet mount examination is the most common test for diagnosis, but it has low sensitivity. Acridine orange staining can be used for diagnosis, but it requires special microscopic facility. Culture is considered as the gold standard, but it takes a long time for diagnosis. OSOM Trichomonas Rapid Test is a recently introduced rapid method based on immunochromatographic assay of trichomonal protein antigens. Hence, the present study was done to compare these four diagnostic techniques for detection of trichomoniasis in females with vaginal discharge. Materials and Methods: Vaginal swabs were taken from 835 female patients and wet mount examination, acridine orange staining, culture in Kupferberg medium, and OSOM Trichomonas Rapid Test, were performed. Results: Out of 835 patients included in our study, 68 (8.1%) positive cases of trichomoniasis were detected by culture. OSOM Trichomonas Rapid Test detected 63 (7.5%) cases, acridine orange staining detected 53 (6.3%) cases, whereas, wet mount examination detected only 45 (5.4%) positive cases. OSOM Trichomonas Rapid Test performed well and showed high sensitivity and specificity of 88.2% and 99.6%, respectively. Conclusion: As OSOM Trichomonas Rapid Test is a point of care test and gave better results than both wet mount examination and acridine orange staining; it can be used as a routine test in peripheral areas lacking laboratory facilities.
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Comparison of immunofluorescence and enzyme-linked immunosorbent assay and immunoglobulin G avidity techniques for screening of anti: Toxoplasma antibodies among single serum sample pregnant women in Tabriz, Iran p. 40
Mehrangiz Rajaii, Mohammad Reza Aliparasti, Behrouz Nagilli, Shohreh Almasi, Najibeh Asle-Rahnamaie-Akbari
DOI:10.4103/0377-4929.151183  PMID:25673590
Background: Congenital toxoplasmosis is that pregnant women acquire the infection during gestation; diagnosis of the acute infection during pregnancy is a complex subject of maternal toxoplasmosis. Thus, the presence of immunoglobulin G (IgG) and/or IgM Toxoplasma antibodies in a single serum sample drawn during gestation cannot be used to define whether the infection was recently acquired or chronic. Materials and Methods: At this cross-sectional descriptive study, sera of 391 pregnant women examined and compared. They were in an age range of 21-35 years, referred by gynecologists and infectious disease specialists, during March 2012-April 2013. They have referred, 215 (54.98%), 102 (26%), 74 (18.92%) in the first, second and third trimesters of gestation, respectively. For each of them, a questionnaire was completed and serum samples were prepared in an equal condition, examined according to the procedures of indirect immunofluorescence (IIF), enzyme-linked immunosorbent assay (ELISA) and IgG Avidity techniques. Results: We have found 111 (28.38%) seronegative and 280 (71.61%) seropositive cases by IIF and 124 (31.70%) seronegative, 267 (68.28%) seropositive cases by ELISA. The IgG avidity test confirmed 45 (69.23%) and 7 (10.76%) doubtful cases of IgM test in IIF and ELISA techniques. Conclusions: This study highlights how to manage pregnant women with toxoplasmosis, especially in a single serum sample condition.
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Selectivity evaluation of a new chromogenic medium to detect group B Streptococcus p. 45
Salvatore Pignanelli, Giovanna Pulcrano, Pasqua Schiavone, Alice Di Santo, Patrizia Zaccherini
DOI:10.4103/0377-4929.151186  PMID:25673591
Background: Group B Streptococcus (GBS) is an important pathogen that causes serious infections in newborns. Pregnant screening and intrapartum antibiotic prophylaxis are actually the strategies to prevent GBS disease in neonates because vaccination is under investigation. Materials and Methods: Simultaneously, 156 isolates of GBS and 156 isolates other than GBS covering 17 different species, were tested to evaluate the selectivity of a new chromogenic medium to screen GBS. Results: The new new chromogenic medium showed an excellent performance, exhibiting a very high level of inclusivity (100%) and exclusivity (96.1%).
