Longevity of Immunoglobulin-G Antibody Response Against Nucleocapsid Protein Against SARS-CoV-2 Among Healthcare Workers

Background

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused the latest pandemic and the most significant challenge in public health worldwide. Studying the longevity of naturally developed antibodies is highly important clinically and epidemiologically. This paper assesses the longevity of antibodies developed against nucleocapsid protein amongst our health-care workers.

Methods

This longitudinal cohort study was conducted at a tertiary hospital, Saudi Arabia. Anti-SARSsCoV-2 antibodies were tested among health-care workers at three-point intervals (baseline, eight weeks, and 16 weeks).

Results

Of the 648 participants, 112 (17.2%) tested positive for Coronavirus (COVID-19) by PCR before the study. Of all participants, 87 (13.4%) tested positive for anti-SARS-CoV-2 antibodies, including 17 (2.6%) participants who never tested positive for COVID-19 using rt-PCR. Out of the 87 positive IgG participants at baseline, only 12 (13.7%) had remained positive for anti-SARS-CoV-2 antibodies by the end of the study. The IgG titer showed a significant reduction in values over time, where the median time for the confirmed positive rt-PCR subgroup from infection to the last positive antibody test was 70 (95% CI: 33.4-106.5) days.

Conclusion

Health-care workers are at high risk of exposure to the SARS-CoV-2 virus, and contracting an asymptomatic infection is not unlikely. Developing and sustaining natural immunity differs from one person to another, while the rate of positive IgG anti-SARS-CoV-2 wanes over time.

Clinicaltrialsgov Identifier

NCT04469647, July 14, 2020.

A Cohort Study of Seroprevalence of Antibodies Against SARS-CoV-2 Infection Among Healthcare Workers at a Tertiary Hospital in Saudi Arabia

Background

The nature of the healthcare workers’ jobs standing at the frontline against the coronavirus disease 2019 (COVID-19) puts them at a higher risk of unknowingly contracting the disease and potentially contributing to the spread. This study aims to assess the overall positive seroconversion prevalence of SARS-CoV-2.

Methods

This is a longitudinal cohort study of healthcare workers at Johns Hopkins Aramco Healthcare (JHAH). JHAH is a tertiary hospital located in Dhahran serving patients in several districts in the Eastern Province of Saudi Arabia. Participants were recruited between June and December 2020. Each participant had a serology blood test and completed the World Health Organization’s risk factor assessment questionnaire.

Results

This study included 682 participants working in JHAH, representing 15.7% of our population. Out of the 682 participants, 15.2% had a positive SARS-CoV-2 rt-PCR before taking part in the study. However, only 87 tested positive for SARS-CoV-2 antibodies, a prevalence of 12.7% of all participants. Out of the 87 positives for SARS-CoV-2 antibodies, 17 participants never tested positive for COVID-19 rt-PCR, a prevalence of 2.9%. Moreover, not properly using alcohol-based hand rub or soap and water after the risk of body fluid exposure and wearing personal protective equipment when indicated were found to be statistically significant to having a positive SARS-CoV-2 IgG assay.

Conclusion

Positive seroconversion rate was considerably low during the first wave of COVID-19 amongst JHAH’s healthcare workers and similar to other healthcare organizations in Saudi Arabia. Seropositivity correlated significantly with following infection prevention and control recommendations.

Clinicaltrials.gov Identifier

NCT04469647.

Immunopathology of Kikuchi-Fujimoto disease: A reappraisal using novel immunohistochemistry markers

AIMS

Kikuchi-Fujimoto disease (KFD) is a self-limited disease characterised by destruction of the lymph node parenchyma. Few studies have assessed the immunohistological features of KFD, and most employed limited antibody panels that lacked many of the novel immunohistochemistry markers currently available.

METHODS AND RESULTS

We used immunohistochemistry to reappraise the microanatomical distribution of plasmacytoid dendritic cells (pDCs), follicular helper T cells and cytotoxic T cells, B cells, follicular dendritic cell (FDC) meshworks, and histiocytes in lymph nodes involved by KFD. The study group consisted of 138 KFD patients (89 women; 64.5%) with a median age of 27 years (range, 3-50 years). Cervical lymph nodes were most commonly involved, in 108 (78.3%) patients. The numbers of pDCs were increased, predominantly around and within apoptotic areas and the paracortex, and tapering off within xanthomatous areas. pDCs formed sizeable tight clusters, most notably around apoptotic/necrotic areas. T cells consisted mostly of CD8-positive cells with predominant expression of T-cell receptor-β. There were notable increases in the numbers of CD8-positive T cells within lymphoid follicles, and their numbers correlated with alterations in FDC meshworks (P < 0.001). The number of follicular helper T cells was decreased within distorted FDC meshworks. CD21 highlighted frequent distortion of FDC meshworks, even in lymph node tissue that was distant from apoptotic/necrotic areas. Distorted FDC meshworks spanned all morphological patterns, and FDC meshwork characteristics (intact; distorted; remnant/nearly absent) correlated with morphological patterns (P < 0.01).

