Hernani Cualing

Cytophagic histiocytic panniculitis—a syndrome associated with benign and malignant panniculitis: Case comparison and review of the literature

Many cases of hemophagocytic syndromes with cytophagic histiocytic panniculitis (CHP) are being classified and considered as a natural disease progression of subcutaneous panniculitic T-cell lymphoma (SPTL). Review of the literature on both CHP and SPTL discloses distinct patterns suggesting these disorders may not be equivalent, even though a terminal hemophagocytic syndrome may be associated with each. Some SPTL appear to have association with Epstein-Barr virus (EBV), show malignant histopathology in the skin, and may disseminate terminally, with a majority of cases showing a rapidly fatal progression. On the other hand, classic cases of CHP without proven lymphoma may not be associated with EBV, appear to be histologically benign, and have an indolent course unless terminal hemophagocytic syndrome develops. We compared and contrasted a case of CHP and a case of SPTL and reviewed the literature. Our observations suggest that the often fatal hemophagocytic syndrome may be associated with both benign and malignant subcutaneous panniculitis.

Effect of image compression on telepathology. A randomized clinical trial.

CONTEXT For practitioners deploying store-and-forward telepathology systems, optimization methods such as image compression need to be studied. OBJECTIVE To determine if Joint Photographic Expert Group (JPG or JPEG) compression, a glossy image compression algorithm, negatively affects the accuracy of diagnosis in telepathology. DESIGN Double-blind, randomized, controlled trial. SETTING University-based pathology departments. PARTICIPANTS Resident and staff pathologists at the University of Illinois, Chicago, and University of Cincinnati, Cincinnati, Ohio. INTERVENTION Compression of raw images using the JPEG algorithm. MAIN OUTCOME MEASURES Image acceptability, accuracy of diagnosis, confidence level of pathologist, image quality. RESULTS There was no statistically significant difference in the diagnostic accuracy between noncompressed (bit map) and compressed (JPG) images. There were also no differences in the acceptability, confidence level, and perception of image quality. Additionally, rater experience did not significantly correlate with degree of accuracy. CONCLUSIONS For providers practicing telepathology, JPG image compression does not negatively affect the accuracy and confidence level of diagnosis. The acceptability and quality of images were also not affected.

Blastic transformation of splenic marginal zone B-cell lymphoma.

To our knowledge, blastic transformation of splenic marginal zone lymphoma, a recently characterized low-grade lymphoproliferative disorder, has not been reported previously. In this regard, we report the unique case of a 70-year-old woman whose untreated splenic marginal zone lymphoma underwent blastic transformation 3 years after diagnosis. Her hematologic medical history started in 1988 as thrombocytopenia refractory to steroids associated with atypical lymphoid infiltrate in the bone marrow. She underwent splenectomy in 1989, which revealed splenic marginal zone lymphoma. One year later, the patient developed lymphadenopathy noted in the chest, axillary, abdominal, and retroperitoneal lymph nodes. Because she was asymptomatic, treatment was limited to a conservative supportive regimen. The nodal lymphoma cells had features associated with marginal zone lymphoma and expressed B-cell monotypic kappa light chain. She was readmitted for the last time 2 years later with findings of 16% blasts in the peripheral blood and massive infiltration of the bone marrow by large blastoid cells. The blasts showed dispersed chromatin and prominent nucleoli, and possessed a moderate amount of clear cytoplasm. The blasts, like the previous nodal and splenic lymphomas, had a CD20-, CD19-, IgM-positive phenotype, but lacked reactivity for CD5, CD10, and CD23. The patient displayed clinical remission after treatment with vincristine and prednisone, but died of aspiration pneumonia 1 month later. These observations suggest that, similar to the other low-grade lymphoproliferative disorders, an untreated splenic marginal zone lymphoma may undergo high-grade blastic transformation.

Cutaneous lymphoplasmacytoid lymphoma (immunocytoma) with Waldenström's macroglobulinemia mimicking rosacea

A 50-year-old woman presented with a 2-year history of facial lesions that were resistant to rosacea therapy. Evaluation of histology, immunohistochemistry, gene rearrangement study, bone-marrow biopsy specimen, and systemic workup revealed the findings of lymphoplasmacytoid lymphoma (immunocytoma) in both the skin lesions and bone marrow, and IgM kappa paraprotein. Lesions cleared after chemotherapy.

Bronchus-associated lymphoid tissue lymphoma.

41-year-old white woman presented with nonspecific respiratory symptoms. The results of physical exam were nonrevealing; however, a computed tomographic scan showed multiple pulmonary nodules in the right lower and middle lobes (subpleural nodules shown at arrowhead in Figure 1). Bronchial brushing and a bronchoalveolar lavage were performed and revealed no evidence of malignancy and yielded no acid-fast bacilli or fungal microorganisms. Because of the suspicious nature of the nodules, a wedge resection was performed to establish an etiology. The only significant past history provided by the woman was mild adenopathy, idiopathic thrombocytopenic purpura, and absence of exposure to irradiation. On gross examination of wedge resection specimens, the pleural surface appeared unremarkable. Serial sectioning revealed a 0.5-cm firm white subpleural nodule of the right lower lobe with an unremarkable bright red parenchyma. Microscopically, there were scattered peribronchial and perivascular lymphocytic proliferations occasionally associated with germinal centers, and foci of monocytoid cells (Figure 2, A), some of which were associated with lymphoepithelial lesions involving the bronchial mucosa (Figure 2, B). These findings pointed to a low-grade B-cell lymphoma of bronchus-associated lymphoid tissue (BALT) type. However, because flow cytometry results failed to reveal B-cell monoclonality among a predominance of reactive T cells, we made a diagnosis of reactive lymphoid infiltrate. Despite the above flow cytometry findings, we performed molecular studies for gene rearrangement with a polymerase chain reaction for immunoglobulin heavy (H) chain to rule out a lymphoma. The differential diagnosis was lymphoma or a follicular bronchiolitis. The latter diagnosis was supported by rare noncaseating granulomas and inflammation of uncertain etiology because the results of acid-fast and fungal stains were negative. When the results of the immunoglobulin H-chain gene rearrangement were found to be positive, indicating evidence of B-cell clonality, we rendered a final

