Changing Trend of Superficial Mycoses with Increasing Nondermatophyte Mold Infection: A Clinicomycological Study at a Tertiary Referral Center in Assam

Background:

Superficial mycosis is the commonest infections affecting human globally. Though they do not cause mortality, their clinical significance lies in their morbidity, recurrence, and cosmetic disfigurement, thus creating a major public health problem. The infections are more prevalent in the tropical regions. The etiological agents are also seen to vary with time and geographical location.

Aim:

This study was carried out to find out the trend of superficial mycosis in Assam, along with a clinicomycological correlation.

Materials and Methods:

A total of 130 clinically diagnosed cases of superficial mycoses attending the outpatient department (OPD) of a tertiary hospital in Assam for a period of 1 year were taken up for the study. After taking the informed consent and a proper history, the clinical materials like skin scrapings, nail clippings, and infected hair were sent for mycological examination.

Results:

The infection was found to be more prevalent among males than females (M:F, 3:2) and among the farmers and laborers (24.61%). Tinea corporis was the commonest clinical type (21.5%). Among the fungal isolates, dermatophytes were the most frequent isolates (43.54%), out of which Trichophyton rubrum was commonest. nondermatophyte moulds like Fusarium, Aspergillus, Scopulariopsis, Trichosporon, and Penicillium spp. were isolated.

Conclusion:

The epidemiology of fungal infection and the causative fungi is seen to vary geographically and with time. This study reflects the changing trend of fungal infection in the north eastern region with a high rate of isolation of nondermatophyte moulds as the causative agent.

Hyperkeratotic porokeratosis ptychotropica with satellite lesions: a rare presentation of an unusual variant of porokeratosis

Since its description in 1995, porokeratosis ptychotropica (PP) has remained a less-recognized variant of porokeratosis (PK). The term porokeratosis ptychotropica was coined in reference to its characteristic of affecting body folds. It mimics many other dermatological diseases and is therefore often misdiagnosed. We report a patient with multiple hyperkeratotic, warty lesions across the buttocks that mimicked cutaneous tuberculosis (CTB), but histological examination confirmed the correct diagnosis of PP.

Genomic profiling in a homogeneous molecular subtype of non-small cell lung cancer: An effort to explore new drug targets

BACKGROUND

Patients' who are positive for kinase domain activating mutations in epidermal growth factor receptor (EGFR) gene, constitute 30-40% of non-small cell lung cancer (NSCLC), and are suitable candidates for Tyrosine Kinase Inhibitor based targeted/personalized therapy. In EGFR non-mutated subset, 8-10% that show molecular abnormalities such as EML4-ALK, ROS1-ALK, KIP4-ALK, may also derive the benefit of targeted therapy. However, 40% of NSCLC belong to a grey zone of tumours that are negative for the clinically approved biomarkers for personalized therapy. This pilot study aims to identify and classify molecular subtypes of this group to address the un-met need for new drug targets in this category. Here we screened for known/novel oncogenic driver mutations using a 46 gene Ampliseq Panel V1.0 that includes Ser/Thr/Tyr kinases, transcription factors and tumor suppressors.

METHODS

NSCLC with tumor burden of at least 40% on histopathology were screened for 29 somatic mutations in the EGFR kinase domain by real-time polymerase chain reaction methods. 20 cases which were EGFR non-mutated for TK domain mutations were included in this study. DNA Quality was verified from each of the 20 cases by fluorimeter, pooled and subjected to targeted re-sequencing in the Ion Torrent platform. Torrent Suite software was used for next generation sequencing raw data processing and variant calling.

RESULTS

The clinical relevance and pathological role of all the mutations/variants that include SNPs and Indels was assessed using polyphen-2/SIFT/PROVEAN/mutation assessor structure function prediction programs. There were 10 pathogenic mutations in six different oncogenes for which annotation was available in the COSMIC database; C420R mutation in PIK3CA, Q472H mutation in vascular endothelial growth factor receptor 2 (VEGFR2) (KDR), C630W and C634R in RET, K367M mutation in fibroblast growth factor receptor 2 (FGFR2), G12C in KRAS and 4 pathogenic mutations in TP53 in the DNA binding domain (E285K, R213L, R175H, V173G).

CONCLUSION

Results suggest, a potential role for PIK3CA, VEGFR2, RET and FGFR2 as therapeutic targets in EGFR non-mutated NSCLC that requires further clinical validation.

