Time to revisit the purported link of leprosy reactions with infective triggers: An unnecessary economic burden for patients

Existing literature on factors triggering leprosy reactions is based only on case reports and case series, and thus probably gives a biased view. We undertook a case-control study to investigate such purported trigger factors in 42 leprosy reaction patients and 40 non-reactional controls, and the cost of investigations required for the same. Detailed history, clinical evaluation and investigations for triggers were carried out. Infections (typhoid, dental caries) were the most common triggers found, followed by pregnancy. Trigger factors were commoner in the type 2 reaction (T2R) group compared to type 1 (T1R) reaction group. There was however no statistical difference between the two groups. The average estimated cost of investigations was higher in the reactional group and this difference was statistically significant. Hence, except for essential investigations required for initiating steroids, an extensive battery of investigations is unjustified unless the medical history suggests a definitive infective trigger.

Trans-epidermal extrusion of lepra bacilli from histoid lesions: a risk of continued transmission

The current goal of Zero Leprosy focuses on the interruption of the transmission of infection within endemic regions. While the role of the skin in the transmission dynamics of leprosy has not been clearly delineated, recent research on the environmental presence of lepra bacilli brings this aspect back into focus. We present a case of lepromatous leprosy with perforated-appearing histoid lesions on the palms and soles, demonstrating the presence of lepra bacilli throughout the epidermis.

Primary leiomyosarcoma with osteosarcomatous differentiation of the breast

Primary leiomyosarcoma with osteosarcomatous differentiation of the breast is an uncommon entity. We present the case of a 37-year-old female who presented with a lump in the breast and pulmonary lesions on PET-CT, for which she underwent a toilet mastectomy. Histopathological examination revealed a tumor with cells arranged in sheets. These tumor cells had moderate eosinophilic cytoplasm, highly pleomorphic, irregular hyperchromatic nuclei, coarse chromatin, and prominent nucleoli. Areas with spindle-cell morphology were noted. Osteoid was seen intermingling with the tumor along with numerous osteoclast-like multinucleate giant cells. A wide panel of Immunohistochemistry was applied, and Desmin, h-Caldesmon, SMA, and Vimentin were positive. The patient died 3 months post-surgery and had a recurrence at the surgical site.

Mesenteric cystic lymphangioma in adults: a rare entity presenting as acute abdomen - a report of two cases

Lymphangiomas are rare benign tumors that mainly involve the head and neck region in pediatric patients. Lymphangiomas of the small bowel mesentery in adults are rarer. We present two cases of mesenteric lymphangioma with acute abdominal pain on presentation. Case 1: A 38-year-old female presented with abdominal pain, vomiting, fever, and difficult evacuation. On abdominal examination, she had an ill-defined, tender lump, and radiological findings raised a possibility of perforation peritonitis. Thus, exploratory laparotomy was planned. Per-operatively, a mesenteric mass was found, which, on histopathological evaluation, was found to be a mesenteric lymphangioma involving the bowel. Case 2: A 27-year-old male presented with abdominal pain and difficult evacuation. Radiological evaluation revealed a multilobulated lesion involving the mesentery and with differential diagnoses of mesenteric fibromatoses and inflammatory pseudotumor. Histopathological assessment of the resected mass revealed a lymphangioma that was limited to the mesentery. Owing to their rarity and non-specific presentation, mesenteric lymphangiomas are often misdiagnosed on clinical examination and imaging. Thus, histopathological examination is the gold standard to reach a definitive diagnosis.

Analysis of Histomorphologic/Molecular Association and Immune Checkpoint Regulators in Epithelioid Glioblastoma and Pleomorphic Xanthoastrocytoma: Are These Tumors Potential Candidates for Immune Checkpoint Blockade?

