Patricia Ann Chandran

Severe malaria - a case of fatal Plasmodium knowlesi infection with post-mortem findings: a case report.

BackgroundZoonotic malaria caused by Plasmodium knowlesi is an important, but newly recognized, human pathogen. For the first time, post-mortem findings from a fatal case of knowlesi malaria are reported here.Case presentationA formerly healthy 40 year-old male became symptomatic 10 days after spending time in the jungle of North Borneo. Four days later, he presented to hospital in a state of collapse and died within two hours. He was hyponatraemic and had elevated blood urea, potassium, lactate dehydrogenase and amino transferase values; he was also thrombocytopenic and eosinophilic. Dengue haemorrhagic shock was suspected and a post-mortem examination performed. Investigations for dengue virus were negative. Blood for malaria parasites indicated hyperparasitaemia and single species P. knowlesi infection was confirmed by nested-PCR. Macroscopic pathology of the brain and endocardium showed multiple petechial haemorrhages, the liver and spleen were enlarged and lungs had features consistent with ARDS. Microscopic pathology showed sequestration of pigmented parasitized red blood cells in the vessels of the cerebrum, cerebellum, heart and kidney without evidence of chronic inflammatory reaction in the brain or any other organ examined. Brain sections were negative for intracellular adhesion molecule-1. The spleen and liver had abundant pigment containing macrophages and parasitized red blood cells. The kidney had evidence of acute tubular necrosis and endothelial cells in heart sections were prominent.ConclusionsThe overall picture in this case was one of systemic malaria infection that fit the WHO classification for severe malaria. Post-mortem findings in this case were unexpectedly similar to those that define fatal falciparum malaria, including cerebral pathology. There were important differences including the absence of coma despite petechial haemorrhages and parasite sequestration in the brain. These results suggest that further study of knowlesi malaria will aid the interpretation of, often conflicting, information on malaria pathophysiology in humans.

Shearwave Elastography Increases Diagnostic Accuracy in Characterization of Breast Lesions.

AbstractThe purpose of this study was to investigate the diagnostic efficacy of shearwave elastography (SWE) in differentiating between benign and malignant breast lesions.One hundred and fifty-nine lesions were assessed using B-mode ultrasound (US) and SWE parameters were recorded (Emax, Emean, Emin, Eratio, SD). SWE measurements were then correlated with histopathological diagnosis.The final sample contained 85 benign and 74 malignant lesions. The maximum stiffness (Emax) with a cutoff point of ≥ 56.0 kPa (based on ROC curves) provided sensitivity of 100.0%, specificity of 97.6%, positive predictive value (PPV) of 97.4%, and negative predictive value (NPV) of 100% in detecting malignant lesions. A cutoff of ≥80 kPa managed to downgrade 95.5% of the Breast Imaging-Reporting and Data System (BI-RADS) 4a lesions to BI-RADS 3, negating the need for biopsy. Using a combination of BI-RADS and SWE, the authors managed to improve the PPV from 2.3% to 50% in BI-RADS 4a lesions.SWE of the breast provides highly specific and sensitive quantitative values that are beneficial in the characterization of breast lesions. Our results showed that Emax is the most accurate value for differentiating benign from malignant lesions.

Glomus Tumour: a retrospective review of 15 years. experience in a single institution

ABSTRACT Glomus tumours (GT), neoplasms of the glomus body comprise 4.5% of upper limb tumours. Seventy-five per cent of these occur in the hand, and most are subungual (50%). We performed a literature review and retrospective search of histopathologically confirmed GT seen from 1995 to 2009. Fifteen patients were identified, with an average age of 49.6 years. Eight were in the hand, 2 in the upper limb, 2 lower limb and 3 in the ear. Eighty-six per cent presented with pain and 50% underwent radiological investigation. Most diagnoses followed biopsy findings. Surgical excision resulted in a recurrence rate of 13%. The average time to diagnosis was 3.3 years. The average duration of symptoms was 7 to 11 years with an average of 2 to 3 consultations prediagnosis. MRI remains the most useful imaging modality (82 to 90% sensitivity). Excision biopsy is the most common treatment. Greater awareness is needed for quicker diagnosis. KEY WORDS Glomus Tumour, Presentation, Imaging, Recurrence.

Advanced MRI applications and findings of malignant phyllodes tumour: review of two cases.

