Rare Case of Tubercular Serpiginous-Like Choroiditis

Serpiginous choroiditis is a rare cause of posterior uveitis, included in the spectrum of white dot syndromes. It occurs as a result of an autoimmune process but could be associated with infections such as tuberculosis (TB) (serpiginous-like choroiditis). Tubercular serpiginous-like choroiditis is more commonly reported in Southeast Asian countries than in Western countries. We report a case of an Indian male in his late 30s with bilateral grey-yellowish subretinal infiltrates at the level of choroid with active scalloped edges having a positive TB-QuantiFERON Gold test (Cellestis Limited, Carnegie, Australia), who responded well to the treatment of intravenous methylprednisolone and systemic steroids (given initially to control the acute inflammation) while on anti-tubercular (anti-TB) therapy. The lesions finally completely healed on the anti-TB therapy.

Congenital Radioulnar Synostosis: A Case Report and Review of Various Osteotomies

Introduction

Congenital radioulnar synostosis is a rare deformity of the forearm characterized by a malformation of the proximal aspect of the radius and ulna. Various modalities of treatment options available include observation, excision of the synostosis and placing an interposition material, or performing derotation osteotomy. Several types of osteotomies at different forearm levels have been described in the literature.

Case Report

A 5-year-old female presented with bilateral congenital radioulnar synostosis which was treated with percutaneous corrective osteotomy and Joshi's external stabilizing system fixator application.

Conclusion

We describe the management of congenital radioulnar synostosis in a 5-year-old female child using a novel minimally invasive, single-staged procedure . This innovative technique provided the patient with a good functional outcome and she could return to her daily activities with a satisfactory range of motion.

Validation of Remote Digital Pathology based diagnostic reporting of Frozen Sections from home

Background

Despite the promising applications of whole-slide imaging (WSI) for frozen section (FS) diagnosis, its adoption for remote reporting is limited.

Objective

To assess the feasibility and performance of home-based remote digital consultation for FS diagnosis.

Material & Method

Cases accessioned beyond regular working hours (5 pm-10 pm) were reported simultaneously using optical microscopy (OM) and WSI. Validation of WSI for FS diagnosis from a remote site, i.e. home, was performed by 5 pathologists. Cases were scanned using a portable scanner (Grundium Ocus®40) and previewed on consumer-grade computer devices through a web-based browser (http://grundium.net). Clinical data and diagnostic reports were shared through a google spreadsheet. The diagnostic concordance, inter- and intra-observer agreement for FS diagnosis by WSI versus OM, and turnaround time (TAT), were recorded.

Results

The overall diagnostic accuracy for OM and WSI (from home) was 98.2% (range 97%-100%) and 97.6% (range 95%-99%), respectively, when compared with the reference standard. Almost perfect inter-observer (k = 0.993) and intra-observer (k = 0.987) agreement for WSI was observed by 4 pathologists. Pathologists used consumer-grade laptops/desktops with an average screen size of 14.58 inches (range = 12.3-17.7 inches) and a network speed of 64 megabits per second (range: 10-90 Mbps). The mean diagnostic assessment time per case for OM and WSI was 1:48 min and 5:54 min, respectively. Mean TAT of 27.27 min per case was observed using WSI from home. Seamless connectivity was observed in approximately 75% of cases.

Conclusion

This study validates the role of WSI for remote FS diagnosis for its safe and efficient adoption in clinical use.

Splenic surprise in a case of renal cell carcinoma: Unusual case or association?

Littoral cell angioma (LCA) is a rare benign tumor originating exclusively from the venous sinus lining cells of the splenic red pulp. These cells are unique in having a distinctive hybrid endothelial/histiocytic phenotype. Also, there are reports of the association of LCA with internal malignancies. We present a case report highlighting an unusual association of LCA with conventional renal cell carcinoma (RCC), masquerading as a metastatic lesion. Knowledge of such an association is necessary to avoid misdiagnosis and prevent potential overtreatment.

