Pictorial Review of Post COVID-19 Acute Invasive Fungal Sinusitis: Clinical Radiologists' Perspective

Acute invasive fungal sinusitis (AIFS) is a rapidly progressive infection predominantly seen in immunocompromised patients. There is an increasing incidence of AIFS post COVID-19 infection. Yet, there is sparse literature regarding spectrum of cross-sectional imaging findings (CT and MRI) in these patients, which is prudent for appropriate timely surgical intervention. This study aims to highlight spectrum of imaging findings in patients with post-COVID-19 AIFS integrating the clinical details from presentation to follow-up. We retrospectively reviewed the demographics, clinical details and radiological imaging of 31 histopathological proven cases of post COVID-19 AIFS. MR and CT images of these patients were retrieved from the PACS and analysed. 90-day follow-up of these patients was obtained. Statistical analysis was performed using descriptive statistics. Cross-sectional imaging showed nasal cavity involvement in all patients, bilateral in (15, 48%) cases; predominant involvement of maxillary (31, 100%) followed by ethmoid sinuses (29, 93.5%) was seen. MR showed patchy/complete loss of normal mucosal enhancement in the turbinates and sinuses as predominant imaging finding. Maxillary sinus walls erosions were seen in 28 cases (90%). Rhino-orbital and rhino-orbito-cerebral mycosis was seen in 24 (77%) and 14 (45%) respectively. Optic nerve-sheath complex was involved in 15 (48%) cases. Cerebral involvement was seen in form of meningeal enhancement, cerebritis, ischemic changes, cavernous sinus and intracranial arterial thrombosis and aneurysms. Comprehensive knowledge of imaging features of AIFS and recognition of extent of their spread allows radiologists to play pivotal role in alerting the clinician for appropriate therapy to avoid protracted and fatal outcome.

Renal lymphoma diagnosed on kidney biopsy presenting as acute kidney injury

Introduction:

Renal manifestations associated with hematolymphoid malignancies are known. Primary or secondary involvement of the kidney by lymphomatous infiltration has various clinical presentations. Acute kidney injury is not an uncommon finding in relation to lymphomatous interstitial infiltration proven on kidney biopsy. However, diagnosing it solely on renal biopsy remains a challenge and needs expertise and aid of immunohistochemistry as the prognosis is dismal.

Methods:

This is a retrospective study of kidney biopsy-proven cases of renal lymphoma presenting with acute kidney injury.

Results:

The study included 12 patients with ages ranging from 4 to 50 years who presented with serum creatinine ranging 2.1–9.6 mg%. Renal biopsy findings showed interstitial lymphomatous infiltrate. Two cases were diagnosed as primary lymphoma and the other 10 as secondary lymphomas. Among the 12 cases, nine were B-cell non-Hodgkin lymphoma, of which diffuse large B-cell lymphoma was diagnosed in six (50%), low-grade B-cell type in two (16.6%), chronic lymphocytic leukemia in one (8.3%), and three were T-cell-type. Two were acute T-cell lymphoblastic lymphoma and one other was a high-grade T-cell lymphoma. Four patients succumbed. The other four patients are alive; one is on chemotherapy, while two of them are on hemodialysis.

Conclusion:

Acute kidney injury as a presenting feature with lymphomatous infiltration of renal parenchyma is not uncommon. The patchy involvement makes it challenging on kidney biopsy with definitive diagnosis being made with the help of immunohistochemistry. Appropriate multidisciplinary involvement improves patient outcome.

Study of Histomolecular Classification of Glioma-Integrating Histology and Molecular Analysis in the Diagnosis of Brain Tumors

Introduction The updated 2016 classification of gliomas incorporates well-established molecular parameters into the classification of diffuse gliomas, taking into account isocitrate dehydrogenase 1 (IDH1) mutation, α-thalassemia/mental retardation syndrome X-linked (ATRX) loss, and 1p/19q co-deletion.

