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   2017| October-December  | Volume 60 | Issue 4  
    Online since January 12, 2018

 
 
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LETTERS TO EDITOR
An easy way of performing reticulocyte count by manual method
Amit Kumar Adhya
October-December 2017, 60(4):623-624
DOI:10.4103/IJPM.IJPM_196_17  PMID:29323098
  7,723 201 -
CASE REPORTS
Orofacial granulomatosis: A disease or a concealed warning.??
Priya Anil Bhagde, Jyoti D Bhavthankar, Mandakini Mandale
October-December 2017, 60(4):556-559
DOI:10.4103/IJPM.IJPM_401_17  PMID:29323072
Granulomatosis is any condition characterized by the formation of multiple nodules or granulomas in the soft tissues. Differential diagnosis for orofacial region includes a wide spectrum of diseases, but most of these lesions present histopathologically as noncaseating granulomas, giving a nonspecific depiction and leading to a diagnostic impasse. In the absence of any diagnosable entity, the disease is labelled as “orofacial granulomatosis”. A nine-year-old girl child reported with recurrent gingival enlargement and persistent macrochelia which histopathologically presented as noncaseating granulomas. The disease was progressive raising the suspicion of being oral manifestation of a systemic disorder such as Sarcoidosis or Crohn's disease. This paper throws some light on this rare entity and reports rarer features of this disease, like eye involvement and staphylococcal mucositis in the case report.
  5,828 117 -
Monoclonal gammopathy with double M-bands: An atypical presentation on serum protein electrophoresis simulating biclonal gammopathy
Kaustubh Bora, Umesh Das, Bhupen Barman, Alice Abraham Ruram
October-December 2017, 60(4):590-592
DOI:10.4103/IJPM.IJPM_311_17  PMID:29323083
Monoclonal gammopathies, such as multiple myeloma, typically exhibit high levels of a monoclonal immunoglobulin (M-protein), produced by a clone of abnormally proliferating B-lymphocytes and/or plasma cells. The M-protein can be evaluated by serum protein electrophoresis (SPEP), which yields a single discrete band (M-band), usually in the γ-globulin region. Rarely, two M-bands appear simultaneously at different positions during SPEP – a condition known as biclonal gammopathy, which is a result of clonal expansion of two different neoplastic cell lines. Here, we describe an atypical case of IgA-λ multiple myeloma, where double M-bands (one in β- and the other in γ-globulin region) were found during SPEP simulating biclonal gammopathy, although it was monoclonal in nature. This peculiar presentation of double M-bands in monoclonal gammopathy was attributed to polymeric forms of IgA by systematic workup. Further, we discuss how true and apparent biclonality can be distinguished by inexpensive analytical techniques in resource-constrained settings.
  4,413 115 -
ORIGINAL ARTICLES
Role of salivary biomarkers in early detection of oral squamous cell carcinoma
Nidhi Awasthi
October-December 2017, 60(4):464-468
DOI:10.4103/IJPM.IJPM_140_16  PMID:29323056
Introduction: Oral cancer is prevalent worldwide and is a common cause of morbidity and mortality. Despite advances in treatment, the survival of patients with oral cancer has not significantly improved over the past several decades owing to late detection and treatment failures. The present study was undertaken with an objective to explore the role of salivary CYFRA 21-1, CA 19-9, lactate dehydrogenase (LDH), total proteins, and amylase as biochemical markers of oral squamous cell carcinoma (OSCC) and premalignant lesions (PML). Materials and Methods: This was a cross-sectional study for diagnostic test evaluation conducted in KGMC Lucknow, between 2010 and 2011. The study population comprised newly diagnosed cases of OSCC (Group I) and PML of oral cavity (Group II) who had not yet received any definitive therapy along with age- and gender-matched healthy controls (Group III). Unstimulated whole saliva was collected from the cases and controls. CYFRA 21-1 and CA19-9 were estimated by ELISA while LDH, total proteins, and amylase were evaluated as per standard kit method. Results: Both OSCC and PML group showed increased salivary CYFRA 21-1, LDH, and total protein concentrations as compared to controls, but the increase in PML was significantly lower as compared to OSCC. A considerable decrease in concentration of amylase was seen in OSCC and PML as compared to control group. Conclusion: The outcome of this study suggests that concurrent analysis of salivary CYFRA 21-1, LDH, total protein, and amylase can be utilized for early detection of oral cancer.
  3,708 582 -
Spectrum of hepatobiliary cystic lesions: A 7-year experience at a tertiary care referral center in North India and review of literature
Prasenjit Das, Pragya Sharma, Tripti Nakra, Shouriyo Ghosh, Rajni Yadav, Brijnandan Gupta, Gaurav Khanna, KS Madhusudhan, Rajesh Panwar, MK Anoop, Ragini Kilambi, Anand N Singh, Nihar R Dash, Sujoy Pal, Siddhartha Datta Gupta
October-December 2017, 60(4):487-500
DOI:10.4103/IJPM.IJPM_691_16  PMID:29323060
Context: Cysts arising from the hepatobiliary tree are a group of heterogeneous lesions with regard to pathogenesis, clinical presentation, and radiological finding. They can be intrahepatic or extrahepatic, developmental, secondary to infective/inflammatory etiologies, as well as neoplastic. This study was conducted to determine the spectrum of hepatobiliary cysts in surgically intervened cases, with regard to their prevalence, histological spectrum, and clinicoradiological correlation, wherever possible. Methods: In this retrospective observational study, hematoxylin and eosin stained slides of all cases of hepatobiliary cystic lesions, operated between 2009 and 2016 were reviewed. Special stains as reticulin, Masson's trichrome, and periodic acid Schiff were done wherever necessary. Overall prevalence, age-sex distribution, clinical presentation and histopathological patterns were studied. Relevant imaging findings were correlated wherever possible. Results: A total of 312 cases of hepatobiliary cysts were identified, the majority in females. Choledochal cysts (CCs) were the most common type (n = 198,63.5%), followed by hydatid cysts (n = 73,23.3%), simple hepatic cysts (n = 10,3.2%), congenital hepatic fibrosis (n = 10,3.2%), biliary cystadenomas (n = 4,1.2%) hepatic mesenchymal hamartomas (n = 7,2.2%), and cavernous hemangiomas (n = 3,0.9%). Fibropolycystic liver disease (n = 2,0.6%), Caroli's disease (n = 1, 0.3%), liver abscess (n = 2, 0.6%), infantile hemangioendothelioma (n = 1,0.3%), and biliary cystadenocarcinomas (n = 1,0.3%) were rare. Lesions noted mostly in 1st decade of life were: CCs, fibrocystic liver disease, Caroli's syndrome, cystic mesenchymal hamartoma, and infantile hemangioendotheliomas. Conclusion: In our cohort of surgically intervened cases of hepatobiliary cystic lesions from a tertiary care hospital in North India, the CCs, followed by hydatid cyst were the most common lesions. Histology can play vital role in characterization, as often clinical findings and radiology can overlap.