Critical Role of Flow Cytometric Immunophenotyping in the Diagnosis, Subtyping, and Staging of T-Cell/NK-Cell Non-Hodgkin's Lymphoma in Real-World Practice: A Study of 232 Cases From a Tertiary Cancer Center in India

Background

T-cell/NK-cell non-Hodgkin’s lymphoma (T/NK-NHL) is an uncommon heterogeneous group of diseases. The current classification of T/NK-NHL is mainly based on histopathology and immunohistochemistry. In practice, however, the lack of unique histopathological patterns, overlapping cytomorphology, immunophenotypic complexity, inadequate panels, and diverse clinical presentations pose a great challenge. Flow cytometric immunophenotyping (FCI) is a gold standard for the diagnosis, subtyping, and monitoring of many hematological neoplasms. However, studies emphasizing the role of FCI in the diagnosis and staging of T/NK-NHL in real-world practice are scarce.

Methods

We included T-cell non-Hodgkin’s lymphoma (T-NHL) patients evaluated for the diagnosis and/or staging of T/NK-NHL using FCI between 2014 and 2020. We studied the utility of FCI in the diagnosis and subtyping of T/NK-NHL and correlated the FCI findings with the results of histopathology/immunohistochemistry. For correlation purposes, patients were categorized under definitive diagnosis and subtyping, inadequate subtyping, inadequate diagnosis, and misdiagnosis based on the findings of each technique.

Results

A total of 232 patients were diagnosed with T/NK-NHL. FCI findings provided definitive diagnoses in 198 patients and subtyping in 187/198 (95.45%) patients. The correlation between FCI and histopathological/immunohistochemistry results (n = 150) demonstrated an agreement on the diagnosis and subtyping in 69/150 (46%) patients. Of the remaining cases, the diagnosis and subtyping were inadequate in 64/150 (42.7%), and 14/150 (9.33%) were misdiagnosed on histopathology/immunohistochemistry results. FCI provided definitive diagnosis and subtyping in 51/64 (79.7%) patients. Among these, 13 patients diagnosed with peripheral T-cell lymphoma not-otherwise-specified were reclassified (angioimmunoblastic T-cell lymphoma (AITL)-11 and prolymphocytic leukemia-2) on FCI. It corrected the diagnosis in 14 patients that were misdiagnosed (6 B-cell NHL (B-NHL), 3 Hodgkin’s lymphoma, 1 acute leukemia, and 1 subcutaneous panniculitis-like T-cell lymphoma) and misclassified (3 T-NHL) on histopathological results. AITL was the commonest T-NHL misclassified on histopathological results. FCI also confirmed the definite involvement in 7/83 (8.4%) and 27/83 (32.5%) bone marrow (BM) samples reported as suspicious and uninvolved, respectively, on histopathological evaluation.

Conclusion

AITL was the most frequently diagnosed T/NK-NHL in this study. FCI provided a distinct advantage in detecting BM involvement by T/NK-NHL, especially in patients with low-level involvement. Overall, our study concluded that FCI plays a critical role in the diagnosis, subtyping, and staging of T/NK-NHL in real-world practice.

Post-penetrating keratoplasty astigmatism

Postoperative astigmatism is one of the common complications affecting visual outcomes after a penetrating keratoplasty. It can result from various factors related to host, donor and surgical technique, resulting in suboptimal visual outcome. While some of the measures taken during preoperative planning and during actual surgery can reduce the magnitude of postoperative astigmatism, postoperative correction of astigmatism is often required in cases with high degrees of astigmatism. When spectacles and contact lenses fail to provide optimal visual outcomes, various surgical techniques that include astigmatic keratotomy, compression sutures, toric intraocular lens placement, and laser refractive procedures can be considered. When none of these techniques are able to achieve a desired result with in the acceptable optical range, a repeat keratoplasty is considered a last option. We discuss the various causes and management of complication of postoperative astigmatism occurring after a full thickness corneal transplantation surgery.

Diagnostic Efficacy of BRAFV600E Immunocytochemistry in Thyroid Aspirates in Bethesda Category IV and Papillary Thyroid Carcinoma

Background

In papillary thyroid carcinoma (PTC), BRAFV600E is a common mutation and is associated with aggressive clinical behaviour. Immunocytochemistry (ICC) and molecular testing are recommended in the Bethesda System for Reporting Thyroid Cytopathology 2017 (TBSRTC) category III, IV and V.

