Congenital nephrotic syndrome with diffuse mesangial sclerosis caused by compound heterozygous mutation in LAMA5 gene

A two-and-a-half-month-old female infant presented with generalized edema for 10 days. At presentation, she had periorbital puffiness, moderate ascites, and pedal edema. Laboratory investigations revealed serum albumin 1.3 g/dL, spot urine protein to creatinine ratio (Up:Uc) 20.87 mg/mg, total cholesterol 380 mg/dL, and serum creatinine 0.31 mg/dL. Exome sequencing revealed compound heterozygous variants in LAMA5 gene (NM_005560.6). There was a heterozygous likely pathogenic missense variant in exon 2: LAMA5: c.385C > A (depth 195 ×) and another heterozygous pathogenic variant in exon 31: LAMA5: c.3932_3936dup; parental segregation by Sanger sequencing proved that the variants were in trans. Kidney biopsy showed diffuse mesangial sclerosis (DMS). Our case adds LAMA5 gene to the constellation of genes causing DMS, in addition to the classically described WT1, LAMB2, and PLCE1 genes and to the list of genes causing congenital nephrotic syndrome (CNS).

A comparison between conventional and the Paris systems of reporting urinary cytopathology with a literature update

INTRODUCTION

Owing to certain inherent limitations of earlier reporting systems, "The Paris System for Reporting Urinary Cytology (TPS)" was implemented in 2015 to standardize reporting urine cytology with more stringent cytomorphologic criteria. We share our post-TPS experience, comparing it with the conventional system (CS).

AIM

To assess and compare the cyto-histopathologic/cystoscopic agreement between the conventional and the Paris systems (CS and TPS) for reporting urine cytology.

MATERIALS AND METHODS

It is a cross-sectional study involving urine samples from 170 patients divided into two groups (CS and TPS). Of the 170 cases, 85 were reported according to the CS, and 85 were reported according to TPS with all the relevant clinical, radiologic, and cystoscopic findings. Using the kappa statistics, both groups were statistically analyzed for sensitivity, specificity, predictive values, and agreement.

RESULTS

The sensitivity and specificity for high-grade urothelial carcinoma (HGUC) as per TPS were 83.33% and 94.59%, respectively, while they were 73.47% and 80.56% for the conventional system. The agreement for HGUC with TPS was 87.06% with a kappa value of 0.7416, while it was 76.5% with a kappa value of 0.53 for the CS. Implementing the TPS minimized usage of the atypical urothelial cells (AUC) category, increasing the clarity in detecting HGUC.

CONCLUSION

TPS provides better agreement with histopathology than the CS for diagnosing HGUC, which is attributable to stringent TPS criteria that prompt cytopathologists to look more diligently for morphologic and numeric criteria.

Pre-Transplant Cytokine Levels as Signatures of Microvascular Inflammation in Kidney Allograft Biopsies

BACKGROUND

 The presence of microvascular inflammation (MVI) characterized by leukocyte margination in the glomeruli (glomerulitis, Banff score 'g') and peritubular capillaries (peritubular capillaritis, Banff score 'ptc') is a hallmark histological feature of antibody-mediated rejection (AMR), even in the absence of circumferential C4d positivity. In this study, we assessed the efficacy of pre-transplant plasma cytokines as an ancillary screening tool to identify MVI in kidney allograft indication biopsies to facilitate better graft survival.

METHOD

 This single-center prospective analytical study comprises 38 kidney transplant recipients whose peripheral blood was collected before transplant and assessed for the plasma cytokine concentrations of FOXP3, IL-6, TGF beta, and IL-17 using enzyme-linked immunosorbent assays (ELISA). Histopathological assessment was done in post-transplant indication biopsies, and Banff scores of 'g+ ptc' were calculated to categorize recipients into three MVI groups. The correlational, regression, and ROC curve analyses were used to assess the association and predictive ability of the cytokines with respect to MVI.

