Residual goitre in the postiodization phase: iodine status, thiocyanate exposure and autoimmunity

OBJECTIVE

This study was done to assess goitre prevalence, thyroid functional status and cause of residual goitre among school children in the postsalt iodization phase in India.

DESIGN

A cross-sectional study in which, 14762 school children in the age group of 6-18 years, from different States and Union territories of India, were evaluated for goitre prevalence, urinary iodine and thiocyanate excretion, functional status of the thyroid as well as serological and cytopathological markers for thyroid autoimmunity.

MEASUREMENTS

Urinary iodine (wet ashing method), urinary thiocyanate (colourimetric method), serum thyroxine [in-house radioimmunoassay (RIA)], serum TSH (IRMA), antithyroid microsomal and antithyroglobulin antibodies (haemagglutination method) were estimated. Fine-needle aspiration cytology was performed in all goitrous subjects giving consent.

RESULTS

The overall goitre prevalence was 23% (27.1% girls; 17.8% boys, P < 0.001). Subjects belonging to poor socio-economic strata had significantly higher goitre prevalence. Median urinary iodine excretion (UIE) in goitrous subjects (2-53 micromol/l) was significantly higher than in controls (2-24 micromol/l; P < 0.001). Levels of UIE observed among goitrous subjects showed no relationship with the presence or absence of thyroid dysfunction or with thyroid antibody status. High titres (> or = 1:1600) of TMA were present more often in goitrous subjects (6.08%) than nongoitrous controls (0.34%; P < 0.001) and in girls (7.3%) than boys (2.35%; P < 0.001). TMA positivity were significantly more among goitrous subjects with thyroid dysfunction than in euthyroid subjects. Significantly higher median urinary thiocyanate (USCN) excretion was observed in goitrous subjects (0.75 mg/dl) compared to controls (0.64 mg/dl; P < 0.001) and goitrous girls compared to goitrous boys. USCN excretion of goitrous subjects and controls showed no relationship with functional or thyroid antibody status in various groups.

CONCLUSIONS

Persistent, albeit reduced prevalence of goitre, despite adequate iodine prophylaxis, suggests existence of additional factors in goitrogenesis in India. Thyroid autoimmunity can explain only a part of the goitre prevalence. The role of goitrogens in residual goitre prevalence is brought forth.

Semi-quantitative analysis of soft-tissue reactions in fine needle aspirates from tissue cysticercosis

Fine needle aspiration cytology (FNA) has a well-documented role in the diagnosis of cysticercosis. However, little is discussed about the associated inflammatory response in the host tissues. Aspirates from 182 cases of subcutaneous cysticercosis were semiquantitated for the type and degree of inflammatory response, and the amount and preservation of the parasite. Tissue sections were reviewed where available. In the FNA where no parasite was observed but a confirmatory tissue diagnosis was available, it was found that eosinophils (52%), epithelioid cell granulomas (30%), palisading histiocytes (33%) and giant cells (28%) were seen less frequently than in those where larval fragments were identified in the aspirated material in varying quantities, the response being 88-92% eosinophils, 50-70% palisading histiocytes, 68-80% epithelioid cell granulomas and 46-74% giant cells. Repair cells were maximally seen when readily identifiable larval fragments were seen in the aspirate. Bizarre cells were equally distributed in these aspirates. The tissue response in FNA from subcutaneous cysticercosis can be varied and eosinophils are found to increase with the presence of the degenerating parasite. In soft-tissue aspirates, palisading histiocytes with epithelioid cell granulomas with or without giant cells and an inflammatory exudate with predominantly eosinophils alerts one to search diligently for a parasite.

Cytodiagnosis of anaplastic astrocytoma with metastasis to the cerebrospinal fluid in a neonate--a case report

A case of left cerebral hemispheric anaplastic astrocytoma with metastasis to the cerebrospinal fluid in a 50-day-old male child diagnosed on cytology and later confirmed by histological examination is reported.

Malignant Degeneration in a Mature Cystic Teratoma of Ovary A Case Report

Malignant transformation of benign cystic teratoma of ovary is rare and the mostcommon malignancy encountered is squamous cell carcinoma. The diagnosis is rarelymade preoperatively and the prognosis is usually poor. Here we report a case ofsquamous cell carcinoma arising in a dermoid in a 44 years old lady who presentedwith bilateral dermoid cysts. The preoperative findings, surgical approach andadjuvant therapy are discussed.Key Words: Malignant transformation, benign cystic teratoma, squamous cell carcinoma.