Accurate diagnosis of Epithelioid glioblastoma (eGB) and pleomorphic xanthoastrocytoma (PXA) is sometimes challenging owing to overlapping histologic and genetic features. There are limited reports on the immune profile of these tumors. In this study, we assessed 21 PXA [15 PXA Grade 2 (PXAG2); 6 PXA Grade 3 (PXAG3)] and 14 eGB for their histopathological and molecular association. Further, their immune profile was compared with GB, IDH1 wild-type (wt) (n-18). Morphologically, PXAG2 mostly differed from eGB; however, it was occasionally difficult to differentiate PXAG3 from eGB due to their epithelioid pattern and less obvious degenerative features. PXAG2 showed predominantly diffuse, whereas variable positivity for epithelial and glial markers was seen in PXAG3 and eGB. All cases showed retained nuclear ATRX and INI-1 . H3K27M or IDH1 mutation was seen in none. P53 mutation was more common in eGB, followed by PXAG3, and least common in PXAG2. BRAF V600E mutation was observed in 66.67% PXAG2, 33.33% PXAG3, and 50% eGB, with 100% concordance between immunohistochemistry (IHC) and sequencing. Thirty-six percent eGB, 33% PXAG3, and 61% PXAG2 harbored CDKN2A homozygous deletion. EGFR amplification was observed in 14% eGB and 66% of GB, IDH wt. PDL1 and CTLA-4 expression was higher in eGB (71.4% and 57.1%), PXAG3 (66.6% and100%), and PXAG2 (60% & 66.7%) as compared with GB, IDH wt (38.8% and 16.7%). Tumor-infiltrating lymphocytes were also observed in a majority of eGB and PXA (90% to 100%) in contrast to GB, IDH wt (66%). This analysis highlights the homogenous molecular and immune profile of eGB and PXA, suggesting the possibility that histologically and molecularly, these two entities represent 2 ends of a continuous spectrum with PXAG3 lying in between. Higher upregulation of PDL1, CTLA-4, and increased tumor infiltrating lymphocytes in these tumors as compared with GB, IDH wt suggests potential candidature for immunotherapy.

Role of Permeability Surface Area Product in Grading of Brain Gliomas using CT Perfusion

Purpose  The aim of this study was to evaluate the role of permeability surface area product in grading brain gliomas using computed tomography (CT) perfusion Materials and Methods  CT perfusion was performed on 33 patients with brain glioma diagnosed on magnetic resonance imaging. Of these, 19 had high-grade glioma and 14 had low-grade glioma on histopathological follow-up. CT perfusion values were obtained and first compared between the tumor region and normal brain parenchyma. Then the relative values of perfusion parameters were compared between high- and low-grade gliomas. Cut-off values, sensitivity, specificity, and strength of agreement for each parameter were calculated and compared subsequently. A conjoint factor (permeability surface area product + cerebral blood volume) was also evaluated since permeability surface area product and cerebral blood volume are considered complimentary factors for tumor vascularity. Results  All five perfusion parameters namely permeability surface area product, cerebral blood volume, cerebral blood flow, mean transit time, and time to peak were found significantly higher in the tumor region than normal brain parenchyma. Among these perfusion parameters, only relative permeability surface area product and relative cerebral blood volume were found significant in differentiating high- and low-grade glioma. Moreover, relative permeability surface area product was significantly better than all other perfusion parameters with highest sensitivity and specificity (97.74 and 100%, respectively, at a cut-off of 9.0065). Relative permeability surface area product had a very good agreement with the histopathology grade. The conjoint factor did not yield any significant diagnostic advantage over permeability surface area product. Conclusion  Relative permeability surface area product and relative cerebral blood volume were helpful in differentiating high- and low-grade glioma; however, relative permeability surface area product was significantly better than all other perfusion parameters. Grading brain gliomas using relative permeability surface area product can add crucial value in their management and prognostication; hence, it should be evaluated in the routine CT perfusion imaging protocol.

A case-control study addressing the population of epidermal and dermal inflammatory infiltrate including neural milieu in primary prurigo nodularis using S-100 and toluidine blue stain and its therapeutic implications

BACKGROUND

The pathogenesis of prurigo nodularis (PN) is considered to be multifactorial, with numerous cells and cytokines confabulating to produce an aberrant immune response.

METHODS

A cross-sectional observational study was done in cases of untreated primary prurigo nodularis cases with histopathological assessment in 49 cases from lesional and nonlesional skin with assessment of epidermal and dermal changes, dermal infiltrate, S-100 and toluidine blue staining to assess the expression of nerve and mast cells.