Aims

The current study aimed to evaluate the diagnostic efficacy of conventional FNAC versus FNAC with BRAFV600E immunostaining in cases of TBSRTC category IV, cases of suspicious for PTC and cases of PTC.

Methods and Material

The study included a prospective case series of 45 patients with clinically palpable thyroid nodules with TBSRTC category IV, category V (suspicious for PTC) and PTC. The corresponding histology specimens of all the 45 cases were also analyzed. Immunostaining for BRAFV600E was performed on FNAC cell blocks and their corresponding histology sections using anti-BRAF (VE1) clone (Ventana). The diagnostic efficacy of the BRAFV600E immunostaining was compared on cytological specimens with histological specimens.

Results

BRAFV600E immunostaining helped to improve the sensitivity of the cytology to confirm the PTC as a diagnostic aid for thyroid FNAs. Cytology alone had a sensitivity of 62.96% and a lower specificity of 60.70%. The combination of both the tests together provided 84.62% sensitivity and much higher specificity of 100%. PPV was also increased to 100% and NPV was raised 94.12%.

Conclusions

The performance of BRAFV600E immunostaining on the cytological specimen is a rapid, simple and cost-effective test and could be considered in TBSRTC category IV and suspicious and malignant cases of PTC.

Scurvy Masquerading as Septic Arthritis in a Case of Cerebral Palsy

Introduction:

Scurvy is a rarely seen in pediatric patients nowadays, seen more in those with developmental delay, autism or those who are severely malnourished. Epiphyseal separations are known to occur in scurvy, but only a few such cases have been reported in children with cerebral palsy. The diagnosis is often misleading since other morbidities as trauma, malignancies, coagulopathies, septic arthritis, osteomyelitis, or rheumatologic disorders are often considered at first. We report the case of 4-year-old female child with cerebral palsy in whom the initial concern was septic arthritis/osteomyelitis based upon clinical presentation, ultrasonic and magnetic resonance imaging, led to a surgery revealing subperiosteal hematomas.

Case Report:

A 4-year-old girl was admitted in the pediatrics department for fever and bilateral knee joint pain for 3 days. She was a diagnosed case of with cerebral palsy, psyco-developmental delay, and epileptogenic disorder put under valproic acid. She was toxic and febrile. Within 4 h after admission, both knees developed tense shiny intense swelling associated with pain, redness, and local rise of temperature with limited active range of motion. Near-complete passive range of motion was noted. There were no abnormal findings on the rest of the musculoskeletal examination. Aspiration of the knee revealed subperiosteal hematoma diagnostic of scurvy.

Conclusion:

Scurvy is exceedingly rare in children nowadays; however, its presentation among risky populations should not be forgotten. Musculoskeletal revelations, mostly subperiosteal hematoma, are the main manifestation of scurvy in the pediatric population. Scurvy as a differential diagnosis for trauma, osteomyelitis, septic arthritis will always be a bane for orthopedic surgeons. A heightened awareness is needed to avoid unnecessary surgery, unnecessary tests, and procedures and to be able to start treatment for a potentially fatal but easily curable disease.

The prognostic role of PET myocardial perfusion imaging in patients with cardiac sarcoidosis: a systematic review

Funding Acknowledgements

Type of funding sources: None.

Background

Sarcoidosis is a multi-systemic inflammatory disease of unknown etiology. Cardiac Sarcoidosis (CS) has been reported in as much as 25% of patients with systemic involvement. 18Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) has a high diagnostic sensitivity/specificity in the diagnosis of CS.

Purpose

The aim of this review is to summarize evidence on the prognostic role of FDG PET.

Methods

Studies were identified by searching MEDLINE from inception to October 2020. Medical Subject Headings (MeSH) terms for sarcoidosis; cardiac and FDG PET imaging were used. Studies of any design assessing the prognostic role of FDG PET in patients with either suspected or confirmed cardiac sarcoidosis imaging done at baseline were included. Abnormal PET was defined as abnormal metabolism (presence of focal or focal-on-diffuse uptake of FDG) OR abnormal metabolism and a perfusion defect. Studies reporting any outcome measure were included. Pooled risk ratio for the composite outcome of MACE was done.

