Reena Bharadwaj

Emerging organisms in a tertiary healthcare set up

BACKGROUND One-tenth of all infectious diseases are attributable to emerging organisms. As emerging organisms sporadically affect a relatively small percentage of population they are not studied at large. This study was aimed at studying the characteristics of emerging organisms encountered from various clinical samples in an apex tertiary care multispeciality teaching and research hospital. METHODS 16,918 positive isolates obtained from 66,323 culture samples processed in the clinical microbiology lab of an apex multispeciality hospital during 2011-2012 were included after a pilot study. Both manual and automated systems were used for identification and antimicrobial susceptibility. The frequency of isolation, sources, referring centers, resistance and susceptibility profiles, phenotypic characteristics and number of reports in PubMed were studied. RESULTS Out of 16,918 isolates, 13,498 (79.78%) were Gram negative bacteria, 3254 (19.23%) were Gram positive bacteria and 166 (0.98%) were yeasts. A total of 483 (2.85%, 95% CI 2.6%-3.1%) emerging organisms including 116 (0.69%, 95% CI 0.57%-0.81%) emerging species were identified comprising 54 genera. CONCLUSION Emerging organisms are likely to evade routine identification or be disregarded as non-contributory. Astute efforts directed at identification of emerging isolates, decisions by clinical microbiologists and treating physicians and containment of infection are required.

Pulmonary Hydatid : Diagnosis and Response to Hypertonic Saline Irrigation and Albendazole

BACKGROUND Pulmonary hydatid is caused by larval stage of parasite Echinococcus granulosus. Although surgery still remains the definitive therapy, various workers have tried albendazole and sterilization of cysts with varying result. METHODS 32 patients(21 males, 11 females) of pulmonary hydatid disease with average age 32.5 years(21-51 years) treated by us between Jan 97 to Apr 2001 were analysed. Diagnosis was established clinically, radiologically and by serological testing. 16 patients who had simple cyst were treated with 20 ml percutaneous hypertonic(20%) saline irrigation of the cyst along with albendazole (400 mg twice a day, 6 cycles of 4 weeks with 2 weeks drug free period between the cycles). 13 patients of complicated cysts were treated with 6 cycles of albendazole. All cases were followed up for one year. 16 patients including three fresh cases were subjected to surgical resection. RESULTS Pleural involvement was noted in 10 patients. On chest radiography 19 patients had homogenous oval or circular cysts, 6 patients had crescent sign and 10 had water lily sign. After percutaneous hypertonic saline irrigation all patients showed initial regression in size and developed complicated cysts with water lily sign but subsequently there was no regression. Of 13 patients treated with albendazole, 3 patients showed complete resolution and 2 patients showed regression of cyst. All these 5 patients had shown regression during first cycle of albendazole. 16 patients were subjected to surgery (6 after saline irrigation, 7 after albendazole course and 3 fresh cases). No difference was noted in these groups on histopathological examination. CONCLUSION From this study it was evident that those patients who demonstrate regression in size during first cycle of albendazole are likely to benefit and improve with further cycles of it. Those who do not respond should be subjected to surgery. Result of percutaneous hypertonicsaline irrigation as scolicidal was not encouraging.

Benign fibrous histiocytoma of the ethmoids in an infant

Benign fibrous histiocytoma (BFH) is a benign neoplasm of mesenchymal origin composed of histiocytes and fibroblasts.1 It is commonly found as the cutaneous form in the sun exposed skin and rarely as a non-cutaneous lesion in the head and neck. We report the clinical and pathological aspects of a rare case of BFH of the ethmoid sinus in a nine-month-old male infant patient treated at our center.

Angiomyxolipoma: Unusual swelling of oral cavity

Angiomyxolipoma (AML) is a rare variant of lipoma which presents as well circumscribed tumor characterized by proliferation of adipose tissue with a myxoid stroma and multiple thick and thin walled blood vessels. Review of literature reveals 12 cases of AML with only one case of AML of oral cavity being reported till date. We present a rare case of AML of floor of mouth with relevant review of literature.

Unusual autopsy finding in a case of metastatic teratocarcinoma.

An unusual autopsy finding was seen in a young case of metastatic teratocarcinoma of the right testis. The patient presented with features of myocardial ischemia and died of sudden cardiac arrest. At autopsy, the lungs were studded with variably sized metastatic nodules composed of glistening hyaline cartilage. Examination of the coronary arteries revealed complete occlusion of the left anterior descending and left circumflex artery lumina by tumor emboli composed of glistening white chondromyxoid material. Histopathology confirmed the presence of mature hyaline cartilage and chondromyxoid material in tumor emboli. The individual died due to severe coronary insufficiency and sudden cardiac arrest secondary to complete luminal occlusion of the left anterior descending and left circumflex artery lumina by tumor emboli composed of hyaline cartilage.