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CLINICO PATHOLOGICAL CONFERENCE Top

A young leukemic patient with unusual catastrophic intestinal complication p. 48
Kim Vaiphei, Amita Trehan, Man Updesh Singh Sachdeva, Pankaj Malhotra
DOI:10.4103/0377-4929.151187  PMID:25673592
A 14-year-old child with acute lymphoblastic leukemia who had completed induction chemotherapy presented with fever and diffuse musculoskeletal pains which was thought to be a constellation of myositis, arthralgias and arthritis. Investigations revealed initially showed normal peripheral blood counts but had pancytopenia and pre-terminally blasts were seen in the peripheral blood smear. He had bone marrow necrosis. Disseminated intravascular coagulation was suspected with a positive fungal serology. At autopsy, he had evidence of disease relapsed in lymph nodes, liver, spleen, testes and kidneys. There was extensive pseudomembranous colitis and appendicitis with changes of toxic megacolon.
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BRIEF COMMUNICATIONS Top

Calcifying/ossifying synovial sarcoma: A clinicopathologic and molecular study of 5 cases p. 55
Nasir Ud Din, Amanda Hopkins, Aisha Memon, Zubair Ahmad, Rashida Ahmed
DOI:10.4103/0377-4929.151188  PMID:25673593
Background: Synovial sarcoma (SS) is a soft tissue sarcoma with a generally aggressive behavior. Calcifying/ossifying SS is a rare variant associated with a favorable prognosis. Aim: The aim was to report clinicopathological features and molecular analysis of 5 cases of calcifying/ossifying SS. Materials and Methods: Record of 370 cases of SS reported in the section of Histopathology, of a tertiary care Hospital, between 2002 and 2011 were retrieved. Five cases exhibiting extensive calcification and ossification were identified. Immunohistochemistry was performed using Flex technique. Molecular analysis of these 5 cases was performed later at the collaborative Hospital abroad, by reverse transcription polymerase chain reaction. Results and Conclusions: The ages of the patients ranged from 13 to 44 years (mean age 27 years; female to male ratio 1.6:1). The duration of symptoms ranged from 5 months to 5 years. Histologically, 4 were monophasic, and 1 was biphasic. Three cases exhibited extensive calcification and two extensive ossification. Immunohistochemical stain (epithelial membrane antigen was positive in all 5 cases, CKAE1/AE3 (3/4), Bcl2 (4/4), S100 (4/4), CK7 (2/2), CD99 (1/3) and vimentin (2/2). Intact RNA was obtained from 3 cases, all of which were positive for the SYT/SSX fusion transcript. Follow-up was available in 4 cases and ranged from 19 months to 85 months (mean 50 months). Local recurrence was seen in 2 cases. In conclusions, we report clinicopathologic features of 5 cases of calcifying/ossifying SS. The duration of symptoms and mean age of patients is similar to the literature. A slight female predominance was seen in contrast to a male predominance described in the literature. The clinical course of our cases validates the favorable prognosis of this rare type of SS.
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Study of the reproducibility of the 2004 World Health Organization classification of urothelial neoplasms p. 59
Pallavi Sharma, Hema Kini, Radha R Pai, Kaushalya K Sahu, Jyoti Kini
DOI:10.4103/0377-4929.151189  PMID:25673594
The aim of the study was to evaluate urinary bladder biopsies showing papillary urothelial neoplastic lesions based on the 2004 WHO/ISUP classification of Urothelial Neoplasms of the Urinary Bladder, to assess the reproducibility of the bladder carcinoma grade. Fifty consecutive transurethral tumor resection biopsies were evaluated by four pathologists independently. The final diagnoses of each pathologist were subjected to statistical analysis to assess the degree of interobserver variability and reproducibility of this classification. Significant interobserver variation was found in the reporting of urothelial neoplasms. In 22 instances there was difference in opinion between PUNLMP and low-grade carcinoma, and in 59 instances between low and high grade carcinoma. The 4 observers never unanimously agreed on the diagnosis of PUNLMP.
