Ritesh Sachdev

Extraoral Plasmablastic Lymphoma Detected Using Ascitic Fluid Cytology and Flow Cytometry: A Case Report with a Review of the Literature

Background: Plasmablastic lymphoma (PL) is a relatively new category of lymphoma, which has been considered to be found predominantly in the oral cavity and has a strong association with HIV. Case: We report a case of extraoral/mesenteric PL detected using cytological examination of ascitic fluid assisted by flow cytometric (FC) analysis. The cells were positive for CD38, CD138, CD10, CD45 and CD56 and negative for CD3, CD19, CD20 and CD79a, with cytoplasmic lambda light-chain restriction. We also reviewed 67 cases of extraoral PL from the available literature and found them to be less often associated with HIV (than oral PL), occurring mostly in males aged 30-60 years, with the most common extraoral site being the anorectal region. Conclusion: A high index of suspicion at the level of the cytopathologist is imperative for identifying lymphoma cells in a body fluid. A rare entity like PL can also be diagnosed on cytology assisted by ancillary techniques (like FC), without the need for a biopsy. We also suggest that the minimum panel to diagnose PLs should include CD138, MUM-1, Ki-67, ALK-1, CD3, immunoglobulin light-chains, CD20 and PAX5.

Adrenal Histoplasmosis in Immunocompetent Patients Presenting as Adrenal Insufficiency.

Abstract Objective: Histoplasmosis is an infectious disease caused by the dimorphic fungus Histoplasma capsulatum, endemic in central and eastern states of United States, South America and Africa. India is considered to be non-endemic area for histoplasmosis. Disseminated histoplasmosis may affect almost all systems. Disseminated histoplasmosis with asymptomatic adrenal involvement has been described in immunocompromised patients; whereas isolated adrenal involvement with adrenal insufficiency as the presenting manifestation of the disease is rare. Material and Method: Twelve patients from a non-endemic area with adrenal histoplasmosis, who were immunocompetent and diagnosed as adrenal histoplasmosis by cytology/histopathology between January 2012 to December 2014 were studied. 18F-FDG PET/CT (fluorodeoxyglucose positron emission tomography/computed tomography) was used to assess the extent of involvement. Results: There were a total of 12 immunocompetent males (mean age: 56.9 years). Ten patients had bilateral adrenal involvement and two had a unilateral left adrenal mass. All the patients had histopathologically/cytologically proven adrenal histoplasmosis. Two patients had simultaneous histoplasmosis of other sites, one in the epiglottis and the other in the alveolus. 18F-FDG PET/CT was performed in 10 patients showing high FDG uptake in the adrenals. All these patients received Amphotericin B and/or Itraconazole treatment that led to symptomatic improvement. Conclusion: A diagnosis of invasive fungal infection requires a high index of suspicion, especially in immunocompetent patients who present with nonspecific symptoms, clinical signs, laboratory and radiological features that can resemble adrenal neoplasms. Clinical specimens must be sent for cytopathology/histopathology together with fungal culture for a definite diagnosis and appropriate management.

Metastatic Renal Cell Carcinoma: An Unusual Cause of Bleeding Pancreatic Mass.

Renal Cell Carcinoma metastasizing to pancreas is uncommon, occurring in 1-2% of cases; lung being the most common site. It is usually asymptomatic, or may present as abdominal pain, weight loss, pancreatitis or gastrointestinal bleeding. Herein, we present a case of 75-year-old male presented as intraabdominal bleeding to the Emergency Department. Contrast enhanced computed tomography with angiography of abdomen showed lobulated soft tissue mass in the uncinate process region, infiltrating into the distal third and proximal fourth part of duodenum. A clinico-radiological diagnosis of carcinoma head of pancreas infiltrating into duodenum was made and the patient underwent Whipples operation. With past history of nephrectomy 3 years back, microscopy and the immunoprofile; a final diagnosis of clear cell renal cell carcinoma metastasizing to pancreas was given on histopathology. A high index of suspicion is required for patients with a history of RCC and they should be monitored lifelong for early detection of metastases and to improve survival.

Tubercular Epididymo-orchitis Masquerading as Testicular Malignancy: An Interesting Case

