V. Venkatarami Reddy

Unusual presentation of esophageal tuberculosis mimicking malignancy.

Sir, Tuberculosis of the esophagus is rare in both immunocompetent and immunocompromised hosts. Esophageal tuberculosis usually occurs secondary to tuberculous infection of adjacent organs, such as lungs, larynx or mediastinum.[1] More cases of secondary tuberculosis of the esophagus have been reported compared with primary esophageal tuberculosis.[1] The diagnosis may be difficult as due to the lack of characteristic clinical features, imaging studies or laboratory findings. Even histology cannot always establish the diagnosis, usually leading to misdiagnosis as esophageal carcinoma. A 75-year-old man presented with complaints of fever and vomiting of 1-week duration. Fever was intermittent, not nocturnal and not associated with chills and rigor. The patient did not suffer from any immunological disorders, was not on any immunosuppressive drug, and did not have any prior history of tuberculosis. He noticed a scalp swelling of 4-day duration, measuring 1 × 1 cm and soft in consistency. Upper gastrointestinal endoscopy revealed an excavating ulcer with undermined edges. The clinical suspicion was esophageal malignancy with probable scalp metastasis. Fine needle aspiration done from the scalp swelling yielded a pus-like material, the cytology smear of which showed acute and chronic inflammatory cells with epithelioid cell clusters and macrophages. Ziehl-Neelson stain demonstrated many acid-fast bacilli. Subsequently, the endoscopic biopsy specimen taken from the esophagus also revealed epithelioid granulomas. Esophageal tuberculosis has various presentations. It generally affects the middle-third of the esophagus around the carina and is usually caused by direct extension and spread from mediastinal structures. Symptoms such as dysphagia and retrosternal pain are the most common complaints.[1–3] Diagnosing esophageal tuberculosis can be difficult and is usually discovered during surgery. Esophageal tuberculosis is suspected in patients with pulmonary or systemic tuberculosis who later develop dysphagia. Delay in diagnosis and instituting appropriate therapy might induce severe complications.[3,4] Most cases can be successfully treated with antituberculous chemotherapy, even in the presence of fistulous tracts. The patient responded to treatment with antituberculous drugs. In conclusion, it is difficult to distinguish esophageal tuberculosis from malignancy on clinical findings alone. We report an unusual presentation of disseminated esophageal tuberculosis mimicking metastatic malignancy. Fine-needle aspiration cytology demonstrating acid fast bacilli, along with histological demonstration of epitheloid granulomas on endoscopic specimens played an important role in diagnosing this case.

Utility of immunohistochemistry in demonstrating Helicobacter pylori

Background: Helicobacter pylori is the causative organism for chronic active gastritis, duodenal ulcer and also for malignancies like gastric adenocarcinoma and mucosa associated lymphoid tissue lymphoma. It is essential to mention the presence of H. pylori in gastric biopsies as it has an important role in patient care. Though there are several special stains to detect H. pylori in histological sections, their specificity and sensitivity vary greatly. Immunohistochemically H. pylori can be detected by using anti H. pylori antibody, which reacts with somatic antigens of the whole bacteria. The aim of this study was to compare the reliability of routine hematoxylin and eosin (H and E), Giemsa, Warthin-Starry (WS) silver stain and immunohistochemical technique in diagnosing H. pylori. Materials and Methods: In this retrospective 1-year (2009) study, endoscopic gastric biopsies taken from patients during gastrointestinal-endoscopy with histopathological diagnosis of gastritis were studied. Standard H and E staining was performed on 5-μm-sections from paraffin block of each specimen. Microscopic sections of biopsy specimens of patients showing features of gastritis histopathologically in routine H and E stain and where the presence of H. pylori was suspected were also stained with Giemsa, WS, and immunohistochemistry (IHC) using purified polyclonal H. pylori antiserum (BioGenex). We have not included gastric resection specimens in our study. Results: Of the 29 cases, 26 (32.9%) showed presence of H. pylori on H and E, Giemsa and WS stains, whereas 49 (62.0%) cases demonstrated H. pylori on IHC stain. Conclusion: We conclude that H. pylori detection by IHC has advantage over routine H and E staining. However, in the developing countries with financial constraints, routine H and E staining in combination with special staining are fairly reliable in demonstrating H. pylori.