RESULTS

 In our study cohort, 27 recipients had MVI=0, five had MVI=1, and six had MVI≥2. A significant difference in plasma cytokines was observed between these groups, and we found a strong negative correlation of FOXP3 with MVI, whereas a strong positive correlation of IL-6, TGF beta, and IL-17 was recorded with MVI. We have also assessed the predictive ability of these cytokines, FOXP3, IL-6, TGF-beta, and IL-17, through the ROC curve, which showed an AUC of 0.70, 0.76, 0.84, and 0.72, respectively.

CONCLUSION

 Our findings suggest that the pre-transplant levels of cytokines FOXP3, IL-6, TGF-beta, and IL-17 could be measured to identify recipients at risk of post-transplant MVI, which could further serve as an additional tool for effective management of the kidney allograft.

Prevalence and risk factors for chronic pulmonary aspergillosis in chronic obstructive pulmonary disease patients with acute exacerbations

Chronic obstructive pulmonary disease (COPD) patients often experience acute exacerbations requiring hospitalization. Recently, attention has focused on Aspergillus sensitization in the airways of these COPD patients. This study aimed to assess the prevalence of chronic pulmonary aspergillosis (CPA) in COPD patients with acute exacerbations and identify associated risk factors. A cross-sectional descriptive study was conducted at the Jawaharlal Institute of Postgraduate Medical Education and Research from January 2021 to June 2022. Sixty-one COPD patients presenting with acute exacerbations were included. Demographic details, blood investigations, and sputum examinations were performed for all patients. A high-resolution computed tomography thorax was conducted for eligible patients. The prevalence of CPA among patients with an acute exacerbation of COPD was found to be 9.8%, with chronic cavitary pulmonary aspergillosis being the most common presentation (50%). Among post-tubercular COPD patients, the prevalence of CPA was significantly higher at 22.7%. Hemoptysis (p<0.001) and a previous history of tuberculosis (p=0.008) were associated with Aspergillus sensitization. This study highlights the substantial prevalence of CPA in COPD patients with acute exacerbations, particularly in those with a history of tuberculosis. Early recognition and targeted management of CPA in COPD patients may improve outcomes and reduce hospitalization rates. Further large-scale multi-center studies are needed to validate these findings and comprehensively address the impact of CPA on all COPD patients.

The urgency of Burkitt lymphoma diagnosis in fluid cytology-A tertiary care experience

BACKGROUND

Burkitt lymphoma (BL) is an aggressive high-grade B-cell non-Hodgkin lymphoma commonly diagnosed in young age and is known to involve extra nodal sites. But the involvement of body fluids by BL is an uncommon presentation. Rapid diagnosis of BL is vital to prevent complications like tumour lysis syndrome. Cytological examination of body fluids continues to be an indispensable tool for rapid diagnosis of BL.

OBJECTIVES

In this study, we aim to study the clinical, cytomorphological and immunophenotypic characteristics of BL involving serous effusions and other fluids.

MATERIALS AND METHODS

In this retrospective study, 17 cases reported as BL in fluid cytology from 2016 to 2022 were collected and reviewed. We performed a comprehensive analysis of the clinical data, cytomorphological features, immunophenotyping data along with the haematological workup of these cases. We have also compared with the histopathological diagnosis for those cases where biopsy was available.

RESULTS

BL more commonly involved ascitic fluid (52%), followed by pleural fluid (4 cases) and cerebrospinal fluid (CSF; 4 cases). Primary diagnosis of BL in fluid was done in 88% of the cases. Bone marrow involvement was noted in two cases. Cytological smears showed discrete monomorphous population of medium-sized atypical lymphoid cells with frequent apoptotic bodies. Classic cytoplasmic punched out vacuoles were observed in 88% of the cases. Immunophenotyping data was available for 12 cases in which tumour cells showed positivity for CD20 (100%), CD10 (4 of 7 cases), BCL6 (3 of 5 cases) and cMYC (7 of 7 cases-100%) and were negative for Terminal deoxynucleotidyl transferase (TdT) (11 of 11 cases). Mean Ki67 labelling index was 95%. Histopathological diagnosis was available for 9 cases, and there was 100% agreement between cytological and histopathological diagnosis in 7 cases.

