Reeta Dhar

Fine Needle Aspiration Cytology of Follicular-patterned Thyroid Lesions

Introduction: Fine needle aspiration cytology (FNAC) plays a vital role in diagnosing thyroid lesions. However, follicularpatterned lesions need to be evaluated meticulously due to markedly overlapping cytomorphological features. Aim: To study the role of FNAC in follicular-patterned lesions of thyroid. Materials and methods: A retrospective and prospective study of 50 cases in which thyroid FNAC showed follicular-patterned lesions along with histopathological correlation wherever available was done over a period of 3 years (January 2013– December 2015). Results: Out of 50 cases of follicular-patterned lesions, 44 cases were reported as adenomatous goiter (AG), 3 cases each of follicular neoplasm (FN), and follicular variant of papillary thyroid carcinoma (FVPTC) on FNAC. Out of total 24 cases available for histopathological correlation, 5 cases (20.83%) showed discordance and the possible causes for the discordance were analyzed. The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 83.3, 42.9, 100, 100, and 81.0% respectively. Conclusion: Diagnosing follicular-patterned lesions on FNAC is challenging and will remain a “gray zone” for all cytopathologists. Scrupulous and thorough examination of all cytological smears should be done for predominant follicular pattern along with cytomorphological and background details to differentiate follicular-patterned thyroid lesions in order to minimize falsenegative diagnosis on FNAC.

Kyrle’s Disease: A Rare Presentation in Diabetic and Hypertensive Patients

Two rare cases of Kyrle’s disease in diabetic patients who presented with papules on legs, back and abdomen, are reported. Pathology of this disease and management are described in detail. Importance of treating the underlying condition associated with this disease is highlighted.

Diagnostic Value of Fine Needle Aspiration Cytology in Enlarged Cervical Lymph Nodes in a Tertiary Care Hospital in Navi Mumbai, Maharashtra, India

A retrospective study of 362 patients with cervical lymphadenopathy, who underwent fine needle aspiration cytology (FNAC) at Mahatma Gandhi Mission (MGM) Medical College & Hospital, Navi Mumbai, Maharashtra, India, is presented. Tuberculosis was the commonest pathology (42%). Other causes were reactive lymphadenitis, granulomatous lymphadenitis, metastases, chronic nonspecific lymphadenitis, acute suppurative lymphadenitis, and lymphoma. Histopathological examination of lymph node biopsy specimens was carried out in 26 cases.

Erythema induratum: a rare case with unusual presentation

Tuberculosis, still one of the most common infectious diseases globally, manifests primarily as pulmonary tuberculosis. Extra-pulmonary tuberculosis can occur in other sites including skin. Cutaneous tuberculosis, comprising merely 1-2% of all forms of tuberculosis, has been classified into various morphological variants. One of the morphological variants of cutaneous tuberculosis is erythema induratum, a tuberculid, which is caused by hematogenous spread of tuberculosis, the pathogenesis of which is due to hypersensitive reaction against the mycobacterial antigens. The skin biopsy findings of erythema induratum are characterized by panniculitis with formation of non-caseating epithelioid granulomas with no mycobacteria detected in the lesions, though mycobacterial antigens or DNA could be detected by polymerase chain reaction (PCR). In this context, being presented here is a case of erythema induratum which is rare and unusual in its presentation inasmuch as caseating epithelioid granulomas were seen in the lesional skin biopsy along with detection of acid-fast bacilli. In our study a 57-year-old male presented to the Dermatology OPD with multiple erythematous lesions bilaterally over the groin and thigh regions. Clinically the lesions were considered to be equivocally suggestive of migratory erythema or erythema marginatum. The skin biopsy taken from the lesions revealed multiple epithelioid granulomas in the dermis with central areas of caseation necrosis. Sections stained with Ziehl-Neelsen stain showed the presence of occasional acid-fast bacilli. Erythema induratum, a rare tuberculid form of cutaneous tuberculosis, which is pathogenetically considered to be occurring as a result of hypersensitivity reaction against mycobacterial antigens with characteristic absence of tubercle bacilli. In the case presented here erythema induratum presents in a rare unusual manner as a caseating granulomatous lesion with presence of demonstrable acid-fast bacilli.