  3,471 257 -
BRIEF COMMUNICATIONS
Recurrent dermatophytosis: A rising problem in Sikkim, a Himalayan state of India
Rekha Sharma, Luna Adhikari, Rukma Lall Sharma
October-December 2017, 60(4):541-545
DOI:10.4103/IJPM.IJPM_831_16  PMID:29323069
Changing pattern of dermatophytic infection among people of Sikkim over the past few years and its recurrence rate has brought a need to do a study on clinical pattern and its recurrence from this part of the country. The objectives of this study are to discern the clinical patterns of dermatophytosis, identification of the isolated fungi to its species level and to see the pattern of its recurrence. The study was carried out from January 2015 to May 2016. A total of 192 samples were collected from the patients with clinical findings of dermatophytic infection. Required history of the patients was taken, followed by clinical examination of the lesions and sample collection. The samples were processed for mycological study till species identification and a follow up of patients were done to assess its recurrence pattern. The age distribution of the patients was from 2 to 80 years. The mean and median age was 30.33 and 33 years respectively. The male female ratio was 1.8:1. Dermatophytosis was noted more commonly in students (n = 64, 33.33%) and jawans (n = 44, 22.92%). Maximum occurrence was noted from April to July (n = 106, 55.20%) and was seen mainly in young Hindu males. Tinea corporis (n = 104, 54.16%) was the most common clinical manifestation followed by tinea unguium (n = 30, 15.63%). T. mentagrophyte (40%) was the most common species followed by T. schoenleinii (33.3%), T. tonsurans (16.6%) and T. rubrum (6.6%). The recurrence rate was seen most commonly in clinical cases of tinea faciei 100%, followed by tinea pedis 80% and tinea unguium 46.6%. Overall clinical cure rate was 58.3% and recurrence rate was 34.3%. In the isolated species of dermatophytes, the recurrence rate was 73.68% and that of non-dermatophytes it was 28.07%. Dermatophytosis is an important health problem with high recurrence in Sikkim with difference in the etiological agent from other parts of India.
  2,770 250 2
GUEST EDITORIAL
Immunohistochemical and molecular markers in urothelial carcinoma
Ranjan Agrawal
October-December 2017, 60(4):462-463
DOI:10.4103/IJPM.IJPM_474_17  PMID:29323055
  2,652 329 1
ORIGINAL ARTICLES
Role of p53 and Ki-67 immunomarkers in carcinoma of urinary bladder
Brijesh Thakur, Sanjeev Kishore, Kanika Dutta, Sanjay Kaushik, Aparna Bhardwaj
October-December 2017, 60(4):505-509
DOI:10.4103/IJPM.IJPM_246_17  PMID:29323062
Background: Urothelial carcinoma is common urinary malignancy responsible for a significant proportion of cancer morbidity and mortality. We carried out the present study to demonstrate the clinicohistopathological features and to correlate the p53 and Ki-67 immunoexpression with grade and stage of bladder carcinomas. Materials and Methods: We investigated 110 cases of bladder tumor. Grading and staging were done according to the WHO-2004 and American Joint Committee on Cancer-TNM staging recommendations. Immunohistochemical staining for p53 and Ki-67 was performed in all the cases, categorized as high and low expression taking 20% positivity as cutoff value. Statistical analysis was done using McNemar's Chi-square test and Fisher's exact test. Results: There were 61 cases of high grade and 49 cases of low grade exhibiting urothelial carcinoma as the most common variant (97.3%). Muscle invasive carcinomas (pT2) noted in 29 cases whereas 23 and 58 cases revealed stage pTa and pT1, respectively. Evaluation of p53 and Ki-67 immunoexpression showed a significant association with histological grade and stage individually and also in combination (P < 0.05). Conclusion: Our results corroborate with the opinion that combined use of p53 and Ki-67 immunomarkers may provide additional prognostic information along with histological grading and staging in bladder carcinomas.
  2,676 277 1
IMAGES
Urinary schistosomiasis: Schistosoma haematobium infection diagnosed by histopathology
Yung-Yao Lin, Victor Chia-Hsiang Lin, I-Wei Chang
October-December 2017, 60(4):614-615
DOI:10.4103/IJPM.IJPM_182_16  PMID:29323093
  2,595 59 -
ORIGINAL ARTICLES
Modified Cajal's trichrome stain as a diagnostic aid in the study of epithelial pathology
Karpagaselvi Sanjai, Anjum Baker, Lokesh Papiah Reddy, Bhavna Pandey
October-December 2017, 60(4):528-532
DOI:10.4103/IJPM.IJPM_202_16  PMID:29323067
Background: Diagnosis of initial epithelial pathology maybe difficult in Squamous Cell Carcinoma (SCC), Carcinoma In Situ and other atypical epithelial malignancies, under routine Haematoxylin and Eosin (H and E) stain. The detection of minor basement membrane alterations in doubtful cases is both time consuming and confusing. Aims: To evaluate efficacy of Modified Cajal's Trichrome Stain (CTS) in relation to Haematoxylin and Eosin for study of epithelial dysplasia, carcinoma in situ, micro invasive SCC, frank SCC, and SCC in lymph nodes. Materials and Methods: Formalin-fixed, paraffin-embedded tissue blocks of mild epithelial dysplasia (n = 2), moderate epithelial dysplasia (n = 2), severe epithelial dysplasia (n = 4), carcinoma in situ (n = 1), micro-invasive SCC (n = 4), verrucous carcinoma (n = 1), and frank OSCC (n = 5) were stained with CTS and H&E. The sections were compared based on set histopathological criteria. Results and Conclusion: In SCC cases stained with CTS, invasion into connective tissue and keratin pearls were strikingly evident. Depth of invasion could be more accurately determined. Tumour cells in lymph node were intensely contrasted and easily discernible. Thus, CTS is a good differential stain, clearly delineating the epithelial elements from the connective tissue elements visually. This helps in tracing the basement membrane very clearly. It is an economic, rapid and easy to use method which cannot replace Haematoxylin and Eosin stain in cancer diagnosis, but can definitely be used adjunctive to it. Prompt diagnosis is crucial to effective treatment, and this stain assists in early and rapid diagnosis of cancer.