CONCLUSION

Precise diagnosis of BL can be rendered in body fluids by identification of classic cytomorphological features and by performing supportive ancillary tests in fluids for immunophenotyping.

Predictive accuracy of histopathological profile and immunohistochemical markers for the aging of abrasion: an autopsy-based study

Wound age estimation is a crucial medicolegal task for forensic pathologists. The main objective of the current study was to evaluate the ability of the histopathological profile and immunohistochemical markers (CD14 and IL-8) to predict the age of abrasion and, furthermore, identify the relationship between the histopathological profile and immunohistochemical markers in abrasion aging. The study involved postmortem cases (n = 246) of abrasion injuries in which the injury infliction time was known. The test skin samples were taken from the abrasion site, and an adjacent area of uninjured skin was sampled for control. Hematoxylin and eosin stain was applied to tissue sections for the histopathological analysis. The semi-quantitative evaluation was made for expressing immunohistochemical markers CD14 and IL-8 on the infiltrating inflammatory cells. The study showed that the age of abrasion was significantly higher (p < 0.05) among the cases with positive staining than those with negative staining for both CD14 and IL-8. Additionally, the study found a significant association between the age of the abrasion and the IHC staining for IL-8. However, no significant association was seen between the age of abrasion and the CD-14 IHC staining. The odds ratio (95% confidence interval) for more than 72 h of the age of abrasion was compared to 0 to 72 h of the age of abrasion. The odds ratios were 39.00 (4.177-364.13) for the predominant mononuclear cell infiltration and 84.50 (9.287-768.814) for cases with the appearance of fibroblast, granulation tissue, and collagen deposition when compared to an unremarkable change on histopathological examination. Positive staining of immunohistochemical markers CD14 and IL-8 for the age of abrasion of more than 72 h showed a sensitivity of 40% and 80.95%, respectively, and specificity of 71.6% and 52.5%, respectively. The quantification of the histopathological changes of predominant mononuclear cell infiltration and the appearance of fibroblast, granulation tissue formation, and collagen deposition showed a significant correlation for the age of abrasion of more than 72 h. The immunohistochemical analysis revealed IL-8 as a more accurate marker than CD14 in identifying abrasions older than 72 h.

Giant cell collagenoma: Report of a rare tumor and review of literature

ABSTRACT

Giant cell collagenoma (GCC) is a rare benign dermal fibrous tumor. Although it has many clinicopathological differential diagnoses, it is often confused with cutaneous sclerotic fibroma/storiform collagenoma (SF/SC) and dermatofibroma. The following characteristic features point to GCC's diagnosis over the latter: the presence of peculiar multinucleated giant cells, and vimentin positivity of both single and multinucleated giant cells on immunohistochemistry. Most of the reported cases have mentioned that GCC is a variant of SF/SC. We report a rare case of GCC presenting as a slow-growing solitary firm nodule over the right ankle. To the best of our knowledge, only less than ten cases have been reported, including the index case. We have also reviewed the clinicopathological features of those cases and discussed the approach to the diagnosis.

Inflammatory Myofibroblastic Tumor of the Testis in a Patient With Cecal Carcinoma

Inflammatory myofibroblastic tumors (IMTs) are uncommon tumors that can be classified among fibroinflammatory disorders. IMTs are diagnosed after excluding all other entities, which can be considered differential diagnoses of IMTs. Microscopic examination of IMTs shows multiple myofibroblastic spindle cells, which are surrounded by inflammation. IMTs have lesser chances of progression to malignancy. The case defined below is one of the few cases in the literature that reports the presentation of IMT and another malignancy. We describe a 72-year-old man who was found to have cecal carcinoma and later diagnosed with an IMT of the testis. IMTs are generally benign tumors with a tendency for local recurrence. Patients affected by IMTs usually get diagnosed only after more than one biopsy. IMT is diagnosed only after ruling out other differential diagnoses. They rarely show invasiveness and metastasize. The presence of metastasis, recurrence, and other malignancies probably indicate poor prognosis and poor survival. The course of IMTs is usually benign, with good outcomes after surgery. IMTs have been known to recur, invade, or metastasize in sites such as paranasal sinuses, mediastinum, and the abdomen. In the case that we researched, vimentin and smooth muscle actin were strongly positive in the spindle-shaped cells, whereas anaplastic lymphoma kinase-1 was negative.