Primary squamous cell carcinoma of stomach: A rare entity - case report and brief review of literature

Very few case reports of pure squamous cell carcinoma (SCC) of stomach are available in the world literature. The exact pathology of this uncommon carcinoma in stomach remains unknown. This is an additional case report of SCC in an elderly female arising in the gastric antrum. She underwent distal gastrectomy, gastrojejunostomy and jejunojejunostomy. The histopathology was reported as SCC of stomach without any adenocarcinomatous component. She had no other source of extra gastric primary SCC. After surgery, the patient was advised adjuvant chemotherapy. This is an additional case of primary SCC of stomach.

Helicobacter pylori in Cholecystectomy Specimens-Morphological and Immunohistochemical Assessment.

INTRODUCTION Helicobacter pylori (H.pylori) is associated with gastritis, peptic ulcer, gastric carcinoma and gastric lymphoma. Current literature describes presence of H.pylori in various extra-gastric locations and its association with many diseases. Apart from the conventional location of gastric and duodenal mucosa, H.pylori have been isolated and cultured from gallbladder. AIM Analysis of cholecystectomy specimens to detect H.pylori by means of immunohistochemical staining. MATERIALS AND METHODS There were a total of 118 cholecystectomy specimens received in the Department of Pathology in three months duration. We have performed immunostaining for H.pylori in 45 consecutive cases of cholecystectomy specimen. Clinical and other investigational information were retrieved from the medical records department. For each case, routine Haematoxylin and Eosin stain was studied. Immunohistochemistry (IHC) was done using purified polyclonal Helicobacter pylori antiserum. RESULTS Majority of the patients had undergone laparoscopic cholecystectomy for the presenting complaint of right hypochondrial pain. Multiple pigmented stones were present in majority (27/45) of them. Immunostain for H.pylori was positive in ten cases. Six of these cases had pigmented gall stones, two had stones not specified and in two of the cases there were no stones. CONCLUSION Helicobacter pylori is present in gall bladder and is commonly seen in association with stones. A more detailed study of cholecystectomy cases (both neoplastic and non-neoplastic) with serological, culture and molecular data of H.pylori is desirable to study the pathogenesis of cholecystitis, its association with gall stones and other gall bladder disorders.

Solid-cystic pseudopapillary neoplasm of pancreas: An increasingly diagnosed entity

Recently, SPN is getting more frequently diagnosed in the Indian subcontinent as there is better diagnostic preevaluation and increased awareness about this uncommon tumor.[3,4] Although it is predominantly seen in females, occasionally it can be seen in males.[1,3] Ultrasound‐guided fine‐needle aspiration (FNA) is useful in providing preoperative diagnosis. [1] Whenever possible, trucut biopsy of the lesion should be done which can provide a histopathological diagnosis. Histopathologically, the main differential diagnoses of SPN are well‐differentiated neuroendocrine neoplasm and acinar cell carcinomas.[2,3] A panel of immunohistochemical markers along with clinical, imageological, and morphological findings may help in arriving at a conclusive diagnosis. The typical paranuclear positivity of CD99 aids in the diagnosis of SPN.[3,5]

Tubulovillous adenoma of stomach: A cause for intussusception - Report of an unusual case with brief literature review

In the stomach, benign tumors are not common. Even when they do occur, they are usually considered as premalignant lesions with a risk of transformation to malignant ones. Tubulovillous adenomas of the stomach are rare. However, these tumors are being diagnosed with increasing frequency due to more widespread use of endoscopy. We present an unusual case of a large tubulovillous adenoma of the stomach. The partial gastrectomy specimen showed a large polypoidal growth at the greater curvature of the stomach. The patient is symptom-free, after 2 years of follow-up.