  2,126 298 -
Familiar trespassers in histopathology: An obstacle in diagnosis? A single-blind study
P Shashikala, GM Sreevidyalatha, Sonam S Nandyal, Gowda Kavita Umapathy
October-December 2017, 60(4):524-527
DOI:10.4103/IJPM.IJPM_241_17  PMID:29323066
Background: Histopathologists encounter strange structures in tissue sections that appear unrelated to tissues, and these artifacts may be misinterpreted and misdiagnosed as pathological lesions. These substances may either be present within the tissues or can get implanted into tissue during biopsy procedure or laboratory handling or processing. Aims: The aim of this study is to observe the microscopic appearance of different abnormal structures like commonly implanted food particles or easily incorporated substances during tissue processing with their probable histological misdiagnosis. Materials and Methods: Certain food particles, suture materials, wood pieces, insects, and filter paper were intentionally introduced in the tissue specimens of uterus and lung. Following routine processing and hematoxylin and eosin staining, the slides were subjected to single-blind study and viewed under light and polarizing microscope. Results: The vivid appearances of these structures lead to histological misdiagnosis. Conclusion: Knowledge and familiarity of these commonly encountered extraneous substances will help to prevent misinterpretation.
  2,104 227 -
Histological and morphometric analysis of dilated cardiomyopathy with special reference to collagen IV expression
Parul Jain, Sudheer Arava, Sandeep Seth, Sanjeev Lalwani, Ruma Ray
October-December 2017, 60(4):481-486
DOI:10.4103/IJPM.IJPM_213_16  PMID:29323059
Introduction: Collagen distribution alterations are well known in dilated cardiomyopathy. There are also changes in microvasculature along with other histomorphorphological features. Aims and Objectives: To study the histomorphological features of DCM along with their quantitative correlation with LVEF. Alterations in collagen IV distribution pattern and microvasculature in DCM were also evaluated. Materials and Methods: The present study includes 34 right ventricular endomyocardial biopsies, 7 explanted native hearts and 41 autopsy control hearts. Sections were taken from lower half of right interventricular septum and stained for H and E, Masson trichrome and immunohistochemistry for CD34, SMA and Collagen IV to study the histological features, pattern of fibrosis, capillary and arteriolar distribution and collagen IV expression respectively. Morphometric analysis was carried out in all cases and controls using Image analysis software Image pro plus 7 and correlated with left ventricular ejection fraction. Results: The histomorphological changes of DCM include myocyte hypertrophy, nucleomegaly, and interstitial fibrosis. Interfiber fibrosis was the commonest. There was evidence of myocarditis, ischemic change and vessel wall alterations. Considerable alteration in Collagen IV distribution was observed with reduction in intensity and proportion of staining around myocytes quantified using Allred scoring against uniform pericellular staining in controls. Morphometric analysis revealed significant increase in nuclear area, myocyte width, percentage of fibrosis and reduction in capillary myocyte ratio in cases as compared to controls. There was no significant difference in arteriolar density. No significant association was observed between morphometric parameters and LVEF. Conclusion: Histomorphological changes in DCM are non-specific. Quantitation of histological parameters cannot be used to predict the disease progression as there was no significant correlation with LVEF. There is appreciable alteration in Collagen IV distribution in DCM owing to extracellular matrix alterations.
  2,170 111 -
Vascular endothelial growth factor expression in placenta of hypertensive disorder in pregnancy
Abd Fuaat Azliana, Mohamad Razi Zainul-Rashid, Sabrina Florence Chandramaya, Wirda Indah Farouk, Alfian Nurwardah, Yin Ping Wong, Geok Chin Tan
October-December 2017, 60(4):515-520
DOI:10.4103/IJPM.IJPM_376_16  PMID:29323064
Introduction: Hypertensive disorder in pregnancy (HDP) represents the most common medical complication in pregnancy. It is the leading cause of maternal and perinatal mortality and morbidity. Vascular endothelial growth factor (VEGF) stimulates vascular endothelial cell growth, survival, and proliferation, and they are known to be expressed in human placenta. The aim of this study was to determine the VEGF expression in the placenta of hypertensive and normotensive patients. Materials and Methods: This is a retrospective, cross-sectional study from January 1, 2015 to December 31, 2015. A total of 30 placentae comprised of 15 hypertensive and 15 normotensive cases were assessed. VEGF expression in placenta was assessed by immunohistochemistry, and the number of syncytial knots was counted. Results: Our study showed an increased syncytial knot formation in the placenta of hypertensive mothers. VEGF expression was seen in syncytiotrophoblasts of 14 of the hypertensive cases (14/15, 93.3%), while only two of the normotensive cases were positive (2/15, 13.3%). There were no statistically significant differences in VEGF expression in other placenta cells, that is, cytotrophoblasts (P = 1.0), decidual cells (0.1394), maternal endothelial cells (0.5977), and fetal endothelial cells (P = 1.0). Conclusions: This study showed an increased number of syncytial knots is a consistent histological finding in the placenta of patient with HDP. VEGF expression was significantly increased in syncytiotrophoblasts in placenta of hypertensive group, and it could be used as a biomarker for hypertension.
  2,079 165 2
Hypoxia-induced factor-1 alpha, vascular endothelial growth factor expression in BRCA1-related breast cancer: A prospective study in tertiary care hospital
Manisha Sharma, Sanjay Piplani, Manas Madan, Mridu Manjari, Saumil Garg, Komalpreet Kaur
October-December 2017, 60(4):469-474
DOI:10.4103/IJPM.IJPM_524_16  PMID:29323057
Introduction: Breast cancer is the commonest cause of death among middle aged women. BRCA1 associated tumors carry a poor prognosis. Angiogenesis is considered necessary for tumor growth and for its metastasis. Hypoxia stimulates HIF-1α which then activates transcription of various proangiogenic cytokines like VEGF. In the present study we examined HIF-1α expression, sVEGF levels and BRCA1 mutations and their relation with clinicopathological parameters. We also determined whether the angiogenic markers have different role in angiogenesis in BRCA1 related cancers as compared to sporadic breast cancers. Materials and Methods: The study was conducted on 50 cases of breast cancer specimens. Histopathological typing and grading was done followed by immunohistochemistry for BRCA1 and HIF-1α. VEGF was done in the serum by ELISA. Results: All the tumors were infiltrating ductal carcinoma NOS. 16 cases were reported grade II and 34 cases as grade III. On immunohistochemistry, 27 cases showed BRCA1 positivity and HIF-1α was positive in 39 cases. sVEGF levels were increased in 21 cases (42%). BRCA1 positivity, HIF-1α expression and increased VEGF levels were significantly associated with higher grade and lymph node metastasis. There was significant correlation of BRCA1 positivity with increased HIF-1α expression (P = 0.009) and increased sVEGF levels (P = 0.005). Conclusion: Our findings suggest that BRCA 1 positive tumors have unique molecular profile and different mechanism of tumorigenesis. Such tumors are associated with increased HIF-1α expression and VEGF levels.
