Arvind Bhake

Tophi as first manifestation of gout

Chronic tophaceous gout classically occurs after 10 years or more of recurrent polyarticular gout. However, tophi can also occur as first sign of the disorder. Here we report a 20-year-old male presenting with multiple subcutaneous nodules on bilateral feet and toes, left palm, right elbow, helix of left ear since last one and half year prior to any other manifestation of gout. He was having mild intermittent arthritis since last six months. Fine Needle Aspiration Cytology of one tophus showed monosodium urate crystals, which are pathognomonic for gout. His serum uric acid was normal and ultrasound revealed bilateral nephrocalcinosis. So far as we know, this is the first case report from India, demonstrating tophi as the initial clinical presentation of gout.

Utility of color Doppler ultrasound in evaluating the status of cervical lymph nodes in oral cancer

OBJECTIVE The aim was to study the utility of color Doppler ultrasound (CDUS) in diagnosis of cervical lymphadenopathy in oral cancer patients. STUDY DESIGN In a prospective study, 70 cervical lymph nodes in 30 known primary oral cancer patients were evaluated with CDUS during a period of 8 months. The intranodal perfusion sites and vascular resistance were the key CDUS features used to differentiate between reactive and metastatic cervical lymph nodes. Histopathologic confirmations were obtained by excisional biopsy of the lymph nodes. The results of preoperative clinical palpation of cervical lymph nodes and CDUS evaluation were compared with histopathologic outcome. RESULTS Clinical evaluation suspected 61 cervical lymph nodes to be malignant. According to the CDUS, out of 70 nodes, 49 lymph nodes showed features of benign lymphadenopathy and 21 lymph nodes showed features of malignant lymphadenopathy, whereas histopathologic evaluations were in favor of reactive for 57 (81.42%) and for malignant lymphadenopathy in 13 (18.57%). CONCLUSION The CDUS evaluation was found to be highly significant with a sensitivity of 92.90% and a specificity of 84.21%, after comparing the CDUS findings with histopathologic findings.

Giant lumbar paraspinal atypical teratoid/rhabdoid tumor in a child.

Atypical teratoid/rhabdoid tumor (AT/RT) is a highly aggressive and uncommon tumor of the central nervous system, primarily affecting young children. AT/RT of the paraspinal region with involvement of the spine and spinal cord is extremely rare, with only few case reports in the literature. We report an unusual case of giant lumbar paraspinal AT/RT with intraspinal extension in a previously healthy 18-month-old female child. To the best of our knowledge, this kind of presentation has not been reported previously in the English literature.

Cervical Intramedullary Epidermoid Cyst with Liquid Contents

Intramedullary spinal epidermoid cysts are benign ectopic embryological growths with reported incidence of less than 1% of intramedullary tumors. In this case we report an unusual cervical intramedullary epidermid with liquid contents. A 40-year-old patient presented with progressive weakness of all four limbs of four months duration, bowel and bladder disturbances of two days duration, pain and paresthesias in all four limbs. Magnetic resonance imaging (MRI) revealed a well defined intramedullary lesion extending from C2-C3 level with widening of the cord. The lesion was hypointense on T1W images, hyperintense on T2W and fluid attenuation and inversion recovery images with thin rim of enhancement after contrast administration. Histopathological examination of the excised specimen revealed epidermal lining and keratinous material features of an epidermoid cyst. As in present case, rarely epidermoid cyst can have clear contents, and an MRI finding can closely mimic the features of arachnoid cyst, findings not classical and is different than described in literature.

Hemorrhage in Brain Stem Cavernoma Presenting with Torticollis

Spasmodic torticollis due to an identified focal brain stem lesion is uncommon and abrupt-onset spasmodic torticollis due to midbrain lesions in humans is rarely reported. A 9-year-old female child who had fallen off a bicycle and had lost consciousness for 10 min, vomiting 2–3 times, developed acute torticollis immediately after the injury. Examinations suggested hemorrhage in brain stem cavernoma. A search of the literature written in English revealed that this type of presentation has not been reported previously.

Metastatic lung cancer presenting with jugular foramen syndrome in a case of von Recklinghausens disease

Metastatic carcinomas from a distant primary malignancy involving the temporal bone particularly the jugular foramen are rare tumors. A 57-year-old gentleman had multiple gradually increasing swellings over the body since many years. For last two years, he noticed enlargement of the swelling in left calf and rapidly enlarging painful new swelling over the left chest wall in back for last one year. He had recent involvement of left seventh, eighth and lower cranial nerves. CT scan showed an extensive lesion in left jugular foramen region with bone destruction. The patient underwent decompression of the left jugular foramen mass lesion. The tumor was extremely vascular and a partial decompression could only be performed. Although there was relief in the headache but the neurological deficits were persisting. Histopathology of the tumor showed features of metastatic small ling cancer. In the present case, there was presence of long standing multiple swelling all over the body and the patient had painful enlargement that he perceived as an ongoing process of the von Recklinghausens disease and made a delay in seeking the medical advice resulting in a well advanced disease and with poor prognosis.