Gastrointestinal stromal tumors: Indian perspective

4. Anderson KN, Schwab RB, Martinez ME. Reproductive risk factors and breast cancer subtypes: A review of the literature. Breast Cancer Res Treat 2014;144:1-10. 5. Mashkoor FC, Al-Asadi JN, Al-Naama LM. Serum level of prostate-specific antigen (PSA) in women with breast cancer. Cancer Epidemiol 2013;37:613-8. 6. Fakri S, Al-Azzawi A, Al-Tawil N. Antiperspirant use as a risk factor for breast cancer in Iraq. East Mediterr Health J 2006;12:478-82. 7. El-Basmy A, Al-Mohannadi S, Al-Awadi A. Some epidemiological measures of cancer in Kuwait: National cancer registry data from 2000-2009. Asian Pac J Cancer Prev 2012;13:3113-8. 8. Al Moustafa AE, Al-Awadhi R, Missaoui N, Adam I, Durusoy R, Ghabreau L, et al. Human papillomaviruses-related cancers: Presence and prevention strategies in the Middle East and North African Regions. Hum Vaccin Immunother 2014;10. 9. Dhaini HR, Kobeissi L. Toxicogenetic profile and cancer risk in Lebanese. J Toxicol Environ Health B Crit Rev 2014;17:95-125.

A case of nonfunctioning pancreatic islet cell tumor in a young female

Pancreatic endocrine tumors are uncommon and represent 1-2% of all pancreatic neoplasms. Nonfunctioning pancreatic endocrine tumors constitute 30-40% of pancreatic endocrine tumors. They can occur at any age, but are rare in childhood. About 65-80% of nonfunctioning pancreatic endocrine tumors are associated with clear-cut evidence of malignant behavior. A 14-year-old girl presented with abdominal pain of 2 weeks duration with occasional vomiting. Abdominal examination did not reveal any abnormality. Ultrasound and computed tomography (CT) scan of the abdomen showed solid mass lesion located in the head of pancreas. The patient underwent Whipples pancreaticodudenectomy. Microscopically, the mass was circumscribed, containing oval to polygonal cells. There was no pleomorphism, significant mitotic activity or evidence of capsular or vascular invasion, and a diagnosis of benign pancreatic islet cell tumor was made. Although benign nonfunctioning pancreatic islet cell tumor is rare in children, such diagnosis should be considered when there is an isolated mass in the pancreas. Appropriate resection of such mass is attended with good outcome.

REPAIR OF AN EXTENSIVE TRAUMATIC DEGLOVING INJURY OF THE PENIS AND SCROTUM USING SCROTAL SKIN FLAP

Penile and scrotal skin avulsions are rare1 and are caused mainly by industrial and agricultural machinery accidents.2,3 These injuries are both physically and mentally traumatic.2 If judiciously managed, permanent disabilities can be prevented. A 28-year-old male met with traumatic degloving injury of the penile and scrotal skin following road traffic accident. In the first step, debridement of devitalized tissues was done. In the second step, skin of left hemiscrotum was used to reconstruct left half of the shaft of penis and the right half was mobilized anteriorly over the right testis to the root of penis and sutured. In the final step, skin of left hemiscrotum was mobilized further with multiple Z-plasty and reconstruction was completed (Fig. 1). The patient was discharged on the 10th day of final step and he was advised abstinence for 3weeks. After 1month, the patient reported of achieving normal voiding and re-established sexual function. Industrial machineries were responsible for maximum cases of penoscrotal injury.2,3 Penile burial in the scrotum or in the suprapubic region is carried out when there is no available skin.1 Other techniques, such as testicular burial in the inguinal region or the inner thigh or expansion of the scrotal tissue can be used.3 Among the postoperative complications that have been reported in the literature are oedema, infection, haemorrhage and cicatricial retraction.2 The treatment of these complications is usually conservative for the benefit of the patient.3 In most of the earlier reported cases split-thickness skin graft was used, but in our case we achieved good aesthetic result, normal voiding and re-established sexual function by using remnant scrotal skin as covering.