Prevalence of KRAS mutations in metastatic colorectal cancer: A retrospective observational study from India

BACKGROUND

One of the genetic alterations implicated in tumor progression in colorectal cancers (CRCs) are abnormalities in Kristen Rat Sarcoma (KRAS) gene. Evaluation of KRAS mutation status is an important prognostic factor and has predictive value in deciding first line therapy based on monoclonal antibodies such as Cetuximab and Panitumumab in metastatic CRCs.

MATERIALS AND METHODS

In this retrospective study, we analyzed 7 different somatic mutations in Exon 2 of KRAS gene in 299 unselected incidental CRC patients who visited the hospital for clinical management during the period 2009-2013. Most of the tumors were primarily originating from colon and rectum; nevertheless, there were a few from rectosigmoid, sigmoid, ceacum and anal canal in the study group. Genomic DNA extracted from paraffin embedded tumor tissues was screened for 7 point mutations located in Codons 12 and 13 of KRAS gene, using Scorpions amplified refractory mutation system real time polymerase chain reaction technology. Statistical analysis was performed to assess bivariate relationship between different variables that includes: mutation status, mutation type, tumor location, tumor morphology, age and sex.

RESULTS

Prevalence of mutation in Codons 12 and 13 was 42.8% in the study group. Well-differentiated tumors had significantly more mutation positivity than moderately and poorly differentiated tumors (P = 0.001). 92% of the mutations were from Codon 12 and 8% in Codon 13. Glycine to Arginine was relatively more common in rectosigmoid followed by ceacum, while Glycine to Alanine mutation was relatively more prevalent in sigmoid, followed by rectum and rectosigmoid.

CONCLUSION

The results suggest a prevalence of KRAS mutation at 42.8% in Indian population indicating that this testing is very crucial for targeted therapy management in metastatic CRC in India. Further analysis on mutation status of other homologues such as NRAS and downstream partner, v-raf murine sarcoma viral oncogene homolog B1, would add value to understanding the role of anti-epidermal growth factor receptor therapy in CRC management.

Clinical and epidemiological study of EGFR mutations and EML4-ALK fusion genes among Indian patients with adenocarcinoma of the lung

Background

Mutation in the tyrosine kinase domain of epidermal growth factor receptor (EGFR) is a common feature observed in lung adenocarcinoma. A fusion gene between echinoderm microtubule-associated protein-like 4 (EML4) and the intracellular domain of anaplastic lymphoma kinase (ALK), named EML4-ALK, has been identified in a subset of non-small-cell lung cancer (NSCLC) tumors. The objective of this study was to determine the prevalence of EGFR mutations and EML4-ALK fusions in Indian patients with NSCLC (adenocarcinoma) as well as evaluate their clinical characteristics.

Patients and methods

Patients with NSCLC, adenocarcinoma histology, whose tumors had been tested for EGFR mutational status, were considered for this study. ALK gene rearrangement was detected by fluorescence in situ hybridization using the Vysis ALK Break Apart Rearrangement Probe Kit. ALK mutation was tested in samples that were negative for EGFR mutation.

Results

A total of 500 NSCLC adenocarcinoma patients were enrolled across six centers. There were 337 (67.4%) men and 163 (32.6%) women with a median age of 58 years. One hundred and sixty-four (32.8%) blocks were positive for EGFR mutations, whereas 336 (67.2%) were EGFR wild-type. Of the 336 EGFR-negative blocks, EML4-ALK fusion gene was present in 15 (4.5%) patients, whereas 321 (95.5%) tumors were EML4-ALK negative. The overall incidence of EML4-ALK fusion gene was 3% (15/500).

Conclusion

The incidence of EGFR mutations (33%) in this Indian population is close to the reported incidence in Asian patients. EML4-ALK gene fusions are present in lung adenocarcinomas from Indian patients, and the 3% incidence of EML4-ALK gene fusion in EGFR mutation-negative cases is similar to what has been observed in other Western and Asian populations. The mutual exclusivity of EML4-ALK and EGFR mutations suggests implementation of biomarker testing for tumors harboring ALK rearrangements in order to identify patients that can benefit from newer targeted therapies.

A clinicopathological study of cutaneous tuberculosis at Dibrugarh district, Assam

BACKGROUND

Cutaneous tuberculosis forms a small subset of extra pulmonary tuberculosis and has a worldwide distribution.

AIMS

The present study is an attempt to find out the incidence, clinical spectrum, and histopathological features of cutaneous tuberculosis.