Can combined non-invasive methods improve diagnosis of lung cancer?

Background

Lung cancer is the most common malignancy in both gender. Early diagnosis is needed to reduce morbidity and mortality. There is a debate about the most accurate investigating modality for the diagnosis of lung cancer.

Methods

It is a retrospective cohort analysis to determine whether an approach of combined contrast-enhanced computed tomography (CECT) thorax with bronchoscopy method has higher sensitivity and specificity than combined CECT thorax with sputum cytology method. Records of patients with lung cancer who had visited the hospital within the last 6 months were retrospectively analyzed for their diagnostic modality. SPSS version 19 software was used for statistical analysis of the data. CECT scan thorax, bronchoscopy, and sputum cytology for lung cancer patients were analyzed. The CECT thorax plus bronchoscopy method was compared with the CECT thorax plus sputum cytology method. Their sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in diagnosing lung cancer were analyzed.

Results

Sixty-two patients were considered, including 62.9% males with a mean age of 55.5 years. In patients diagnosed with lung cancer, CECT thorax combined with bronchoscopy method was found to have a sensitivity of 96.67% than CECT thorax combined with sputum cytology method with a sensitivity of 90% and the difference in sensitivity between all individual approaches as well as the combined method was statistically significant with a P = 0.00001 and Chi-square value of 86.5909 owing to the low sensitivity of sputum cytology. CECT thorax combined with sputum cytology approach had a better specificity than CECT thorax combined with bronchoscopy.

Conclusion

Combined CECT thorax with sputum cytology method has a better specificity in diagnosing lung cancer than combined CECT thorax with bronchoscopy method.

Bacillary Positive Tuberculous Body Fluid Smears: A Perspective on How Fast to Use Acid Fast

Background Tuberculous effusions are common. Classically, they are described as bacteria poor and lymphocyte rich. Our experience, however, has been more varied. We compiled this rare group of bacteria-positive tuberculous fluids to document their cytologic spectrum and to look for possible predictors of bacillary positivity. Methods Fifty-one cases of bacillary positive fluids were identified and their clinicopathological details were noted. Per case, the smear background was assigned as either clear, caseous, suppurative, granular proteinaceous or frankly hemorrhagic. Fine, punched-out vacuoles in the smear background were also noted. The bacillary load in each case was classified from scanty to 3+. Eventually, the clinicopathologic variables were tabulated for frequency and studied for any association with bacillary presence. Results Only 19 of the 51 patients had a history of tuberculosis. Retropositive patients comprised a small proportion (9.8%) and did not always indicate strong (3+) bacillary positivity. The granular proteinaceous background was the most frequent (35%) pattern. Only a suppurative background was associated with strong bacillary positivity. Fine vacuoles were seen almost always with caseous and granular proteinaceous backgrounds but without statistical significance. Conclusion Tuberculous effusions can have diverse smear backgrounds, not necessarily one rich in caseous material. When tuberculosis is known or clinically suspected, non-classical findings such as abundant neutrophils or suppurative background should not dissuade one from requisitioning mycobacterial stains. In fact, acid-fast stains should probably routinely accompany Giemsa slides of clinically idiopathic effusions in endemic areas since it is still the cheapest and fastest method for a conclusive diagnosis.