  1,943 159 1
CASE REPORTS
Small cell medullary thyroid carcinoma: A diagnostic dilemma
Anuj Verma, Shubhada Kane, Sushant Vinarkar, Anil K D'Cruz
October-December 2017, 60(4):562-564
DOI:10.4103/IJPM.IJPM_187_17  PMID:29323074
Small cell variant of medullary thyroid carcinoma (MTC) is a rare variant. In the past, primary thyroid lymphomas were thought to be small cell MTC (SCMTC). However, with the advent of immunohistochemistry, it was realized that SCMTC is rare. Our patient presented with neck mass for 1 year with an outside laboratory report of neoplastic lesion. His serum calcitonin levels were normal, but serum carcinoembryonic antigen (CEA) levels were high. He underwent total thyroidectomy and was diagnosed to have small cell variant of MTC. Immunohistochemistry for AE1/AE3 and CEA were positive while calcitonin was negative. The patient underwent radiotherapy but developed metastasis 3 months later. Thus, SCMTC is a rare and aggressive variant of MTC. In the absence of raised serum calcitonin levels, raised serum CEA levels are helpful. It is necessary to identify this rare variant as it connotes a poor prognosis and should be treated aggressively.
  1,935 119 1
ORIGINAL ARTICLES
Accuracy of vascular invasion reporting in hepatocellular carcinoma before and after implementation of subspecialty surgical pathology sign-out
Aaron R Huber, Raul S Gonzalez, Mark S Orloff, Christopher T Barry, Christa L Whitney-Miller
October-December 2017, 60(4):501-504
DOI:10.4103/IJPM.IJPM_827_16  PMID:29323061
Context: Liver cancers (including hepatocellular carcinoma [HCC] and cholangiocarcinoma) are the fifth most common cause of cancer death. The most powerful independent histologic predictor of overall survival after transplantation for HCC is the presence of microscopic vascular invasion (VI). Aims: Given that VI is known to have somewhat high interobserver variability in both HCC and other tumors, we hypothesized that pathologists with special interest and training in liver pathology would be more likely to identify and report VI in HCC than would general surgical pathologists. Settings and Design: We searched our departmental surgical pathology archives for transplant hepatectomies performed for HCC. Subjects and Methods: We identified 143 such cases with available sign-out reports and hematoxylin and eosin-stained slides. Statistical Analysis Used: Kappa results (level of agreement) were calculated. Results: Before surgical pathology subspecialty sign-out (SSSO) implementation, 49 of 88 HCC cases were reported as negative for VI; on rereview, 20 of these had VI. After SSSO implementation, 39 of 55 cases were reported as negative for VI; on our review, 8 of these had VI. Kappa (agreement) between general SO and subspecialty rereview was 0.562 (95% confidence interval [CI] = 0.411–0.714) “weak agreement.” Kappa (agreement) between SSSO and rereview by select liver pathologists was 0.693 (95% CI = 0.505–0.880) “moderate agreement.” Conclusions: Our study is one of only a few so far that have suggested improved accuracy of certain parameters under SSSO.
  1,914 76 1
CASE REPORTS
A rare case of Shewanella putrefaciens bacteremia in a patient of road traffic accident
Ritesh Ranjan, Priti Chowdhary
October-December 2017, 60(4):599-600
DOI:10.4103/IJPM.IJPM_254_16  PMID:29323086
Shewanella putrefaciens rarely causes human infection. These are mostly found in environment and food stuffs. Shewanella are often found in mixed culture. It has been implicated in cellulitis, otitis media, and septicemia. It may be found in respiratory tract, urine, feces, and pleural fluid. There is no definite guideline for therapeutic option. In general, these are susceptible to various antimicrobial agents but are often resistant to penicillin and cephalothin. We report a rare case of bacteremia by S. putrefaciens in a patient of head injury with polytrauma after a road traffic accident.
  1,892 60 -
BRIEF COMMUNICATIONS
Scedosporium apiospermum, an emerging pathogen in India: Case series and review of literature
Dabet Rynga, Malini R Capoor, Swati Varshney, Mayuresh Naik, V Gupta
October-December 2017, 60(4):550-555
DOI:10.4103/IJPM.IJPM_742_16  PMID:29323071
Scedosporium apiospermum is a rare cause of infection but is increasingly being reported among immunocompromised individuals around the world. We report two cases of S. apiospermum, one of keratitis and the other of nasal polyp both from immunocompetent patients. The two cases were successfully treated with voriconazole. It is important to diagnose such infections as their antifungal susceptibility to amphotericin B is variable.
  1,822 108 -
CASE REPORTS
Primary signet cell adenocarcinoma of bladder
Prateek Kinra, SP Rashmi, Aftab Alam, Harkirat Singh, SC Dash
October-December 2017, 60(4):584-586
DOI:10.4103/IJPM.IJPM_201_16  PMID:29323081
Primary signet cell cancer of the urinary bladder is a relatively rare entity. Since there is no mucinous epithelium in the bladder, It is proposed that the tumor arises from metaplastic urothelium. Two thirds of the tumours are mucin secreting, in most of which the site of the deposition is either extracellular or intracellular displacing the nucleus to a peripheral crescent, giving the cells a signet ring appearance. The tumours are most often infiltrative and diffusely involving the majority of the bladder akin to its name sake in stomach. It is essential to distinguish this carcinoma from gastrointestinal metastases as different therapeutic strategies are often necessary.
