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   Table of Contents - Current issue
Coverpage
July-September 2016
Volume 59 | Issue 3
Page Nos. 269-433

Online since Wednesday, August 10, 2016

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EDITORIAL  

From Editor's desk p. 269
Vatsala Misra
DOI:10.4103/0377-4929.188128  PMID:27510656
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GUEST EDITORIALS Top

Combination of laboratory diagnostic tests for cutaneous tuberculosis p. 271
Ling-Juan Zhang
DOI:10.4103/0377-4929.188106  PMID:27510657
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Salivary gland anlage tumor in a neonate Highly accessed article p. 273
Sunil Vitthalrao Jagtap
DOI:10.4103/0377-4929.188116  PMID:27510658
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ORIGINAL ARTICLES Top

Evaluation of laboratory diagnosis for cutaneous tuberculosis Highly accessed article p. 274
Ilhan Afsar, Fatma Sule Afsar
DOI:10.4103/0377-4929.188132  PMID:27510659
Background and Aim: Cutaneous tuberculosis (CTB) is still difficult to diagnose due to its varied clinical presentation and limitations of diagnostic methods. The aim of this study was to evaluate the results of diagnostic laboratory tests available for CTB. Materials and Methods: Twenty-six skin biopsy specimens belonging to clinically suspected cases of CTB were studied retrospectively. The specimens were divided into two portions, one part processed for histopathological evaluation and the other was used for microscopy and inoculation for the isolation of mycobacteria. Polymerase chain reaction (PCR) technique was applied to 14 of 26 specimens to detect Mycobacterium tuberculosis complex (MTBC) DNA. Results: Of the 26 biopsy specimens, 11 were confirmed as CTB by identification of MTBC in culture and/or histopathologic affirmation. Of these, four were lupus vulgaris, four were TB verrucosa cutis, one was scrofuloderma, one was primary inoculation TB, and one was periorifical CTB. Culture for mycobacteria was positive for five (45.45%) specimens, while histopathologic affirmation was obtained in ten (90.90%) specimens. Acid-fast Bacilli were not demonstrated in any of the specimens on microscopic examination. The PCR was found to be applied to six of the 11 specimens diagnosed as CTB and was positive in two specimens (33.3%), which were positive for growth in culture and histopathological correlation. Conclusion: The recovery rate of MTBC from biopsy specimens was found to be satisfactory for CTB with histopathological correlation, but the combination of culture with a rapid method, PCR, may improve the diagnostic rate.
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Pathology of thyroid in acquired immunodeficiency syndrome p. 279
Dhaneshwar Namdeorao Lanjewar, Sushma Nagsen Ramraje, Sonali Dhaneshwar Lanjewar
DOI:10.4103/0377-4929.188143  PMID:27510660
Background: The course of human immunodeficiency virus infection and the acquired immunodeficiency syndrome can be complicated by a variety of endocrine abnormalities, including abnormalities of thyroid gland. Materials and Methods: This study was designed to understand the spectrum of pathology of thyroid in Indian patients with AIDS. The present study describes the findings of retrospective autopsy findings of 158 patients with AIDS which revealed infectious diseases from a time period before the use of highly active antiretroviral regimen. Results: A wide range of bacterial, fungal, and viral infections were observed. Tuberculosis was recorded in 14 (09%) patients, Cryptococcus neoformans in 11 (7%) patients and cytomegalovirus in 3 (2%) patients. Hashimoto's thyroiditis and lymphocytic thyroiditis were seen in 02 (01%) patients each. One patient had dual infection comprising of tuberculosis and cytomegalovirus infection. The other microscopic findings observed were goiter (2 patients), interstitial fibrosis in thyroid (7 patients), and calcification in thyroid (8 patients). Conclusions: Abnormalities of thyroid are uncommon findings in patients with HIV infection however several case reports of thyroid involvement by infectious agents and neoplasm are described in these patients; hence patients with HIV infection should be closely followed up for development of goiter or abnormalities of thyroid functions.
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Apoptosis in oral epithelial dysplastic lesions and oral squamous cell carcinoma: A prognostic marker p. 284
Shwetha Nambiar, Veda Hegde
DOI:10.4103/0377-4929.188126  PMID:27510661
Background: Apoptotic index (AI) using light microscopy as an indirect measure to assess the significance of apoptosis as a proliferative marker in dysplastic lesions and malignant epithelial lesions of the oral cavity. Aims: (1) To quantify the apoptotic bodies/cells in oral epithelial dysplastic (OED) lesions and oral squamous cell carcinoma (OSCC). (2) To measure AI in OED and OSCC. (3) To compare AI in OED and OSCC. Settings and Design: The proposed laboratory-based retrospective study involved the use of hematoxylin and eosin (H and E)-stained slides of previously diagnosed OED lesions and OSCC from institutional archives. Materials and Methods: This study constituted 50 cases, each of H and E-stained slides of previously diagnosed cases of OED and OSCC. AI was calculated as the number of apoptotic bodies/cells expressed as a percentage of the total number of nonapoptotic tumor/dysplastic cells counted in each case. Statistical Analysis Used: Nonparametric tests such as Kruskal–Wallis test and Mann–Whitney test were used. Results: There was a statistically significant increase in AI from OED to OSCC (P = 0.000). Conclusions: Further studies need to be undertaken to detect and understand the apoptotic mechanisms in the progression from OED to OSCC.