Aim and Objectives To study IDH1 and ATRX mutations in gliomas, 1p/19q co-deletion by fluorescent in situ hybridization (FISH) in oligodendroglioma, and to correlate IDH1, ATRX, and 1p/19q with tumor type and grade.

Material and Methods Total 73 cases of gliomas were diagnosed on histology and graded as astrocytoma (grades 2–4), oligodendroglioma (grades 2–3), and oligoastrocytoma (grades 2–3) by two pathologists independently. IDH mutation and ATRX expression were analyzed using immunohistochemistry in all cases whereas 1p/19q co-deletion was studied using FISH in cases with oligodendroglioma and oligoastrocytoma morphology.

Results Total 48 cases of astrocytoma, 9 cases of oligoastrocytoma, and 16 cases of oligodendroglioma were included. The maximum number of IDH1 mutation cases were seen in diffuse astrocytoma (7/10; 70%) as compared with anaplastic astrocytoma (5/15; 33.33%), glioblastoma multiforme (GBM) (3/23; 13.04%) grade II oligoastrocytoma (3/6; 50%), anaplastic oligoastrocytoma (2/3; 66.67%), and oligodendroglioma grade II (7/10; 70%). ATRX loss was seen in diffuse astrocytoma grade II (6/10; 60%), anaplastic astrocytoma (6/15; 40%), oligoastrocytoma grade II (2/6; 33.33%), and anaplastic oligoastrocytoma (1/3; 33.33%). 1p/19q co-deletion was seen in oligoastrocytoma (2/2; 100%), anaplastic oligoastrocytoma (1/2; 50%), oligodendroglioma (3/4; 75%), and anaplastic oligodendroglioma (1/3; 33.33%). Six of the seven cases with 1p/19q co-deletion also showed IDH1 mutation. One of seven 1p/19q co-deleted cases had loss of expression of ATRX.

Conclusion Incorporation of IDH1 mutation, ATRX loss, and 1p/19q co-deletion molecular studies help in a more accurate diagnosis and classification of gliomas.

Melanorrhea: Noncontiguous spread of palpebral conjunctival melanoma to the nasolacrimal duct

A 42-year-old Asian Indian male with a history of conjunctival melanoma in the left eye presented with a recurrent tumor in the upper tarsal conjunctiva. The tumor was completely excised under margin control, followed by two-staged eyelid reconstruction. During the second stage of the eyelid reconstruction, a brown-colored discharge was noted at the punctum, which on cytology was confirmatory of melanoma. Left dacryocystectomy with en bloc nasolacrimal duct (NLD) excision was performed. Histopathology demonstrated infiltration of the NLD by the tumor with no presence of melanoma in the lacrimal sac. Lacrimal oncorrhea is a term used to describe tumor spread by free-floating cells in the tear film. All conjunctival tumors carry a risk of tumor spread by oncorrhea.

Ovarian apoplexy resulting from ruptured heterotopic pregnancy following intrauterine insemination

Heterotopic pregnancy is on the rise with the use of assisted conception and commonly involves the fallopian tube. Ovarian heterotopic pregnancy is rare, with fewer than 40 reported cases in PubMed/Medline; cases of ovarian ectopic pregnancy after intrauterine insemination are even rarer, with only seven published reports. We report here a case of ovarian heterotopic pregnancy following intrauterine insemination; this could possibly be the first such report. Our patient presented with circulatory collapse in the first trimester and laparoscopy disclosed an ovarian pregnancy with hemoperitoneum. Following resection of the ovarian pregnancy, the intrauterine gestation continued undisturbed and the patient delivered at term. Heterotopic pregnancy and unusual ectopic locations should be considered a possibility in pregnant women with pelvic pain, particularly following fertility treatment, including ovarian stimulation and intrauterine insemination.