Parasites in fine needle breast aspirates--assessment of host tissue response

Parasites in the human breast are uncommon but not rare. Cysticercus and filariasis in fine needle breast aspirates have been documented and their cytomorphology is well characterised. However, the host tissue response to these parasites and the factors responsible for their initiation are not clear. Over a 21 year period, 28 cases of breast parasites (16 cases of cysticercus and 12 of filariasis), diagnosed by fine needle aspiration cytology, were reviewed to assess the host tissue response.

Clinical evaluation of human placental extract (placentrex) in radiation-induced oral mucositis

To evaluate human placental extract in the treatment of radiation mucositis involving the oral/oropharyngeal region, a prospective randomized study was carried out in 120 patients with squamous cell carcinoma of the head and neck from August 1997 to March 1999. The study was conducted in patients receiving radical external radiation therapy, planned for = > 60 Gy/30 F/6 weeks, who developed grade 2 radiation mucositis (patchy mucositis) during radiation treatment. The patients were randomized in two groups of 60 patients each to receive either placentrex treatment (placentrex group) or conventional treatment (control group). Placentrex treatment was given as Inj Placentrex 2 ml by deep intramuscular injection 5 days a week for 15 injections. Conventional treatment given in the control group was disprin gargles and betamethasone oral drops. A subjective decrease in pain was observed in 48/60 (80%) of patients in the placentrex group compared with 22/60 (36.7%) in the control group. The progression to grade 3 radiation mucositis was 24/60 (40%) in the placentrex group compared with 52/60 (86.7%) in the control group. The subjective improvement in difficulty in swallowing was seen in 56/60 (93%) of patients in the placentrex group compared with 9/60 (15%) of patients in the control group. Only one patient in the placentrex group compared with three in the control group required interruption of radiation therapy because of severe radiation reactions. Human placental extract appears to be effective in the management of radiation-induced oral/oropharyngeal mucositis and especially in controlling subjective symptoms.

Fine-needle aspiration cytology of umbilical nodules: "Sister Joseph's nodule"

Metastatic tumor deposits in the umbilicus are not uncommon. Fine-needle aspiration cytology is an important, simple, cost-effective diagnostic tool for delineating the value of umbilical nodules. However, only a few reviews and case reports of diagnosis of umbilical metastases by fine-needle aspiration cytology are available. A review of 52 cases of umbilical nodule aspirates over a 16-yr period forms the basis of this brief report.

Far-infrared fizeau interferometry

We present an interferometry using a far-infrared light as a tool for surface topography measurement of rough reflective surfaces. The method is based on the optical configuration of classical Fizeau interferometry, but we achieve roughness tolerance by using a long-wavelength infrared light (lambda = 10.6 mum). The method is called far-infrared Fizeau interferometry. We conducted a rigorous mathematical analysis to describe the true intensity distribution of fringe patterns while considering multiple reflections and surface roughness. The mathematical derivation is verified with experimental data obtained from specimens with various values of reflectivity and roughness. The effect of reflectivity and roughness on fringe contrast is discussed.

Maternal mortality in rural India: a hospital based, 10 year retrospective analysis

OBJECTIVES

To estimate the maternal mortality ratio (MMR) in Ludhiana, a city of Northern India in order to determine the causes associated with MMR and to suggest ways to reduce it.

METHODS

Retrospective analysis of the mortality records of obstetrics cases in Christian Medical College, Ludhiana, India.

RESULTS

The mean MMR for the 10 year period was 785 per 100,000 live births. Of the total 116 reported maternal deaths, 44 (41.9%) were due to induced septic abortion. The reasons were unwanted pregnancy in 22 (50%) and 11 (25%) were female feticide.

CONCLUSIONS

In our hospital based analysis, MMR was very high. Most maternal deaths are preventable by intervention at the appropriate time and it is important for health professionals, policy makers and politicians to implement the introduction of programs for reducing maternal mortality. Special emphasis should be placed on antenatal care, the establishment of a registration system and measures to abolish illegal abortion.

Langerhans cell histiocytosis in lymph nodes. Cytomorphologic diagnosis and pitfalls

OBJECTIVE

To delineate the cytomorphology of Langerhans cell histiocytosis (LCH) in lymph nodes.