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Do phosphatase of regenerating liver-3, matrix metalloproteinases-2, matrix metalloproteinases-9, and epidermal growth factor receptor-1 predict response to therapy and survival in glioblastoma multiforme? p. 287
Priyanka Soni, Nuzhat Husain, Anil Chandra, Bal Krishan Ojha, Madan Lal Brahma Bhatt, Rakesh Kumar Gupta
DOI:10.4103/0377-4929.188121  PMID:27510662
Context: Poor survival of the glioblastoma multiforme (GBM) has been attributed in part to the invasive nature of the lesion making complete surgical removal near impossible. Phosphatase of regenerating liver-3 (PRL-3), matrix metalloproteinases-2 and -9 (MMP-2 and MMP-9), and epidermal growth factor receptor (EGFR-1) play a role in invasive nature of tumor cells. Aims: This study was conducted to evaluate PRL-3, MMP-2, MMP-9, and EGFR-1 (markers) expression in cases to GBM and to correlate their expression with therapy response and survival. Settings and Design: GBM cases (n = 62) underwent surgery followed by radiation (n = 34) and chemoradiation (n = 28). Using WHO Response Evaluation Criteria in Solid Tumors criteria response to therapy was assessed at 3 months and cases followed up for survival. Subjects and Methods: Expression of markers was assessed by immunohistochemistry as a percentage of positive tumor cells in hot spots. Statistical Analysis Used: Kaplan–Meier, ANOVA, Chi-square test, univariate, and multivariate Cox-regression analysis was done. Results: Response to therapy was evident in 54.8% cases of responders with the mean survival of 494.03 ± 201.13 days and 45.2% cases of non responders (278.32 ± 121.66 days) with P = 0.001. Mean survival for the patient's opted chemoradiation was 457.43 ± 222.48 days which was approximately 3 months greater than those who opted radiation alone (P = 0.029). We found PRL-3 overexpression was an independent, significant, poor prognostic factor for survival by multivariate analysis (P = 0.044). Cases negative for MMP's and EGFR showed increased survival, but the difference was insignificant. Conclusion: PRL-3 expression appears to be related to an adverse disease outcome.
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A tissue microarray study of toll-like receptor 4, decoy receptor 3, and external signal regulated kinase 1/2 expressions in astrocytoma p. 294
Chih-Kung Lin, Chun-Chieh Ting, Wen-Chiuan Tsai, Yuan-Wu Chen, Dueng-Yuan Hueng
DOI:10.4103/0377-4929.188122  PMID:27510663
Introduction: Decoy receptor 3 (DcR3) functions as a death decoy inhibiting apoptosis mediated by the tumor necrosis factor receptor family. It is highly expressed in many tumors and its expression can be regulated by the MAPK/ERK signaling pathway and ERK is a vital member of this pathway. Toll-like receptor 4 (TLR4) is expressed on immune cells. Increased TLR4 expression has been associated with various types of cancers. Material and Methods: The study was conducted to investigate the expression of DcR3, ERK1/2, and TLR4 in astrocytomas and evaluate if they are validating markers for discriminating glioblastoma from anaplastic astrocytoma in limited surgical specimen. Expression of DcR3, ERK1/2, and TLR4 was determined by immunohistochemical staining of tissue microarray from 48 paraffin-embedded tissues. A binary logistic regression method was used to generate functions that discriminate between anaplastic astrocytomas and glioblastomas. Results: The expression of TLR4 and DcR3 was significantly higher in glioblastomas than in anaplastic astrocytomas. DcR3 could discriminate anaplastic astrocytomas from glioblastomas with high sensitivity (93.8%), specificity (90%), and accuracy (92.3%). Conclusion: Our results suggest that DcR3 may be a useful marker for discriminating anaplastic astrocytomas from glioblastomas.
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The evaluation of the caveolin-1 and AT-rich interactive domain 1 alpha expressions in uterine smooth muscle tumors p. 301
Duygu Ayaz, Gulden Diniz, Dudu Solakoglu Kahraman, Sevil Sayhan, Melek Uncel, Tugba Karadeniz, Muzaffer Sanci
DOI:10.4103/0377-4929.181891  PMID:27510664
Objectives: This retrospective study was designed to evaluate the importance of tissue expressions of caveolin-1 (Cav-1) and AT-rich interactive domain 1 alpha (ARID-1A) which are known as signal regulator and tumor suppressor in differential diagnosis of uterine smooth muscle tumors (SMTs). Materials and Methods: Thirty patients recently diagnosed as uterine SMTs at the Tepecik Training and Research Hospital were identified using pathology databases. Immunohistochemical stains for Cav-1 and ARID-1A were performed. Results: In this series, there were 10 leiomyosarcomas (LMSs), 10 uterine smooth muscle tumors of uncertain malignant potentials (STUMPs), and 10 leiomyomas (LMs). Cav-1 expression located cytoplasmic or perivascular area. Cytoplasmic Cav-1 expression was determined in 5 LMSs and 2 STUMPs while perivascular Cav-1 expression was determined in 9 LMSs and 2 STUMPs. Statistically, it was determined that if the tumor becomes malignant and more invasive, it gains the perivascular Cav-1 expression (P = 0.029). On the other hand, the mean nuclear staining rate for ARID-1A in LMSs (63 ± 23.4%) was higher than both STUMPs (60 ± 18.5%) and LMs (34.5 ± 16.5%). Statistically, it was determined that the expression of ARID-1A was significantly downregulated in LMs when compared with STUMPs and LMSs (P = 0.004). Conclusions: Our findings were demonstrated that perivascular Cav-1 expression was seen to be a marker for malignancy of uterine SMTs. Similarly, we found to link of ARID-1A expression and the aggressiveness of SMTs. Therefore, it may be suggested that Cav-1 and ARID-1A may act as predictive biomarkers in uterine SMTs.
