Anita Ramdas

A Rare Case Report of Subcutaneous Phaeohyphomycotic Cyst Caused by Exophiala oligosperma in an Immunocompetent Host with Literature Review

We report a rare case of phaeohyphomycotic cyst in an immunocompetent patient caused by Exophiala oligosperma. This fungus is earlier known to cause infections in the immunocompromised. Identification of black fungi at species level is more challenging by conventional methods, and hence final identification of the fungi was based on sequencing of rDNA. The patient was managed with surgical excision. To the best of our knowledge, this is the first case report of E. oligosperma human infection from India.

Hemophagocytic lymphohistiocytosis: critical reappraisal of a potentially under-recognized condition

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon, potentially life threatening, hyper inflammatory syndrome of diverse etiologies. Cardinal signs include prolonged fever, organomegaly, and persistent unexplained cytopenias. In spite of the well known diagnostic criteria put forth by HLH society, this continues to pose great diagnostic challenge in both pediatric and adult intensive care settings. We describe 4 adult (2 males, 2 females, aged 19, 29, 40, and 17 years) and 3 pediatric (2 males, 1 female, aged 1 month, 6 months, and 12 years) patients with secondary HLH who satisfied the HLH-2004 diagnostic criteria. Definite evidence of hemophagocytosis was noted in 4 patients on initial bone marrow examination. The underlying etiologies were as follows: Rickettsia tsutsugamushi (case 1), autoimmune disorder (case 2), systemic onset juvenile idiopathic arthritis (sJIA) (case 3), unknown bite (possibly a venomous snake) (case 4), Plasmodium vivax (case 5), Cytomegalo virus (case 6), and Mycobacterium tuberculosis (case 7). In one patient, hemophagocytosis was presumed to have been exacerbated by administration of granulocyte monocyte colony stimulating factor (GMCSF) for severe neutropenia. Two patients died with disseminated intravascular coagulation (DIC) and multi organ failure within few days of HLH diagnosis. Immunosuppressive therapy was started in 3 patients, and etoposide was started in one patient only. Due to lack of specificity of diagnostic criteria, diagnosing and differentiating HLH from its closest mimickers like sepsis/septic shock may be quite challenging in critically ill patients. Therefore, increasing awareness among physicians is essential for early diagnosis and effective therapy to reduce the mortality.

Cyclin D1 expression in multiple myeloma by immunohistochemistry: Case series of 14 patients and literature review.

Background: Cyclin D1 dysregulation is an early and unifying oncogenic event in patients of multiple myeloma (MM). This may be detected up to 30% cases by immunohistochemistry (IHC) and up to 40-50% cases by molecular studies. However, studies on the clinical significance of cyclin D1 dysregulation in MM have been inconclusive. We aimed to study the pattern of cyclin D1 expression in MM by IHC and correlate with selected clinicopathologic features. Materials and Methods: Formalin fixed, decalcified, bone marrow trephine sections from 14 symptomatic patients of MM (13 newly diagnosed and one relapsed) were subjected to cyclin D1 IHC by using a rabbit monoclonal antibody to cyclin D1 (clone EPR2241). Results: Cyclin D1 expression (in ≥10% tumor cell nuclei) was observed in 8 of 14 cases (57%). Cyclin D1 positive (+) group had significantly lower hemoglobin level (P = 0.03) than cyclin D1 negative (−) group (n = 6); though both groups showed no statistical significance (P > 0.05) in regard to age, gender, Durie and Salmon stage, lytic bone lesions, light chain phenotype, creatinine, calcium, lactate dehydrogenase, leukocyte and platelet count and bone marrow histology. Ten of 14 (71.5%) showed a favorable response (follow-up; 7 days to 34 months) to thalidomide and/or bortezomib based chemotherapeutic regimen. Four of eight cyclin D1− patients showed complete response, two had a partial response (PR) and two died of the disease; whereas 4/6 cyclin D1 − patients had PR, one refused definitive therapy and one was lost to follow-up (P > 0.05, Fischers exact test). Conclusion: IHC may be a feasible tool for the demonstration of cyclin D1 expression on adequately processed trephine biopsy specimen in MM patients in a resource poor setting. Negative IHC results should be correlated with molecular techniques for prognostication.

Pulmonary alveolar microlithiasis: an interesting case report with systematic review of Indian literature

Pulmonary alveolar microlithiasis is a rare disease characterized by intra-alveolar presence of microliths. This study reports an interesting case of pulmonary alveolar microlithiasis and provides a systematic review of cases reported from India. A 23-year-old female presented with a history of cough, wheeze, chest pain, and episodic wheeze for five months. Pulmonary function tests demonstrated an obstructive pattern, and chest Xray showed fine micronodular opacities predominantly involving the middle and lower zones of both lungs. Transbronchial lung biopsy revealed the diagnosis. She responded well to inhaled steroid therapy. A systematic review of literature was performed and identified 73 cases of pulmonary alveolar microlithiasis reported from India. The mean (SD) age of the patients was 28.8 (14.9) years, with an almost equal male:female ratio. Many patients were asymptomatic at presentation. Breathlessness and cough were the most common symptoms, and the disease progressed into respiratory failure associated with cor pulmonale. About one-third of the cases were initially misdiagnosed and treated as pulmonary tuberculosis. Extra-pulmonary manifestations and comorbidities were also evident in our series. This systematic review helps to determine epidemiological and clinical characteristics of pulmonary alveolar microlithiasis. Further research is needed to elucidate the etiopathogenesis, diagnosis, and therapeutic options, which are beneficial in developing and identifying costeffective treatment for pulmonary alveolar microlithiasis.