Delayed presentation of a virilising, pure testosterone-secreting adrenocortical carcinoma with coexistent composite myelolipoma and a venous thrombus extending to the heart

A 40-year-old normotensive woman presented with abnormal facial hair for 4 years and amenorrhoea for 13 years. Hormonal, biochemical and haematological evaluation showed isolated elevation of serum testosterone and free testosterone. Her follicle-stimulating hormone and luteinising hormone were in the premenopausal range. Until recently she had reconciled to early 'menopause' and visited beauty clinics but never sought medical evaluation. Imaging revealed an enhancing left adrenal mass with fat densities and venous thrombus extending through the inferior vena cava to a 7 cm mass in the right atrium. She underwent left kidney-preserving surgery utilising hypothermic cardiopulmonary bypass with early clamping of the pulmonary artery without circulatory arrest. Histology showed adrenocortical carcinoma with composite incidental myelolipoma and neoplastic thrombus. At 2 months, testosterone has normalised and she is doing well. Isolated testosterone-secreting adrenocortical carcinoma with massive venous thrombus is rare as is coincidental composite macroscopic myelolipoma.

Plasma Cell Infiltration of the Kidney as a Manifestation of Myeloma: A Report of Three Cases

Infiltration of renal parenchyma by neoplastic plasma cells in myeloma patients is an unusual finding. We report 3 cases of myeloma, with renal biopsy being the first clue to the diagnosis in one. The plasma cell infiltrate in other two cases was not so evident but immunofluorescence (IF) and immunohistochemical (IHC) stains for light chains helped establish the monoclonal nature of the infiltrate. We surmise that plasma cell infiltration in the kidney can be an important clue to the diagnosis of an underlying myeloma and could in future be regarded as a myeloma-defining event (MDE) if monoclonality is confirmed. This finding could directly affect the prognosis and be a direct indicator of the tumor burden. Further studies are however required to determine the exact prognostic value and precise relationship of such a finding with deranged renal functions in myeloma.

A rare case of fever of unknown origin: subcutaneous panniculitis-like T-cell lymphoma (SPTCL)

A 26-year-old man presented with high-grade fever, chills, productive cough and episodic abdominal pain of 6 months duration. Physical examination revealed that the patient was febrile and had multiple, ill-defined, tender, indurated, erythematous nodules and plaques over the trunk and thighs. Systemic examination and investigations revealed bilateral exudative pleural effusion with an increased adenosine deaminase (ADA) level. Pulmonary tuberculosis was suspected and the patient was started on a standard four-drug antitubercular regimen. Since his fever persisted, biopsy of the plaque over the trunk was performed, which showed lobular panniculitis with atypical lymphoid cells. Immunohistochemistry showed atypical lymphoid cells, which were CD3 and CD8 positive and CD4 negative. Based on the clinical features, skin biopsy and immunohistochemistry, the diagnosis of subcutaneous panniculitis-like T-cell lymphoma was made. The patient was treated with chemotherapy followed by bone marrow transplantation, and 4-year follow-up showed complete remission of lymphoma.

Rosette-forming glioneuronal tumors: a report of two cases

Rosette-forming glioneuronal tumor, a mixed glial and neuronal tumor, is a relatively new entity in tumors of the central nervous system, included in 2007 classification published by World Health Organization (WHO). It was initially described to occur in and around the fourth ventricle; however, recent case series have reported other locations also. Their occurrence in supratentorial and spinal locations has recently been reported. We report two cases of rosette-forming glioneuronal tumors, one in the midbrain and one in a suprasellar location, and review the literature.

Collagenofibrotic glomerulopathy in association with Hodgkin's lymphoma

Deposit glomerulopathies are characterized by fibrillary deposits of various sizes, mainly in the mesangial area. Collagenofibrotic glomerulopathy is a rare type of such fibrillary glomerulopathies characterized by deposits of 60-80 nm fibrils in the sub-endothelial and mesangial areas. It is also associated with increased levels of serum pro-collagen type III peptide (PIIINP). Although most of the initial reports have emanated from Japan, many other scientists around the globe have later reported this disease. Possibility of systemic disease affecting metabolism of type III collagen is postulated but so far no such association has been identified. We report a 26-year-old male patient who presented with insidious onset of febrile illness associated with lymphadenopathy and proteinuria. Lymph node biopsy revealed features of Hodgkin's lymphoma while percutaneous renal biopsy showed features of collagenofibrotic glomerulopathy.