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Comparative evaluation of immunoperoxidase versus immunofluorescent techniques in interpretation of kidney biopsies p. 305
Swasti Shubham, Minakshi Bhardwaj, Himansu Sekhar Mahapatra
DOI:10.4103/0377-4929.188105  PMID:27510665
Background: Immunofluorescence (IF) on frozen sections has been considered to be the gold standard for evaluation of kidney biopsy specimens. Immunohistochemistry (IHC) method can also be used for this purpose with advantages of being applicable on paraffin embedded tissue, providing permanent sections, and not requiring a specialized microscope for interpretation. Our aim was to evaluate IHC as an alternative to IF in the diagnostic assessment of kidney biopsy specimens. Methods: One hundred kidney biopsy specimens were subjected to both IF and IHC staining for immunoglobulins (Ig), IgG, IgA, IgM and complement components c3 and c1q. IF staining was done on frozen sections. IHC staining was performed on paraffin-embedded tissue following proteolytic antigen retrieval. The sections were evaluated, and the results of IHC were compared with IF. Results: Concordant observations were 98%, 87%, 89%, 83%, and 89% for IgA, IgM, IgG, C3 and C1q, respectively. The sensitivity of IHC method for Igs was found to be high (92%, 86.5%, and 95.1%, respectively for IgA, IgM, and IgG). 91% cases showed concordance of the intensity of the deposits while 100% cases showed a concordance of the pattern. Statistically, there was no significant difference in outcomes between IF and IHC for IgA, IgM, and IgG. However, statistically significant difference was found in the results for complement proteins. Conclusion: In this study, it is documented that IHC is, with few exceptions, equal to IF for the detection of Igs. Standardized immunoperoxidase method on the paraffin embedded, formalin fixed needle kidney biopsies could successfully replace the IF method in the diagnosis of glomerulonephritis.
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Expression of CD71 by flow cytometry in acute leukemias: More often seen in acute myeloid leukemia p. 310
Amit Pande, Pranav Dorwal, Dharmendra Jain, Neetu Tyagi, Simmi Mehra, Ritesh Sachdev, Vimarsh Raina
DOI:10.4103/0377-4929.188145  PMID:27510666
Background: CD71 is a marker that has been usually used for identifying dysplasia in the erythroid series. We have tried to evaluate the expression of CD71 in various types of acute leukemias. Materials and Methods: We studied 48 patients of acute leukemia, of which 25 were acute myeloid leukemia (AML), 13 were precursor B-acute lymphoblastic leukemia (B-ALL), 8 were T-ALL, and 2 were mixed phenotype acute leukemia (T/myeloid) as per the WHO classification. Results: We found that the expression of CD71 was most prevalent in AMLs (84%), followed by T-ALL (50%) and least in B-ALL (30%). Conclusion: This finding clearly shows the higher expression of CD71 in AMLs compared to other common type of leukemias, such as B- and T-ALL. We suggest that the high expression of CD71 in AMLs could be used as a diagnostic marker and may also be used for minimal residual disease analysis after further studies in posttreatment scenario. This study is the first of its kind in the South Asian population.
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Comparative analysis of phenotypic and genotypic detection of methicillin resistance among Staphylococcus aureus p. 314
Tulin Demir, Nilay Coplu, Berrin Esen
DOI:10.4103/0377-4929.188103  PMID:27510667
Aims: Staphylococcus aureus is a common pathogen causing a wide range of infections ranging from mild skin and soft tissue infections to severe, life-threatening infections. Accuracy in the detection of methicillin resistance is important to avoid treatment failures. The aim of this study was to compare the results of phenotypic and genotypic test methods to detect methicillin resistance and also to determine the antimicrobial susceptibilities. Materials and Methods: Two hundred and forty-two S. aureus strains isolated from skin and soft tissue samples were analyzed for methicillin resistance using oxacillin and cefoxitin disk diffusion (DD), oxacillin screen agar test, cefoxitin E-test, and mecA gene polymerase chain reaction (PCR). Results: 77 of 242 S. aureus isolates were mecA positive. Oxacillin, cefoxitin DD, oxacillin screen agar test and cefoxitin E-test exhibited sensitivities as 98.7%, 98.7%, 100%, 100%, and specificities as 96.9%, 97.5%, 96.9%, 97.5%, respectively. Conclusion: Results of oxacillin screen agar and cefoxitin DD test were in concordance with mecA gene PCR. Thus, it is determined that especially cefoxitin test can be an alternative to PCR in routine.
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Role of type-specific herpes simplex virus-1 and 2 serology as a diagnostic modality in patients with clinically suspected genital herpes: A comparative study in Indian population from a tertiary care hospital p. 318
Vrushali Patwardhan, Preena Bhalla
DOI:10.4103/0377-4929.188104  PMID:27510668
Introduction: Type-specific serology (TSS) test for herpes simplex virus (HSV) have been used as a research tool in seroepidemiological studies for some years. However, TSS as a diagnostic modality for diagnosis of current episode of genital herpes is not well documented. Aims and Objectives: To measure the seroprevalence of type-specific HSV Type 1 (HSV-1) and Type 2 (HSV-2) IgG antibodies in cases provisionally diagnosed as primary and recurrent genital herpes and to evaluate the role of TSS as a diagnostic modality for diagnosis of genital herpes versus polymerase chain reaction (PCR). Materials and Methods: A cross-sectional study was performed over a period of 10 months in which 44 adult patients with clinically suspected genital herpes were recruited. An in-house glycoprotein G gene base PCR was performed directly from the genital lesion specimen for simultaneous detection and typing of HSV. TSS was performed to detect IgG antibody against HSV-1 and 2 in all patients using commercially available kits, and the results were compared. Results: Seroprevalence of HSV-1 IgG was 43% among primary and 65% among recurrent genital herpes cases (P = 0.22). Whereas that of HSV-2 IgG was found to be 14% and 83% in respective patient group (P = 0.0001). When compared to PCR results HSV-1 IgG detection in both primary and recurrent genital herpes diagnosis had poor specificity, positive predictive value, and sensitivity. Whereas, HSV-2 serology had a sensitivity of 13.33% and 73.33% in primary and recurrent genital herpes and specificity of 83.33% and 85.71%, respectively. Conclusion: HSV-2 IgG detection helps in strengthening the diagnosis of recurrent HSV-2 disease, whereas the absence of HSV-2 IgG antibody helps in excluding genital herpes as a likely cause of recurrent genital ulceration. However, detection of HSV-1 IgG antibody may not be useful for diagnosis in patients of genital ulcer disease.