  1,811 71 -
ORIGINAL ARTICLES
Story of survival in anaplastic large cell lymphoma - sometimes more than the anaplastic lymphoma kinase status: An evaluation of pathologic prognostic factors in 102 cases
Komal Agrawal, Tanuja Shet, Epari Sridhar, Suhas Dhende, Manju Sengar, Brijesh Arora, Siddhartha Laskar, Sumeet Gujral, Hari Menon, Shripad Banavali
October-December 2017, 60(4):533-540
DOI:10.4103/IJPM.IJPM_778_15  PMID:29323068
Introduction: Systemic anaplastic large cell lymphoma (ALCL) accounts for 5%–10% of adult non Hodgkin's lymphoma (NHL) and 10%–30% of childhood NHL. Owing to significant differences in survival and gene expression profile, current WHO classifies ALCL into two distinct entities as anaplastic lymphoma receptor tyrosine kinase (ALK) positive and ALK negative ALCL with ALK expression by tumour as a good prognostic indicator. However, in our institute which is a cancer referral institute, our preliminary experience was that even ALK positive tumours did not fare well as compared to ALK- negative ALCL. So, the current study aims at exploring more clinical and pathological factors impacting survival in ALCL patients. Objective: To study clinical and pathological prognostic factors in cases of ALCL. Methods: 102 cases of ALCL were retrieved from pathology database. Pathological features and clinical features of these cases were recorded and factors found to impact overall survival (OAS) and disease-free survival (DFS) curves were identified based on univariate and multivariate analysis. Results: ALK 1 expression was seen in 71/102 (69.6%) cases and was not found to impact OAS or DFS. The 2 year OAS rate for ALK positive patients was 63.5% and DFS rate was 54.4%, while for ALK negative patients, the OAS was 60.5% and DFS was 43.5%. The Ann Arbor stage, performance status, international prognostic index, histological subtype, and the degree of the background inflammatory infiltrate were found to impact the OAS significantly. Increased reactive inflammatory component also negatively impacted DFS. In the multivariate analysis, only the histologic type emerged as significant for OAS. Conclusion: Though ALK plays a role in prognostication of systemic ALCL, advanced stage disease and an inflammatory milieu may modulate the final outcome. We report a study of clinical and pathologic prognostic features in 102 cases of anaplastic large cell lymphoma (ALCL) from a cancer referral institute in India. Anaplastic lymphoma receptor tyrosine kinase (ALK-1) expression was seen in 71/102 (69.6%) cases and was not found to impact overall survival (OAS) or disease-free survival (DFS). The 2-year OAS rate for ALK-positive patients was 63.5% and DFS rate was 54.4%, while for ALK-negative patients, the OAS was 60.5% and DFS was 43.5%. The Ann Arbor stage, performance status, international prognostic index, histological subtype, and the degree of the background inflammatory infiltrate were found to impact the OAS significantly. Increased reactive inflammatory component also negatively impacted DFS. In the multivariate analysis, only the histologic type emerged as significant for OAS. Thus, though ALK plays a role in prognostication of systemic ALCL, advanced stage disease and an inflammatory milieu may modulate the final outcome.
  1,722 97 -
CASE REPORTS
Renal cell carcinoma with t(6,11): A case report and review of literature
KS Jansi Prema, KS Devanathan, Anila Abraham Kurien
October-December 2017, 60(4):574-576
DOI:10.4103/IJPM.IJPM_751_16  PMID:29323078
Renal cell carcinomas (RCCs) with t(6,11) are very rare tumours. Only a few cases have been reported so far. t(6,11) results in fusion of alpha gene and transcription factor EB (TFEB) gene resulting in the overexpression of TFEB. The specific light and immunohistochemical features help in the diagnosis of this rare type of tumor. We report a case of t(6,11) RCC in a 38-year-old female who was incidentally found to have a right renal mass. We present this case to emphasize the typical light microscopic picture of this extremely rare tumor. Two population of cells are seen: larger cells with abundant cytoplasm and smaller cells with scant cytoplasm. Smaller cells are arranged around hyaline nodules resulting in the formation of characteristic pseudorosettes. Immunohistochemically, these tumors are diffusely positive for vimentin and focally positive for HMB 45 and CD 117. Knowledge about the typical biphasic light microscopic appearance and the characteristic immunohistochemical features help in the diagnosis of this rare type of translocation associated RCC.
  1,663 62 -
BRIEF COMMUNICATIONS
Is diabetes mellitus an important risk factor for the antibiotic resistance in extraintestinal pathogenic Escherichia coli?
Arindam Chakraborty, Shalini Shenoy, Prabha Adhikari, Vishwas Saralaya, Satish Rao
October-December 2017, 60(4):546-549
DOI:10.4103/IJPM.IJPM_261_16  PMID:29323070
Escherichia coli is a major cause of extraintestinal infections in all age group. However, the infection becomes more severe when patients have some underlying condition such as Diabetes Mellitus. The aim of the study was to determine whether diabetic mellitus may act as an important risk factor for the E. coli to express drug resistance property. This descriptive study was carried out in a multi-specialty tertiary care hospital. One hundred and twenty-seven E. coli isolates from diabetic patients, and one hundred seventy-three isolates from nondiabetic patients were studied. Possession drug resistance genes were determined by multiplex polymerase chain reaction (PCR). Phylogenetic analysis was performed by triplex PCR. Antibiotic sensitivity testing was performed by Kirby-Bauer disk diffusion method. Among the study isolates from Diabetic patients maximum numbers were from phylogroup B2 (42.5%) and D (33%) similarly in case of nondiabetic patients B2 (29%) and D (38%) were the most common phylogroup. Presence of drug resistance genes among the diabetic and nondiabetic patient's isolates were as followed extended-spectrum beta-lactamase (70% and 70.5%) AmpC (9.5% and 14.5%) and NDM-1 ( 7% and 4.5%) and by disk diffusion methods susceptibility pattern were meropenem (94% and 94%), imipenem (92% and 92%), amikacin (76% and 74%), and ampicillin/sulbactam (68% and 69%), respectively. The proportion of diabetic patients strains with the drug resistance characteristics were not significantly different from that seen in nondiabetic patients strains, which indicating that in a predisposed host additional or subtraction bacterial aids for drug resistance property are not a necessity.
