Jaya Mishra

Analysis of Human Papilloma Virus 16/18 DNA and its Correlation with p16 Expression in Oral Cavity Squamous Cell Carcinoma in North-Eastern India: A Chromogenic in-situ Hybridization Based Study

BACKGROUND The incidence of head and neck squamous cell carcinoma (HNSCC) is quite high in North Eastern India. Apart from the traditional risk factors like tobacco and alcohol consumption, human papilloma virus (HPV) is now considered an established causative agent. These HPV related tumour have a clinico-pathological profile that is quite divergent from conventional non-HPV related tumours. Association of HPV in oral cancers has not been explored in north-east India. MATERIALS AND METHODS Thirty-one patients with oral cavity squamous cell carcinoma (OSCC) on treatment from October 2010 to January 2013 were included in the study. Patients who received neo-adjuvant chemotherapy were excluded. HPV 16/18 DNA was evaluated using Chromogenic in-situ Hybridization (CISH). Presence of nuclear signals was taken as positive HPV expression. p16 was evaluated using immunohistochemistry and was considered positive if ≥ 80% of the tumour cells showed strong and diffuse nuclear/cytoplasmic immunostaining. The results were analysed using Fisher exact test and confidence interval was calculated where required. RESULTS The study group age ranged from 30 to 80 years (median age- 54.2 years). The most common site was gum, with well differentiated squamous cell carcinoma being the most common histology. HPV 16/18 DNA was positive in 29% (95% CI: 13.03% - 44.97%) cases and had a clear tendency towards statistical significance with non-smoker cases (p=0.05), lymph node metastasis (p=0.05) and a significant correlation with p16 overexpression (p=0.04). There was no significant correlation with other clinico-pathological parameters. CONCLUSION HPV 16/18 is associated with OSCC, commonly seen among non-smokers and may be related to nodal metastasis. So, HPV may be used as a prognostic factor in OSCC and p16 may be considered as a surrogate marker for HPV.

Lichenoid drug reaction to isoniazid presenting as exfoliative dermatitis in a patient with acquired immunodeficiency syndrome.

Human immunodeficiency virus-infected patients are at increased risk of drug reactions because of immune dysregulation and multiple drug intake. Lichenoid drug reactions to isoniazid have been reported previously in the literature. However, for lichenoid drug reaction to isoniazid to be so extensive to present as exfoliative dermatitis is rare. We report here a rare case of lichenoid drug reaction to isoniazid presenting as exfoliative dermatitis in a patient with acquired immunodeficiency syndrome.

Primary Extraskeletal Osteosarcoma Arising from the Optic Nerve: A Rare Case Report

Orbital location of extraskeletal osteosarcoma is extremely rare with only 4 cases reported so far in the English literature. We present the case of a 32-year-old female who presented with proptosis and complete loss of vision of the left eye. Contrast-enhanced computed tomography scan showed a densely calcified lobulated lesion in the left optic nerve showing strong enhancement. A left fronto-occipito-zygomatic osteotomy was conducted and a greyish brown tumor was identified. Histopathological and immunohistochemical examination of the curetted material revealed it to be extraskeletal osteosarcoma. A left partial maxillectomy with ethmoidectomy and left orbital exenteration was done and the patient was advised chemotherapy with radiotherapy.

Metachronous Cancer of Breast and Adenocarcinoma of Cervix: A Rare Case Report

The occurrence of a second primary cancer in a cancer survivor is well documented. It may be synchronous or metachronous. Incidence of metachronous cancer involving cervix is 0.82% to 1.33%. One such metachronous cancer is that of breast and cervix. We present a case of a woman who received tamoxifen for invasive ductal cancer of breast following a modified radical mastectomy and subsequently developed adenocarcinoma of cervix after six month of tamoxifen therapy. The role of tamoxifen in pathogenesis of cervical cancer and that of human papillomavirus infection in pathogenesis of both cancer of cervix and breast cancer has been well recognized. In our patient, the adenocarcinoma of cervix (rare occurrence) which is likely due to six month of tamoxifen therapy is a perplexing question. Women diagnosed and treated for breast cancer need to be followed up for development of other metachronous gynecological cancers.

