Pradeep Vaideeswar

Pathology of Takayasu arteritis: A brief review

Takayasu arteritis (TA) is a chronic idiopathic and granulomatous vasculitis, manifesting mainly as a panaortitis. Autoimmune cell-mediated immunity is probably responsible for the disease. The inflammation commences from the adventitia and progresses to the intima and leads to, both in adults and children, segmental stenosis, occlusion, dilatation, and/or aneurysm formation. This review focuses briefly on the etiopathogenesis, and describes the pathological and clinical features in adults and children.

Subvalvular Left Ventricular Aneurysms

Subvalvular left ventricular aneurysms can be subaortic or submitral with variable etiology. This is a retrospective study of 19 subvalvular aneurysms seen in 16 cases. There were 12 isolated subaortic aneurysms, 3 isolated submitral aneurysms, and in 1 case with multiple subaortic and submitral aneurysms. Subaortic aneurysms were associated with infective endocarditis, while there seems to be a strong association between submitral aneurysms and tuberculosis. Five cases of subvalvular aneurysm has associated aneurysm sinus of Valsalva-this association suggests a congenital weakness in the attachment of aortic and mitral annuli to the underlying myocardium. Cardio Pathol 2000;9:267-271

Extranodal follicular dendritic cell sarcoma of the tonsil - case report of an epithelioid cell variant with osteoclastic giant cells.

Follicular dendritic cell sarcomas are rare neoplasms arising from the accessory cells of the lymph nodes, the follicular dendritic cells. They commonly occur in the lymph nodes, but have also been reported at extranodal sites (especially the tonsil). At both sites, there is usually a proliferation of spindled to ovoid cells, mimicking a mesenchymal tumor. Herein, we report a tonsillar tumor in a 50-year-old man, which was composed exclusively of large polygonal cells and numerous osteoclastic giant cells that resembled a giant cell carcinoma. The true nature of the tumor was revealed after an array of immunohistochemical stains. The patient is well 4 years after tonsillectomy.

Pathology of the diffuse variant of supravalvar aortic stenosis

Supravalvar aortic stenosis is a rare congenital heart anomaly, producing left ventricular outflow tract obstruction. Of the two anatomic variants that have been described, diffuse type is the rarest. We report five such cases in children between two months and nine years of age. None had features of Williams syndrome. The entire aorta was involved in three cases, with abdominal aortic coarctation in two cases. Stenosis was mainly due to involvement of the media, which showed smooth muscle hypertrophy, abnormal elastic fibers, and mild collagenization. Predominant intimal change was seen in one case. Pulmonary, coronary, arch, renal, and common iliac arteries were also involved.

Cardiovascular lesions in leptospirosis: An autopsy study

OBJECTIVES Leptospiral involvement of the cardiovascular system often remains an under-estimated critical clinical factor. This report studied the cardiovascular changes in fatal cases of leptospirosis in Mumbai city, India in the year 2005. METHODS This is a years retrospective study of autopsied cases of leptospirosis, selected on the basis of clinical criteria. The demographic details, clinical presentation, and investigations were noted. Detailed gross examination of the cardiovascular system was carried out and multiple sections were taken. RESULTS Forty-four cases of leptospirosis in the year 2005 formed 3.52% of the autopsies performed. The highest number of cases (25 patients) was seen in the month of August that corresponded to the deluge on the 26th of July. The majority (86%) were adults; all presented as acute febrile illness that terminated with severe respiratory insufficiency. Involvement of the cardiovascular system was found in 41 cases, an incidence of 93.2%. Clinical evidence of cardiac affection was not noted in most. Gross cardiac features noted were cardiomegaly and petechiae in one or more layers. The predominant feature on histopathological examination was the presence of interstitial myocarditis (100% of cases), with involvement of the epicardium/endocardium (39%), valves (36%), coronary arteries (51%) and aorta (56%). CONCLUSIONS Correlating the autopsy, leptospirosis can be visualized as an infective systemic vasculitis. The unusual manifestation of pulmonary hemorrhagic syndrome in these cases camouflaged the cardiovascular involvement.

Pathology of pulmonary aspergillomas

Aspergilloma refers to a fungal ball formed by saprophytic overgrowth of Aspergillus species and is seen secondary to cavitatory/cystic respiratory diseases. Paucity of clinical and pathological data of aspergilloma in India prompted us to analyze cases of aspergilloma over 15 years. The clinical features were recorded in all and correlated with detailed pathological examination. Aspergillomas were identified in 41 surgical excisions or at autopsy. There was male predominance; half the patients were in their fourth decade. Episodic hemoptysis was the commonest mode of presentation (85.4%). Forty aspergillomas were complex, occurring in cavitatory lesions (82.9%) or in bronchiectasis (14.6%). Simple aspergilloma was seen as an incidental finding in only one. Tuberculosis was the etiological factor in 31 patients, producing cavitatory or bronchiectatic lesions; other causes were chronic lung abscess and bronchiectasis (unrelated to tuberculosis). Surgical resections are endorsed in view of high risk of unpredictable, life-threatening hemoptysis.