Phyllodes tumour or cystosarcoma phyllodes is a rare stromal breast tumour that is usually benign but on rare occasions can turn malignant. Non-specificity of the imaging features on sonography and mammography makes it difficult to distinguish malignant from benign counterparts solely based on imaging. The final diagnosis is still highly dependent on histopathological assessment. Herein, we describe two cases of malignant phyllodes tumour with emphasis on magnetic resonance (MR) imaging features using advanced MR applications.

Lupus vulgaris in an immunocompromised patient.

Interest in tuberculosis (TB) has recently increased, particularly in developing countries, in response to a resurgence in human immunodeficiency virus (HIV) infection and multidrug-resistant pulmonary TB. Cutaneous TB is relatively rare in the Western world. However, it accounts for 0.4% of patients with skin diseases in the Far East and its incidence has fallen from 2.0% to 0.15% in India. Among a large variety of cutaneous TBs, lupus vulgaris is the most common morphological variant, accounting for approximately 59% of cases of cutaneous TB. Lupus vulgaris is typically a chronic and progressive form of cutaneous TB acquired via endogenous spread or direct exogenous inoculation. Typical sites of lupus vulgaris lesions vary from country to country. The most common sites of lupus lesions in patients in European countries are on the head and neck, whereas sites of predilection in patients in India are the buttocks and trunk. These variations are likely to reflect differences in the underlying socioeconomic status of patients and environmental factors. Lupus vulgaris is diagnosed based on a combination of clinical presentation, histopathological examination, and culture results. A majority of cases of lupus vulgaris, both confirmed and presumptive, have been treated with antiTB drugs with good response. Treatment duration varies from six months to one year. We report a case of lupus vulgaris in an immunocompromised woman in Malaysia, who was successfully treated with antituberculous therapy. The patient was a 39-year-old Chinese woman with a medical history of hypertension. She had received a renal transplant from a living related donor in 2000. Posttransplant, the patient had been well until the middle of 2010, when she presented to the dermatology clinic with a 2-month history of multiple ulcers over both upper arms. The condition had initially manifested on the right arm as a nodule that ulcerated spontaneously and was followed by two further nodules on the right elbow and left arm. The nodules were of varying size and had welldefined margins. They were painless and ulcerated spontaneously, discharging pus, which became dry and crusted. They became progressively enlarged over a 2month period. The patient had lost weight amounting to about 3 kg over the two months. However, she reported no fever, night sweats, cough, or other symptoms of respiratory tract infection. She denied any history of TB or contact with TB patients. The patient’s renal transplant had been performed in July 2000. The cause of kidney failure was uncertain because no renal biopsy was carried out at the time. Posttransplant, the patient suffered acute, followed by chronic, graft rejection. Throughout her illness, her baseline creatinine remained stable at 170–190 lmol/l. She has since remained on immunosuppressants which consist of oral prednisolone, mycophenolate mofetil and tacrolimus. 234

Cox-2, progesterone receptor expression and ki-67 index in meningioma: a malaysian hospital series

Aims: Meningiomas are common central nervous system tumours. Despite being low-grade, those located at surgically inaccessible locations, atypical and anaplastic meningiomas present a therapeutic challenge. The expression of Cox-2 and progesterone receptor (PR) are potential biological predictors of tumour behaviour and therapeutic targets. This study evaluates the expression of these markers with various tumour parameters. Methods: 122 archival formalin fixed, paraffin embedded meningioma specimens from 2004 to 2011 in University Malaya Medical Centre were evaluated. Haematoxylin and eosin (H&E) slides were reviewed and regraded according to the 2000 WHO criteria. Cox-2, PR and Ki-67 immunohistochemistry were performed. Immunohistochemical score (Cox-2, PR) and proliferative index (Ki-67) were analysed. Results: The majority of our patients were female (68%) and of Chinese ethnicity (44.3%). Most tumours were WHO grade 1 (92.5%), meningothelial subtype (57.4%), intracranial (88.5%) and located along the brain convexity (extra-axial) and skull base (42.6% each). The Ki-67 value was significantly higher with increasing WHO grade (p value < 0.001). Most of the meningiomas in our series were positive for Cox-2 (77.9%) and PR (83.6%). Cox-2 was expressed in all extracranial tumours (p = 0.038). Discussion: High positivity of Cox-2 and PR expression in our population, especially Cox-2 in extracranial tumours, suggests future biological studies to explore these markers as potential therapeutic targets.