Water melon seed bodies in wrist? An unusual and rare case of tuberculous arthritis with water melon seed bodies

Tuberculosis primarily affects lungs, though involvement of extra-pulmonary sites is on a relative rise in the backdrop of increased incidence of immune compromised disorders such as HIV/AIDS. The extra-pulmonary sites which are most commonly involved are lymph nodes, genitourinary tract, bone marrow, CNS and musculoskeletal system. Tuberculosis of musculoskeletal system includes bones, joint, bursas and tendons or tenosynovium, the incidence of which is rare. Though tuberculosis involves various parts of musculoskeletal system, involvement of wrist and hand is quite rare. Since the involvement of joints of wrists by tuberculosis is very uncommon. Early diagnosis of tuberculosis of wrist is often difficult, in as much as clinical manifestations of other arthritides mimic tuberculous tenosynovitis. Many times, operative findings of melon seed bodies are characteristically suggestive of tuberculosis. The case being presented here is unique and unusual one, which characteristically presented with intraoperative finding of numerous water melon seed which are considered in literature to be helpful in diagnosis of tuberculous arthritis.

Buccal Mucosa Exfoliative Cell Prussian Blue Stain Co-Relates with Iron Overload in β-Thalassemia Major Patients

Thalassemics require regular blood transfusion therapy leading to iron overload in the body tissues, which is a major cause of morbidity and mortality in these patients. We hereby attempted to measure this iron overload by means of exfoliative cytology, a non-invasive and inexpensive technique. The aims and objectives of our study were: 1. To detect iron overload by oral exfoliative cytology using Perl’s Prussian blue stain in β-thalassemia major patients. 2. To correlate staining positivity with serum ferritin levels. Smears were obtained from buccal mucosa of 50 β-thalassemia major patients (who had taken more than 12 transfusions) and 25 healthy subjects of the same age group as controls. Smears were stained with Perl’s Prussian blue. Blood samples were taken from the study group for estimation of serum ferritin levels. Grading criteria were defined for assessing the Prussian blue positivity. Perl’s positivity was observed in 49 out of 50 of thalassemic patients (98%). 1 patient had Grade 0, 7 patients had Grade I, 5 had Grade II, 12 had Grade III, 14 had Grade IV while 11 patients had Grade V positivity. Spearman Rank’s Correlation Co-efficient was 0.38, signifying a weak positive correlation between positivity of buccal smears for Perl’s Prussian blue staining and respective serum ferritin levels. Perl’s Prussian blue staining of exfoliated cells from buccal mucosa can be used to assess iron overload in β-thalassemia major patients, as a screening as well as diagnostic tool. With the grading system we can give a semi-quantitative assessment of the same.

Filariasis in Bone Marrow Aspiration of a Child with Pyrexia of Unknown Origin - A Case Report

A variety of haemoparasites infecting humans occur in the tropical and subtropical regions of the world. Filariasis is one of them that usually manifests as hydrocoele, elephantiasis, lymphadenopathy and fever. The microfilaria causing these symptoms can usually be demonstrated in the peripheral circulation or get lodged into one of the organs and are discovered on fine needle aspiration samples. However, occurrence of microfilaria in the bone marrow is a rare presentation. We hereby report one such case of a paediatric patient who presented as a case of pyrexia of unknown origin, anaemia and raised creatinine levels.