STUDY DESIGN

Nine histologically documented LCH cases with a prior lymph node aspirate and five more cases in which a cytologic diagnosis of LCH was rendered in a background of corroborative clinical and radiologic findings were included in a retrospective study over a 12-year period (January 1988-January 2000). Papanicolaou- and May-Grünwald-Geimsa-stained smears were reviewed by two independent observers. Staining for S-100 protein was available in four cases.

RESULTS

Nine cases had multisystem involvement, while in five cases only lymph nodes were involved. The ages ranged from 5 months to 27 years, with 11 males and 3 females. An initial cytologic diagnosis of LCH had been rendered in six, suspected in four and missed in four. On review, all were reclassified as LCH except two cases, which were still thought to be reactive and necrotizing lymphadenitis. The pathognomic feature of LCH, the "LCH cell," was identified in 12 of 14 cases along with varying numbers of eosinophils, polymorphs and lymphocytes. Giant cells were seen in six cases, and plasma cells were rarely seen.

CONCLUSION

Lymph node involvement by LCH can be identified by fine needle aspiration in 85% of cases. The presence of the LCH cell is a must. The differentials to be considered are dermatopathic lymphadenitis, sinus histiocytosis with massive lymph-adenopathy, Hodgkin's lymphoma and malignant histiocytosis.

Infantile periocular haemangioma treated with two days in a week betamethasone oral mini pulse therapy

A one-month-old male infant had a large asymptomatic, bright red swelling on the face with inability to open his right eye since birth. On cutaneous examination there was a large brightly erythematous, lobulated, soft plaque on the right side of the forehead of 12 cm x 10 cm, involving the right upper eyelid obscuring the visual axis and extending on to the right upper lip. Ocular examination revealed normal anterior and posterior segments. Computed tomography of head and orbit confirmed the diagnosis of capillary haemangioma. The child was treated with oral betamethasone 2 mg as the signal daily dose on the two consecutive days in a week. After six weeks there was 80% reduction in the size of the lesion and the right upper eyelid almost completely cleared the visual axis. In another six weeks, the improvement was more than 90%.

Papillary carcinoma of the thyroid and its variants: a cytohistological correlation

Fine-needle aspiration cytology (FNAC) is considered highly specific for the diagnosis of papillary carcinoma of the thyroid (PCT). In recent years, several variants of PCT have been described. An attempt was made to gauge the accuracy of classification of variants of PCT on aspirates. Cytology smears from 124 of 150 cases of histologically proven PCT with a prior FNAC were reviewed over a 16-yr period. A diagnosis of papillary carcinoma on FNAC was made in 93 cases. Further subclassification of these cases was done on cytology and tissue sections independently. The variants of PCT classified on FNAC were classical PCT (PCT-CL), 76 cases; Hurthle-cell variant (PCT-HCV), 3 cases; follicular variant (PCT-FV), 6 cases; tall-cell variant (PCT-TCV), 2 cases; high-grade variant (PCT-HG), 2 cases; and 2 cases each which were debatably PCT-CL/PCT-FV and PCT-CL/PCT-HG. Cytology typing was accurate in 65 of the 72 classical variants, while only 7 of the 22 follicular variants were correctly identified on cytology. Two of the 3 high-grade papillary carcinomas (PCT-HG) were identified on FNAC, and the solitary case of tall-cell variant could readily be classified on cytology. In conclusion, identification of the various variants of PCT is possible, though difficulty is encountered in correctly categorizing the follicular variant, which is often mistaken for a follicular neoplasm. Also, identification of the solid variant and the papillary carcinoma with nodular fasciitis-like stroma was a problem on cytology. Another interesting observation in our series is that an admixture of various cell types was seen in the smears and corroborated on histology to be present in focal areas.

Is incidence of cancer on the decline in Delhi, capital of India?

The incidence of cancer varies to a great extent in the resident population of Delhi (Urban area). The purpose of this study is to examine the time trends of incidence rates in different sites (ICD.9) of cancer. Average Annual Age-Adjusted (world population) incidence rates by site (ICD.9) is used to estimate the parameters by linear regression method. Time trends analysis of 8 years from 1988 to 1995 in Delhi for age-adjusted, truncated (35-64 years) incidence rates to world population and crude incidence rate by site (ICD.9) did not reveal statistically significant decrease or increase in the incidence.

Langerhans cell histiocytosis infiltration in cerebrospinal fluid: a case report

Langerhans cell histiocytosis (LCH) is a disease of unknown etiology characterized by a proliferation of histiocytic cells resembling the integumentary cells bearing the name of Langerhans cells. LCH can be unifocal or multifocal, with one- or many-organ involvement. We present a case of LCH diagnosed in the cerebrospinal fluid of a patient with generalized lymphadenopathy and central nervous system involvement.