Disseminated rhinosporidiosis masquerading as soft tissue round cell tumour diagnosed by fine needle aspiration cytology

Rhinosporidium seeberi belongs to the eukaryotic class Mesomycetozoea and causes chronic granulomatous lesions known as rhinosporidiosis. Rhinosporidiosis frequently involves the nasal cavity and nasopharynx through transepithelial invasion. Atypical presentations of this disease at other body sites have been reported, including the subcutis, visceral organs, bones, and genitals. Only a few cases of cutaneous and subcutaneous involvement have been reported to date. This chronic granulomatous condition is known for its recurrence following autoinoculation unless the correct diagnosis and appropriate treatment are given. We describe a case of an immunocompetent adult who had undergone fine needle aspiration cytology (FNAC) of mass-like swellings in the right thigh and right calf at another healthcare centre and had been diagnosed with a small round blue cell tumour. FNAC at our centre confirmed a rare case of rhinosporidiosis that was clinically mimicking a soft tissue neoplasm of the lower extremity, and the erroneous interpretation of the prior cytology studies had resulted in misinterpretation of the individually dispersed pathogenic organisms as individual malignant cells. FNAC of rhinosporidiosis can lead to early diagnosis and prompt treatment of this pathogen when it presents at unanticipated body sites.

Analytical Study of Ocular Surface Changes in Patients of Chronic Kidney Disease undergoing Hemodialysis and Peritoneal Dialysis

Objectives The idiopathic group is a significant cause of chronic kidney disease (CKD) in developing countries. Literature available on ocular surface changes has predominantly been reported in patients undergoing hemodialysis. Little is known about the changes in patients undergoing peritoneal dialysis. The present study aimed to identify ocular surface changes in an idiopathic group of CKD undergoing dialysis.

Aim To compare tear film disorders and the severity of ocular surface changes (goblet cell density, squamous metaplasia, and corneoconjunctival calcification) in patients of idiopathic etiology with CKD undergoing hemodialysis and peritoneal dialysis. This is an analytical study.

Materials and Methods Asymptomatic adult patients of idiopathic CKD, on treatment with dialysis underwent comprehensive ophthalmic examination, including best-corrected visual acuity, slit-lamp examination, and a dilated fundus examination. Dry eye assessment was done by ocular surface staining score, Schirmer test, and tear breakup time (TBUT). Conjunctival impression cytology was studied to assess changes on ocular surface. Chest X-rays for aortic calcification were reviewed and data analyzed.

Results Both eyes of 76 patients of hemodialysis and 32 patients of peritoneal dialysis were studied. Ocular surface staining (OSS) scores were low. Impression cytology showed a drop in goblet cell density, presence of squamous metaplasia, and conjunctival keratinization significantly more in the hemodialysis group. No correlation was seen between the presence of conjunctival calcification and aortic calcification.

Conclusion The hemodialysis group had mild subclinical dry eye but keratinization of conjunctiva was seen. Similarly, advanced squamous metaplasia was seen in the peritoneal dialysis group. These changes were positively correlated to decrease in goblet cell density.

How FNAC and flowcytometry helped in diagnosing a high-grade B cell lymphoma masquerading as leukemia

High-grade B cell lymphoma (HGBL) has been recently introduced in the category of aggressive, mature B cell lymphomas. They are biologically different from diffuse large B cell lymphoma and Burkitt Lymphoma and have an aggressive course. Leukemic presentation though is known in various types of mature B cell and mature T cell lymphomas, it is rare in high-grade B cell lymphoma. We report one such case of a high-grade B cell lymphoma which was masquerading as acute leukemia with a soft tissue infiltration with added emphasis on the role of fine-needle aspiration cytology and flow cytometry in the diagnosis and its therapeutic significance.

Revisit of Polyomavirus Nephropathy Grading in Renal Allograft Recipients According to the Banff 2019 Working Group Classification: A Study From a Large Transplant Center in South India

Background

In renal transplant patients, the biopsy-proven incidence of polyomavirus nephropathy (PVN) is approximately 5%. There is no consensus in the morphologic classification of definitive PVN, which is attempted in the Banff 2019 Working Group classification, which groups histologic changes, reflects clinical presentation, and facilitates comparative outcome analyses. This study aims to analyze the clinical and histopathological findings and outcomes among the three classes in the recent classification.