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V-raf murine sarcoma viral oncogene homolog B (BRAF) mutations in hairy cell leukaemia p. 62
Neeraj Arora, Sheila Nair, Rekha Pai, Sukesh Nair, Rayaz Ahmed, Aby Abraham, Auro Viswabandya, Biju George, Poonkuzhali Balasubramanian, Alok Srivastava, Vikram Mathews
DOI:10.4103/0377-4929.151190  PMID:25673595
Introduction: Hairy cell leukemia (HCL) is a B-cell non-Hodgkin lymphoma with distinct clinical, morphological and immunophenotypic features; however, there are many other B-cell lymphomas, which closely mimic HCL. Accurate diagnosis of HCL is important as treatment with 2-chloro-2'-deoxyadenosine (cladribine) is associated with >80% chance of complete cure. The recent description of BRAF p.V600E mutations in almost all HCL cases in various studies has not only improved the pathogenetic understanding of this entity but also increased the diagnostic accuracy of this disorder. Aim: The aim of the study was to standardize a molecular test for diagnosis of HCL and compare with standard established morphological, cytochemical and immunophenotypic parameters for HCL diagnosis. Materials and Methods: The incidence of this mutation was sought in 20 patients with either classical HCL or HCL variant (HCLv) by Sanger sequencing and allele-specific polymerase chain reaction. BRAF p.V600E mutation was present in all HCL cases and absent in the only HCLv case. Results: A high degree of correlation was noted between the presence of BRAF p.V600E and established diagnostic criteria in 20/20 patients with HCL/HCLv. Our data supports the observation that this mutation is present in all cases of HCL and is absent in HCLv. Hence, detection of the BRAF p. V600E mutation can be a useful adjunct in the diagnostic algorithm.
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An analysis of multimodal occupational exposure leading to blood borne infections among health care workers p. 66
N Lakshmi Priya, K Usha Krishnan, G Jayalakshmi, S Vasanthi
DOI:10.4103/0377-4929.151191  PMID:25673596
Occupational exposure poses a significant risk of transmission of blood-borne pathogens to healthcare workers (HCWs). Adherence to standard precautions, awareness about post exposure prophylaxis is poor in developing countries. This retrospective study analyzes the self-reported cases of occupational exposure in a tertiary care hospital. During the study period, 105 HCWs sustained occupational exposure to blood and body fluids. Majority of the victims 36 (34.2%) were interns and the clinical practice that led to the occupational exposure was withdrawal of blood (45.7%). Good infection control practices and emphasis on appropriate disposal are needed to increase the occupational safety for HCWs.
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Comparative analysis of enzyme-linked immunosorbent assay and direct microscopy for the diagnosis of Giardia intestinalis in fecal samples p. 69
Shipra Singhal, Vineeta Mittal, Vineeta Khare, Yengkokpam Ibotomba Singh
DOI:10.4103/0377-4929.151192  PMID:25673597
Context: Giardiasis is one of the most common nonviral infections causing diarrheal illness worldwide. In this prospective cross-sectional study, we evaluated the RIDASCREEN ® Giardia kit for detection of Giardia intestinalis in stool samples and compared the results with direct microscopy. Materials and methods: A total of 360 fecal samples were collected. They were then processed by wet film, iodine preparation and an enzyme-linked immunosorbent assay (ELISA) kit to determine the presence of Giardia trophozoites and cysts. Statistical analysis was performed by sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy. Results and Conclusion: Of the 360 cases, 17.2% samples were positive for Giardia by direct microscopy and 23.6% were found to be positive by ELISA (sensitivity ~97%), but specificity was ~92% only. Because of less specificity, we need to perform ELISA in congruence with direct microscopy, etc. Further studies need to be performed on a larger sample size using other molecular tests in order to get more accurate estimations.
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CASE REPORTS Top

Blastic plasmacytoid dendritic cell neoplasm: Report of two pediatric cases p. 72
Preeti Ashok Dharmani, Neha Manish Mittal, PG Subramanian, Komal Galani, Yajamanam Badrinath, Pratibha Amare, Sumeet Gujral
DOI:10.4103/0377-4929.151193  PMID:25673598
Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare subtype of acute leukemia that typically follows a highly aggressive clinical course in adults, whereas experience in children with this disease is very limited. We report cases of two children in whom bone marrow showed infiltration by large atypical monocytoid 'blast-like' cells which on immunophenotyping expressed CD4, CD56, HLA-DR and CD33 while were negative for CD34 other T-cell, B-cell and myeloid markers. The differential diagnoses considered were AML, T/NK-cell leukemia and acute undifferentiated leukemia. Additional markers CD303/BDCA-2 and CD123 which are recently validated plasmacytoid dendritic cell markers were done which helped us clinch the diagnosis of this rare neoplasm. An accurate diagnosis of BPDCN is essential in order to provide prompt treatment. Due to its rarity and only recent recognition as a distinct clinicopathological entity, no standardized therapeutic approach has been established for BPDCN.