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Distribution of plasmid-mediated quinolone resistance in Gram-negative bacteria from a tertiary hospital in Nigeria p. 322
David Olusoga Ogbolu, Armstrong Oyebode Alli, Michael C Anorue, Oluwole Adebayo Daini, Afolabi Oluwadun
DOI:10.4103/0377-4929.188108  PMID:27510669
Background: Until recently, mechanisms of resistance to quinolones in Gram-negative bacteria were believed to be only chromosome encoded. However, emergence of plasmid-mediated quinolone resistance (PMQR) has been reported worldwide. Aim: This study investigated distribution of PMQR in Gram-negative bacteria from a tertiary hospital in eastern part of Nigeria. Materials and Methods: Seventy-one nonduplicate Gram-negative bacterial isolates of eight species were analyzed for antimicrobial susceptibility, genotypic detection of various PMQRs, typed by random amplified polymorphic DNA (RAPD) and analysis of plasmids present, including replicon typing. Results: The minimum inhibitory concentrations showed MIC90values as high as 256 μg/ml for fluoroquinolones. Carriage of PMQR was found to be 35.2%. Twenty (28.2%) isolates carried various qnr genes, of which seven (9.9%) qnrA1; four (5.6%) qnrB1; eight (11.3%) qnrS1 while one (1.4%) encoded qnrD1. Eighteen (25.4%) isolates were positive for aac(6')-Ib-cr while carriage of multiple genes exists in some strains. Similarly, 13 isolates (18.7%) were found to carry PMQR efflux pump gene, qepA. Conjugation experiments revealed that the plasmids once transferred coded for fluoroquinolone resistance. The transconjugant strains carried a common plasmid estimated to be 65 kb. These plasmids were untypable for replicon/incompatibility. Typing revealed high diversity among all species tested with no identical RAPD pattern seen. Conclusion: This study further confirms high level resistance to many antimicrobials in different species of Gram-negative bacteria including fluoroquinolones and spread of PMQR genes in Southern Nigeria.
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Emerging enteric fever due to switching biotype of Salmonella (paratyphi A) in Eastern Odisha p. 327
Ashoka Mahapatra, Somi Patro, Snigdharani Choudhury, Ambareesh Padhee, Rekha Das
DOI:10.4103/0377-4929.188124  PMID:27510670
Background: Typhoid fever is classically caused by Salmonella enterica serotype typhi.Recently the frequency of isolation of S. paratyphi A (SPA) has been increased in comparison to S. typhi in Indian scenario. Aim: To observe the rate of isolation and antimicrobial susceptibility pattern of SPA from suspected enteric fever cases attending tertiary care centres of Eastern Orissa. Settings and Design: Retrospective study Materials and Methods: 1488 blood samples were collected during different duration of fever and cultured in BACTEC blood culture system and bottles showing signal for growth were subcultured and identified as Salmonella spp. by standard procedure and mini API (Biomeriux) and antimicrobial susceptibility by disc diffusion method. Statistical Analysis: Chi square test. Results: 167 Salmonella spp. were isolated including 83.8% Salmonella paratyphi A and 16.6% S. typhi. Among them 102 were males and 65 were females with mean age of 22.7 yrs. S. paratyphi A was the predominant spp. each year but during 2008 – 2011, there was a dramatic rise (significant P value- 0.034). Multidrug resistance was noticed in 10.2% of the isolates. 98% of S. paratyphi A were resistant to nalidixic acid and 41% to ciprofloxacin, but the MIC of ciprofloxacin was raised between 1-2 μgm/dl showing the relation between nalidixic acid resistance and raised MIC of ciprofloxacin. Conclusion: Nalidixic acid should be tested along with ciprofloxacin disc while testing for susceptibility and MIC of ciprofloxacin is mandatory before advocating therapy to prevent treatment failure.
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Comparison of multiplex RT-PCR and real-time HybProbe assay for serotyping of dengue virus using reference strains and clinical samples from India p. 330
Anita Chakravarti, Mayank Singh Chauhan, Sayantan Banerjee, Priyamvada Roy
DOI:10.4103/0377-4929.188141  PMID:27510671
Background: Dengue virus serotyping is crucial from clinical management and epidemiological point of view. Aims: To compare efficacy of two molecular detection and typing methods, namely, multiplex reverse transcription polymerase chain reaction (RT-PCR) and real-time Hybprobe assay using a panel of known dilution of four reference Dengue virus strains and a panel of sera collected from clinically suspected dengue patients. Settings: This study was conducted at a tertiary-care teaching hospital in Delhi, India. Materials and Methods: Dengue serotype specific virus strains were used as prototypes for serotyping assays. Viral load was quantified by quantitative real time reverse transcription polymerase chain reaction (qRT-PCR). Acute phase serum samples were collected from 79 patients with clinically suspected Dengue fever on their first day of presentation during September-October 2012. Viral RNA from serum and cell culture supernatant was extracted. Reverse transcription was carried out. Quantitative detection of DENV RNA from reference strain culture supernatants and each of the 79 patient samples by real-time PCR was performed using light cycler Taqman master mix kit. Serotyping was done by multiplex RT-PCR assay and Hybprobe assay. Results: The multiplex RT-PCR assay, though found to be 100% specific, couldn't serotype either patient or reference strains with viral load less than 1000 RNA copies/ml. The Hybprobe assay was found to have 100% specificity and had a lower limit of serotype detection of merely 3.54 RNA copies/ml. Conclusions: HybProbe assay has an important role especially in situations where serotyping is to be performed in clinical samples with low viral load.
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BRIEF COMMUNICATION Top

A novel PTCH1 gene mutation in a pediatric patient associated multiple keratocystic odontogenic tumors of the jaws and Gorlin–Goltz syndrome p. 335
Gozde Ozcan, Burhan Balta, Ahmet Ercan Sekerci, Osman A Etoz, Claudia Martinuzzi, Ozlem Kara, Lorenza Pastorino, Fatma Kocoglu, Omer Ulker, Murat Erdogan
DOI:10.4103/0377-4929.188148  PMID:27510672
Gorlin–Goltz syndrome (GGS) is an uncommon autosomal dominant inherited disorder which comprises the triad of basal cell carcinomas (BCCs), odontogenic keratocysts, and musculoskeletal malformations. Besides this triad, neurological, ophthalmic, endocrine, and genital manifestations are known to be variable. It is occasionally associated with aggressive BCC and internal malignancies. This report documents a case of GGS with a novel mutation in the PTCH1 gene in an 11-year-old child. The clinical, radiographic, histopathologic and molecular findings of this condition, and treatment are described, and a review of GGS was carried out.