MATERIALS AND METHODS

A total of 42 cases of newly diagnosed patients of cutaneous tuberculosis attending dermatology out patient department over a period of 1 year were included in the study. A detailed clinical examination and investigations including histopathological examination were carried out.

RESULTS

Scrofuloderma was the most common form seen in 50% cases followed by lupus vulgaris in 42.86%, tuberculosis verrucosa cutis in 4.76%, and lichen scrofulosorum in 2.38% cases. The Mantoux test was positive in 83.33% cases. Characteristic tuberculoid granulomas were seen in 72.22% cases of lupus vulgaris, 42.86% cases of scrofuloderma and all cases of tuberculosis verrucosa cutis and lichen scrofulosorum.

CONCLUSION

Cutaneous tuberculosis is still highly prevalent in upper Assam. Early diagnosis and treatment are essential to prevent its complications.

Atypical cutaneous lesions of Penicillium marneffei infection as a manifestation of the immune reconstitution inflammatory syndrome after highly active antiretroviral therapy

Penicillium marneffei infections normally manifest as molluscum contagiosum like skin lesion in HIV-infected persons. We report a case with verrucous lesions over nose and face due to Penicillium marneffei infection after HAART treatment. A 28-year-old man presented, after two weeks of HAART treatment, with multiple erythematous, scaly, papules and nodules with central necrosis predominantly in face and both extremities and scrotum. Microbiological investigations confirmed the diagnosis of Penicillium marneffei infection. This is perhaps the first case report with such manifestation due to Penicillium marneffei infection.

Generalized pustular psoriasis of pregnancy successfully treated with cyclosporine

Two multigravidae aged 27 and 29 years, with previous uneventful pregnancies, second being psoriatic, reported at 24 and 28 weeks of pregnancies, with generalized pustular lesions. Laboratory findings, including serum calcium were normal. Ultrasonography showed normal fetal growth. Histopathology confirmed pustular psoriasis. Patients were put on cyclosporine 3 mg/ kg weight/ day after failure of an initial systemic steroid. Blood pressure, pulse, and fetal heart sounds were recorded every 12 hours, and ultrasonography and blood parameters, biweekly. Cyclosporine was tapered and stopped after delivery of two healthy babies at 38 weeks. We conclude that cyclosporine can be an option in the management of pustular psoriasis of pregnancy or psoriasis with pustulation in pregnancy.

Prevalence of communicable disease among restaurant workers along a highway in Assam, India

105 workers of 29 roadside restaurants along a highway in Assam were interviewed for their habits, educational status and were examined for their hygienic status and presence of communicable diseases (STDs,TB etc). Most of them were young, males with 40% literacy; more than half were unmarried. About 30% of them were alcoholic and smokers and 2.9% were addicted to cannabis. The hygienic conditions of the workers were poor. More than one third had sexual contact with multiple sex partners or commercial sex workers and 2% were engaged in homosexual activity. Most of them did not use condom. 25.7% of them had genital lesions suggestive of sexually transmitted disease, 11.8% showed gram negative diplococci in urethral smears and 5.1% were VDRL reactive. Skin infections followed by gastrointestinal disorders and respiratory tract infections were other prevalent problems. 70.6% were positive for intestinal parasites and 22.2% were sputum positive for acid fast bacilli. However all the collected blood samples were negative for HIV.

Fine needle aspiration cytology of hepatocellular carcinoma

Fine needle aspiration cytology (FNAC) is an extremely useful technique in the evaluation of hepatic masses. This study was undertaken with the aim of describing the morphological spectrum seen in fine needle aspirates from hepatocellular carcinoma (HCC) seen in our patients hailing from South India. Thirty two cases of HCC were studied. Trabacular pattern covered by endothelium was the most common. Pseudoglandular, spindle cell and dispersed patterns were also seen. Individual tumour cells were generally reminiscent of hepatocytes, and had a prominent nucleolus. The presence of intranuclear and intracytoplasmic inclusions were notable features. FNA cytology in HCC is sufficiently distinctive to form an invaluable tool in the diagnosis of this malignancy.

Diagnosis of clival chordoma by fine needle aspiration of an oropharyngeal mass. A case report

A sphenooccipital chordoma presenting as a large nasopharyngeal mass extending into the oropharynx was diagnosed by transoral fine needle aspiration biopsy (FNAB) and confirmed by subsequent histologic studies. The cytologic features of chordoma are presented, and the diagnostic utility of FNAB in evaluating similar lesions in the head and neck region is discussed.