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Eosinophilic angiocentric fibrosis of the orbit: A case report and review of literature p. 77
Santhi Radhakrishnan, Namrata G Adulkar, Viji Rangarajan
DOI:10.4103/0377-4929.151194  PMID:25673599
Eosinophilic angiocentric fibrosis is a rare condition presenting with tumefactive lesions of the nasal cavity, paranasal sinuses, upper respiratory tract and rarely the orbit; and has characteristic histopathological features. We report the case of a 38-year-old lady with a mass lesion in right orbit. Histopathological examination of the biopsy specimen revealed extensive areas of perivascular fibrosis showing a characteristic angiocentric whirling with onion skin pattern; along with perivascular exudates of eosinophils accompanied by collection of plasma cells and lymphocytes. Rheumatology review and autoimmune screening was negative. She underwent surgical debulking followed by tapering course of oral steroids and was completely free of orbital disease at her last follow-up visit.
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Cytomegalovirus colitis masquerading as rectal malignancy in an immunocompetent patient p. 80
Sunitha Jacob, Najah R Zayyani
DOI:10.4103/0377-4929.151195  PMID:25673600
Gastrointestinal tract (GIT) involvement by cytomegalovirus (CMV) infection is well-recognized in immunosuppressed patients but is uncommon in immunocompetent hosts. The colon and esophagus are the most frequently affected sites with punched out ulcers being the characteristic mucosal lesion. CMV-induced pseudotumor is an exceptionally rare presentation, especially in immunocompetent hosts. A 76-year-old immunocompetent female presented with abdominal pain and constipation. Colonoscopy revealed an ulcerated polypoidal tumor-like mass in the anorectal region. Biopsy of the lesion showed large basophilic intranuclear inclusions which were positive for CMV on immunohistochemical staining. The patient responded to 2 weeks of antiviral therapy with complete resolution of the mass. Although rare, pseudotumors associated with CMV infection should be considered in the differential diagnosis of tumorous lesions of the GIT.
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Acute urinary retention caused by seminoma in a case of persistent Mullerian duct syndrome p. 83
Jayesh Modi, Deepika Modi, Lira Bachani
DOI:10.4103/0377-4929.151196  PMID:25673601
Urinary symptoms have been described secondary to a pelvic mass originating from the ovary, uterus, cervix, prostate, or rectum. Persistent Mullerian duct syndrome is a rare form of intersex disorder, characterized by the presence of uterus and fallopian tubes in an otherwise 46 XY male. We report an adult male with bilateral cryptorchidism and a pelvic mass, who presented with acute urinary retention, and was diagnosed with a seminoma of the right testis, intratubular germ cell neoplasia of the left testis with the presence of Mullerian remnants. Pelvic mass was caused due to seminoma is a rare cause of urinary retention.
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Colorectal malakoplakia in a child presenting as multiple polyposis coli p. 86
Meena N Jadhav, Rashmi K Patil, Shreekant K Kittur, Jayalaxmi yadav
DOI:10.4103/0377-4929.151197  PMID:25673602
Malakoplakia of the gastrointestinal tract is a rare chronic inflammatory disorder, usually affecting the descending colon, sigmoid colon and rectum. It is commonly seen in adults. Only few cases have been reported in children. We report a case of malakoplakia of colon and rectum in a 7-year-old child who presented with multiple polyposis coli.