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CLINICO-PATHOLOGY CONFERENCE Top

Severe liver dysfunction in an infant with cystic fibrosis masquerading as metabolic liver disease p. 339
KP Srikanth, Inusha Panigrahi, Babu Ram Thapa, Kim Vaiphei
DOI:10.4103/0377-4929.188137  PMID:27510673
We present a rare presentation of cystic fibrosis with neonatal cholestasis. Histological features of mucoviscidosis were present in liver involving the biliary tract, intestinal mucosa, pancreas, and lung. Besides, there was a rare association with autosomal dominant type of polycystic renal disease.
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CASE REPORTS Top

Solid pseudopapillary neoplasm of the ovary with metastases to the omentum and regional lymph nodes p. 348
Gaurav Pratap Singh Gahlot, Asit Ranjan Mridha, Mukund Sable, Mehar Chand Sharma, Raja Pramanik, Lalit Kumar
DOI:10.4103/0377-4929.188107  PMID:27510674
Extrapancreatic solid pseudopapillary neoplasms (SPNs) are rare tumors, which bear morphological, immunohistochemical, and molecular features similar to those of pancreatic counterparts. SPN occurs primarily in adolescent girls and young women. It is considered to be a malignant neoplasm with low-grade biology. Ovarian SPNs are uncommon, have benign morphology, usually limited to the ovary and local surgical excision is curative. We report an unusual case of SPN of right ovary with extraovarian spread and metastases to lymph nodes. To the best of our knowledge, this is the second documented case of extragonadal spread of ovarian SPN.
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Primary thymic mediastinal seminoma with florid granulomatous reaction p. 351
Devika Gupta, Ashutosh Rath, Khushi Ram Rathi, Giriraj Singh
DOI:10.4103/0377-4929.188113  PMID:27510675
Primary mediastinal seminomas are rare tumors. Morphologically, they can be associated with secondary changes in the form of thymic remnants, cystic change, epithelioid granulomas, abundant fibrosis, and syncytiotrophoblast like cells. Ours was an interesting case where a 17-year-old adolescent male presented with anterior mediastinal mass. Fine needle aspiration and trucut biopsy of the mass favored tuberculosis; however, he did not respond to antituberculosis treatment regime. He was subjected to video-assisted thoracoscopic surgery and the histopathological examination along with supportive immunohistochemistry of the mass revealed scattered seminoma cells which were being masked by extensive granulomatous reaction. The aim of this article is to report a case of primary mediastinal thymic seminoma in a young male associated with extensive granulomatous reaction masking the neoplastic population of cells leading to erroneous diagnosis on small biopsy.
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Lipoleiomyoma of the left broad ligament with dermoid cyst in ipsilateral ovary and synchronous multiple benign lesions of female genital tract: An unusual association p. 355
Sweta Singh Mishra, Arpita Saha, Pritinanda Mishra, Saubhagya Kumar Jena
DOI:10.4103/0377-4929.188117  PMID:27510676
Lipoleiomyoma of the uterus is a rare variant of leiomyoma, and lipoleiomyoma of the broad ligament is still rarer, with only a handful of cases being reported. The present case was a perimenopausal woman who presented with a huge lower abdominal mass. Ultrasonography and computed tomography showed a heterogeneous solid mass in the left adnexa. The histopathological findings confirmed the nature of the lesions as a benign lipoleiomyoma with dermoid cyst of the left ovary and its other associated benign lesions, were the interesting features seen in this case which were not suspected clinically and radiologically.
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Combined presence of multiple gastrointestinal stromal tumors along with duodenal submucosal somatostatinoma in a patient with neurofibromatosis type 1 p. 359
Tarun Kumar, Brijnandan Gupta, Prasenjit Das, Deepali Jain, Hemant Ashok Jain, Kumble S Madhusudhan, Nihar Ranjan Dash, Siddhartha Datta Gupta
DOI:10.4103/0377-4929.188123  PMID:27510677
Neurofibromatosis type-1 (NF-1) is an autosomal dominant disorder, with increased risk of developing benign and malignant tumors of the gastrointestinal tract (GIT). However, the synchronous presence of multiple GIT stromal tumors and duodenal submucosal somatostatinoma, like in this 50-year-old female NF-1 patient, is very rare. She presented with hematemesis, malena, along with multiple neurofibromas all over the body. Thorough radiological and peroperative work-up revealed multiple ulcerated submucosal and serosal nodules in the proximal small intestine. Histological work-up revealed diagnosis of a duodenal submucosal somatostatinoma with multifocal serosal gastrointestinal stromal tumors. This case is being reported to highlight the rare coincidence of multiple GIT tumors in an NF-1 patient.
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An unusual presentation of chondroid syringoma p. 362
Dilip Chandra Barman, Abhijit Bhowmik
DOI:10.4103/0377-4929.188111  PMID:27510678
Chondroid syringoma (CS) is a rare benign tumor of the sweat gland. It generally presents as a painless, slowly growing, subcutaneous swelling, typically located on the head and neck region. The majority of the cases develop in middle aged and elderly males. We present a case of CS located over the right thumb of a 25-year-old male. The diagnosis was made initially by cytological evaluation and later confirmed by histopathological examination. There was no recurrence on two year follow up after the complete surgical excision of the tumor.
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Isolated ileal ganglioneuromatosis in an 11-year-old boy: Case report and review of literature p. 365
Subhashis Mitra, Sanghamitra Mukherjee, Hema Chakraborty
DOI:10.4103/0377-4929.188109  PMID:27510679
Ganglioneuromatous proliferation in the gastrointestinal tract is a rare occurrence and is usually associated with specific syndrome complexes such as multiple endocrine neoplasia Type 2B or von Recklinghausen's disease. We report here a case of diffuse intestinal ganglioneuromatosis, presenting as intestinal obstruction and chronic constipation in an 11-year-old boy. Sporadic cases of intestinal ganglioneuromatosis in the absence of any systemic manifestations are a very rare cause of enteric motility disorders in childhood, and we discuss the pathological and clinical significance of this finding. Histopathological identification of this uncommon cause of a common pediatric problem is important since the condition is amenable to surgical treatment.