Hemangiopericytoma of bone--a case report

A case of low grade hemangiopericytoma of three years duration occurring in the upper end of the femur of a 70 year old man is described. Radiologically, the upper third of the right femur showed a destructive expansile osteolytic lesion with soft tissue extension. The tumour was partially encapsulated. Mitoses were 0-1 per 10 high power fields, suggesting the low grade malignant nature of the lesion. It is felt that all hemangiopericytomas occurring in bone should be considered biologically malignant.

Fine needle aspiration cytology of chondroblastoma and chondromyxoid fibroma. A report of two cases

The fine needle aspiration cytology in two cases of chondroblastoma and chondromyxoid fibroma are described. The diagnosis of chondroblastoma was made on a recurrent tumor of which the histopathology was known, whereas chondromyxoid fibroma was diagnosed initially on fine needle aspiration cytology. The radiologic appearances and differential diagnoses of these chondroid neoplasms are discussed.

Adult paratesticular sarcomas: a report of eight cases

Eight adult paratesticular sarcomas seen at a Regional Cancer Centre over a 7-year period are described. There were three cases of rhabdomyosarcoma (RMS), three cases of leiomyosarcoma (LMS), and two cases of liposarcoma (LS). The RMS occurred in a younger age group (3rd decade) than the LMS and LS (6th and 7th decades). Most of our patients presented with advanced disease after orchiectomy at other hospitals, three with recurrent or residual disease and four with metastasis. The single patient with RMS who received intensive adjuvant therapy is free of disease at 84 months in spite of the advanced stage at presentation. All three patients with LMS had an unfavourable clinical course. Both the patients with LS had well differentiated (WD) tumours and presented with recurrences, one over several years, following initial local excisions. The necessity for early adequate surgical and adjuvant therapy and the need for a uniform treatment policy are discussed.

Sclerosing stromal tumour of the ovary

Sclerosing stromal tumour (SST) of the ovary is a rare entity. It is a benign neoplasm which forms a distinct subgroup separate from the other ovarian stromal tumours, including thecomafibromas, by virtue of its unique histology. One such tumour in a 25-year old female is reported.

Fine needle aspiration cytology of Wilms' tumor. A study of 17 cases

The cytologic features of 17 cases of Wilms' tumor are described. All three elements identifiable histologically are usually present in the fine needle aspiration smears. In our cases the blastemal component predominated, with varying degrees of epithelial and stromal differentiation, which was identifiable in the form of skeletal and smooth muscle. Early epithelial differentiation was identified as rosette-like and gland-like structures, groups of cells with peripheral palisading and spherical, tightly bound clusters of cells. More-differentiated epithelial cells were seen individually, in small, loose clusters, in sheets with a honeycomb appearance and as elongated tubules. Coarse, magenta, granular material was seen in the background of the smears in the majority of our cases. Fine needle aspiration under ultrasound guidance to accurately localize the tumor and a posterior approach to avoid peritoneal spillage are recommended. In difficult cases, a cell block of the aspirated material is a useful adjunct.

Salivary duct carcinoma

Salivary duct carcinoma is an uncommon malignant tumor that occurs mainly in the parotid gland of elderly men. The 11 cases of salivary duct carcinoma which are included in this study occurred in older men (mean age 56 years) and were located in the parotid (7), submandibular salivary gland (2), and the minor salivary glands in the maxilla (2). The maximum tumor dimension ranged from 3 to 9 cm. Microscopically, all had infiltrating margins, with circumscribed groups of epithelial cells arranged in various patterns; the invasive component was embedded in a desmoplastic stroma. Perineural invasion and lymph node metastasis were noted in seven and three cases, respectively, at the time of initial surgery. Radical surgery was offered to ten patients and postoperative radiotherapy to nine patients. Salivary duct carcinoma appears to be an aggressive tumor with distinctive histological features, which has not been described in the minor salivary glands of the maxilla to date. The clinicopathologic features of these tumors are presented, with a review of the literature.

Fine needle aspiration biopsy cytology of chondrosarcoma

The cytomorphological appearances of bone and soft tissue tumours, when combined with radiology and clinical presentation, can lead to a positive diagnosis in the majority of cases. Our experience with fine needle aspiration biopsy of 13 cases of chondrosarcoma, encountered over a four year period is presented, in correlation with their radiological appearances. It is concluded that. FNAB is a valuable pre-operative tool in characterising chondroid neoplasms in soft tissue and bone.