RESULTS

The most common histological changes seen in lesional skin were hyperkeratosis (98%), irregular hyperplasia (69.4%), hypergranulosis (69.4%), subepidermal clefting (6%), vertical collagen bundles (51.0%), and dermal fibrosis (48.9%). Chronic inflammatory infiltrate was seen in all cases (100%) predominantly of lymphocytes (100%) followed by eosinophils (18.4%), plasma cells (8.2%), and neutrophils (2.0%). There was a marked increase in the expression of S-100 (6.92 ± 3.40 vs. 3.94 ± 2.15, P < 0.001) and toluidine blue (4.99 ± 4.47 vs. 1.22 ± 1.28, P < 0.001) in the lesional skin as compared to the nonlesional skin.

CONCLUSION

We can infer that the epidermal and dermal pathology in PN is related to the infiltrate of lymphocytes, mast cells, and neural hyperplasia which perpetuate the pathogenesis by triggering the itch-inflammation cycle. Thus, apart from immunosuppressive agents that target lymphocytes and their cytokines, therapy targeted at mast cells and neural proliferation may be needed to treat prurigo nodularis.

Gastric outlet obstruction as an unusual presentation of metastatic breast carcinoma

Gastrointestinal (GI) metastasis from breast carcinoma is a rare occurrence. If metastasis occurs to the stomach/duodenum, it can present with symptoms of gastric outlet obstruction (GOO). Hence, it clinically mimics a variety of benign as well as malignant causes of GOO, including primary malignancy. GI metastasis from breast carcinoma occurs several years after the primary diagnosis and sometimes may be the first presenting symptom. If clinical records are not available, it may be misdiagnosed as poorly differentiated adenocarcinoma on biopsy. A high index of suspicion, subtle histologic clues, and appropriate immunohistochemistry helps in clinching the right diagnosis. Hereby, we report the case of a 55-year-old female who presented with metastasis to the duodenum 8 years post mastectomy which mimicked a primary ampullary/periampullary tumor.

Rare cause of intussusception in a young male with a new possible etiology - A case report

INTRODUCTION

Inflammatory Fibroid Polyp (IFP) is a rare benign tumor of the gastrointestinal tract with no proven etiology. IFPs may sometimes produce complications like intussusception when present in the small bowel. This is a case report of a patient with an established diagnosis of inflammatory fibroid polyp with abdominal tuberculosis. Such co-existence has not been reported yet in literature.

CASE PRESENTATION

In this case report we see a 22-year-old gentleman presenting with a 10-day history of generalized abdominal pain which then progressed to obstipation. X-ray abdomen findings were consistent with small bowel obstruction. Computerized tomography imaging revealed the presence of a Jejuno-ileal intussusception. The patient was taken up for emergency laparotomy and he underwent resection of the intussuscepted segment with a polyp found as the lead point accompanied by dense bowel adhesions. Histopathological examination revealed it to be a Benign Fibro epithelial Polyp. Histopathology of the resected bowel segment and mesenteric lymph node also revealed findings confirmatory of abdominal tuberculosis. This may be a possible new etiology of the fibro epithelial polyp and this co-existence has never been reported before in literature.

CONCLUSION

Tuberculosis may be a possible inciting factor for the development of benign fibro epithelial polyp in the small bowel which may in turn lead to complications such as small bowel intussusception warranting need for surgical intervention.

Cancer Stem Cell Markers - CD133 and CD44 - in Paediatric Solid Tumours: A Study of Immunophenotypic Expression and Correlation with Clinicopathological Parameters

Paediatric solid tumours account for about 30% of all the paediatric malignancies. They differ from adult tumours in various aspects like incidence, etiopathogenesis, biology, response rate and outcome. Immunohistochemical markers such as CD133, CD44, CD24, CD90, CD34, CD117, CD20 and ALDH 1 (aldehyde dehydrogenase-1) have been proposed to detect cancer stem cells in tumours. CD133 is a marker of tumour initiating cells in many human cancers and therefore, it may be possible to develop future therapies by targeting cancer stem cells via this marker. CD44 is a transmembrane glycoprotein also known as homing cell adhesion molecule. It is a multifunctional cell-adhesion molecule and plays an important role in cell-cell interaction, lymphocyte homing, tumour progression and metastasis. In the present study, we assessed the expression of CD133 and CD44 in paediatric solid tumours and correlated their expression with clinico-pathological parameters in paediatric solid tumours. This study was a cross-sectional observational study conducted in the department of pathology at a tertiary care centre. All the histologically diagnosed paediatric solid tumours for a period of one year and four months were retrieved from the archives. The cases were reviewed and included in the study after obtaining informed consent. Immunohistochemistry using the monoclonal antibodies for CD133 and CD44 was performed in the representative tissue sections of all the cases. Immuno-scores were assessed, and the results were compared using Pearson's chi-square test. The present study included 50 cases of paediatric solid tumours. The majority (34%) of the patients were in the age group of less than 5 years, with male preponderance (M:F = 2.3:1). The tumours included were Wilms tumour, yolk sac tumour, rhabdomyosarcoma, lymphoma, neuroblastoma, hepatoblastoma, gastrointestinal stromal tumour (GIST), medulloblastomas, pilocytic astrocytomas, ependymomas and glioblastoma. On immunohistochemical analysis, high expression of CD133 and CD44 was found. A significant association between the expression of CD133 and various tumour groups was observed (p = 0.004). However, CD44 showed variable expression in different tumour groups. Both CD133 and CD44 identified cancer stem cell in paediatric solid tumours. A further validation is warranted to investigate their potential role in therapy and prognosis.