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Cytomorphological findings and histological correlation of papillary cystadenocarcinoma of the parotid: Not always a low-grade tumor p. 368
Yasmeen Khatib, Madhura Dande, Richa D Patel, Shubhada V Kane
DOI:10.4103/0377-4929.188114  PMID:27510680
Papillary cystadenocarcinoma (PCAC) is a rare salivary gland tumor characterized by a predominantly cystic growth that often exhibits intraluminal papillary growth without specific histologic features of other cystic salivary gland tumors. The preoperative cytological diagnosis can pose a diagnostic challenge as it has to be differentiated from other cystic papillary tumors such as mucoepidermoid carcinoma, papillary cystic variant of acinic cell carcinoma, and low-grade cribriform CAC. It is considered to be a low-grade malignant salivary gland tumor with an indolent biological behavior. We report a case of PCAC of the parotid in a 55-year-old male diagnosed on fine needle aspiration cytology. Although it showed mild atypia cytologically, on excision tumor showed vascular and perineural invasion with regional node metastasis indicating a wider morphologic spectrum than what is described. This prompted us to write a case report describing the cytological and histological features of this rare tumor and also discuss the diagnostic challenges.
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Sertoli cell tumor arising in a cryptorchid testis presenting as a content of inguinal hernial sac p. 372
Kusuma Venkatesh, Mahantappa Hemalata, S Sathyavathi, Satish Kumar
DOI:10.4103/0377-4929.188135  PMID:27510681
Sertoli cell tumors (SCTs) are rare tumors accounting for <1% of all testicular tumors. Here, we report a rare case of SCT in a 60-year-old man presenting as a painless swelling in the right groin since childhood. Clinically, he presented with right-sided inguinal hernia with absence of the right testis. He had normal left testis and had no gynecomastia or infertility. The specimen of hernial sac showed testis with a 1.6 cm × 1.5 cm nodular mass having gray tan-cut surface. Histopathologically, the testis showed atrophy and the nodular portion showed tumor cells arranged in tubular and microcystic pattern, with no solid pattern or necrosis. The diagnosis of SCT was confirmed with immunohistochemical staining for inhibin which showed fine granular cytoplasmic positivity. Cryptorchid testis having SCT and presenting as a content of inguinal hernia is a rare occurrence.
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Pseudoangiomatous variant of spindle cell lipoma: Report of a rare case p. 376
Amoolya Bhat, C Vijaya, Suraksha B Rao
DOI:10.4103/0377-4929.188142  PMID:27510682
Pseudoangiomatous spindle cell lipoma is a rare variant of spindle cell lipoma. It exhibits irregular and branching spaces with villiform connective tissue projections, leading to formation of a characteristic angiomatoid pattern in addition to benign spindle cells and mature adipocytes. Recent studies have shown that these branching spaces are lined by endothelial cells and express markers. Therefore, the term “angiomatous variant” instead of “pseudoangiomatous” has been proposed for these lesions. We describe one of such lesions in the thumb of a young female. To the best of our knowledge, this is the first reported case of pseudoangiomatous variant of spindle cell lipoma from India.
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Pleomorphic rhabdomyosarcoma of the left atrium mimicking myxoma p. 379
Tanvi Aggarwal, Surbhi Goyal, Sufian Zaheer
DOI:10.4103/0377-4929.188138  PMID:27510683
Primary rhabdomyosarcoma (RMS) of the heart is a rare malignant tumor which has poor prognosis and survival despite surgery and adjuvant chemotherapy. The preoperative diagnosis is often difficult in view of nonspecific clinicoradiological findings. This report describes a case of a 60-year-old woman who was clinically diagnosed as left atrial myxoma. A diagnosis of pleomorphic RMS was made on histopathology after excision. Our case discusses the clinicopathological features and treatment options of cardiac RMS emphasizing the fact that histopathology and immunohistochemistry are essential to confirm the diagnosis of such an aggressive malignant tumor.
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A rare case of multifocal pseudomyogenic hemangioendothelioma, involving soft tissues and bone, misdiagnosed as a rhabdomyosarcoma: Diagnostic and treatment implications p. 382
Bharat Rekhi, Ashish Gulia, Venkatesh Rangarajan
DOI:10.4103/0377-4929.188144  PMID:27510684
Pseudomyogenic hemangioendothelioma (PHE) is an uncommon, but distinctive soft tissue tumor, characterized by multifocality. A 17-year-old male referred to us with progressively increasing multiple subcutaneous nodular lesions over his left leg and foot, reported elsewhere as a spindle cell rhabdomyosarcoma. On review, microscopy showed a cellular tumor comprising plump spindle cells arranged in loose fascicles with interspersed inflammatory cells. Tumor cells exhibited mild nuclear variation. Immunohistochemically, tumor cells expressed AE1/AE3, CD31, Fli-1, and smooth muscle actin (SMA), confirming diagnosis of PHE. Whole-body positron emission tomography–computed tomography (PET-CT) scan revealed multiple, metabolically active, subcutaneous nodular lesions over the left lower leg and in the distal tibia. Subsequently, resection specimens from the various lesions and bone curettage also revealed features of PHE. Three months later, the patient developed multiple lesions over his fourth toe and left foot, for which he underwent tumor resections. At present, he is disease-free. PHE is a locally aggressive soft tissue tumor characterized by multifocality, rarely bony involvement and can be misdiagnosed as a high-grade sarcoma.