Parapharyngeal ganglioneuroma. Report of a case diagnosed by fine needle aspiration

A case of ganglioneuroma presenting in a parapharyngeal location in a 4-year-old girl was subjected to fine needle aspiration cytology. A preoperative diagnosis of ganglioneuroma was subsequently confirmed on histopathologic examination. Only a few reports on the cytologic features of this tumor exist. The importance of considering this diagnosis for a tumor at an unusual site and in an uncommon age group is stressed.

Aspiration biopsy cytology of primary bone lesions

Fine needle aspiration cytology of 79 primary bone lesions was done, and the clinical and radiologic features were correlated with cytopathology. Seventy-four of these cases were primary malignant bone tumors, two cases each were tumor-like or inflammatory lesions, and one case was a benign bone tumor. Osteosarcoma (37.7%) and Ewing's sarcoma (15.6%) were the most common primary lesions. Correlation with histopathology was possible in 37 cases, and an accuracy rate of 94.1% was achieved. There was an 89% correlation between radiologic and cytologic diagnoses. It was concluded that in this oncology center a working diagnosis based on cytology was possible in almost all cases after correlating with the radiologic findings. However, when there was a discrepancy between the clinical, radiologic and cytologic diagnoses, an open biopsy was mandatory.

Extranodal sinus histiocytosis with massive lymphadenopathy--a case report

Sinus histiocytosis with massive lymphadenopathy involving organs other than the lymph nodes is a rare event. A case of SIIML presenting with multiple skin and subcutaneous nodules and multiple osteolytic lesions is described. A search of the Indian literature revealed many cases of nodal SIIML, but none of the reported cases had prominent extranodal involvement.

An interactive image analysis system for quantitative cytology & to classify cervical cells

Introduction of computers and image analysis systems are gaining faster momentum in order to quantitate the assessment of cells for diagnosis and prognosis, and this system aims to relieve the operator from the tedium of microscopic observation and reduce operator bias and human error. This paper discusses the design and configuration of an interactive image analysis system built in the laboratory for the purpose of cell analysis and classification. The software developed to compute various textural and morphological parameters of cells on smear are briefly described. The results of the experiments carried out to classify normal and abnormal cells on cervical smear show 94 per cent success rate.

Cytogenetic characterisation of small round cell tumours using fine needle aspiration

Cytogenetic analysis of short term cultures of fine needle aspirates from two tumours, characterised cytologically as small round cell neoplasms, showed specific clonal chromosomal abnormalities. In both cases the cytogenetic finding of a t(11; 22) (q24; q12) helped determine their diagnosis as peripheral neuroectodermal tumours of the thoraco-pulmonary region (Askin's tumour). These findings suggest that cytogenetics can reliably distinguish neoplasms which present as undifferentiated small round cell tumours.

Cystosarcoma phyllodes. Diagnosis by fine needle aspiration cytology

The cytologic features of 10 benign, 2 borderline and 5 malignant phyllodes tumors were studied, and an attempt was made to correlate the cytologic findings with corresponding histologic categories. Seventy-five percent of the benign and borderline tumors were interpreted as benign cystosarcoma phyllodes on fine needle aspiration cytology. Eighty percent of the malignant phyllodes tumors were identified as malignant lesions cytologically. The cytologic features assessed were the epithelial:stromal ratio and morphology of the stromal component, including the degree of atypia, mitotic activity, capillary vessels traversing the stromal fragments, presence of foamy macrophages, histiocytic giant cells and bipolar naked nuclei. A diagnosis of phyllodes tumor was suggested cytologically by the presence of both epithelial and stromal elements; the stroma was present as cellular "phyllodes fragments" and isolated mesenchymal cells. The parameters suggesting malignancy were extreme paucity or absence of epithelial elements and stromal cells in diffuse sheets and clusters less cohesive than normal, with marked stromal atypia and mitotic activity.

Melanotic neuroectodermal tumor of infancy initially diagnosed by fine needle aspiration cytology

A five-month-old male child presented with a tumor of the maxilla, which was clinically diagnosed as an eruption cyst or a rhabdomyosarcoma. Fine needle aspiration smears showed two types of cells: neuroblastlike cells and cells containing melanin pigment. A cytologic diagnosis of melanotic neuroectodermal tumor of infancy was made. This diagnosis was confirmed by histopathologic examination of the subsequently excised mass.