Assessment of Clinically Suspected Tubercular Lymphadenopathy by Real-Time PCR Compared to Non-Molecular Methods on Lymph Node Aspirates

Background: The diagnosis of tubercular lymphadenitis (TBLN) is challenging. This study assesses the role of diagnostic intervention with real-time PCR in clinically suspected tubercular lymphadenopathy in relation to cytology and microbiological methods. Methods: The cross-sectional study involved 214 patients, and PCR, cytology, and Ziehl-Neelsen (ZN) staining was performed on aspirates. The findings were compared with culture on Lowenstein-Jensen medium. The overall concordance of cytology and PCR, both individually and combined, was calculated. χ2 and Phi values were assessed between cytology, PCR, and culture. Results: A cytological diagnosis of tuberculosis (TB), reactive lymphoid hyperplasia, and suppurative lymphadenitis was made in 71, 112, and 6 patients, respectively. PCR and culture were positive in 40% of the cases. Among the TBLN patients, PCR showed higher positivity in necrosis and culture showed higher positivity in necrotizing granuloma. Positive ZN staining was observed in 29.6% of the TBLN cases, with an overall positivity of 11%. PCR could additionally detect 82 cases missed by ZN staining. The overall concordance rate for either diagnostic modality, i.e., PCR or cytology, was highest (75%), and for PCR alone was 74%. Phi values were observed to be 0.47 between PCR and culture. Conclusion: Real-time PCR for Mycobacterium tuberculosis complex on aspirates offers a definitive and comparable diagnosis of TBLN. Including this approach as the primary investigation in the work-up of TBLN could reduce the burden of TB.

Malignant hemangioendothelioma of occipital bone

Epithelioid hemangioendothelioma is a rare vascular tumor of bone, and rarely these lesions can present as unique and extremely aggressive tumor. We report a case of highly aggressive epithelioid hemangioendothelioma and discuss the imaging findings. CT brain plain study revealed a poorly-defined, mixed density expansile and lytic lesion involving the occipital bone with extension to the left side with poorly defined trabecula formation. There was significant but irregular enhancement after intravenous administration of contrast material and also marked bone destruction. Microscopic examination of the fine needle aspiration cytology showed a tumor composed of vascular channels lined by plump endothelial cells, which had enlarged hyperchromatic nuclei. In view of the extensive infiltration the patient was submitted for the radiotherapy.

Diffuerent Locations of Hydatid Cysts: Case Illustrations and Review of Literature

Hydatid disease is a parasitosis caused by Echinococcus granulosus and an important health problem worldwide. Incidental human infestation with larval form results in formation of hydatid cysts in various parts of the body, the liver being the most common site. Peritoneal cavity, spleen, kidney, spinal column, retroperitoneal space, abdominal wall, myocardium, and the thoracic wall are unusually involved.

Diagnosis of clinically suspected and unsuspected tubercular lymphadenopathy by cytology, culture, and smear microscopy

BACKGROUND Tubercular lymphadenopathy (TBLN) accounts for 20-40% cases of extrapulmonary tuberculosis. But the common presenting symptoms of tuberculosis like fever, cough, weight loss, fatigue, and night sweats are not always associated with tuberculosis lymphadenopathy, thereby, making its diagnosis difficult. Our aim was to study if Fine Needle Aspiration Cytology (FNAC) combined with Zeihl Neelsen stain and culture for Mycobacterium tuberculosis bacilli could improve the diagnostic accuracy in patients clinically suspected and unsuspected for tubercular lymphadenitis. METHODS The study was conducted at Department of Pathology, Acharya Vinoba Bhave Rural Hospital, Jawaharlal Nehru medical College, Wardha, India. One hundred and twenty-nine patients with enlarged lymph node for more than two weeks duration were evaluated. All the patients were subjected to cytology, smear, and culture examination of their lymph node aspirate. RESULTS Age range for the patients was from 1 to 74 years (mean 30.49±16.69) and F:M ratio was 1:1.18. Most common site of involvement was cervical lymph node. 48 patients were diagnosed as TBLN, out of which 19 patients had no associated symptoms and 28 patients had one or more presenting symptoms of tuberculosis. Fever was the most common presenting symptoms. Pediatric age group patients were more commonly associated with symptoms than adults (p value=0.000). Culture and ZN stain were positive in 32 and 10 cases respectively among TBLN. Additionally, culture was positive in 20 patients diagnosed as reactive lymphoid hyperplasia. CONCLUSION Cytology combined with culture improves the diagnostic accuracy in cases with enlarged lymph nodes, suspected or unsuspected for tuberculosis.