Role of fine needle aspiration cytology in the diagnosis of papillary carcinoma thyroid: A retrospective study from north-east India

Background: Thyroid cancer is the most common endocrine malignancy, and 85% of thyroid cancers are papillary thyroid carcinoma (PTC) making it the most common malignant tumor among all thyroid cancers. Objectives: To analyze the efficacy of fine needle aspiration cytology (FNAC) as the first-line diagnosis of PTC. Materials and Methods: A retrospective study was conducted over a period of 10 years 6 months from January 2007 to June 2017. All the cases of thyroid nodules, which are suspected to have thyroid malignancy from history and clinical examination, and morphologically proven cases of PTC either on FNAC or histopathology were included in the study. FNAC results were compared with the definitive histological diagnosis, which was considered the gold standard. The cytological evaluation and reporting of thyroid lesions were done in accordance with the Bethesda system of reporting thyroid cytopathology. Results: A total of 106 cases were included in the study. Out of the 106 cases, FNAC was inadequate in 8 cases (7.54%), benign in 18 cases (16.98%), atypia of undetermined significance/follicular lesion of undetermined significance in 2 cases (1.88%), follicular neoplasm (FN)/ suspicious for FN in 8 cases (7.54%), suspicious for malignancy in 27 cases (25.47%), and malignant in 43 cases (40.56%). Out of the 106 cases, 75 cases (70.75%) were PTC, which had histopathological correlation. The sensitivity and specificity of FNAC were 87.14% and 77.27%, respectively. Conclusion: FNAC is helpful in triaging the suspicious thyroid lesions for further management. FNAC is quite useful in diagnosis of PTC.

A Classical Image of Dermographism

Clinical Image: A 31year old male presented with complain of itching followed by localised swelling of the part that has been scratched. He also complained of swelling of parts of limb and back on being hold tightly, stroked or rubbed and intermittent swelling of lips. Symptom was worsened by abrasive and tight clothings. The patient had no history of respiratory symptoms suggestive of asthma. General survey and systemic examination was normal other than raised skin within minutes on scratching left arm with a pinhead suggestive of dermographism (Panel A-G). Routine blood count revealed haemoglobin 13 gm/dl, a leucocyte count of 8000/ cumm with increase in the percentage of eosinophils. The absolute eosinophil count was 880/cumm. Serum IgE level was 835 IU/ml. The patient was treated with albendazole (400 mg), levocetrizine (5 mg) for four weeks and with a H2 receptor antagonist with an advice to follow after one month.

Scrub Typhus Presenting with Bilateral Lateral Rectus Palsy in A Female.

Scrub typhus, a rickettsial disease is endemic in several parts of India usually presenting with acute symptoms. Fever, maculopapular rash, eschar, history of tick exposure and supportive diagnostic tests usually leads to diagnosis. Scrub typhus should be included in the differential diagnosis in occasions when a patient presents with fever with or without eschar and isolated cranial nerve palsy. Here we are reporting a case of Scrub typhus who presented with fever and altered sensorium of short duration, eschar formation and bilateral lateral rectus palsy. Patient was treated with doxycycline with complete reversal of neurodeficit.

Pyogenic granuloma with onychomadesis following plaster cast immobilization.

A healthy 14-year-old boy presented with a red nodule on the left thumb for 3 weeks and loss of proximal nail plate of the left index finger for 4 weeks. The patient had developed left distal radio-ulnar joint dislocation following trauma around 3 months back for which a plaster cast was applied from above the elbow up to the metacarpophalangeal joint for 3 weeks. During this period there was no pain, paresthesia or sudomotor change of the fingers of the left hand. One and a half months after the plaster cast was removed, he noticed bleeding from the proximal nail fold of the left index finger and thumb following trivial trauma. It was associated with increased sweating on the cuticular area of these digits. Within a few days, he observed protrusion of red nodules from the proximal nail fold of both left index finger and thumb. The patient was able to pull off the nodule on the index finger; however, he could not remove the thumb lesion. On examination, there was a well-defined erythematous fleshy, transversely elongated nodule on the left thumb involving the proximal nail fold. There was onychomadesis of both left index finger and thumb [Figure 1]. There was no history of local trauma, drug intake or infection prior to development of the nodule. The routine blood investigations were within normal limits. ELISA for antibodies to human immunodeficiency virus was nonreactive. The nerve conduction and electromyographic tests were normal. The lesion was removed by curettage [Figure 2] under local anesthesia and sent for histopathological examination which showed features of pyogenic granuloma [Figure 3]. A final diagnosis of pyogenic granuloma with onychomadesis following plaster cast immobilization was made.