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Central nervous system teratomas in infants: A report of two cases p. 89
Shatavisha DasGupta, Sanghamitra Mukherjee, Ram Narayan Das, Anway Sen, Uttara Chatterjee, Chhanda Datta, Sandip Chatterjee
DOI:10.4103/0377-4929.151198  PMID:25673603
Intracranial teratomas are uncommon neoplasms with most of them being encountered in the pediatric age group. Teratomas are composed of derivatives of all the three germ cell layers and are classified into mature, immature and teratoma with malignant transformation. Two cases of intracranial teratomas in infants are presented here with the idea of highlighting this relatively uncommon condition in an uncommon age.
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Pancreatoblastoma in an adult p. 93
Di Zhang, Na Tang, Yang Liu, En-Hua Wang
DOI:10.4103/0377-4929.151199  PMID:25673604
Pancreatoblastoma is a malignant pancreatic tumor that rarely occurs in adults. We report a case of an adult female with pancreatoblastoma. A mass was detected in the pancreatic head using computed tomography and ultrasonography. The clinical diagnosis was a solid-pseudopapillary neoplasm of the pancreas. However, after the operation, the final diagnosis was pancreatoblastoma, which showed two lines of differentiation: Acinar differentiation and squamoid corpuscles. The patient is currently in good condition.
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Bronchogenic cyst mimicking an adrenal mass in the retroperitoneal region: Report of a rare case p. 96
Gulay Bulut, Mehmet Deniz Bulut, Inci Bahadır, Çetin Kotan
DOI:10.4103/0377-4929.151200  PMID:25673605
We report the surgical excision of a retroperitoneal bronchogenic cyst that presented as a nonfunctioning left adrenal mass in a 25-year-old woman with continuous pain in the left flank. Preoperative biochemical testing confirmed that the mass was nonfunctional. Bronchogenic cysts are mostly benign congenital abnormalities that originate from the remnants of the primitive foregut and typically occur in the lung. Subdiaphragmatic and especially, retroperitoneal locations are rare. Despite the rarity of this pathologic entity, bronchogenic cysts should be considered in the differential diagnosis of retroperitoneal cystic lesions. Diagnosis must be definitively confirmed by histology.
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Idiopathic systemic granulomatous pathology causing sudden death due to myocarditis: A rare case report p. 99
Harpal Singh, Ramesh Kundal
DOI:10.4103/0377-4929.151201  PMID:25673606
Idiopathic granulomatous myocarditis is extremely rare, particularly since the introduction of drugs effective against tuberculosis (TB), viruses, fungi and the effective treatment of sarcoidosis. Here is a case of a 65-year-old female prisoner having history of sudden collapse and ultimately death. Autopsy findings of various viscera on histopathological examination show granulomatous pathology, that is, in spleen, liver and in the left ventricular wall of heart. Ziehl-Neelsen staining of the sections show the absence of acid fast bacilli, negative for fungal staining as most of the granulomas are noncaseating type with presence of giant cells having no asteroid body and Schuamann body, real-time polymerase chain reaction for TB is negative. Idiopathic giant cell myocarditis is a disease of relatively young adults, that is, between 3 rd and 4 th decade of life. So, this case is strongly considered to be a case of sudden death due to myocarditis as a result of idiopathic systemic granulomatous pathology, a rare case in in literature.
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Potter's sequence: A story of the rare, rarer and the rarest p. 102
Saurav Sarkar, Shatavisha DasGupta, Madhumita Barua, Ranajoy Ghosh, Kaushik Mondal, Uttara Chatterjee, Chhanda Datta
DOI:10.4103/0377-4929.151202  PMID:25673607
Potter's syndrome is a rare condition affecting one in 2000-5000. We present here two autopsy cases of Potter's syndrome, with the rare finding of discoid adrenals and the even rarer finding of in situ neuroblastoma in one of the cases.
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High-grade myxofibrosarcoma-presented as a large mass of right upper arm Highly accessed article p. 105
Sunil Vitthalrao Jagtap, Akash Jain, Swati S Jagtap, Ashok Y Kshirsagar
DOI:10.4103/0377-4929.151203  PMID:25673608
Myxofibrosarcoma is one of the rare soft tissue sarcomas. We present a case of a 65-year-old male having large soft tissue mass over right upper arm associated with surface ulceration. On histopathological study tumor was diagnosed as myxofibrosarcoma - high grade according to modified FNCLCC grading system. Like many other tumors of connective tissue, soft tissue sarcoma exhibits high recurrence. In our case, tumor showed features of high grade with local recurrence, large size; however, no evidence of metastasis was noted. For this unpredictable clinical behavior, we are presenting this case.