CONCLUSIONS

The immunohistological landscape of KFD is complex and characterised by increased numbers of pDCs that frequently cluster around apoptotic/necrotic foci, increased numbers of cytotoxic T cells, and substantial distortion of FDC meshworks.

Gastrointestinal stromal tumors. A clinicopathological study

OBJECTIVES

To evaluate the clinical presentations and immunohistochemical (IHC) properties of gastrointestinal stromal tumors (GISTs) and to compare them to internationally published data.

METHODS

Thirty-six patients diagnosed with GISTs between January 1997 and December 2015 were retrospectively studied in 2 tertiary hospitals. Immunohistochemical staining was carried out prospectively when it has not been completed fully at the beginning. Results: The median age of patients was 54 years  (range; 17-81 years). Predominantly, we found more females were affected. The male to female ratio was 1:1.7. The most frequently affected organs were the stomach (63.8%) followed by small bowel (25%) and colorectal region (8.4%). Abdominal pain was the most frequent presentation in 33.3% of the patients then gastrointestinal (GI) bleeding in 30.5%. Most of the gastric GISTs were at early stages at presentation: stage 1 and II (60.8%), while in non-gastric GISTs, the tumor stage was advanced: stage III and IV (69.3%). The IHC characteristic of GIST in descending order showed positivity for vimentin (88.9%), CD117 (83.3%), CD34 (77.8%), Ki67 (63.9%), SMA (38.9%), desmin (27.8%), and S100 (19.4%).

CONCLUSION

Gastrointestinal stromal tumors in our study demonstrates a major similar feature as the published international data. However, minor differences do exist in terms of clinical features and immunohistochemistry.

Mullerianosis of the Urinary Bladder: A Case Report

Mullerianosis is a rare entity consisting of an admixture of 2 or more of the following tissues: endometriosis, endocervicosis, and endosalpingiosis. It most commonly affects the urinary bladder and affects females of fertile age. It presents clinically as hematuria, dysuria, and pelvic pain which may be associated with menstruation. Radiologically and macroscopically, it typically presents as a polypoid mass in the dome or posterior wall of the bladder. Histologically, it consists of glands of varying size lined by endometrial, endocervical, or tubal epithelium. Mullerianosis clinically and histologically mimics other benign and malignant lesions. Herein we report a case of mullerianosis of the urinary bladder. This is a rare lesion with less than 20 cases reported in the literature thus far. We believe raising awareness of this poorly recognized entity is of utmost significance in order to avoid misdiagnosis and the following unnecessary radical procedures.

CD10 and CD138 can be expressed in giant cell tumor of bone: An immunohistochemical study

Giant cell tumor of bone (GCTB) is a primary bone neoplasm which is characterized by the presence of mononuclear cells (MCs) and osteoclast-like multinucleated giant cells (MNGCs). Up to our knowledge, CD10 immunoreactivity in GCTB has not yet been studied, and only one study touched on CD138 immunoreactivity in GCTB. The objective of this study is to investigate the immunoreactivity of CD10 and CD138 in GCTB. We offer a discussion of our findings in the context of the differential diagnosis, particularly in small biopsy material. We retrieved and reviewed 15 well-documented cases of GCTB from January 2008 to December 2014. Well-controlled standard immunohistochemical satins were performed on these cases for CD10 and CD138 and few other selected antibodies. Immunoreactivity for CD10 was membranous and was found in 14 (93%) cases. This immunoreactivity was found only in the MCs, whereas the MNGC were all negative. CD138 showed variable positivity in 11 (73%) while 4 (37%) were completely negative. Similar to CD10, staining for CD138 was only seen in the MC; however, the immunoreactivity was predominantly concentrated in the peri-vascular areas. Most of GCTB cases can show variable immunoreactivity for CD10 and CD138. The aforementioned immune-expression raise the possibility of a role in the pathogenesis of GCTB. Paying attention to this immunoreactivity is recommended when considering the clinical and radiological differential diagnosis, especially in small biopsy specimens.

Breast hamartoma: A report of 14 cases of an under-recognized and under-reported entity

OBJECTIVES

Mammary hamartoma is a rare benign lesion accounting for approximately 4.8% of all benign breast masses. It is often underdiagnosed and therefore is underreported mostly due to lack of awareness of the characteristic clinical and histological features. Raising awareness of this poorly recognized benign entity is of utmost significance as it clinically mimics other breast tumors including both benign and malignant ones. This study is to report and present our experience of breast hamartomas from Johns Hopkins Aramco Healthcare in the Eastern province of Saudi Arabia from which there have not been previous studies in literature.