Relapsing donovanosis rhyming with unexplained decline in CD4 count in a person living with HIV/AIDS: Long-term follow up and therapeutic outcome

Donovanosis is a chronic genital ulcerative disease caused by the intracellular Gram-negative bacterium Klebsiella granulomatis, reported more frequently in people living with HIV/AIDS (PLHA). Here we present a case of relapsing donovanosis in a PLHA on second line antiretroviral therapy who had episodes of transient unexplained decrease in CD4 counts associated with rapid growth of the lesion and non-responsiveness to treatment followed by clinical resolution coinciding with recovery of the CD4 count.

Primary malignant melanoma of prostate: a case report

While primary genitourinary melanomas account for less than 1% of all melanoma cases, prostatic melanoma is extremely uncommon. These patients are challenging to identify, with a dismal prognosis. We reported a 52-year-old male patient who presented with lower urinary tract symptoms in the last one and a half months. The patient underwent Holmium laser enucleation of the prostate, and the histopathology result of the resected specimen showed prostatic melanoma. Investigations for systemic melanoma evaluation were negative, and the patient underwent radical cystoprostatectomy, urethrectomy, and bilateral lymph node dissection. The patient refused chemotherapy, developed lung metastasis shortly after surgery at three months, and succumbed to the metastatic disease with overall survival of 6 months. In conclusion, primary malignant melanoma of the prostate is a very rare disease. The most logical therapeutic strategy is aggressive surgical resection, followed immediately by adjuvant therapy.

An Unusual Case of High-Grade Non-Hodgkin Lymphoma Masquerading as Acute Pyelonephritis with Acute Kidney Injury

Renal involvement in non-Hodgkin lymphoma (NHL) has myriad of morphological features. We discuss an unusual case who presented as acute pyelonephritis (leucocytosis and acute kidney injury), ovarian mass and compressive myelopathy finally diagnosed as Non Hodgkins Lymphoma.

Psoriasiform Drug Eruption to Finasteride: Uncommon Side Effect of a Commonly Used Drug

Finasteride, a 5-α reductase inhibitor, is generally well tolerated on long-term use and cutaneous adverse events have rarely been observed with the drug. We present the case of a 25-year-old male who developed an extensive psoriasiform eruption within a week of starting finasteride 1 mg for androgenetic alopecia.

Pleomorphic Adenoma with Extensive Squamous and Adipocytic Metaplasia Mimicking as Low Grade Mucoepidermoid Carcinoma on FNAC

Pleomorphic adenoma (PA) is the most common salivary gland tumor, accounting for 54-76% of all salivary gland neoplasms. Extensive squamous metaplasia in PA can be mistaken for malignancy, including low grade mucoepidermoid carcinoma and squamous cell carcinoma. Here, we present an unusual case of PA with extensive squamous metaplasia and keratin cyst formations in a minor salivary gland, and discuss its microscopic features, including the immunohistochemical characteristics, and differential diagnosis of this uncommon presentation.

A real-world study of low-dose thalidomide in severe erythema nodosum leprosum highlighting its mechanistic rationale in a resource-constrained target population

BACKGROUND

Corticosteroids remain the main therapy in erythema nodosum leprosum (ENL), and long-term usage in chronic or recurrent ENL is a cause of significant morbidity and mortality. Thalidomide exerts dramatic effect in controlling ENL and helps reduce the dose of steroids, but the cost is a hindrance to its usage.