  1,617 93 1
ORIGINAL ARTICLES
Evaluation of MUC1 and P53 expressions in noninvasive papillary urothelial neoplasms of bladder, their relationship with tumor grade and role in the differential diagnosis
Esin Kaymaz, Elif Ozer, Hatice Unverdi, Sema Hucumenoglu
October-December 2017, 60(4):510-514
DOI:10.4103/IJPM.IJPM_204_16  PMID:29323063
Purpose: The aim of this study was to investigate the usability of MUC1 and p53 for differential diagnosis of noninvasive papillary urothelial neoplasias, especially for distinguishing papillary urothelial neoplasm of low malignant potential (PUNLMP) from low-grade papillary urothelial carcinoma (LGPUC) when the histologic signs are not obvious. Materials and Methods: Seventeen biopsy specimens of the patients with PUNLMP, 20 with LGPUC and 13 with high-grade papillary urothelial carcinoma (HGPUC) were stained for MUC1 and p53 protein by immunohistochemical methods. Histological grading was performed according to an algorithm, which allows histological parameters used in 2004 WHO/ISUP 1998. Results: We had obvious statistical difference for aberrant expression pattern of MUC1 between PUNLMP and LGPUC-HGPUC (P = 0.007). Positivity of MUC1 expression in cytoplasm of basal cells was more observed in HGPUC and LGPUC, whereas PUNLMP was more often showing apical and superficial positivity of MUC1 expression (P = 0.001 and 0.011). Nuclear p53 protein in HGPUC was obviously more frequent than that in LGPUC and PUNLMP (P < 0.001). Measures showed statistical difference among aberrant MUC1 expression, p53 overexpression, and tumor grade (P < 0.001). Conclusions: MUC1 and p53 may be helpful immunohistochemical markers for distinguishing PUNLMP from LGPUC and HGPUC, when the histologic signs are not obvious.
  1,573 136 2
CASE REPORTS
Bilateral lung metastases unveils an asymptomatic sacrococcygeal yolk sac tumor
Krishnendu Mondal, Rupali Mandal
October-December 2017, 60(4):565-567
DOI:10.4103/IJPM.IJPM_385_16  PMID:29323075
Sacrococcygeal yolk sac tumor is an uncommon pediatric neoplasm. It usually presents with intra-abdominal or gluteal pain and mass. At later stage, it disseminates to regional nodes and distant organs. We describe one such neoplasm in an 18-month-old male child who turned symptomatic with multiple bilateral lung metastases. The tumor produced the least deformity to his physique, to become detectable on routine inspection and clinical examination. Finally, a combined approach through clinical, radiological, pathological, and biochemical perspectives established the diagnosis.
  1,616 39 1
Immunoglobulin G4-related tubulointerstitial nephritis: A not to be missed diagnosis
Smita Mary Matthai, Anjali Mohapatra, Raiyani Palak, Gopal Basu
October-December 2017, 60(4):577-580
DOI:10.4103/IJPM.IJPM_37_17  PMID:29323079
Immunoglobulin G4-related tubulointerstitial nephritis (IgG4-TIN) is a newly recognized clinicopathological entity characterized by a dense interstitial infiltrate of IgG4-positive plasma cells accompanied by fibrosis and obliterative phlebitis causing acute or chronic renal dysfunction amenable to corticosteroid therapy. IgG4-TIN is the dominant manifestation of renal involvement in IgG4-related disease (IgG4-RD) which is a novel, immune-mediated, fibroinflammatory and multiorgan disorder. We describe a case of IgG4-TIN with isolated renal involvement in an elderly male patient with poor response to corticosteroid therapy. The distinctive serological, histopathological, and ultrastructural features of this condition which can facilitate differential diagnosis of TIN are highlighted to emphasize the need for early diagnosis and preservation of kidney function.
  1,586 59 -
Opportunistic free: Living amoeba now becoming a usual pathogen?
Dnyaneshwari Purushottam Ghadage, Archana Chintaman Choure, Archana Bhimrao Wankhade, Arvind Vamanrao Bhore
October-December 2017, 60(4):601-603
DOI:10.4103/IJPM.IJPM_815_16  PMID:29323087
Acanthamoeba species cause granulomatous Acanthamoeba encephalitis in immunocompromised patients. We report a case of acute purulent meningoencephalitis with a focal neurological deficit caused by Acanthamoeba species in a 2 years immunocompetent child.
  1,552 83 -
IMAGES
Intracytoplasmic inclusions in plasma cells: A diagnostic adjunct in monoclonal gammopathy of undetermined significance
Smeeta Gajendra, Rashi Sharma, Swachi Jain, Ritesh Sachdev, Nitin Sood
October-December 2017, 60(4):618-619
DOI:10.4103/IJPM.IJPM_80_17  PMID:29323095
  1,547 82 -
EDITORIAL
From Editor's desk
Vatsala Misra
October-December 2017, 60(4):461-461
DOI:10.4103/0377-4929.222999  
  1,512 95 -
IMAGES
Nerve sheath myxoma: Unusual location and a diagnostic pitfall
Hee Jung Kwon, Jae Hwang Kim, Joon Hyuk Choi, Mi Jin Gu
October-December 2017, 60(4):610-611
DOI:10.4103/IJPM.IJPM_302_17  PMID:29323091
  1,562 45 -
CASE REPORTS
CD19-negative B-lineage acute lymphoblastic leukemia: A diagnostic and therapeutic challenge
Shashi Bansal, Upendra Sharma, Akansha Jain, Richa Sharma, Bhargav Yagnik
October-December 2017, 60(4):596-598
DOI:10.4103/IJPM.IJPM_379_17  PMID:29323085
B-lineage acute lymphoblastic leukemia (B-ALL) is an aggressive neoplasm of B-lymphocyte precursors that express the pan B-cell marker CD19 in all the cases. Rarely, a case may be assigned as B-lineage even if CD19 is negative. Here, a 16-year-old male presented with complaints of pain abdomen, on and off fever, joint pain, and hepatosplenomegaly for 2 months. Bone marrow examination was suggestive of acute leukemia with numerous leukoblasts on aspiration. On flow cytometry, gated blast population was negative for CD19, cytoCD3, and myeloperoxidase MPO and positive for CD34, TdT, HLA-DR, CD22, CD79a, and CD10. Immunohistochemistry study showed positivity for TdT, CD34, CD10 (focal), and PAX 5 and negativity for CD20, CD3, MPO, CD117, and CD68. Lack of awareness of negative CD19 expression in B-ALL can lead to incorrect immunophenotypic diagnosis, treatment, and monitoring of B-ALL. Proper diagnosis should be based on clinical features, immunophenotypic profiles, immunohistochemistry findings, and molecular analysis.