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Unusual immunophenotype of T-cell large granular lymphocytic leukemia: Report of two cases p. 108
Nikhil Rabade, Dia Mansukhani, Shanaz Khodaiji, Balkrishna Padte, Abhay Bhave, Prashant Tembhare, Papagudi Ganesan Subramanian, Kunal Sehgal
DOI:10.4103/0377-4929.151204  PMID:25673609
Large granular lymphocytes (LGL) leukemias are commonly of the T-cell or NK-cell type. T-cell LGL leukemia is typically a disorder of mature CD3, CD8 and T-cell receptor TCR (TCR - T cell receptor)-αβ positive cytotoxic T-cells. Rare variants include TCRγδ+ variants and CD4 + TCRαβ+ cases. We report a case of each of these rare variants. An 83-year-old female presented with anemia and lymphocytosis with LGLs on peripheral smear. Six-color multiparametric flowcytometric analysis showed expression of CD3, heterogeneous CD7, dim CD2 and TCRγδ and lacked expression of CD5, TCRαβ, CD56, CD4 and CD8. A final diagnosis of TCRγδ+ T-cell LGL leukemia was made. Differentiation between TCRγδ+ T-cell LGL leukemia and other γδ+ T-cell malignancies is of utmost importance due to the indolent nature of the former as compared to the highly aggressive behavior of the latter. An 85-year-old male diagnosed with liposarcoma was identified to have lymphocytosis during preoperative evaluation. Peripheral smear showed presence of LGLs. Flowcytometric immunophenotyping showed expression of TCRαβ, CD3, CD2, CD5, CD4, dim CD8, CD56 with aberrant loss of CD7 expression. Vβ repertoire analysis by flowcytometry showed 97% cells with Vβ14 clonality. A final diagnosis of TCRαβ+ CD4 + T-cell LGL leukemia was made. CD4 + T-cell large granular lymphocytic leukemias have an indolent, less aggressive course when compared to their CD8 + counterparts and are not necessarily associated with cytopenias. However, their association with secondary neoplasia (29% of the cases) warrants a high degree of suspicion in the diagnosis as also noted in the index case. Use of a wide panel of antibodies and newer modalities such as Vβ repertoire analysis helps in accurate subtyping of LGL leukemia.
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A case of extended spectrum beta-lactamase producing Salmonella enterica serotype paratyphi A from India p. 113
Priyamvada Roy, Deepti Rawat, Sonia Malik
DOI:10.4103/0377-4929.151205  PMID:25673610
Enteric fever caused by Salmonella enterica is a systemic infection with high rates of morbidity and mortality. Increasing antibiotic resistance in S. enterica has led to shift in the choice of antibiotics used against this organism from chloramphenicol and ampicillin to trimethoprim-sulfamethoxazole, fluoroquinolones, and extended-spectrum cephalosporins. Resistance to cephalosporins, due to the production of extended-spectrum beta-lactamases (ESBLs), is the cause of serious concern worldwide. So far, these enzymes have been detected in many species of the family Enterobacteriaceae including different serotypes of S. enterica. To the best of our knowledge, however, ESBL production in Salmonella Paratyphi A has not yet been reported from India. We present here a case of ESBL producing Salmonella Paratyphi A from India. This is a worrisome finding with grave clinical implications, since the dissemination of this resistance trait would further limit the therapeutic options available for the treatment of enteric fever.