Pulmonary Aspergilloma-A Case Report

Introduction: To report a case of pulmonary aspergilloma in an individual presented with healed fibrocavitory lesion of lung. Method: A case of 26 years old male, non smoker presented with complaints of hemoptysis , fever , weight loss and allergy to dust since 8 months . Patient was a case of pulmonary tuberculosis and had taken treatment for 1 year . Chest X ray showed shadow in right upper lobe . The shadow showed crescent sign . CT scan showed fibrocavitary Kochs lesion in apicoposterior segment of right upper lobe. Bronchiectatic smaller cavities in adjacent lung parenchyma and aspergilloma in one large cavity . We received the gross specimen of right upper lobe lung measuring 8x7x5cms. Cut section showed a cavity bearing necrotic, friable grayish brown mass measuring 4x3x2.5cms. The cavity showed communication with bronchus. Microscopic sections from necrotic mass revealed fungal hyphae uniform , narrow, tubular & regularly septate. Branching was regular, progressive & dichotomous. Cavitary wall was lined by granulation and fibrocollagenous tissue. Lung parenchyma showed alveoli with extensive hemorrhage. Few bronchioles showed dilatation and degenerative changes . Conclusion : Healed fibro cavitary lesion of lung can present with Aspergilloma. INTRODUCTION PulmonaryAspergilloma caused by A.fumigatus, also known as Aspergillus fungus ball grows in pre-existing pulmonary cavity which may formed due to previous tuberculosis condition, carcinoma, emphysematous bulla or sarcoidosis[1-2]. The patients ranged in age from 40 to 81 years ,with a mean of 59 years. They are usually present in upper lobe of lung. Other sites of involvement are the brain and the kidneys. Patients may remain asymptomatic or may present with episodes of haemoptysis which may be massive and life-threatening. Cough with fever ,dyspnoea and weight loss are other clinical manifestations.The diagnosis is usually made clinically and radiographically without lung biopsy.Bleeding is usually caused by local invasion and endotoxic or mechanical irritation of exposed bronchial blood vessels. Radiologically it presents as a single or multiple ball like lesions inside a cavity/cavities, partially surrounded by a radiolucent crescent (Monod’s sign)[3]. A recent thickening of the wall of a pre-existing cavity and/or pleural thickening may indicate early disease. Many of these patients either do not expectorate or their sputa are negative for mycelia[4,5] . CASE PRESENTATION A case of 26 years old male, non smoker presented with complaints of hemoptysis , fever , weight loss and allergy to dust since 8 months . Patient was a case of pulmonary tuberculosis and had taken treatment for 1 year . On examination, respiratory systemVocal Fermitus – increased in right supramammary and right interscapular region.Dull note heard over above mentioned areas.Vocal Resonanceincreased in above mentioned areas. Presence of inspiratory crackles. On investigations,hemoglobin was 13.6 gm/dl,total leucocyte count of 6510cells/mm3, differential leucocyte count was P 52% , L 40% , E 8%,erythrocyte sedimentation rate was 21 mm in the first hour. Sputum examination for acid-fast bacilli(2 samples) were negative. After induction sputum for acid-fast bacilli(2 samples) were negative. Chest X ray [fig.1]showed shadow in right upper lobe . The shadow showed crescent sign . CT scan [fig.2]showed fibrocavitary Koch’s lesion in apicoposterior segment of right upper lobe. Bronchiectatic smaller cavities in adjacent lung parenchyma and aspergilloma in one large cavity . Surgical resection of right upper lobe was done and tissue was submitted for histopathological examination. We received the gross specimen[fig.3&4] of right upper lobe lung measuring 8x7x5cms. Cut section showed a cavity bearing necrotic, friable grayish brown pultaceous mass measuring 4x3x2.5cms. The cavity showed communication with bronchus. Microscopic sections[fig.5,6,7&8] from necrotic mass revealed fungal hyphae uniform , narrow, tubular & regularly septate also on (GMS) stain on necrotic material showed fungal hyphae and globose. Branching was regular, progressive & dichotomous. Cavitary wall was lined by granulation and fibrocollagenous tissue. Lung parenchyma showed alveoli with extensive hemorrhage. Few bronchioles showed dilatation and degenerative changes . However no invasion into surrounding lung parenchyma was seen.