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Primary intraosseous atypical inflammatory meningioma presenting as a lytic skull lesion: Case report with review of literature p. 386
Sangita Bohara, Swapnil Agarwal, Nita Khurana, PN Pandey
DOI:10.4103/0377-4929.188131  PMID:27510685
Primary extradural meningiomas of the skull comprise 1% of all meningiomas, and lytic skull meningiomas are still rarer and are said to be more aggressive. We present a case of 38-year-old male with an extradural tumor which on histopathological examination showed features of inflammatory atypical meningioma (WHO Grade II). The intense inflammatory nature of osteolytic primary intraosseous meningioma has not been reported before. This entity deserves special mention because of the need for adjuvant therapy and proper follow-up.
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Vulvar granular cell tumor p. 389
Fatma Cavide Sonmez, Nadiye Koroglu, Beril Guler, Dilek Sema Arici
DOI:10.4103/0377-4929.188134  PMID:27510686
Granular cell tumors (GCTs) are rare and approximately half of the all lesions arise from head and neck, especially from the tongue. However, they are rarely seen in the vulva. They can occur in patients of any age, but peak age incidence is in the fourth to sixth decades. They generally occur as small, slow growing, and skin-colored nodule. GCTs are usually benign, but malignant cases were reported. Recurrence can be seen in benign tumors with clear margins, but rates increase with positive margins. The treatment is complete surgical excision. We report a case of benign GCT of the vulva. A 41-year-old patient presented with vulvar mass, and biopsy was consisted with GCT.
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Recurrent multifocal cutaneous Kaposiform hemangioendothelioma: A rare vascular tumor of infancy and childhood p. 392
Bhagyalakshmi Atla, PV Sudhakar, Nagarjun Rao, Uma Prasad
DOI:10.4103/0377-4929.188130  PMID:27510687
Kaposiform hemangioendothelioma (KHE) is a locally aggressive vascular tumor of childhood although cases occurring in adulthood are also described. The features overlap with juvenile capillary hemangioma and Kaposi sarcoma. We report a rare case of recurrent, multifocal (nose and chin) cutaneous KHE initially occurring in a 3-year-old female child, uncomplicated by Kasabach–Merritt syndrome. Recurrences occurred over the next 6 years and resulted in complete distortion of the nose, requiring plastic repair.
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Unusual ganglioglioma with extensive calcification and ossification p. 395
Vikas Shashikant Kavishwar, Kirti G Chadha, Shaikhali Moiz Barodawala, Anuradha Krishna Murthy
DOI:10.4103/0377-4929.188115  PMID:27510688
Ganglioglioma is a slow-growing relatively low-grade mixed glioneuronal tumor with most cases corresponding to the WHO Grade I category. It frequently presents with seizures. The temporal lobe is the most common location followed by frontal, parietal, and occipital lobes. These generally behave in a benign fashion and have a favorable prognosis. We describe a case of a 24-year-old male presenting with convulsions and a calcified parieto-occipital mass. This mass removed from the parietal lobe showed neoplastic glial and dysplastic neuronal tissue amidst extensive areas of calcification and foci of ossification. On immunohistochemistry, the glial component expressed glial fibrillary acidic protein whereas the dysplastic neuronal component expressed synaptophysin and CD34. Epithelial membrane antigen was negative and Ki-67 showed a low proliferative index. After the surgery, the patient is free of neurological symptoms. Widespread calcification and ossification are very unusual in ganglioglioma, which prompted us to report this case.
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Pulmonary hemangioendothelioma with osteoclast-like giant cells: A rare observation p. 398
Shraddha A Adamane, Kedar K Deodhar, Amit M Gupta, George Karimundackal, Sangeeta B Desai
DOI:10.4103/0377-4929.188125  PMID:27510689
Pulmonary epithelioid hemangioendothelioma (PEH) is a rare vascular neoplasm, predominantly encountered in women, more often in the age group of 40 years and below. It is a tumor of borderline malignant potential with a clinical course intermediate between hemangioma and angiosarcoma. The tumor has variable prognosis, and treatment options include surgical excision in operable cases and chemotherapy in disseminated ones. The present report describes complete clinical, radiological, and histopathological features of PEH with osteoclast-like giant cells and metaplastic ossification in a 20-year-old boy who presented with dyspnea and episodes of hemoptysis with review of literature.
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Fine-needle aspiration cytology of isolated skull nodule: Unfolding the clinical spectrum p. 401
Prajwala Gupta, Minakshi Bhardwaj
DOI:10.4103/0377-4929.188133  PMID:27510690
Follicular thyroid carcinoma (FTC) has been classified as either minimally invasive or widely invasive carcinoma and shows a propensity for blood-borne metastasis. Most common sites of metastasis are lung and bone followed by brain, liver, and skin. Minimally invasive FTC (MIFTC) is characterized by limited capsular and/or vascular invasion with good long-term outcomes, some cases of which show a poor prognosis because of severe distant metastasis. Skull metastasis in adults commonly arises from the lung, breast, and prostate and uncommonly from the thyroid. In our case, fine-needle aspiration cytology of isolated skull nodule was a reliable tool in the diagnosis of metastasis and suggesting the primary in thyroid thereby prompting early workup of a patient. The case is unique since it represents the rare disseminated metastasis from MIFTC with incomplete capsular penetration alone without angioinvasion that can behave as aggressively as a widely invasive FTC.
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Adenocarcinoma of the anal canal: A report of two cases with review of literature p. 404
Medha Pradip Kulkarni, Yasmin Altaf Momin, Amitkumar Bapuso Pandav, Kalpana Ranjitsingh Sulhyan
DOI:10.4103/0377-4929.188139  PMID:27510691
Adenocarcinoma of the anal canal accounts for about 20% of all anal canal cancers. It is subclassified into two types. (1) Colorectal type, which arises from the mucosa above dentate line and (2) extramucosal type, which includes adenocarcinoma arising in anorectal fistulae and adenocarcinoma arising from anal glands. Anal gland adenocarcinomas are extremely rare. In this article, we present two cases of anal adenocarcinoma, one colorectal type, and other anal gland carcinoma along with review of literature.