Materials and methods

The study was conducted in the department of pathology and nephrology over a period of six years. All cases diagnosed as PVN on renal allograft biopsies were included. The clinical and biochemical findings were obtained from hospital records. Histopathology slides were reviewed and classified according to Banff 2019 criteria and were analyzed with clinical, laboratory, histopathological parameters along with the clinical outcome.

Results

Out of 205 renal transplants performed during the study period, 14 patients (6.8%) were diagnosed with PVN. The mean age of diagnosis was 38 years, with a Male: Female ratio of 1.8:1. The median period of diagnosis of the viral infection after transplant was 10 months. Histomorphology grading according to Banff 2019 revealed four cases (28.5%) in PVN class 1, eight cases (57.2%) in PVN class 2, and two cases (14.3%) in PVN class 3. Cases in PVN class 1 presented early. PVN class 1 was associated with a single type of inclusion, and multiple type inclusions were observed in higher classes. Associated diseases were thrombotic microangiopathy (TMA), borderline cellular rejection, antibody-mediated rejection (ABMR), and concomitant infections. PVN class 1 had a better outcome compared to PVN class 2 and class 3.

Conclusion

PVN1 was observed to have better clinical presentation and outcomes than PVN2 and 3; however, this could not be statistically concluded due to the low sample size and other associated diseases.

Extramedullary early T-cell lymphoblastic crisis in a young pregnant chronic myeloid leukemia patient: Diagnosis with fine-needle aspiration cytology and flow cytometry

Chronic myeloid leukemia (CML) most commonly presents in chronic phase. Blast crisis in CML is usually of myeloid phenotype, whereas among lymphoid lineage, B-cell lymphoblastic crisis is common. T lymphoblastic crisis is rare with near early T-cell precursor (ETP) immunophenotype being exceedingly rare and very little is known about its characteristics, treatment, and prognosis. Blast crisis can occur in extramedullary sites with lymph node being the most common site. CML is also less investigated and studied in pregnancy as it is considered a disease of older adults. We report a rare case of CML presenting in extramedullary site (lymph node) as extramedullary T-cell lymphoblastic crisis of near ETP immunophenotype in a young pregnant female, which was diagnosed on fine-needle aspiration cytology in combination with flow cytometry.

CSF involvement by nonhematolymphoid malignancies: A descriptive study with emphasis on cytomorphological clues

Introduction:

Detection of malignant cells in cerebrospinal fluid (CSF) samples in suspected cases of malignancy is critical for the management of patients. CSF involvement by nonhaematolymphoid malignancies is less common. We aimed to study the cytomorphologic characteristics of various nonhaematolymphoid malignancies in CSF.

Methods:

A retrospective cytomorphological analysis of 27 CSF cytology smears reported as positive or suspicious for nonhematolymphoid malignancies from January 2010 to April 2020 over 10 years was carried out. Smears in all cases were prepared by cytospin technique and stained with May-Grunwald-Giemsa (MGG) and papanicolaou (Pap) staining procedures. Cell immunohistochemistry/immunocytochemistry was done wherever cell block/extra slides were available.

Results:

Twenty-four of 27 cases were interpreted as “positive,” while three were reported as “suspicious” of malignancy. Nineteen of 27 cases were metastatic adenocarcinomas including three suspicious malignancy cases with the primary sites of origin being the breast (10), stomach (2), rectum (1), gall bladder (1), lung (1), and four cases of unknown primary. Of the remaining positive cases, there were five cases of metastatic medulloblastoma, two cases of metastatic pineoblastomas, and one case of metastatic extraskeletal Ewings sarcoma. Each of these metastatic malignancies had at least a single diagnostic cytomorphological clue, similar to those observed in other body cavities and primary malignancy sites.

Conclusion:

Nonhematolymphoid malignancies are readily diagnosable on CSF cytology, most of them are metastatic. Identification of malignant cells in CSF is critical, as it has therapeutic and prognostic implications.