Basal cell carcinoma (BCC) is said to be the most common malignant tumor of the eyelid encountered in the ophthalmic practice,1 accounting for 80–95% of all malignancies involving the eyelid and canthi. It does not metastasize, but often extends beyond its apparent clinical margins and has a tendency to recur if not adequately excised.2 Pigmented BCC has to be differentiated from melanoma and other pigmented tumors due to their varied biologic behavior.3,4 A preoperative diagnosis of pigmented BCC is not always easy. In a study of 9 cases of pigmented BCC by Hornblass and Stefano,5 only 1 case was correctly diagnosed clinically. Even pathologically, pigmented BCC often may be misdiagnosed as melanoma, and the diagnosis may have to be supported by immunostaining.3 We report a case of pigmented BCC highlighting the cytologic features and emphasizing the role of the fine needle aspiration biopsy (FNAB) in its pretreatment diagnosis. A 60-year-old woman presented in our outpatient ophthalmology department with a history of a painful, pigmented and ulceronodular lesion of the left eyelid for 3 months. On examination, the swelling was blackish, firm and nodular, with an irregular ulceration and serous discharge. The swelling measured 7 × 5 cm (Figure 1), with involvement of the periorbital region, and extended up to the left ala of the nose medially and the temple region laterally. Except for a single left submandibular lymph node measuring 1 × 1 cm, no other positive findings were noted. Clinical diagnosis was BCC. A routine FNAB of the lesion and the lymph node was performed. Papanicolaou and MayGrünwald-Giemsa stained smears showed high cellular yield with many tightly cohesive 3-D clusters and monolayered sheets of round-ovoid-spindle cells with LETTERS TO THE EDITORS

Downgraded Lymphoma: B-Chronic Lymphocytic Leukemia in a Known Case of Diffuse Large B-Cell Lymphoma--De Novo Occurrence or Transformation.

Low-grade indolent lymphomas can be transformed into high-grade aggressive lymphomas [1,2,3,4]. Very few cases of transformation of high/intermediate-grade lymphoma to low-grade lymphoma have been reported in the literature [5,6]. This may arise through transformation of the original clone or may represent a new neoplasm resulting from additional genetic mutations that alter the growth rate, growth pattern, and sensitivity to treatment. A 57-year-old male diagnosed with diffuse large B-cell lymphoma (DLBCL) (non-germinal center B-cell type) in 2002 completed 6 cycles of CHOP followed by radiotherapy. In 2006, 18Ffluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) showed no active disease. In 2007 there was recurrence in the left obturator and external iliac nodes. Lymph node biopsy done outside our facility showed CD20+ B-cell lymphoma. The patient was advised to undergo intensive chemotherapy, but was lost to follow-up. In 2010, the patient came to our hospital with bilateral firm non-tender inguinal and right axillary lymphadenopathy without any organomegaly. 18F PET/CT revealed heterogeneous uptake in the left paraaortic, retrocaval, precaval, and bilateral internal iliac nodes. A previous diagnostic lymph node biopsy was reviewed, showing diffuse infiltration of large atypical cells, positive for CD20, CD30, MUM1, and Bcl2 with a Ki67 index of 80% and negative for CD3, CD5, and CD10, which was consistent with DLBCL (Figure 1A). Biopsy of the paraaortic mass revealed sheets of small lymphoid cells, which were positive for CD20, CD5, and CD23 and negative for CD3 and cyclin D1 with a low Ki67 index, suggestive of small-cell lymphoma (Figure 1B). 18F PETCT was repeated after 1 year, showing multiple FDG-avid cervical, supraclavicular, mediastinal, axillary, abdominal, and pelvic lymphadenopathies (Figure 1C). After 10 months, hemoglobin was 90 g/L, total leukocyte count was 21.1x109/L, and platelet count was 40x109/L. Peripheral blood smear showed 84% abnormal lymphoid cells, which were immunopositive for CD19, CD5, CD23, CD22 (dim), CD200, and CD20 with lambda light chain restriction and negative for CD10, FMC7, CD38, IgM, and CD103, confirming the diagnosis of chronic lymphocytic leukemia (CLL) (Figure 1D). The patient was started on a fludarabine, cyclophosphamide, and rituximab (FCR) regimen. After 6 cycles of FCR, he was in complete remission and was started on rituximab maintenance therapy. Letters to the Editor

Disseminated Histoplasmosis in an Immunocompetent Host Presenting as Pancytopenia with Bilateral Adrenal Masses