Neurogenic cyst of ovary: an unusual massive monodermal teratoma

An unusual massive benign cystic monodermal teratoma of the ovary in a 14-year-old girl is reported. The multilocular cyst measured 80 x 70 x 80 cm and contained 23 l of fluid. The cyst wall composed of purely mature central nervous system tissue with a prominent microvasculature resting on a thin rim of ovarian cortical tissue. Immunohistochemical stains supported the diagnosis. To the best of our knowledge only one such case has been described in the literature.

Hashimoto's thyroiditis: countrywide screening of goitrous healthy young girls in postiodization phase in India

Countrywide salt iodization, to prevent nutritional iodine deficiency, has been achieved in India recently. The current study was planned to evaluate the prevalence of goiter and thyroid autoimmunity and assess thyroid functional status in a cohort of 6283 healthy schoolgirls from different parts of the country in the postiodization phase. Goitrous girls (n = 1810; 28% of subjects) were investigated for serum T4 and TSH, antithyroid microsomal antibody (TMA) and antithyroglobulin antibody (TGA), urinary iodine excretion, and cytomorphology by fine-needle aspiration cytology (FNAC). FNAC carried out successfully in 764 goitrous girls revealed juvenile autoimmune thyroiditis (JAT) in 58 (7.5%), which included Hashimoto's thyroiditis in 43 (5.6%) and focal lymphocytic thyroiditis in 15 (1.9%). TMA and TGA estimated in 722 goitrous girls detected significantly positive titers of TMA (> or =1:1600) and TGA (> or =1:160) in 52 (7.2%) and 4 (0.55%) girls, respectively. Only 29 (67.4%) girls with Hashimoto's thyroiditis were TMA positive. In patients with FNAC-proven JAT, overt clinical and biochemical hypothyroidism was seen in three (6.5%) and subclinical hypothyroidism in seven (15%). Subclinical hyperthyroidism was detected in 5.1% cases of JAT, and none had overt hyperthyroidism. No definite correlation was seen between urinary iodine excretion and thyroid autoimmunity.

Phyllodes tumor of the breast. A cytohistologic study of 80 cases

OBJECTIVE

To study the cytologic features of phyllodes tumor (PT) of the breast and determine the accuracy of their subclassification in fine needle aspirates.

STUDY DESIGN

Eighty cases of histologically diagnosed PT between 1982 and 1997 with a previous fine needle aspiration (FNA) were evaluated. The FNA smears of each case were reviewed without knowledge of the initial cytologic diagnosis and subclassified into benign, borderline or malignant PT.

RESULTS

Benign PTs were characterized by a dimorphic mixture of stromal and epithelial cells. The stromal fragments showed mild to moderate cellularity with absent to minimal pleomorphism and no mitosis. There were occasional, if any, single stromal cells. Borderline PTs had stromal fragments with moderately cellular stroma exhibiting moderate pleomorphism. Two additional features were the presence of single stromal cells and an occasional mitosis in the stromal fragments/single cells. Aspirates from malignant PT were very cellular, with a high stromal/epithelial ratio and marked stromal cellularity. The stromal cells were highly pleomorphic, with frequent mitosis and atypical single stromal cells in the background. Fifty-seven of the 80 histologically documented cases (71.3%) were diagnosed as PT on FNA (40 benign, 10 borderline and 7 malignant). In 81% (46 of 57 PTs), good cytohistologic correlation (32 benign, 8 borderline and 6 malignant) was observed. In another eight cases, one grade differentiation between cytologic and histologic grade was observed. Six of the nine malignant PTs on histology were correctly subclassified on cytology. There were one false positive and two false negative cases.

CONCLUSION

Cytologic diagnosis and grading of PT on FNA is possible. Special care should be undertaken in interpreting phyllodes fragments, cellularity of stroma, pleomorphism and mitosis. Single stromal cells are also important morphologic criteria for subclassification. Multiple-site aspiration is advisable to avoid diagnostic errors.

Diabetic autonomic neuropathy causing gall bladder dysfunction

OBJECTIVE

The objective of the study was to study gall bladder volume in fasting and 45 minutes post-prandial, by real time ultrasound in healthy controls and diabetic patients with and without autonomic neuropathy and to compare them.

