Derek B. Laskar

Can Whole Slide Imaging Replace Conventional Microscopic Evaluation? A Comparative Study over a Spectrum of Cases

This pilot study compares the agreement in diagnosis between scanned slides and conventional microscopy in both low and high magnifications.

A Rare Cause of Cecal Fistula

Department of Pathology, SUNY Downstate Medical center, and Department of Pathology, Kings County Hospital, Brooklyn, New York 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 Question: An 81-year-old woman presented to our clinic with abdominal distension and constipation for the past 1 week. She had nausea, vomiting, and an unintentional 15-pound weight loss over the past few months. Past medical history was significant for hypertension and glaucoma. Vital signs were remarkable for fever of 102 F. Physical examination showed abdominal distension and mild to moderate suprapubic tenderness. Laboratory studies showed leukocytosis with a white blood cell count at 15.90 K/mL (normal, 4.5-10.9) and mild anemia with hemoglobin at 10.4 g/dL (normal, 12.0-16.0). Tumor markers alpha fetoprotein, CA-125, and human chorionic gonadotropin levels were within normal ranges. Abdominal and pelvic contrast-enhanced computed tomography scans revealed moderate terminal ileum wall thickening with an adjacent right lower quadrant mass measuring 7.5 cm in greatest dimension. The mass had an irregular contour with internal air, fluid, and enteric contrast (Figure A, red arrows). Subsequent abdominal and pelvic magnetic resonance imaging showed a large heterogeneous mass with fistulous connection to the cecum (Figure B, green arrow, fistulous tract). At laparotomy, the mass appeared to be an enlarged, solid, and cystic right ovary (Figure C, white arrows) that was firmly adherent to the terminal ileum, cecum, and pericolic fat (Figure C, blue arrow). The gross appearance of the mass was suspicious for malignancy, and thus the decision was made to excise the mass with en bloc ileocoloectomy. What is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Cardiac Involvement by HIV-Associated DLBCL

Non-Hodgkins lymphoma (NHL) is a common AIDS-defining malignancy among people living with HIV. Of the different types of NHLs, diffuse large B-cell lymphoma (DLBCL) is the most common. Prognosis of DLBCL has improved over the years in the general population but remains relatively poor in HIV-positive individuals. Almost any organ system can be affected by DLBCL; however, cardiac involvement remains rare and suggests aggressive disease. We present a case of DLBCL in an HIV-positive patient, who had cardiac involvement, with the only clue to cardiac involvement being symptom being tachycardia and dysphagia.

Case Report: Monoclonal Gammopathy of Undetermined Significance is Associated with Loa loa Infection

A 63-year-old woman who migrated from Nigeria to the United States was found to have an elevated total serum protein, anemia, and eosinophilia. Serum protein electrophoresis (SPEP) and serum protein immunofixation electrophoresis (SPIFE) demonstrated monoclonal immunoglobulin G (IgG) κ restricted bands (IgG 3,820 mg/dL; κ/λ ratio 4.47), indicative of monoclonal gammopathy of unknown significance (MGUS). A rapid diagnostic test (RDT) for malaria was positive for Plasmodium falciparum (BinaxNOW®; Alere Scarborough Inc., Scarborough, ME). Giemsa-stained blood smears were negative for malarial parasites, however, Loa loa microfilariae were identified. Reverse transcription polymerase chain reaction for P. falciparum, Plasmodium ovale, Plasmodium malariae, and Plasmodium vivax yielded a negative result. She was treated for loiasis with diethylcarbamazine and received no malaria medication. Treatment resulted in a resolution of the microfilaremia and eosinophilia, a negative RDT for malaria, and marked reduction in the monoclonal gammopathy. This is the first reported human case of MGUS associated with loiasis and its resolution after antiparasitic treatment.

Evaluation and characterization of monoclonal gammopathies using serum protein electrophoresis in a major urban population: one institution’s experience

Serum protein electrophoresis (SPEP) with serum protein immunofixation electrophoresis (SPIFE) are clinical laboratory techniques used to identify, evaluate and monitor a widexa0range of disease states where abnormal serum protein levels are observed.1 Such disorders include solid tumors, lymphoproliferative disorders (eg, multiple myeloma (MM), monoclonal gammopathy of undetermined significance (MGUS), Waldenstrom macroglobulinemia, primary amyloidosis, chronic lymphocytic leukemia, lymphoma), acute and chronic infections, trauma, connective tissue diseases, and liver disorders.2 Clinical indications for ordering SPEPs are varied: suspected lymphoproliferative disorders; unexplained back pain, anemia, weakness or fatigue; osteolytic lesions; unexplained renal insufficiency; hypercalcemia; unexplained peripheral neuropathy; elevated erythrocyte sedimentation rate; and recurrent infections.2nnChanges observed in SPEPs follow predictable patterns guiding clinicians toward correct interpretation and diagnosis. Polyclonal gammaglobulin protein elevation typically results from reactive, inflammatory or infectious processes. Monoclonal gammaglobulin protein elevation (monoclonal gammopathy; MG) is typified by a sharp band or monoclonal spike (M-component) confined to the gammaglobulin region of the electrophoretogram; however, MG proteins can also be observed within α-1, α-2 and β-globulin regions.1 2 These monoclonal bands result from a single abnormal plasma cell or B lymphocyte clone, which could be from a malignant (MM, Waldenstrom macroglobulinemia) or premalignant process (MGUS).1 2 Initial SPEP evaluation is typically performed in conjunction with SPIFE to identify and confirm monoclonality, and determine the …

Stability of values for the activities of critical enzymes assayed in serum

OBJECTIVESnOur medical center laboratory receives frozen clinical chemistry samples from outlying hospitals for which assays for critical enzyme activities are requested. Our objective is to determine the effects of freezing (-20°C) on these enzyme activities in samples over a one month period.nnnMETHODSnEnzyme activities for ALP, AST, ALT, CK and LD for 30 patients sera were stored at-20°C and were assayed on a Beckman-Coulter AU5800 analyzer at 0, 15 and 30 days after collection. Statistical tests were performed to determine if the values were statistically the same or different.nnnRESULTSnF-tests for all five enzyme levels showed no statistically significant differences (p>>0.05); linear regression analysis showed high correlation of results (r>0.99 for all correlations) with some bias for ALT.nnnCONCLUSIONSnWe conclude that the activities of these enzymes are stable, except possibly ALT, when stored frozen at -20°C over the 15- and 30-day storage periods.