METHODS

Patients of ENL (steroid naïve and steroid-dependent) were recruited over a 1-year period. An escalating dose of low-dose thalidomide with a reducing dose of prednisolone was titrated depending on the control of disease activity. The primary aim was to reduce the dose of steroids to the lowest effective dose, and the secondary aim was to stop.

RESULTS

Sixteen patients of ENL were studied (mean duration of ENL 22.1 months, 15 severe ENL), and a majority (11/16, 68%) were on steroids with a mean duration of 11.27 months. All patients had steroid-related side effects (cushingoid habitus 81.8%, weight gain 54.5%, diabetes mellitus 9%, hyperlipidemia 18.18%, cataract 18.1%, osteoporosis 36.3%, striae 36.3%, acneiform eruptions 18.1%, and myopathy 9%). Steroids could be tapered in a majority of patients (n = 9) within 3 months (mean 2.44 months) with a low dose of thalidomide (25-150 mg/day, mean 78.3 mg) achieving a significant reduction in prednisolone dose (33.16 mg at baseline; 4.28 mg at 3 months, P < 0.05). Steroids could be stopped in 92% of patients by 3.03 months, and both drugs could be stopped in 80% of cases by 5.83 months.

CONCLUSION

The rapid and effective control of ENL with low-dose thalidomide in our series is comparable to the historical efficacy of high-dose thalidomide regimens, making it an affordable therapy in resource-constrained settings and an excellent steroid-sparing agent. The rapid onset of disease control is likely attributable to its action via neutrophils.

Medullary carcinoma of jejunum presenting as perforation peritonitis: A case report

Small intestinal medullary carcinoma (MC) is a newly recognized subclass of small intestinal carcinomas and is an exceptional entity for this site. A search of the literature for similar cases arising in the small intestine revealed only six previously reported cases. Here we present a case of MC arising in the jejunum of a 65-year-old male. The patient presented to the emergency with features of perforation peritonitis with liver metastasis and no known predisposing factors like inflammatory bowel disease and celiac disease. Studies conducted on this tumor's colonic counterpart have shown microsatellite instability (MSI) and B-type Raf kinase (BRAF) mutations; however, few exceptions are known. Also, this subtype of carcinoma is known to have a better prognosis than its other histological subtypes.

Case Report: Chemoradiation with Paclitaxel and Carboplatin Unveiling Leprosy Type 1 Downgrading Reaction

Type 1 lepra reaction (T1R) is a major complication seen in nonpolar forms of leprosy and leads to significant morbidity. The classification of T1R as up and downgrading, based on previously defined histopathological criteria (by Ridley), has therapeutic and prognostic implications. The trigger factors for these reactions are poorly described, especially in case of downgrading T1R and we describe a case of leprosy reaction that was possibly triggered by chemoradiation and elucidate the possible mechanism.

Alveolar soft part sarcoma : a case report and review of literature

Alveolar soft part sarcoma (ASPS) is a rarely diagnosed tumor of deep soft tissue origin. This tumor is more common in adolescents and young adults and has a slowly progressive clinical course which often leads to delayed diagnosis and treatment. It is highly vascular, can be confused with other entities like hemangiomas and arteriovenous malformations clinically and radiologically and thus challenging to report on fine needle aspiration cytology (FNAC). Diagnosing the tumor is difficult on cytology, so knowledge of this entity and the differentials with its morphological mimics on cytology is required for timely diagnosis and early management of the patient. We report a case of ASPS in a young female who presented with a large painless swelling in the thigh, diagnosed on cytology combined with ancillary testing with immunohistochemical markers.

Intestinal mucormycosis in a patient with COVID-19: A case report

The novel coronavirus disease (COVID-19) has spread to all the continents posing a serious threat to global health. It can present with myriad symptoms and complications including susceptibility to fungal co-infections. We hereby describe a case of mucormycosis in a 17 year old COVID-19 positive female with no known comorbidities presenting with abdominal pain and distention and ultimately developing intestinal perforation. Early identication of the symptoms is essential to make a correct and early diagnosis to prevent complications.

Granulomatous prostatitis: A clinico-pathological series of 27 cases

Objectives:

This study aimed to assess the incidence and discern the histomorphological spectrum of granulomatous prostatitis.