Hansen's fingerprints in bone marrow histiocytes

which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. A 47-year-old man from a region endemic for leprosy presented with a 1-month history of high grade fever and red, raised skin lesions on the upper limbs. He had multiple tender papules and nodules on his forearm and thigh along with sensory loss and thickening of nerves. The complete blood count revealed normocytic normochromic red blood cells, a leukocyte count of 15.6×10 9 /L with 81% neutrophils, and a platelet count of 361×10 9 /L. A bone marrow aspiration was performed to investigate the fever. The myeloid to erythroid ratio was 1.5:1. Erythroid and myeloid series were within normal limits. No granuloma or abnormal cells were found in any of the examined smears. Modified Ziehl-Neelsen staining showed numerous acid fast bacilli in the macrophages as well as outside the cells, mainly in the cell fragments (A). Additionally, small clusters of foamy histiocytes in the paratrabecular region with Wade-Fite stain positive lepra bacilli were observed (B). An acid fast bacilli culture using Lowenstein-Jensen medium was negative. A skin biopsy showed numerous foamy histiocytic granulomas admixed with lymphocytes and focally infiltrated by neutrophils in the dermis and subcutis. Therefore, a diagnosis of lepromatous leprosy with a type 2 reaction was made.

Insulin injection site dystrophic calcification with fat necrosis: A case report of an uncommon adverse effect

We report a case of an uncommon adverse effect of insulin injection resulting in hard subcutaneous swelling in the lower abdomen of a 47-year-oldfemale with type 1 diabetes. Extensive dystrophic calcification and fat necrosis was revealed on histopathological examination.

Utility of Nuclear Morphometry in Effusion Cytology

BACKGROUND The cytological analysis of serous effusions is a common investigation and yields important diagnostic information. However, the distinction of reactive mesothelial cells from malignant cells can sometimes be difficult for the cytopathologist. Hence cost-effective ancillary methods are essential to enhance the accuracy of cytological diagnosis. The aim of this study was to examine the utility of nuclear morphometry in differentiating reactive mesothelial cells from malignant cells in effusion smears. MATERIALS AND METHODS Sixty effusion smears consisting of 30 effusions cytologically classified as malignant (adenocarcinomas) and 30 benign effusions showing reactive mesothelial cells were included in the study. ImageJ was used to measure the nuclear area, perimeter, maximal feret diameter, minimal feret diameter and the circularity. A total of ten representative cells were studied in each case. RESULTS Significant differences were found between benign and malignant effusions for the nuclear area, perimeter, maximal feret diameter and minimal feret diameter. No significant difference was found for circularity, a shape descriptor. Receiver operating characteristic (ROC) curve analysis revealed that nuclear area, perimeter, maximal feret diameter, and minimal feret diameter are helpful in discriminating benign and malignant effusions. CONCLUSIONS Computerised nuclear morphometry is a helpful ancillary technique to distinguish benign and malignant effusions. ImageJ is an excellent cost effective tool with potential diagnostic utility in effusion cytology.

A Rare Malignant Transformation of an Ovarian Cystic Teratoma: A Case Report

Mature cystic teratoma (MCT) is the commonest germ cell neoplasm of the ovary but malignant transformation is a rare occurrence (1-2%). Of these malignancies documented in literature the commonest are squamous cell carcinoma and adenocarcinoma. Urothelial carcinomas arising in an MCT are a rare occurrence and only 7 cases have been reported in literature. We report a case of an MCT which was complicated by the presence of urothelial carcinoma confirmed on histopathological examination.

Ulcerated plaque on the buttock of a nonagenarian woman

Figure 1 (a) Plaque with ulceration (white arrow) on the right buttock. (b) Biopsy from the plaque showed psoriasiform epidermal hyperplasia. There was loss of normal cellular polarity of the epidermis giving it a windblown appearance (hematoxylin and eosin, 9 20). (c) Atypical cells with hyperchromatic nuclei and increased mitotic figures. Few dyskeratotic cells were also seen. The basement membrane was intact (hematoxylin and eosin, 9 40)

Xanthogranulomatous osteomyelitis of femur masquerading as neoplasm

Xanthogranulomatous osteomyelitis (XO) is a very rare chronic granulomatous inflammation. It can mimic malignant bone tumors on its clinical presentation, gross features, and radiological imaging. However, histopathological examination can differentiate it from malignancy. We describe the case of a 20-year-old male presented with fever and pain in the right knee joint for 4 months. Plain radiography and magnetic resonance imaging of the right knee joint revealed osteolytic lesion in the lower metaphyseal region of femur. With this clinical presentation and radiological imaging, a diagnosis of primary bone tumor was made. However, XO was confirmed by histopathological examination. This case highlights the rare occurrence and also it can mimic as bone tumor.