  1,516 72 -
IMAGES
Lepromatous leprosy-negative images giving the diagnostic clue
Swati Singla, Gaurav Singla, Kusum Gupta, Rashmi Arora, Ashish Kumar Mandal
October-December 2017, 60(4):616-617
DOI:10.4103/IJPM.IJPM_363_16  PMID:29323094
  1,428 88 -
CASE REPORTS
Pyogenic liver abscess associated with oral flora bacterium, Streptococcus anginosus in a patient with underlying tuberculosis
Sunite A Ganju, Neha Gautam, Garima Sharma
October-December 2017, 60(4):587-589
DOI:10.4103/IJPM.IJPM_842_16  PMID:29323082
Streptococcus anginosus forms a part of the commensal flora of the oral cavity. However, it can be aggressive and may lead to gastrointestinal and urogenital infections. We present an interesting case and course in a 38-year-old immunocompetent female patient with pyogenic liver abscess due to S. anginosus infection who had multiple carious teeth and underlying pulmonary tuberculosis.
  1,447 58 1
Fibroblast growth factor receptor-1 associated myeloproliferative neoplasm and T-lymphoblastic lymphoma
Gayathri Gopan, TM Anoop, NP Prakash, Rakul Nambiar, R Krishnachandran
October-December 2017, 60(4):593-595
DOI:10.4103/IJPM.IJPM_357_17  PMID:29323084
Myeloid and lymphoid hematological malignancies with eosinophilia and abnormalities of fibroblast growth factor receptor-1 (FGFR1) result from the formation of abnormal fusion genes that encode constitutively activated tyrosine kinases. The WHO classification (2008) of hematolymphoid neoplasms recognizes a category of myeloid and lymphoid neoplasms with eosinophilia and abnormalities of FGFR1. Here, we present the case of a 30-year-old-woman who was diagnosed with T-lymphoblastic lymphoma from lymph node biopsy and myeloproliferative neoplasm with eosinophilia from bone marrow studies. She was treated with combination chemotherapy with cyclophosphamide, vincristine, doxorubicin, and dexamethasone (Hyper-CVAD regimen) and is on maintenance chemotherapy for the past 2 months. We present this case to create awareness among physicians about this rare condition associated with dual malignancies.
  1,391 53 -
Myoepithelial carcinoma of the tongue- spindle cell morphology with high mitosis: A case report and review of literature
Abhimanyu Sharma, Priyanka Gogoi, Vinod Kumar Arora
October-December 2017, 60(4):560-561
DOI:10.4103/IJPM.IJPM_758_16  PMID:29323073
Myoepithelial carcinomas represent <1% of salivary gland tumors. Tongue is a rare site of occurrence. We present a case of a 30 year old female with myoepithelial carcinoma seen over dorsum of tongue with predominantly spindle cell morphology with clear cytoplasm and mitotic count of 6–7/10 hpf. We need to differentiate it from a spindle cell squamous cell carcinoma which can be seen at this location, i.e., tongue. In our case, there was no connection of the tumor with overlying squamous epithelium.
  1,374 67 -
Recurrent leiomyosarcoma scrotum: An important differential in scrotal masses
Ranjan Agrawal, Miti Gupta, Nitesh Mohan, Jagdamba Sharan, Parbodh Kumar
October-December 2017, 60(4):581-583
DOI:10.4103/IJPM.IJPM_391_16  PMID:29323080
Soft tissue sarcomas of the genitourinary tract are rare. Paratesticular sarcomas are extremely rare with majority of scrotal masses localizing to the testis and being neoplastic in nature. Paratesticular leiomyosarcomas (LMSs) are located in the spermatic cord, epididymis, or scrotum. However, their location in the scrotal skin or subcutaneous tissue is extremely rare. Only 10 cases have been reported from India previously. Ours is the 11th case. A 50-year-old male presented with a recurrent scrotal mass which was painless and gradually increasing in size. Histopathology and immunohistochemistry confirmed it to be paratesticular LMS. A rare case report with the review of literature is presented.
  1,352 55 1
IMAGES
Hepatic, splenic and thyroidal nodular sarcoidosis
Priya Wadhwa, Pradeep Vaideeswar
October-December 2017, 60(4):608-609
DOI:10.4103/IJPM.IJPM_242_17  PMID:29323090
  1,306 47 -
Salivary amylase crystalloids: An aspiration cytodiagnosis
Anupama Arya, Saranya Singaravel, Dilip Kumar, Poonam S Das
October-December 2017, 60(4):604-605
DOI:10.4103/IJPM.IJPM_306_16  PMID:29323088
  1,261 68 -
CASE REPORTS
Epidermoid cyst of the renal pelvis masquerading as malignancy
Dinesh Pradhan, Gabriela Quiroga-Garza, Ronald Hrebinko, Rajiv Dhir, Anil V Parwani
October-December 2017, 60(4):571-573
DOI:10.4103/IJPM.IJPM_618_16  PMID:29323077
Epidermoid cyst of the renal pelvis is exceptionally rare. The histogenetic mechanism has not been well characterized. Herein, we report a case of intrarenal epidermoid cyst in a 62-year-old woman who had undergone left nephrolithotomy for a staghorn calculus. She was being followed up for bilateral renal cysts when a complex mass was noted arising from the lower pole of the left kidney. Renal ultrasound showed a small left kidney with a solid vascular echogenic mass. A laparoscopic radical nephrectomy was performed. Gross examination revealed a well-circumscribed cystic mass with friable tan-yellow contents. Microscopically, a cystic structure lined by mature epidermis without atypia indicating epidermoid cyst was noted. The lesion appeared to be in continuity with the pelvicalyceal urothelium which displayed extensive squamous metaplasia. The patient is disease free and is doing well. Better clinical awareness of this benign entity and a preoperative biopsy may help preserve a kidney.