Dermatomyositis as a presenting symptom of ovarian cancer

BACKGROUND Among gynecologic malignancies, the coexistence of ovarian cancer and dermatomyositis is most frequent. CASE A 75-year-old woman presented with dermatomyositis, and a search for underlying malignancy found an otherwise asymptomatic ovarian carcinoma with para-aortic lymph node metastases. After resection and chemotherapy, the muscle weakness and skin lesions relating to dermatomyositis began to improve. CONCLUSION Dermatomyositis can be the only presenting symptom of ovarian cancer, so an evaluation for suspected underlying malignancy should be done.

Allergic Granulomatosis Secondary to a Limited Form of Churg-Strauss Syndrome

Allergic granulomatosis is a disorder of obscure etiology characterized by infiltration of lymph nodes with histiocytic granulomas and eosinophils. In this report, we describe a case of allergic granulomatosis that is consistent with Churg-Strauss disease limited to lymph nodes. The histologic findings of this patients lymph nodes demonstrated eosinophilic abscesses and ring-shaped necrotizing and nonnecrotizing granulomas surrounding hyperplastic germinal centers. We report herein a rare type of reactive lymphadenopathy and present its histologic, immunohistochemical, and flow cytometric findings, which may allow its distinction from other lymphadenopathies.

An Empirical Comparison of Dimensionality Reduction Techniques for Pattern Classification

To some extent or other all classifiers are subject to the curse of dimensionality. Consequently, pattern classification is often preceded with finding a reduced dimensional representation of the patterns. In this paper we empirically compare the performance of unsupervised and supervised dimensionality reduction techniques. The data set we consider is obtained by segmenting cells in cytological preparations and extracting 9 features from each of the cells. We evaluate the performance of 4 dimensionality reduction techniques (2 unsupervised) and (2 supervised) with and without noise. The unsupervised techniques include principal component analysis and self-organizing feature maps, while the supervised techniques include Fishers linear discriminants and multi-layered feed-forward neural networks. Our results on a real world data set indicate that multi-layered feed-forward neural networks outperform the other three dimensionality reduction techniques and that all techniques are sensitive to noise.

Pathologic quiz case: A 43-year-old woman with a subcutaneous mass in the upper arm.

The patient was a 43-year-old African American woman who complained of recent development of a mass on the lateral aspect of the left arm. The patient initially thought the mass was related to an insect bite, but when it persisted for several weeks, she sought evaluation. The patient denied pain, fever, extremity paresthesias, and weakness. Her past medical history was significant for albinoism, as well as peripheral eosinophilia. She had no history of collagen-vascular disease and no history of malignancy of any type. The patient was on no medications and had no known allergies. On physical examination, we found the patient was obese, with skin and eye pigmentation consistent with albinoism. Cardiopulmonary examination was unremarkable. Examination of the left upper arm revealed a firm subcutaneous mass present laterally, overlying the distal triceps. The mass measured 10 3 5 cm and was nontender and fixed. There were no overlying skin abnormalities. No axillary or supraclavicular lymphadenopathy was present. Magnetic resonance imaging demonstrated increased signal intensity on T2-weighted images, which was thought to be consistent with a soft tissue neoplasm (Figure 1). Owing to the diagnostic uncertainty, the patient was taken to the operating room, where an incisional biopsy of the mass was performed. The patient recovered uneventfully, and on follow-up examinations the mass has remained stable for 6 months. Our laboratory received 2 fragments of light tan-yellow soft tissue, measuring 0.9 cm and 1.9 cm in greatest dimension. Microscopic examination revealed a vaguely nodular, heavy infiltrate of eosinophils and small lymphocytes admixed with vascular proliferation. Many of the vessels were small, with occasional thickened wall vessels. The infiltrate was seen deep, involving the skeletal muscle and adipose tissue. The stroma showed fibromyxoid change (Figure 2). High-power microscopy showed intense eosinophilia and prominent vessels lined by plump endothelial cells with occasional cytoplasmic vacuoles (arrowhead) (Figure 3). Some of the endothelial cells formed uncanalized cords. Immunohistochemical stains showed focal nodules of B cells and diffuse T-cell infiltrate pre

Heterotopic ovarian splenoma: report of a first case.

We present a case of ovarian splenoma, a form of heterotopic splenic hamartoma consisting of red pulp tissue. The hamartoma was located in ovarian stroma in an otherwise normal ovary. The histology showed interanastomosing vascular channels of splenic sinusoidal red pulp lined by cells that were immunoreactive for antibodies to von Willebrand antigen and CD8, findings consistent with splenic lining cells. The sinuses were lined by cuboidal to flattened cells with ovoid and grooved bland-looking nuclei. Ultrastructurally, the tumor cells showed Weibel-Palade bodies and lysosomes. To our knowledge, this is the first case of splenic tissue arising in an ovary, and it underlines the trend noted in the literature that splenic hamartoma,although a rare entity, can arise in many retroperitoneal organs, including the ovary.