Results

A total of 6 studies were selected for final inclusion (515 patients, 53.4% women, 19.8% racial minorities.) Studies were institution based, retrospective in design and enrolled consecutive patients. All were observational in nature and published in English. All studies used a qualitative assessment of PET scans (abnormal FDG uptake with or without abnormal perfusion). Two studies assessed quantitative metrics (summed stress score in segments with abnormal FDG uptake, standardized uptake value and cardiac metabolic activity.) All studies reported Major Adverse Cardiovascular Events (MACE) as a composite outcome. After a mean follow up ranging from 1.4 to 4.1 years, there were a total of 105 MACE. All studies included death (either all-cause death or sudden cardiac death) and ventricular arrhythmia (ventricular tachycardia or ventricular fibrillation) as a component of MACE. Four of the six studies adjusted for several characteristics in their analysis. All four studies used Left Ventricular Ejection Fraction (LVEF). However, other adjustment variables were not consistent across studies. Five studies found a positive prognostic association with the primary outcome, two of which assessing right ventricular uptake.

Conclusion

Although available evidence indicates FDG PET can be used in the risk stratification of patients with CS, our findings show further studies are needed to quantify the effect in this patient group.

Impact of COVID 19 lockdown on orthopaedic surgeons in India: A survey

BACKGROUND

In the fight against COVID 19, the government of India announced a 3 weeks lockdown of the entire country of 1.3 billion people on 24th March 2020.

METHODS

One week after the lockdown was announced, we conducted an anonymous online survey of the orthopaedic surgeons in India through social media platforms to assess the impact of the lockdown during COVID 19. The survey had a total of 13 questions with (3-5) options and was designed with an aim to understand the perception and the state of mind of the Orthopaedic surgeons in the lockdown situation.

RESULTS

The survey was completed by 611 orthopaedic surgeons from 140 cities in India. There were 22.5% orthopaedic surgeons who said that they were definitely stressed out, and 40.5% who said they were mildly stressed out. As the age decreased, the percentage of orthopaedic surgeons feeling "definitely stressed out" increased. Disruption of life-work balance and uncertainties regarding return to work were other strongly associated factors with the "definitely stressed out" group.

CONCLUSION

The psychological impact of the lockdown during COVID 19 on orthopaedic surgeons may become a potential concern that will require addressal through open discussion.

LEVEL OF EVIDENCE

diagnostic level 4.

Vitamin D supplementation reduces airway hyperresponsiveness and allergic airway inflammation in a murine model

BACKGROUND

Asthma is a chronic disease associated with airway hyperresponsiveness (AHR), airway obstruction and airway remodelling. NF-κB is a transcriptional factor that regulates and co-ordinates the expression of various inflammatory genes. The NF-κB subunits, p50 and Rel-A, are translocated to the nucleus by importin α3 and importin α4. There is growing evidence that vitamin D is a potent immunomodulator. However, the evidence for beneficial or adverse effects of vitamin D in asthma is still unclear.

OBJECTIVE

In this study, we examined the effect of vitamin D status on AHR, airway inflammation and cytokines in the bronchoalveolar lavage fluid (BALF) in a murine model of allergic asthma.

METHODS

Female BALB/c mice were fed with special vitamin D-deficient or vitamin D-sufficient (2000 IU/kg) or vitamin D-supplemented (10,000 IU/kg) diet for 13 weeks. Mice were sensitized and challenged with ovalbumin (OVA). The effect of vitamin D on lung histology, AHR, T regulatory cells (Tregs) and BALF cytokines was examined. The expression of importin-α3 and Rel-A in the lung of OVA-sensitized mice was analysed using immunofluorescence.

RESULTS

Vitamin D deficiency was associated with higher AHR in OVA-sensitized and challenged mice than those in vitamin D-sufficient mice. This was accompanied with marked signs of airway remodelling, high BALF eosinophilia, increased BALF pro-inflammatory cytokines, reduced BALF IL-10 levels, reduced blood Tregs, increased expression of importin-α3 and Rel-A in the lung tissue. Vitamin D supplementation attenuated the pro-inflammatory effects, but did not completely reverse the features of allergic airway inflammation.

CONCLUSION AND CLINICAL RELEVANCE

Vitamin D could be beneficial as an adjunct therapy in the treatment of allergic asthma.