A 44-year-old male presented with fever, progressive weight loss, and anorexia for 6 months. The laboratory results showed deranged renal function tests. Serum adrenocorticotropic hormone was high at 252 pg/mL (normal limit: <46 pg/mL), suggestive of primary adrenal insufficiency. Serum free light chains were elevated, kappa at 87.97 mg/L (reference range: 3.30-19.40 mg/L) and lambda at 91.77 mg/L (reference range: 5.71-26.30). Ultrasonography of the abdomen showed hepatosplenomegaly with space-occupying lesions in bilateral suprarenal regions, while endoscopy ultrasound-guided fine-needle aspiration showed necrotizing granulomatous inflammation. Work-up for tuberculosis and human immunodeficiency virus was negative. The hematological parameters showed pancytopenia. The bone marrow aspiration revealed round to oval organisms with crescent-shaped eccentric nuclei both extracellularly and intracellularly, inside the macrophages and osteoclastic giant cells (Figure 1A). Bone marrow biopsy showed the presence of intracellular and extracellular oval capsulated globose organisms spread throughout the marrow spaces (Figure 1B). Periodic acid-Schiff (PAS) staining showed these organisms as bright eosinophilic structures with clear halos around them (Figure 1C). Gomori methenamine silver (GMS) staining showed clusters of fungal yeasts, morphologically compatible with Histoplasma capsulatum (Figure 1D). The patient was started with intravenous amphotericin B followed by oral itraconazole. His condition improved with recovery of counts and improvement of renal function; he is currently doing well. Informed consent was obtained. Figure 1 A) Bone marrow aspirate showing numerous Histoplasma capsulatum inside the osteoclastic giant cell and macrophage (inset) (Giemsa, 100x), B) bone marrow biopsy showing Histoplasma (H&E, 100x), C) PAS staining showed yeast-like cells with bright ... Histoplasmosis is a fungal infectious disease caused by inhalation of spores of Histoplasma capsulatum. It may present as a self-limiting form or progressive disseminated disease. Disseminated histoplasmosis may affect almost all systems, including the reticuloendothelial system, lungs, gastrointestinal tract, renal tract, central nervous system, visual system, bone marrow, and adrenal glands [1]. Histoplasmosis presenting as a bilateral adrenal mass in an immunocompetent patient is rare. A high index of suspicion is required for the diagnosis of disseminated histoplasmosis in a patient with unexplained fever, as it may mimic other chronic illnesses or a neoplasm. The differential diagnoses that should be considered are tuberculosis, sarcoidosis, adrenal hemorrhage, metastatic carcinoma, and lymphoma. Despite extensive imaging, positron emission tomography scanning, and fine-needle aspiration biopsy, a definite diagnosis may not be reached [2]. Bone marrow examination is a useful diagnostic test to establish a diagnosis of disseminated histoplasmosis. In our case, a middle-aged immunocompetent patient presented with nonspecific symptoms and bilateral adrenal mass with insufficiency, the diagnosis of which was only possible with bone marrow examination. Conflict of Interest Statement The authors of this paper have no conflicts of interest, including specific financial interests, relationships, and/or affiliations relevant to the subject matter or materials included.

Intra-articular glomus tumor– a rare presentation

Glomus tumors are rare, benign, vascular painful swellings arising from glomus bodies. They represent less than 1.6% of all benign soft tissue neoplasms (1), are usually found between ages 30 and 50 years and are more common in women than men with a ratio of 2:1 (2). They are commonly seen in the subungual region of digits but ectopic locations are not uncommon (3). Other rare locations include the extremities, trunk, and even the viscera. The forearm is the most common extra digital location and the shoulder and back the least common sites of involvement by this tumor. In the shoulder area, glomus tumor has been reported to arise from bone (scapula), muscle (deltoid muscle) and soft tissue (4).

Synchronous Nodal involvement by Metastatic Adenocarcinoma and Classical Hodgkin's Lymphoma

The cervical lymph nodes (LNs), along with being the primary site of lymphomas, are also the draining sites for malignancies of the gastrointestinal tract, breasts, lungs, etc. Hodgkin’s disease also most commonly affects the cervical and axillary LNs. We, in the era of modern techniques for diagnosing malignancies, stress the fact that a diligent histopathological examination of the background lymphoid tissue is important to exclude a coexistent lymphoma, particularly after a metastasis is found.

Tumiform Laryngeal Histoplasmosis

Histoplasmosis is caused by a dimorphic fungus, Histoplasma capsulatum. Isolated infection involving the larynx is a rare manifestation, especially in immunocompetent individuals. As it simulates malignancy, it needs to be included in the differential diagnosis of laryngeal neoplasm. We report a case of laryngeal histoplasmosis in an immunocompetent patient that was clinically thought to be squamous cell carcinoma. This highlights the importance of keeping infectious diseases in the differential diagnosis and ruling out the same before giving the diagnosis of carcinoma in an ulcerative lesion of larynx. A 45-year-old male presented to Head and Neck Surgery Outpatient Department with a history of pain and difficulty during swallowing and hoarseness of voice for 6 months. General physical examination including ear and nose examination was unremarkable. Endoscopic laryngoscopy showed a friable growth in the anterior commissure of vocal cords. A clinical diagnosis of carcinoma was made, and biopsy was obtained under direct laryngoscopy. Gross examination of the biopsy showed multiple tissue pieces that were friable and gray white in color. Microscopic examination revealed ulcerated mucosa with dense acute and chronic inflammatory cell infiltrate comprising neutrophils, eosinophils, 677815 IJSXXX10.1177/1066896916677815International Journal of Surgical PathologySharma et al research-article2016

Scrotal Histoplasmosis Masquerading as Fournier’s Gangrene

Figure 1. (A) Clinical picture showing large ulcerative, exudative growth in the penoscrotal region. (B) Wedge biopsy shows clusters of foamy macrophages with ingested fungal spores (H&E, 200×; inset, 1000×)