A case of hypertrophic herpes simplex virus affecting the eyelid and cornea masquerading as IgG4-related disease

Purpose To report a case of hypertrophic herpes simplex virus (HSV) of the eyelid and cornea masquerading as IgG4-related disease. Observations A 37-year old African American female with a past medical history of human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART) and a recent history of treated genital herpes, presented with an ulcerative lesion of the left upper and lower eyelids, and severe ocular inflammation with symblepharon. Initially, eyelid biopsy revealed findings consistent with IgG4-related disease, and the patient was treated with high dose oral prednisone. After one week of therapy, there was no improvement in the patients symptoms, and she subsequently developed a corneal epithelial defect which progressed to chronic ulceration. Repeat biopsy and corneal cultures revealed herpes simplex virus type 2. The patient was treated with high dose acyclovir, and the lid lesion improved. The conjunctival inflammation and corneal epithelial defect resolved but symblepharon restricting her eye movement remained. She also developed corneal vascularization and opacification causing severe vision loss. Conclusions and importance Chronic hypertrophic herpes simplex virus infection is a rare condition reported in patients with HIV. While there have been few reports of hypertrophic HSV affecting the eyelid, this is the first reported case of hypertrophic HSV affecting the eye, resulting in severe vision loss.

Shoulder Mass as the Initial Presentation of Metastatic Hepatocellular Carcinoma

A 70-year-old man with chronic hepatitis C, alcohol abuse, and an active cigarette smoking habit presented to our clinic with left shoulder pain and a soft tissue mass without history of prior trauma. Physical examination revealed a disheveled man, scleral icterus, palmar erythema, and abdominal shifting dullness. Neurological exam was significant for right arm weakness. Laboratory studies showed aspartate transaminase 2,309 IU/L, alanine transaminase 2,879 IU/L, alkaline phosphatase 570 IU/L, and total bilirubin 1.6 mg/dL. Computed tomography (CT) of the shoulder showed a 9.1 5.6 5.5 cm destructive expansile lesion at the proximal humeral metaphysis with pathologic fracture and extraosseous soft tissue extension (Figure 1). Further work-up with subsequent chest CT showed a 3.2 2.4 2.4 cm heterogeneously enhancing soft tissue mass with associated osseous destruction of the fifth right rib at the costochondral junction. A 2 2 cm lytic lesion of the high parietal calvarium near the vertex was identified on head CT (Figure 1). Abdominal CT showed cirrhotic liver with portal hypertension, moderate perihepatic free fluid, and multiple ill-defined hepatic parenchymal hypodensities abutting the gallbladder fossa (Figure 1).

MP8: MONOCLONAL GAMMOPATHY CHARACTERIZATION USING SERUM PROTEIN ELECTROPHORESIS IN A MAJOR URBAN POPULATION

Purpose of Study Serum protein electrophoresis (SPEP) with subsequent immunofixation (IF) are clinical laboratory techniques used to evaluate a wide-range of disorders where abnormal serum protein quantities are characteristic (e.g. multiple myeloma (MM), MGUS, amyloidosis, HIV/AIDS, SLE, CLL/NHL). Thus, it is important to identify or exclude malignancy when considering the analyses. Our aim is to characterize SPEP patients from our institution, a predominantly black population. Methods Used We retrospectively reviewed 50 patients SPEP/IF results. Data recorded were SPEP/IF results, monoclonal immunoglobulin (Ig) identity, clinical diagnoses, age, race and gender. Univariate analysis was used to describe patient demographics. Parametric analysis was used to compare the monoclonal gammopathy (MG) group versus non-MG group. Summary of Results Age range was 12–86 years, mean age was 62 years and male to female ratio was 1:3.5. Forty-eight (96%) patients identify as black, 1 (2%) Asian and 1 (2%) white. SPEP patterns showed 1 (2%) patient had acute inflammation, 3 (6%) had chronic inflammation, 24 (48%) were inconclusive, 16 (32%) had MGs, 3 (6%) had normal results and 3 (6%) had polyclonal bands (table 1). Among MG patients, IgG was most common isotype (75%), kappa was most common light chain (58%) and IgG kappa was most common (44%). Mean age was 69 years for MG patients and 58 years for non-MG patients. MM was identified in 9 (18%) patients; 89% (8/9) had normal total protein (TP) levels and 1 (11%) had increased TP. Neuropathy was seen in 7 (14%) patients; 71% (5/7) had polyclonal gamma Ig increase, and 1 (14%) case with co-HIV infection had monoclonal IgG kappa. Seven (14%) patients had CKD, 4 (8%) had HIV/AIDS, 3 (6%) had anemia, 3 (6%) had MGUS, 1 (2%) had SLE and the remaining 16 (32%) had other co-morbidities (i.e. HTN, DM, CAD, etc.). Conclusions SPEP/IF analyses were used to characterize 50 patients. A wide-range of disorders were observed. MG patients were 11 years older than non-MG patients. IgG kappa was most common MG. Our study showed female-predominance. This study shows SPEP utility to discern various disorders observed at our institution. Abstract MP8 Figure 1