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ORIGINAL ARTICLES
Assessment of topoisomerase II-alpha gene status by dual color chromogenic in situ hybridization in a set of Iraqi patients with invasive breast carcinoma
Rasha Abd Alraouf Neama, Manal A Habib, Sahira A Ali, Ali H Al-Khafaji, Mohammed F Alqanbar
October-December 2017, 60(4):475-480
DOI:10.4103/IJPM.IJPM_62_16  PMID:29323058
Background: The human epidermal growth factor receptor 2(HER2) proto-oncogene is overexpressed or amplified in approximately 15%–25% of invasive breast cancers. Approximately 35% of HER2-amplified breast cancers have coamplification of the topoisomerase II-alpha (TOP2A) gene encoding an enzyme that is a major target of anthracyclines. Hence, the determination of genetic alteration (amplification or deletion) of both genes is considered as an important predictive factor that determines the response of breast cancer patients to treatment. The aims of this study are to determinate TOP2A status gene amplification in a set of Iraqi patients with breast cancer that have had an equivocal (2+) and positive HER2/neu by immunohistochemistry (IHC) and to compare the results with estrogen receptor (ER) and progesterone receptor (PR) and HER2/neu status. Patients and Methods: A cross-sectional prospective study done on 53 patients with invasive breast carcinoma. Twenty-six out of total 53 cases were positive HER2/neu (3+), the remaining 27 equivocal HER2-IHC (2+) cases reanalyzed using dual-color chromogenic in situ hybridization (ZytoVision) probe kit for further identification of HER2/neu gene amplification. Using chromogenic in situ hybridization (CISH), TOP2A gene status determination was done for all cases. Results: There is a direct significant correlation between TOP2A gene amplification and HER2/neu positivity, P < 0.05 in that 15 (39.4%) out of 38 positive HER2/neu cases were associated with topoisomerase gene amplification. Regarding relation of topoisomerase gene to hormone receptor status (ER and PR), there was a significant negative relationship between the gene and ER receptor status. The higher level of gene amplification was noticed in ER and PR negative cases in about 13 (43.3%) and 14 (48.2%) for ER and PR, respectively. Conclusion: TOP2A gene status has a significantly positive correlation with HER2/neu status while it has a significantly negative correlation with hormone receptor status.
  1,239 50 -
Emerging role of preputial vascular pattern and postoperative microvessel density in cases of proximal hypospadias: A pilot study
Vishrut Narang, Amita Sen, Minakshi Bhardwaj
October-December 2017, 60(4):521-523
DOI:10.4103/IJPM.IJPM_792_16  PMID:29323065
Introduction: Understanding of anatomical vascular patterns and anatomy of prepuce is critical for a good outcome in hypospadias surgery. A well-vascularized neourethral and preputial flaps used for repair are exceptionally important for a successful outcome, especially in cases of proximal hypospadias undergoing one-stage procedures. Objective: To evaluate the vascular anatomy of prepuce in cases of proximal hypospadias and to evaluate microvessel density (MVD) by immunohistochemistry and its correlation with postoperative complications. Material and Methods: This was a prospective observational study done between November 2013 and March 2015; 33 cases of proximal hypospadias undergoing surgery were evaluated for vascular pattern by intraoperative cold light method and postoperatively by MVD. Results: Twenty-six cases with a predominant vessel pattern were identified (18 of type 1, 7 of type 2, and 1 of type 3), while seven cases had a reticular pattern (type 4) on cold light transillumination. The mean MVD in cases with predominant vascular pattern (Type 1–3) was 64.83. In cases of Type 4 pattern, mean MVD was found to be low 55.57 (P = 0.37). Patients who underwent single-stage surgery and developed postoperative complications had a low MVD score (mean 45.88, P = 0.040). Conclusion: Cold light transillumination is an effective perioperative test, reliable in the assessment of preputial vascularity. There is no statistically significant difference between the MVD of predominant vascular pattern and reticular pattern signifying that MVD may or may not be good in a given vascular pattern. MVD can be a helpful marker in assessing prognosis of repair in proximal hypospadias.
  1,234 51 -
IMAGES
Gliomatosis peritonei in mature cystic teratoma
Gaurav Singla, Sufian Zaheer, Swati Singla, Sachin Kolte, Ashish Kumar Mandal
October-December 2017, 60(4):606-607
DOI:10.4103/IJPM.IJPM_342_16  PMID:29323089
  1,222 57 -
LETTERS TO EDITOR
Elizabethkingia meningoseptica peritonitis in continuous ambulatory peritoneal dialysis patient: A rare case report with diagnostic challenges
Shikha Ranjan, Ilangovan Veerappan, Sonusing Panduran Patil, Ramaswami Sethuraman
October-December 2017, 60(4):626-628
DOI:10.4103/IJPM.IJPM_28_17  PMID:29323100
  1,211 64 -
CASE REPORTS
Familial biatrial cardiac myxoma with glandular elements: A Rare entity with review of literature
Devajit Nath, Sudheer Arava, Ruma Ray, Amol Kumar Bhoje, Rachit Saxena, Shiv Kumar Chaudhary
October-December 2017, 60(4):568-570
DOI:10.4103/IJPM.IJPM_211_16  PMID:29323076
Cardiac myxomas are benign neoplasm of the heart with an incidence of 0.3%. Glandular cardiac myxomas are very rare and accounts for less than 3% of all cardiac myxomas. Here, we report a case of familial glandular cardiac myxoma in a 35 year old male who complained of exertional dyspneoa and weakness of right side of body on clinical presentation. Associated features of Carney's complex were not present. Family history revealed presence of cardiac myxoma in younger brother and sister. Transthoracic echocardiography detected biatrial myxoma. Excision of both lesions was done under cardiopulmonary bypass. Histopathology confirmed myxoma with glandular elements. Postoperative course was uneventful.
  1,227 39 -
LETTERS TO EDITOR
Balloon cell melanoma metastasis to the temporal lobe
Alexandros Iliadis, Thomas Zaraboukas, Panagiotis Selviaridis, Athanasios Chatzisotiriou
October-December 2017, 60(4):622-623
DOI:10.4103/IJPM.IJPM_741_16  PMID:29323097
  1,180 47 -
IMAGES
Polypoid adenosarcoma of uterus with chondroid differentiation: A rare diagnosis
Nadeem Tanveer
October-December 2017, 60(4):620-621
DOI:10.4103/IJPM.IJPM_70_17  PMID:29323096
  1,165 37 -
LETTERS TO EDITOR
Leiomyosarcoma of parotid gland
Asawari Ambekar, CS Soman, Simi Bhatia
October-December 2017, 60(4):624-626
DOI:10.4103/IJPM.IJPM_394_16  PMID:29323099
  1,042 73 -
IMAGES
Addison's darling crisis
Cyriac Abby Philips, Philip Augustine, Lijesh Kumar, Pushpa Mahadevan
October-December 2017, 60(4):612-613
DOI:10.4103/IJPM.IJPM_717_16  PMID:29323092
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