Preliminary cytomorphologic diagnosis of hematolymphoid malignancies in effusions: A cyto-histo correlation with lessons on restraint

Background:

Effusions as part of hematologic neoplasms are rare and as a primary presentation, rarer. In standalone laboratories of developing countries, resorting to techniques such as flow cytometry or immunohisto/cytochemistry may not be possible. A near definitive diagnosis on cytomorphology would, therefore, be an ideal beginning. To that end, we compiled our cases of primary hematolymphoid effusions, devising reproducible reporting categories and looked at their concordance with the final histopathology.

Subjects and Methods:

Fifty-four cases of primary hematolymphoid effusions over 10 years with cytology-histopathology correlation were chosen. Post morphology assessment, the cases were organized into six categories: suspicious of hematolymphoid malignancy, non-Hodgkin lymphoma-high-grade (NHL-HG), low-grade NHL (NHL-LG), Burkitt lymphoma, acute leukemias, and plasma cell dyscrasias. Discordance with histology was assigned as major and minor based mainly on therapeutic implications.

Results:

Concordance was seen in a good number (81.5%) of cases. The NHL-HG and NHL-LG categories contributed to 33.3% each of major discordance. Tuberculosis and epithelial malignancies comprised the bulk of the major discordance. Overdiagnosis of a high-grade lymphoma for a histologically proven low-grade follicular lymphoma was the only case with minor discordance.

Conclusion:

The cytologic categories used are not foolproof for hematologic neoplasms but have a fairly good concordance. A scanty abnormal population should always be viewed with suspicion and definitive labels should be avoided. While morphologic examination is fraught with danger, a good assessment directs the judicious selection of ancillary methods, and hence cannot be supplanted.

Concomitant Diagnosis of Plasmablastic Lymphoma and Chronic Lymphocytic Leukemia: A Rare Phenomenon

Plasmablastic lymphoma (PBL) is a rare, aggressive non-Hodgkin lymphoma which shows blastic morphology and an immunophenotype of plasma cell differentiation while chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma is an indolent B-cell lymphoma and has a variable clinical course. A CLL transforming into a PBL and the coexistence of CLL with PBL are both extremely rare findings. We report an unusual case of a 72-year-old HIV-negative male who presented with a gingival swelling which was diagnosed as PBL with simultaneous CLL in the blood and bone marrow. Further, in this case, the PBL spontaneously regressed postbiopsy adding to the peculiarity and rarity of this case. This could be due to immune system modulation and can open up a new window to the treatment strategies of PBL in the future.

A nomogram for predicting the risk of neck node metastasis in oral cavity carcinoma using acoustic radiation force impulse imaging (ARFI)

BACKGROUND

The study was conducted to assess the accuracy power of Acoustic radiation force impulse imaging (ARFI) and generate a nomogram using ultrasound and ARFI to predict malignant cervical lymph nodes in head and neck squamous cell carcinoma.

MATERIAL AND METHODS

374 cervical lymph nodes from 67 patients were evaluated. The B-mode ultrasonography and the elastography findings were compared with the final histopathological diagnosis. Radiological variables were used to construct nomogram and clinical utility of the nomogram was cross-validated.

RESULTS

In univariate analysis, status of the hilum, Long Axis Diameter, Short axis diameter, colour virtual touch imaging grade (VTI) and shear wave velocity were significant in predicting metastasis in the cervical lymph nodes. In multivariable analysis, it was found that predominance of red over yellow area on colour VTI was significantly associated with lymph node metastasis. A multiple logistic regression performed to ascertain the effects of on the likelihood that patients had lymph node metastasis on histopathology was statistically significant, χ2(10) = 44.96, p < 0.001. The model was able to correctly classify 93.28% of cases and the concordance index (c-index) was estimated to be 0.8773. A nomogram was thus established to predict metastasis in cervical lymph nodes.