Cerebral atypical teratoid rhabdoid tumour arising in a child treated for acute lymphoblastic leukaemia

Atypical teratoid rhabdoid tumours (ATRT) are rare, arising typically in childhood. ATRT arising as a secondary tumour in children treated for acute lymphoblastic leukaemia have not been reported so far. We report a case of ATRT in a 17-year-old boy, 11 years after he was treatment for acute lymphoblastic leukaemia with cranial radiation.

Myxoid adrenal adenoma with focal pseudoglandular pattern

Adrenal cortical tumors with myxoid change are rare tumors. To our knowledge, only 22 cases have been described so far in literature, which include 13 carcinomas and 9 adenomas. A pseudoglandular pattern has been described in 9 of these tumors. We report a case of a myxoid adenoma of the left adrenal gland in a 67-year-old woman, with a focal pseudoglandular pattern involving about 20% of the studied tumor. Rest of the tumor was composed of anastomosing cords of tumor cells. Abundant myxoid stroma was present, which stained positively with alcian blue and was weakly focally positive with periodic acid Schiff. Immunophenotype was consistent with an adrenal tumor, i.e., positive for vimentin, inhibin, and melan A. Cytokeratin AE1/AE3 and chromogranin were negative. MIB-1 index was < 0.1%.

Primary lymphoma of the breast: a clinicopathological study

3 cases of primary non Hodgkins lymphoma of the breast are described, seen over a period of 2 years among 199 cases of breast malignancies. All were diffuse large B cell type. Application of immunohistochemistry greatly aids in differentiating lymphoma from anaplastic carcinoma, with which it can easily be confused. Preoperative diagnosis on a trucut biopsy is an ideal diagnostic method since diagnosis on fine needle aspiration cytology or frozen section may not be possible. Primary breast lymphoma is a rare disease with reported incidence of 0.04-0.53% of all breast malignancies in most series. Accurate diagnosis is essential, so that appropriate treatment may be applied. Two cases were treated with CHOP chemotherapy and radiotherapy along with surgical excision. One case was treated with CHOP chemotherapy.

Duodenal angiomyolipoma: a case report

The authors present a case of duodenal angiomyolipoma. Angiomyolipoma is a benign neoplasm, the most common site being the kidney. Extrarenal angiomyolipomas are rare. Only one case of duodenal angiomyolipoma has been reported. A 66 year old man presented with GI bleeding for two years. Endoscopy revealed a duodenal polyp which on histopathology revealed features of angiomyolipoma. On immunohistochemistry, smooth muscle component was positive for Smooth Muscle Actin. HMB-45 showed mild focal positivity. Patient had no history of tuberous sclerosis. Surgical excision of angiomyolipoma is usually curative with rare cases of local recurrence.

Benign fibrous histiocytoma of the bladder

Mesenchymal tumors of the bladder are rare with leiomyoma accounting for most of these. We present a rare case of a bladder benign fibrous histiocytoma in a 52-year-old male. He presented with history of straining during micturition since two years. The magnetic resonance imaging revealed a large intravesical mass. The mass was excised. It weighed 600g, with a maximum dimension of 13cm. Histology was that of a benign fibrous histiocytoma. To our knowledge, only two cases of this tumor have been reported in the bladder so far. The clinical and pathological features are discussed.

Rosai-Dorfman disease mimicking a sphenoid wing meningioma

A 40-year-old male presented with a single generalized tonic-clonic seizure. MRI revealed an enhancing, dural-based, left lateral sphenoid wing lesion suggestive of a meningioma. At microsurgical excision, the lesion was firm and relatively avascular. The histopathological report revealed S-100 positive histiocytic proliferation with lymphophagocytosis (emperipolesis) characteristic of the Rosai-Dorfman disease. The case and its management are discussed.