Methods:

A retrospective analysis of histopathological records of 1773 prostatic specimens received in the pathology department was done over a period of seven years. All histologically proven cases of granulomatous prostatitis were retrieved, the relevant clinical data were collected from patient records and the lesions were categorized accordingly.

Results:

Out of 1773 cases, 27 cases of granulomatous prostatitis were identified. The age range of these patients was between 50 and 89 years. Among the patients, non-specific granulomatous prostatitis (NSGP) was the most common followed by tubercular prostatitis, post-surgical prostatitis and xanthogranulomatous prostatitis. Three cases of post-surgical prostatitis were associated with malignancy. Serum prostate-specific antigen (PSA) levels ranged between 0.8 and 20.94 ng/mL (median 10.78 ng/mL). The diagnosis was made by histopathological examination of transrectal ultrasound (TRUS)-guided core biopsies, Trucut biopsies, transuretheral resection of prostate chips, prostatectomy and cystoprostatectomy specimens.

Conclusion:

In the present study, the incidence of granulomatous prostatitis was 1.5%. The patients usually present as hard nodules on digital rectal examination along with raised serum PSA levels. Carcinoma or benign prostatic hyperplasia was kept as a clinical diagnosis in these cases. Since the diagnosis of granulomatous prostatitis is made on histopathological examination only, meticulous histomorphological assessment is therefore required to reach a definitive diagnosis of granulomatous prostatitis.

Gene expression based profiling of pleomorphic xanthoastrocytoma highlights two prognostic subgroups

BACKGROUND

Pleomorphic xanthoastrocytomas (PXAs) are rare, accounting for less than 1% of astrocytomas, and commonly occur in young patients. The majority are WHO grade II. A fraction of tumors that present or recur with malignant change are classified as anaplastic (APXA, grade III). Limited data are available on their molecular characteristics.

METHODOLOGY

Genome-wide expression profiling of 14 PXA and 6 APXAs was performed by microarray. Among differentially expressed genes (DEGs), Cyclin-Dependent Kinase 14 (CDK14) and Mitochondrial Fission Process 1 (MTFP1) were validated by qRT PCR.

RESULT

Unsupervised hierarchical clustering revealed two distinct molecular clusters (Cluster 1: 10 PXA, 3 APXA and Cluster 2: 4 PXA, 3 APXA) with grade II and III tumors distributed in both highlighting molecular heterogeneity within the same grade. There was an insignificant difference in age, sex, immunohistochemical profile, frequency of BRAF mutation, or CDKN2A deletion among the two clusters. Significantly, worse progression-free survival was observed in cluster 2 (P=0.003). mRNA profiling-based prediction of recurrence was superior to and independent of histological grade, BRAF mutation, or CDKN2A deletion status. A total of 10 upregulated and 418 downregulated genes were identified between the PXA clusters. qRT-PCR validation of CDK14 (upregulated in cluster 2) and MTFP1 (upregulated in cluster 1) showed strong concordance with expression array data.

CONCLUSION

This is the first comprehensive study highlighting distinct molecular subgroups of PXA. The differentially expressed genes between two clusters may potentially be used for developing histology independent classification schemes, prognostication and may serve as prospective therapeutic targets for PXA patients.

Extracranial Schwannomas of the Head and Neck: A Literature Review and Audit of Diagnosed Cases Over a Period of Eight Years

Schwannoma is a benign, slow growing, usually solitary and encapsulated tumor derived from Schwann cells of the nerve sheath. Schwannomas can be divided into central, or intraosseous, and peripheral lesions. The etiology is unknown, but it is postulated that lesions arise by the proliferation of Schwann cells at one point inside the perineurium. Schwannomas may mimic other diseases of the head and neck, such as infection, tumor or metastasis. Extracranial schwannomas are rare; in this study we review a series of 22 cases of schwannomas originating in the head and neck region over a period of eight years. All tumors were benign and well-encapsulated. Tumor size ranged from 0.5 to 9 cm. The age range of patients studied was 15-74 years with a mean age of 35 years and a male predilection (M:F, 2.6:1)was noted. Four cases of schwannomas occurred in the tongue (18.18%) and lower lip (18.18%), three in the nasal cavity (13.64%), two each (9.09%) in the buccal mucosa, parapharyngeal space (9.09%), and eyebrow (9.09%), and one each in the upper lip (4.55%), lateral canthus of the eye (4.55%), intraorbital region (4.55%), submandibular gland (4.55%), and ear (4.55%). Schwannomas can present in a wide variety of sites within the head and neck. The tumor is benign and tend to be asymptomatic for long periods of time. Histopathology is the gold standard for diagnosis. Our study describes the clinicopathologic features of extracranial head and neck schwannomas, highlights the histopathologic features, and discusses pertinent findings with correlation to the present literature. It is important that both clinicians and pathologists be familiar with the uncommon sites of occurrence and the potential pitfalls associated with the diagnosis and management of these tumors.