METHOD

Age, Sex and body mass index (BMI) matched 50 healthy subjects and 10 patients with insulin dependent diabetes mellitus and 40 patients with noninsulin dependent diabetes mellitus were evaluated according to National diabetes Data Group of National Institute of Health (1979) criteria: 1. Fasting (overnight) venous plasma glucose concentration of > 140 mg/dl on two separate occasions. 2. Following ingestion of 75 gms of glucose, venous plasma glucose concentration of > 200 mg/dl at second hour and at one other occasion during two hour test. Autonomic neuropathy was assessed by the presence of symptoms like dysphagia, abdominal fullness, nausea, vomiting, diarrhea +/- nocturnal, faecal incontinence or constipation, dysuria, urinary incontinence, the gustatory sweating, impotence etc. and were confirmed by standing test for orthostatic hypotension, hand grip test, Valsalva test and deep breaths test.

RESULT

The study showed that: 1. Patients of diabetes mellitus had statistically significant larger fasting gall bladder volumes and these values were highly significant amongst patients with autonomic neuropathy. 2. Patients of diabetes mellitus and statistically significant larger post fatty meal gall bladder volume and these values were highly significant in patients with autonomic neuropathy.

CONCLUSIONS

We therefore conclude that impaired gall bladder contraction was found amongst patients of diabetes mellitus with autonomic neuropathy. The mechanism responsible for cholecystoparesis is attributed to vagal neuropathy. Incomplete gall bladder emptying leads to sequestration of cholesterol and nidus formation. Therefore gall bladder functions should be evaluated routinely in such patients and early intervention is recommended.

Tuberculosis of the breast. A cytomorphologic study

OBJECTIVE

Extrapulmonary tuberculosis occurring in the breast is rare despite the fact that 1-2 billion people worldwide suffer from tuberculosis. The aim of this study was to examine the cytomorphology of breast tuberculosis (breast TB) and to review the literature.

STUDY DESIGN

Old records from the Cytopathology Laboratory, All India Institute of Medical Sciences, were reviewed from January 1980 to December 1998. Cases of breast TB where a cytologic diagnosis was rendered or a histologic diagnosis with prior fine needle aspiration cytology (FNAC) was available were selected. These slides were reviewed for determining the cytologic findings.

RESULTS

One hundred sixty cases of breast TB were included in the study. Six males and 154 females with a clinical suspicion of carcinoma had undergone FNA that was reported as TB. The majority of the patients (111) were in the reproductive age group, 21-40 years. Of the 160 cases, 118 (73.75%) had cytomorphology diagnostic of tuberculosis--epithelioid cell granulomas with caseous necrosis. Eleven of the remaining 42 cases were positive for acid-fast bacilli (AFB) on Ziehl-Neelsen (ZN) staining, while 31 cases were confirmed to be tubercular on histology. ZN staining was done in 44 cases, and AFB were demonstrated in only 38.6% of cases.

CONCLUSION

Up to 73% of breast TB can be confidently diagnosed when both epithelioid cell granulomas and necrosis are present. Also, the possibility that a woman in the reproductive age group who presents with a palpable lump in the breast may have tuberculosis must be kept in mind, especially as the incidence of breast TB may increase in the future with the global spread of AIDS.

Evaluation of endoscopy-based diagnostic methods for the detection of Helicobacter pylori

BACKGROUND

Helicobacter pylori is an etiological factor in duodenal ulcer. Few studies have objectively assessed the accuracy of diagnostic methods for the detection of H. pylori.

METHODS

The sensitivity and specificity of histology, touch smear, rapid urease test (RUT) and brush cytology of endoscopic antral biopsy from patients with duodenal ulcer were compared. Forty-nine patients were evaluated before, and 34 after, eradication therapy. Each time, sampling was done for all 4 tests. The infection status for each sample was established by a positive concordance of results of three of four tests.

RESULTS

The highest degree of agreement was between RUT and cytology (kappa = 0.69). Brush cytology (100%) followed by RUT (94.5%) were the most sensitive tests. Histology had the highest specificity (89.3%). A combination of RUT or brush cytology with histology had the maximum chance of detecting H. pylori. As single tests, brush cytology and touch smear had high diagnostic accuracies with a Youdin J value of 1.79 and 1.78, respectively.

CONCLUSION

The best method for diagnosis of H. pylori is a combination of the rapid urease test or brush cytology with histology. Brush cytology or touch smear are diagnostic tests of choice if a single test is desired.