Eccrine angiomatous hamartoma: multiple, symmetrical swellings on forearms of a 10-year-old girl

Editor Eccrine angiomatous hamartoma (EAH) is a rare benign tumour, of eccrine glands and blood vessels. It typically presents during childhood as a solitary slowly growing, bluish-purple nodule or plaque on the distal extremities, and may be associated with pain, hyperhidrosis, and/or hypertrichosis. EAH usually presents as a single plaque or nodule and rarely, multiple lesions may be observed. We herby report a rare case of EAH presenting as multiple painful lesions on both forearms and right hand in a 10year-old girl. A 10-year-old girl presented in Dermatology Out Patient Department with multiple, mildly painful, dusky, raised lesions on both forearms and dorsum of right hand. The first lesion appeared on dorsum of right hand 4 years back in the form of a small, mildly painful nodule. Gradually, new similar lesions appeared on both forearms which slowly increased in size. There was history of increased sweating over the lesions. Her developmental milestones were normal and past medical history was insignificant. There was no history of similar skin lesions in family members. General and systemic physical examinations revealed no abnormality. Cutaneous examination revealed multiple, dusky, mildly tender, firm, nodules, of various sizes ranging 2–4 cm with normal surface distributed symmetrically on both forearms and dorsum of right hand (Fig. 1). The nodules were better felt than seen. Histopathology from nodule on dorsal aspect of right hand showed nests of normal appearing eccrine glands, numerous thin-walled blood vessels and lipomatous tissue in deep dermis (Fig. 2). Routine blood investigations like haemogram, liver and renal function tests were within normal limits. Based on the clinical and histopathological features, diagnosis of EAH was made. The patient was advised for regular follow-up. EAH was first described by Lotzbeck in 1859 and termed as EAH by Hyman and colleagues in 1968. EAH usually presents as a solitary lesion on acral skin, although rare cases with multiple lesions have been described. EAH may be painful and may demonstrate hyperhidrosis due to the presence of the eccrine component. Our case was unique as she had multiple lesions symmetrically distributed on both forearms and dorsum of right hand and there was history of both pain and hyperhidrosis. EAH is characterized histopathologically by dermal proliferation of well-differentiated eccrine secretory and ductal elements closely associated with thin-walled angiomatous channels. Other components, particularly hair follicles, fat or mucin deposition may also be closely associated with the eccrine angiomatous complexes. The histopathology in our case demonstrated increased number of eccrine structures intermingled with numerous thinwalled capillaries and lipomatous tissue in the deep dermis. Carcinoembryonic antigen and S-100 protein, which are commonly found in the eccrine sweat apparatus, are found to be diminished in EAH. However, immunohistochemistry could not be performed in our case. Aetiology of EAH remains unknown. A pathophysiological theory to explain EAH involves a biochemical fault in the interactions between the differentiating epithelium and subjacent mesenchyme that gives rise to an abnormal proliferation of adenexal and vascular structures. As most of the lesions of EAH are located on forearm, some authors suggested that there may be a phylogenetic relationship between EAH and the antebrachial organ of the ringtailed lemur. As EAH is a clinicopathological diagnosis, familiarity with this condition is important for its proper diagnosis. Simple excision is usually curative.

Abdominal histoplasmosis mimicking tuberculosis in an immunocompromised patient

Histoplasmosis should be considered as a differential diagnosis especially in immune-compromised patients presenting with gastrointestinal symptoms even in areas where histoplasmosis is non endemic. The presenting symptoms often mimic abdominal tuberculosis. There are reports of simultaneous infections of both histoplasmosis and tuberculosis in patients with acquired immunodeficiency syndrome (AIDS). With early diagnosis and aggressive antifungal therapy gastrointestinal histoplasmosis has a very good prognosis. Here we are reporting a case that initially presented with clinical and radiological evidence initially suggestive of abdominal tuberculosis which on further work up was diagnosed as abdominal histoplasmosis.