Myocardial bridging - Sudden unexpected death of a young girl: A case report

Myocardial bridging (MB) is a relatively uncommon congenital anomaly where a segment of the coronary artery dips inside the myocardium and takes a tunneled course under a bridge of the myocardium. This leads to the compression of the coronary artery during systole resulting in hemodynamic changes and their clinical manifestations. However, it is an incidental finding but can present with multiple complications like myocardial ischemia, infarction, and sudden death, primarily when associated with other risk factors like left ventricular hypertrophy of the heart. Therefore, a careful examination of the heart is essential for evaluating the clinical significance of the MB. Here, we presented a case of a 30-year-old young female who had a sudden death, and her histological examination of the heart showed MB of left anterior descending coronary artery (LAD).

Omental desmoplastic small round cell tumor with metastasis

Desmoplastic small round cell tumor (DSRCT) is a very rare diagnosis with about 200 cases reported in literature. DSRCT is a recently described histopathological entity by Gerald and Rosai in 1989. Abdominopelvic cavity especially peritoneum is the most common site. We report a case of a huge omental DSRCT with lymph node metastasis which was initially misdiagnosed as gastrointestinal stromal tumor on radiology. A 26-year-old male presented with complaints of upper abdominal swelling associated with constant dull pain. On examination there was a large 15 × 12 cm intraabdominal mass in the epigastric and umbilical region. Imaging studies were suggestive of neoplastic mesenchymal etiology. Image-guided fine-needle aspiration cytology (FNAC) was suggestive of mesenchymal neoplastic etiology. On laparotomy, there was a huge 20 × 15 cm mass arising from omentum with multiple omental and mesenteric seedlings and mesenteric, peripancreatic and perigastric lymphadenopathy. The patient underwent debulking surgery with uneventful post-operative recovery. Histopathological examination with immunohistochemistry revealed a diagnosis of DSRCT of omentum and small bowel mesentery with lymph node metastasis. Patient then received adjuvant chemotherapy with multiple chemotherapeutic drugs as per P6 protocol and has stable disease at 1 year follow up.

Rare metastatic sites of renal cell carcinoma: a case series

Renal Cell Carcinoma (RCC) is a lethal cancer with a propensity for wide metastasis. The patterns of metastases are not clearly defined, and patients can present with metastasis to unusual sites at the time of diagnosis of the primary tumor or years after radical nephrectomy. Individual diagnostic and surgical approaches are needed to achieve complete resection with disease-free margins, even in the presence of unusual metastatic sites, multifocality, or history of previous metastasectomy. This provides palliation for symptoms and an opportunity for meaningful disease-free and overall survival. Here we present five cases of RCC with metastasis to unusual sites (scalp, jaw, forearm, parotid, breast, and skeletal muscle). Patients were treated with cytoreductive nephrectomy and/or metastasectomy wherever feasible and/or targeted therapy. In conclusion, a high index of suspicion and accurate diagnosis is important as metastasis to unusual sites presents with atypical manifestations and may masquerade as local pathology, misleading the clinician and directly affecting prognosis and survival.

Invasive cystic hypersecretory carcinoma of the breast

Cystic hypersecretory carcinoma (CHC) of the breast is a rare variant of ductal carcinoma, characterized by variably sized cysts lined by micropapillary fronds to proliferative pseudostratified columnar epithelium. It includes a spectrum of morphological features ranging from clearly benign cystic hypersecretory hyperplasia (CHH), CHH with atypia to invasive CHC. Only 20 cases of invasive CHC have been reported to date. We report a case of a 49-year-old female who presented with a palpable breast lump and nipple discharge. Gross examination showed variable-sized cysts lined by solid grey white tumors. On microscopic examination, cysts were lined by micropapillary fronds with eosinophilic colloid-like secretion with a focus of invasion. A diagnosis of invasive CHC was made. Since there are limited case reports, our understanding of its biological behavior, prognostic factors, and genetic basis is limited.