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A masquerading subcutaneous swelling caused by Scedosporium apiospermum: An emerging pathogen p. 115
A Malini, NS Madhusudan, Sankappa P Sinhasan, Basavanandswamy C Harthimath
DOI:10.4103/0377-4929.151206  PMID:25673611
Scedosporiasis is an emerging infection in immunocompromised individuals. We report a case of multiple subcutaneous swellings in a diabetic ketoacidotic patient, which was clinically diagnosed as lipoma. On fine-needle aspiration cytology, pus was aspirated, which showed septate branching hyphal elements. The pus culture on Sabouraud's dextrose agar yielded Scedosporium apiospermum, which was identified based on its macroscopic and microscopic features. There are very few reports of scedosporiasis from India. The diagnosis of scedosporiasis is difficult and correct etiological diagnosis can help in better management of the patient.
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IMAGES: Ectopic thymic cyst: A rare case report p. 118
Kalpana A Bothale, Sadhana D Mahore, Pragati Karmarkar, Trupti Dongre
DOI:10.4103/0377-4929.151207  PMID:25673612
Ectopic thymic tissue in the neck is rarely reported in medical literature. Being uncommon, they are rarely included in the clinical diagnosis of cervical cystic masses and are misdiagnosed by surgeons as branchial cysts, lymphatic malformations, epidermoid cysts, dermoid cysts or thyroglossal cysts, lymphadenitis or neoplastic masses. Although it is rare, cervical thymic cyst should be considered in the differential diagnosis of a lateral cystic neck mass. Here we report a rare case of thymic cyst in a young 15-year-old male child on the left side of the neck. Histopathology of the excised cyst revealed thymic tissue composed of prominent Hassall's corpuscles, cholesterol clefts, lymphoid aggregates and cyst lined by cuboidal and squamous cells.
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QUIZ PAGE Top

Quiz page p. 120

DOI:10.4103/0377-4929.151223  PMID:25673613
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LETTERS TO EDITOR Top

A rare case of squamous cell carcinoma with rhabdoid differentiation of oral cavity p. 121
Maithili M Kulkarni, Avinash R Joshi, Sinai Khandeparkar, Siddhi Gaurish, Monica Suryavanshi
DOI:10.4103/0377-4929.151210  PMID:25673614
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Calcifying fibrous tumor of the large intestine p. 122
Serkan Senol, Bahar Ceyran Ayşe, Ebru Zemheri, Adem Arslan
DOI:10.4103/0377-4929.151213  PMID:25673615
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Sacrococcygeal teratoma with ectopic immature renal tissue p. 124
Shatavisha DasGupta, Ranajoy Ghosh, Ram Narayan Das, Uttara Chatterjee
DOI:10.4103/0377-4929.151214  PMID:25673616
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Hairy cell leukemia with ascites and coexistent histoplasmosis p. 125
Neeraj Arora, Aroonima Mishra, Poonam Santra, Reena Nair
DOI:10.4103/0377-4929.151215  PMID:25673617
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A rare case of double heterozygous state for HbD and HbE p. 126
Sanjeev Kumar Gupta, Jasmita Dass, Renu Saxena
DOI:10.4103/0377-4929.151217  PMID:25673618
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Leukemic phase of pediatric anaplastic large cell lymphoma with unusual immuno-profile and cytogenetic correlation p. 127
Anurag Gupta, Mayur Parihar, Deepak Kumar Mishra, Arpita Bhattacharyya
DOI:10.4103/0377-4929.151218  PMID:25673619
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Distribution of Salmonella Typhi phage types from Pondicherry, India p. 129
Sreenivasan Srirangaraj, Arunava Kali, Marie Victor Pravin Charles
DOI:10.4103/0377-4929.151220  PMID:25673620
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Tubercular pleural effusion complicated with Elizabethkingia meningoseptica infection in a diabetic male p. 130
Gitanjali Sarangi, Gautam Patnaik, Padma Das, Nirupama Chayani, Jyoti Patnaik
DOI:10.4103/0377-4929.151222  PMID:25673621
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BOOK REVIEW Top

Color Atlas of Tissue Response to Biomaterials p. 133
KP Aravindan
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TRIBUTE Top

Tribute: Dr. Sambhu Nath De: One of the Greatest Indian Scientists p. 134
Shanta Dutta, Surojit Das, AK Nandy, Subir K Dutta
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QUIZ ANSWER PAGE Top

Quiz answer page p. 137
KP Aravindan
DOI:10.4103/0377-4929.151230  
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