An analysis of 24 autopsied cases with supramitral rings.

The supramitral ring is a rare congenital malformation formed by presence of a ridge of connective tissue, usually attached at or above the mitral annulus. The incidence and clinical presentation is highly variable due to difficulty in diagnosis. A review of autopsied congenital heart diseases at our institute over a 17-year-period revealed 24 cases of supramitral ring. These were classified with respect to the morphology of the ridge and the presence of associated cardiac lesions. The ring was found in 1.5% of the autopsied specimens of congenitally malformed hearts, and in 37.5% of those with obstructed left-sided inflow tracts. The majority of the specimens came from children (79.2%). A clinical diagnosis had been made in only two. In one-third of the cases, the ring was associated with incomplete Shones complex. Varied anomalies were seen in others, chiefly ventricular septal defects. An interesting association was the presence of rheumatic mitral valvar disease, found in 3 cases. There was no difference in the completeness or width of the supramitral ridge in the hearts from those with or without Shones complex. Circumferential rings were fleshy and stenosing, while incomplete rings had variable locations and stenosis. The presence of a supramitral ring may be underestimated due to association with other cardiac anomalies, both congenital and acquired. Since the ridge need not always produce stenosis, the correct designation would be simply a supramitral ring.

Isolated infective endocarditis of the pulmonary valve: an autopsy analysis of nine cases.

INTRODUCTION Infective endocarditis (IE) of the pulmonary valve is uncommon and usually occurs in conjunction with tricuspid and/or left-sided valvular endocarditis. There have been only sporadic reports of isolated pulmonary valvular infective endocarditis (PVIE). This report documents the pathological features of nine such cases at autopsy. METHODS Among 155 cases of IE encountered in a 14-year period, we selected nine cases that had isolated PVIE for analysis. The clinical records were reviewed for the patient demographics, presence or absence of underlying cardiac disease or other predisposing factors, and modes of presentation; these were correlated with the relevant investigations. A detailed study of the heart was done in all with special attention to the pulmonary valve morphology. RESULTS The nine cases of isolated PVIE formed 5.8% of the IE cases, seen in six males and three females, largely adults. Seven patients (77.8%) had admissions for about 24 h. Hospital admission was sought for mainly progressive shortness of breath (66.7%) and fever (44.4%). Congenital heart disease was seen in seven (77.8%); two (an infant and an adult) had normal hearts. A single blood sample for blood culture in two patients was negative. Two-dimensional echocardiography, performed in eight, revealed vegetations on the pulmonary valve in four. The pulmonary valve was tricuspid in six cases, bicuspid in two, and unicuspid in one. The vegetations (active in three, active and healing in two, healed in four) were accompanied by concomitant thickening, shortening, perforations, or complete destruction of the cusps. Involvement of the right ventricular outflow tract or the main pulmonary artery was identified in five hearts. Five patients (55.6%) developed pulmonary complications, related to the endocarditis. CONCLUSIONS Detection of PVIE, especially the isolated type, may be underdiagnosed. This condition should be kept in mind during evaluation of patients especially with cardiac anomalies, who present with fever, prominent respiratory symptoms, and negative blood cultures.

Cardiac Valvular Inflammatory Pseudotumor

Inflammatory pseudotumors are quasineoplastic lesions that occur in the lungs as well as other extrapulmonary sites. The heart is an uncommon site of origin. We report a valvular pseudotumor that produced chronic mitral and aortic regurgitation in an elderly woman.

Viral ventilator-associated pneumonia: Uncovering tip of the iceberg

CONTEXT Hospital-acquired infections are frequently encountered by the physicians for ailments demanding prolonged hospitalization, especially in intensive care units, where patients are often mechanically ventilated. The organisms most often implicated are bacteria; viral etiology is infrequent. AIMS The study aims at reviewing lung pathology at autopsy in mechanically ventilated children admitted in pediatric intensive care unit (PICU) to assess the incidence of viral ventilator-associated pneumonias (VAP). SETTING AND DESIGN Retrospective analysis. MATERIALS AND METHODS Among the 275 children who had been autopsied, 13 who had been admitted in the PICU satisfied the criteria for VAP. These cases were analyzed on the basis of clinical data and pulmonary pathology. Depending on the overall histology, the cases were classified as being viral or bacterial in etiology. Immunohistochemistry (IHC) for detection of viral antigens was also performed. RESULTS Of the 13 children, nine (five males and four females) had shown the histomorphologic features, suggesting viral inflammation. The mean age was 33 months. Falling oxygen saturation and increasing respiratory distress had necessitated ventilator support. Acute lymphocytic bronchiolitis, interstitial pneumonitis, diffuse alveolar damage, and necrotizing pneumonia were the histological features. The viruses identified in five patients were adenovirus, respiratory syncytial virus and cytomegalovirus. CONCLUSION This communication, though not representing the true incidence, emphasizes that a proportion of nosocomial infections is due to viral infections. This should alert the treating intensivists to actively pursue investigations to confirm viral etiology.