Camalote sign in intraventricular hydatid cyst: A rare presentation of uncommon disease

Background:

Hydatid cyst is a common zoonotic condition in endemic areas. Intraventricular hydatid cyst is a rare entity with less than 50 cases published in literature. Floating water lily sign (also called Camalote sign) is very rare in intracranial hydatid cysts. Only a single case report of this sign exists in literature in intraventricular hydatidosis suggesting rupture of hydatid cyst leading to CSF dissemination and frequent poor outcome.

Case Description:

This case report describes the successful management of a 5-year-old child who presented with signs and symptoms of raised intracranial pressure due to large intraventricular hydatid cyst in the right frontal horn, and magnetic resonanace imaging of the brain showed hydatid cyst with typical camalote sign.

Conclusion:

Although very rare, the presence of camalote sign in intraventricular cysts is very categorical in establishing preoperative diagnosis of hydatid cyst, especially in endemic areas.

Endometrial Serous Carcinoma Arising From Adenomyosis: A Clinico-Pathological Insight

Objective: Endometrial cancer (EC) is the most commonly diagnosed malignancy and has the second-highest mortality rate among gynecological cancers. Adenomyosis is well-known for abnormal uterine bleeding and is a widely reported entity; however, an EC arising from the adenomyosis is a rare event; even rarer is the occurrence of serous endometrial carcinoma.

Case report: A 60-year post-menopausal female presented with post-menopausal bleeding. Subsequently, she underwent a hysterectomy, which showed atrophic and cystic endometrium with extensive adenomyosis and atypical endometrial glands, which are diffusely P53 positive with intervening negative benign and focally positive dysplastic endometrial glands. A final diagnosis of serous endometrial carcinoma arising from adenomyosis was rendered. In a table format, previously reported serous endometrial carcinoma Arising cases from adenomyosis using PubMed search had been described.

Conclusion: Serous endometrial carcinoma arising from adenomyosis (<20 cases reported) and has a slightly more dismal prognosis than those deriving from the endometrial cavity. Hence, this case report highlights the occurrence, rarity, and importance of such an entity.

Coronary arteritis as a cause of sudden cardiac death in a young girl

A case of probable coronary arteritis in a young girl who died suddenly and unexpectedly is presented. The histologic presentation of the disorder is discussed, especially the differential diagnosis of arteritis of the coronary arteries with an emphasis on tuberculosis (TB). TB myocarditis with or without concomitant lung involvement is rare, and tubercular coronary arteritis without underlying pulmonary Koch’s disease is all the rarer. We herein describe a case where the cause of death was ascertained on post-mortem examination.

Encapsulated papillary variant of medullary carcinoma of thyroid with extensive cystic change: an extremely rare presentation

Papillary variant of medullary carcinoma of the thyroid is an unusual subtype with many diagnostic challenges. The authors report a case of papillary variant of thyroid medullary carcinoma in a 37-year-old female, who presented with complaints of pain in the thyroid nodule for the latter two months. Contrast enhanced computed tomography (CECT) neck revealed an enlarged and heterogeneously enhancing left lobe of thyroid. This was followed by hemithyroidectomy for suspicion of colloid goitre. Gross examination of the cut surface of the thyroid parenchyma had a sponge like appearance. On histopathology a diagnosis of encapsulated papillary variant of medullary carcinoma thyroid was made with the help of special stains and immunohistochemistry (IHC).

Giant virilising adrenal cortical carcinoma

Androgen secreting adrenocortical carcinoma (ACC) is a very rare disease with a poor prognosis. Approximately 80% of tumors are functional, most commonly secreting glucocorticoids. We herewith report a case of a huge functional ACC of the right adrenal gland in a 33-year-old female who presented with complaints of hirsutism, amenorrhea and an abdominal lump. On abdominal examination a large lump was palpable in the right hypochondrium reaching up to the umbilicus. Contrast-enhance computed tomography (CECT) revealed a mass in the right suprarenal region. The tumor measured 29 cm × 20 cm × 12 cm and weighed 7.8 kg, the largest reported case of ACC in the world to the best of our knowledge.