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'Childhood systemic mastocytosis associated with t (8; 21) (q22; q22) acute myeloid leukemia' p. 407
Nikhil Rabade, Prashant Tembhare, Nikhil Patkar, Pratibha Amare, Brijesh Arora, PG Subramanian, Sumeet Gujral
DOI:10.4103/0377-4929.188140  PMID:27510692
Systemic mastocytosis (SM) with associated clonal nonmast cell lineage disease is seen in up to 20% cases of SM. SM is uncommon in the pediatric population. T (8; 21) (q22; q22) is a good prognostic factor in acute myeloid leukemia (AML). However, the presence of SM confers poor prognosis in t (8; 21) (q22; q22) associated AML. We report the case of a child with t (8; 21) (q22; q22) associated AML with SM and her minimal residual disease status over the course of her treatment. In our case, the abnormal mast cells, showing co-expression of CD25 and CD2, persisted even after the marrow showed no evidence of residual AML.
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Lymphoblastic leukemia with surface light chain restriction: A diagnostic dilemma p. 410
Nikhil Rabade, Asma Bibi, Kiran Ghodke, Nikhil Patkar, Prashant Tembhare, Pratibha Amare, PG Subramanian, Sumeet Gujral
DOI:10.4103/0377-4929.188129  PMID:27510693
Surface light chain expression is a feature of mature B-cell neoplasms. Light chain restriction in precursor B acute lymphoblastic leukemia is infrequently seen. We report a case of a 28-year-old female with non-FAB L3 morphology blasts and immunophenotypic features showing overlap between a precursor and mature B-cell neoplasm.
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Early cirrhosis in a young female with protein C deficiency: An extremely unusual case report with review p. 413
Nalini Bansal, Chhagan Bihari
DOI:10.4103/0377-4929.188119  PMID:27510694
Protein C deficiency is a well recognized risk factor for development of venous thromboembolism but has never been reported to be associated with development of liver cirrhosis .We report a case of a 26 years old female who presented with multiple thrombosis involving superior mesenteric vein ,main portal vein and multiple cerebral veins. Liver biopsy done was reported as cirrhosis possibly due to Wilson's disease. However no improvement was seen with D penicillamine and patient's condition detiorated. Further, work up of patient revealed absence of Protein C levels in the plasma. So finally the case was diagnosed as Cirrhosis liver with Protein C deficiency as the likely etiology. We conclude that Protein C deficiency should be investigated in patients with cirrhosis with thrombotic lesions of unknown etiology.
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Neurological melioidosis presenting as intracranial abscess p. 417
Deepak Madi, Santosh P. V. Rai, K Vidyalakshmi, K Nithyananda Chowta
DOI:10.4103/0377-4929.188118  PMID:27510695
Melioidosis is an emerging disease in our country caused by the bacteria Burkholderia pseudomallei. Melioidosis can virtually affect any organ. It has varying clinical presentations ranging from pneumonia to fatal sepsis. Central nervous system (CNS) involvement in melioidosis is rare. We present a case of CNS melioidosis from South India. As the incidence of diabetes is increasing in our country varying manifestations of melioidosis will be seen in routine clinical practice. Melioidosis should be considered in the differential diagnosis of intracranial abscess and meningoencephalitis, especially in diabetics.
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Extended spectrum β-lactamase producing Shigella flexneri serotype-2 causing bacteremia in a patient with uncontrolled diabetes mellitus p. 420
Marilyn M Ninan, Tarun K George, V Balaji, I Ramya
DOI:10.4103/0377-4929.188120  PMID:27510696
We report a case of Shigella flexneri serotype-2 causing bacteremia in an elderly gentleman with uncontrolled diabetes mellitus, who had no other apparent risk factors. Antibiotic susceptibility testing revealed that the organism was a multidrug resistant extended spectrum beta-lactamase producing straian, which was confirmed by molecular characterization. This rare case alerts both the clinician and microbiologist to a previously unaddressed risk factor of Shigella spp. causing bacteremia, as well as emerging resistant strains that are on the rise in immunocompromised patients.
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Maculopapular rash presentation of febrile illness in an adult with Varicella zoster virus infection p. 422
Siddhartha Ojah, Ramya Barani, MK Sudhakar, SR Ramakrishnan, Padma Srikanth
DOI:10.4103/0377-4929.188127  PMID:27510697
Varicella zoster usually manifests as maculopapular rash (MPR), which later progresses to vesicle. It can also manifest as MPR without progression to the vesicle stage. This atypical manifestation is more common in adults and immunocompromised patients. A 30-year-old female presented with high-grade fever and rash over face and body for 5 days. She was diagnosed to have Varicella zoster virus (VZV) infection by positive VZV immunoglobulin M enzyme-linked immunosorbent assay and polymerase chain reaction. We present this case to increase awareness among clinicians on the atypical manifestations of VZV and prevent complications by early diagnosis.
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IMAGES Top

Clear cell metaplasia of the prostatic urethra p. 425
Alessandro Del Gobbo, Francesco Pallotti
DOI:10.4103/0377-4929.188146  PMID:27510698
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LETTERS TO EDITOR Top

Concomitant occurrence of multiple myeloma with diffuse large B-cell lymphoma p. 427
Subhashis Mitra, Sanghamitra Mukherjee, Jay Mehta, Maitreyee Bhattacharyya, Hema Chakraborty
DOI:10.4103/0377-4929.188110  PMID:27510699
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Comparison of carbapenem breakpoints in Clinical Laboratory Standard Institute and European Committee on Antimicrobial Susceptibility Testing guidelines on antibiotic susceptibility test reporting of Acinetobacter baumannii p. 429
Pravin M. V. Charles, Arunava Kali, Sreenivasan Srirangaraj
DOI:10.4103/0377-4929.188112  PMID:27510700
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Undergraduate medical students' perspectives on objective structured practical examination in Pathology p. 430
Mangala Goneppanavar, Rajendra S Dhaka
DOI:10.4103/0377-4929.188136  PMID:27510701
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Salivary gland anlage tumor p. 431
Anuj Khurana, Saranya Singaravel, Urmi Mukherjee
DOI:10.4103/0377-4929.188147  PMID:27510702
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