ALK-Positive Large B Cell Lymphoma—Unusual Subtype of Diffuse Large B Cell Lymphoma (DLBCL)

Anaplastic lymphoma kinase positive diffuse large B-cell lymphoma (ALK-DLBCL) is a rare lymphoma and has been included as a separate entity in the latest WHO classification (2008) of Non-Hodgkin’s lymphomas. We report a case of 65-year-old male patient who presented with multiple subcutaneous nodules on abdominal wall. Histomorphology and Immunohistochemical profile was consistent with that of ALK-positive diffuse large B cell Lymphoma. Anaplastic lymphoma kinase (ALK) staining was cytoplasmic granular staining pattern highly indicative of expression of Clathrin gene (CLTC-ALK protein). CD 20 was strongly expressed in this case which was an unusual finding as this has been reported in only a few cases which have been published. Our patient also responded well to rituximab therapy which is not administered as these are usually CD 20 negative. The case is reported for its rarity and to make the clinicians aware of this entity so that these cases may be diagnosed early and treated aggressively.

Medical renal disease in tumor nephrectomies: The silent killer

In tumor nephrectomy specimens, the evaluation of the normal renal parenchyma is often overlooked. A patient with both end-stage renal diseases (ESRDs) with a renal cell carcinoma is more likely to die of the ESRD rather than cancer. At the time of nephrectomy, a pathologist has a large amount of tissue available to him to comment upon the presence of disease in the nonneoplastic kidney. Hence, this study was undertaken with the idea of characterizing disease in the nonneoplastic kidney at the time of tumor nephrectomy. A two-year retrospective study was carried out on all tumor nephrectomies and partial nephrectomies. Glomerular, tubulointerstitial, and vascular compartments were evaluated for abnormalities. Twenty-four cases were included in the study. A total of 17 cases showed abnormalities in the nonneoplastic renal parenchyma. In the glomeruli, two cases showed IgA nephropathy, one case showed segmental sclerosis, and one case showed the presence of cellular crescents. A single case showed diabetic glomerulosclerosis. Interstitial fibrosis and tubular atrophy were noted in seven cases. Fifteen cases showed intimal sclerosis and medial hypertrophy and six cases showed nodular hyalinosis. Tumor nephrectomy specimens may very often show the presence of various nonneoplastic diseases. Hypertensive and diabetic renal disease are the major contributors, although primary glomerular diseases may also be present. At the time of the evaluation of a renal tumor on nephrectomy specimen, the status of the nonneoplastic kidney may become as an important predictor of clinical outcome as the tumor itself.

Primary Squamous Cell Carcinoma of Breast in a Young Female: An Institutional Experience with Review of Literature

Invasive or infiltrating ductal carcinoma is the most common type of breast cancer while primary squamous cell carcinoma of breast is extremely rare occurring in 0.04%-0.1% of all breast cancer cases known for aggressive behaviour and poor prognosis. We hereby report a case of primary squamous cell carcinoma of breast in a 31-yearold female who presented with a left breast lump of 2 months duration. Lumpectomy done at another non-oncology centre showed invasive ductal carcinoma with margin positivity for which she underwent modified radical mastectomy at our institute. Post-operative immune-histopathology revealed triple negative squamous cell carcinoma. Her metastatic work-up with whole-body positron emission tomography scan was negative. She was treated with adjuvant chemotherapy doxorubicin, cyclophosphamide and docetaxel followed by loco-regional radiotherapy to left chest wall which she tolerated well. No hormonal therapy was given in view of hormone receptor negativity. She is presently on follow-up for more than 6 months without any evidence of recurrence or distant metastasis. This case is being presented to highlight its extreme rarity, it’s occurrence in a young female, the diagnostic and therapeutic challenges it presented and the overall prognosis of this neoplasm.

Invasive cutaneous mucormycosis in a preterm neonate presenting as a vesicobullous lesion

Mucormycosis is a relatively rare fungal infection seen in immunocompromised patients. Very few cases of invasive cutaneous mucormycosis occurring in neonates have been reported in literature. It is an aggressive disease with a mortality rate of around 64% in neonates, so a high index of suspicion is essential for rapid diagnosis and definitive treatment with broad-spectrum antifungals such as Amphotericin B. We present a case of a premature infant born at 25 weeks of gestation who developed vesicobullous lesions all over the body on day 5 of life. Biopsy from the vesicles confirmed the presence of angioinvasive fungal hyphae of mucormycosis which were highlighted on Periodic acid-Schiff and Grocott stain.

Blaschkoid angioma serpiginosum: A dermoscopic diagnosis

The patient we presented had no known risk factors for nasal mucosal dysplasia. However, he had used nasal steroid (mometasone furoate, beclomethasone dipropionate) sprays with benzalkonium chloride for the last 2 years. Therefore, we suggest that long‐term use of intranasal corticosteroids with benzalkonium chloride can lead to high‐grade dysplasia in the nasal mucosa. We present an unusual case of nasal mucosal dysplasia in an otherwise healthy young man to emphasize the possible side effects of benzalkonium chloride in the upper respiratory tract.