Chlamydia trachomatis: TLR4-mediated recognition by human dendritic cells is impaired following oestradiol treatment

Genital Chlamydia trachomatis infection creates a substantial reproductive health burden in women. The high incidence of asymptomatic infection often precludes timely antibiotic therapy to control the sequelae of infection, and therefore a vaccine is required. Dendritic cells (DC) are now being used as an adjuvant for vaccine development; however, the fate of C. trachomatis in human DC and differential regulation of cytokine secretion remains unclear. Hence, an in vitro study was performed using C. trachomatis (serovar D) elementary body (EB)-pulsed, monocytederived DCs co-cultured with autologous CD4+ T cells. Secreted cytokines were measured to assess the protective/pathogenic immune response. The effect of (beta-oestradiol in the modulation of DC function and on Toll-like receptor (TLR) gene expression was also studied. Elementary body-pulsed DCs showed induction of protective Th1 immune response with upregulation of TLR4 expression, secretion of interleukin (IL)-6, IL-12 and interferon (IFN)-y, together with upregulation of major histocompatibility complex (MHC) class II, CD83 and CD86. When co-cultured with autologous CD4+T cells, DCs presented chlamydial antigens efficiently, as shown by proliferation of T cells and secretion of IL-2 and IFN gamma, which provide a protective immune response. However; pretreatment of cells with oestradiol significantly reduced TLR4 expression and upregulated IL-10 secretion, modulating the Th1 immune response to a Th2-type response, which may lead to pathogenesis.

Protective or pathogenic immune response to genital chlamydial infection in women--a possible role of cytokine secretion profile of cervical mucosal cells

Little is known about genital mucosal immune response to chlamydial infection in women with or without sequelae (Chlamydia positive women with or without fertility disorders as infertility and multiple spontaneous abortions). Cervical lymphocytes were stimulated with chlamydial EBs and cytokine secretion was determined by ELISA, RT-PCR and ELISPOT assays. Stimulated cervical cells from women with fertility disorders (FD) secrete significantly (P<0.05) higher levels of IL-1beta, IL-6, IL-8 and IL-10 and cells from fertile women secrete significantly higher levels of IL-12 and IFN-gamma compared to other groups. RT-PCR analysis showed similar results for IFN-gamma and IL-12. For IL-10 and IL-4, mRNA expression levels were significantly higher (P<0.05) in cells obtained from women with FD compared to other groups. Results for ELISPOT assay were similar as those of RT-PCR. The results suggest that cytokine secretion profile of cervical cells may decide whether infection does not hamper fertility or will develop fertility disorder.

Mucosal and peripheral immune responses to chlamydial heat shock proteins in women infected with Chlamydia trachomatis

Most of the studies on 60-kDa and 10-kDa chlamydial heat shock proteins (HSPs) to date have been carried out with blood lymphocytes or serum antibody responses, which do not provide a clear picture of the actual pathogenesis as they do not differentiate primary infection from recurrent infection. Thus, in the present study induction of the immune response was evaluated by studying lymphoproliferation of both cervical and peripheral lymphocytes to synthetic peptides of cHSP60, cHSP10 and major outer membrane protein (MOMP) antigen. In addition, cervical antibody prevalence to MOMP antigen, cHSP60 and cHSP10 and cytokine levels in cervical washes was also determined. Positive proliferative responses of cervical lymphocytes to cHSP10 peptide were significantly higher (P < 0.05) in women with recurrent infections and that to MOMP antigen were significantly higher in primary infection. On proliferation of PBMCs with the above antigens, no significant difference was observed between primary and recurrent infection. Prevalence of cervical IgG and IgA antibodies to Chlamydia trachomatis was significantly higher (P < 0.05) during primary infection than recurrent infections. In contrast, prevalence of IgG and IgA antibodies to cHSP10 and IgG antibodies to cHSP60 was higher during recurrent infections than primary infections. Interferon (IFN)-gamma levels were significantly higher in cervical washes of women with recurrent infection and correlated strongly with cHSP60 antibody titres. Our data thus suggest that mucosal responses are more appropriate in understanding the pathogenesis of chlamydial infection and IFN-gamma could be involved in the modulation of immune responses towards chlamydial infection directly, by causing acute inflammation, or indirectly through modulation of HSP expression.