CONCLUSIONS

ARFI increases the diagnostic accuracy of conventional USG in predicting metastatic lymph nodes in HNSCC. Adding the constructed nomogram to the conventional diagnostic pathway can provide an alternative option to frozen section and FNAC.

Dermoscopic features of basal cell carcinoma in skin of color: A retrospective cross-sectional study from Puducherry, South India

BACKGROUND

Dermoscopy is useful in the diagnosis of basal cell carcinoma (BCC). However, most descriptions of the dermoscopic features of BCCs are in Caucasians (skin types I-III) and there is a paucity of data in dark-skinned Indian patients.

AIMS

The aim of this study was to describe the various dermoscopic features of BCC in dark-skinned patients from South India and correlate these with the histopathologic subtypes.

METHODS

A retrospective observational study of biopsy-proven cases of BCC was conducted at a tertiary care center in South India using nonpolarized contact dermoscopy.

RESULTS

Sixty BCCs in 35 patients predominantly of skin phototypes IV or V were studied. These included 32 nodular, 27 superficial and 1 infiltrative type of BCC. The most common dermoscopic features noted were maple leaf-like areas (61.7%), blue-white veils (53.4%), ulceration (48.4%) and short fine telangiectases (46.7%). Ulceration, blue-white veils and arborizing vessels were significantly associated with nodular BCCs, while maple leaf-like areas, red-white structureless areas, multiple small erosions and spoke wheel areas were noted with superficial BCCs.

LIMITATIONS

The limitations of this study include its retrospective nature, the use of only nonpolarized light for examination, the lack of other histopathological variants of BCC as well as the lack of a comparison group.

CONCLUSION

We report a dermoscopic study of BCC in dark-skinned patients from Puducherry, South India. The blue-white veil was observed in half of the patients and was significantly associated with nodular BCCs. The addition of the blue-white veil to the diagnostic criteria for pigmented BCC could improve the diagnostic accuracy of dermoscopy in Indian patients.

Cholemic Nephrosis: An Autopsy Study of a Forgotten Entity

OBJECTIVE

The aim of the study is to do a clinicopathologic study of post mortem kidney biopsies with significant deposition of bilirubin pigment within tubular epithelial cells and in the lumen of distal tubules as a bile cast.

MATERIAL AND METHOD

All post mortem specimens with acute tubular necrosis, with the presence of bile casts in tubules or bile pigment deposition in the tubular epithelium during the period 2015-2018 were examined for gross and histopathology along with biochemical parameters and viral markers.

RESULTS

Bile casts with sloughed renal tubular epithelial cells and occasional macrophages were present in the distal convoluted tubule in 78.6% of biopsies (11/14). The plugging of distal convoluted tubule with casts was similar to that seen in myeloma and myoglobin cast nephropathies. Bilirubin pigment deposition was present in 35.7% (5/14) of cases. The frequency of bile casts in each biopsy was variable and it did not have any association with serum bilirubin levels or etiology of liver dysfunction. A striking difference from earlier studies is the high number of toxin-induced liver damage including six cases of paraquat and 2 cases of yellow phosphorus poisoning.

CONCLUSION

This study proves importance of the bile cast nephropathy as a reason for kidney injury, especially with varied hepatotoxic etiologies, especially paraquat and yellow phosphorus.

Malignant phyllodes tumor with liposarcomatous differentiation: Diagnosed on cytology

Phyllodes tumor (PT) accounts for less than 1% of all primary tumors of the breast and 2% to 3% of all fibroepithelial lesions. We report a case of heterologous liposarcomatous elements in a malignant PT of the breast on Fine needle aspiration cytology (FNAC) and later confirmed by histopathological examination. A 58-years-old woman presented with a huge breast mass for which FNAC was done. Cytology showed features of malignant PT with a good representation of heterologous liposarcomatous areas. The cytological findings were in concordance with the histologic features. Malignant PT and its various heterologous elements of stroma can be diagnosed on FNA cytology when performed optimally. They can be vital for the preoperative assessment of patients suspected with malignancy to formulate the surgical plan accordingly.