METHOD

A retrospective review of our pathology files was done from 1994 to 2014 for cases diagnosed as breast hamartoma during this 20 year period.

RESULTS

A total of 14 cases with diagnosis of breast hamartoma were identified in our institute. Histologically the lesion is mostly sharply demarcated showing a mixture of varying proportions of fibrous, adipose, and glandular tissue. 13 cases were seen in females (93%) and only one rare occurrence in a male patient (7%). The age ranges quite vastly from 18 to 51 years (mean 33 years). Two-third of these lesions were seen involving the right breast (9 cases/64.3%) and only one-third in the left side (5 cases/35.7%). 13 out of 14 patients had a well circumscribed lesion (92.9%) while only 1 case showed irregular borders (7.1%). The size varied from 1.4 to 9.5cm. Three cases (21.4%) showed evidence of myoid differentiation, a histopathologic variance which is important to identify however has no clinical significance. 3 cases had associated epithelial ductal hyperplasia of the usual type varying from mild (2 cases) to moderate (1 case); with two of these cases exhibiting additional features of fibrocystic mastopathy including adenosis, apocrine metaplasia, and cyst formation. None of our cases showed any malignancy or pseudoangiomatous stroma hyperplasia (PASH).

Angioleiomyoma of urethra: A case report

INTRODUCTION

Angioleiomyomas are benign smooth muscle tumors that arise from blood vessel walls and commonly involve the deep dermal and subcutaneous tissue. Urethral angioleiomyomas are only rarely seen with only less than 5 cases reported in literature.

PRESENTATION OF CASE

We herein present a case of a 72 year old man who presented with gross hematuria. Cystoscopy showed a polypoid urethral lesion that was resected and on pathologic examination was diagnosed as angioleiomyoma.

DISCUSSION

Differential diagnoses of a urethral polypoid lesion, including inflammatory and neoplastic conditions are discussed. The main emphasis is on recognition and review of angioleiomyoma features when presenting in commonly encountered locations and other sites that are only rarely involved.

CONCLUSION

This rare case reports an elderly patient with angioleiomyoma in an extremely unusually encountered location and presenting with unusual symptoms of gross hematuria that did not recur after resection of the lesion.

Blood transfusion transmitted infections in multiple blood transfused patients of Beta thalassaemia

Transfusion Transmitted Infection (TTI) continue to be a problem in many parts of world and multi-transfused patients of beta thalassaemia major are at a particularly increased risk of TTI. This study is aimed to estimate the prevalence of blood TTI in multiple blood transfused patients of beta thalassaemia major. Cross-sectional study of 200 multi-transfused patients of beta thalassaemia major, who were interviewed using a structured questionnaire and history was taken regarding sero-status of HIV (Human Immunodeficiency Virus), HBV (Hepatitis B Virus), HCV (Hepatitis C Virus) infection from their case papers. This study was conducted at the department of Pathology, M.P. Shah medical college, Jamnagar and Thalassemia ward, G.G. Hospital, Jamnagar (Gujarat, India) from March to May 2010. Out of 200 multiple blood transfused patients 7% patients were infected with TTI. Total 9 male patients and 5 female patients were infected with TTI. The seroreactivity for HIV was 3% (06/200); 1% (02/200) were males and 2% (04/200) were females. The seroreactivity for HBV was 2% (04/200) all were males. The seroreactivity for HCV was 2% (04/200); 1.5% (03/200) were males and 0.5% (01/200) was female. HIV, HBV, HCV infections are most prevalent TTI among multiple blood transfused patients of beta thalassemia major, and remains a major health problem for these patients.

Mycotic cysts: report of 21 cases including eight pheomycotic cysts from Saudi Arabia

BACKGROUND

Mycotic cysts are subcutaneous cystic granulomas caused by either dematiaceous (pigmented) fungi (pheomycotic cysts) or eumycotic (nonpigmented fungi) present in soil, wood, and decaying plant material. These fungi gain access to the tissues via a wooden splinter or thorn. No deep tissue involvement or extension to bone is known to occur.

METHODS

We reviewed our surgical pathology files for the last 32 years. All cases with the diagnosis of cysts with fungi, thorns, or splinters and associated granulomatous and acute inflammation were reviewed. Gomori's silver and periodic acid-Schiff stains were performed in all cases.

RESULTS

Twenty-one cases of mycotic cyst were found, including eight pheomycotic cysts (one with a recurrent lesion seen 11 months after the initial excision of the cyst). Thirteen cysts had nonpigmented fungal hyphae. There were 14 males and seven females, with an age range of 5-76 years. The dorsum of the foot was the most frequently affected site (12 cases). Four cases involved the fingers, two involved the knee area, two involved the big toe, and one each involved the leg, ankle, and forearm. The cysts measured 0.6-4.5 cm in diameter. Histologically, there was granulomatous inflammation with a variable degree of neutrophilic infiltrate giving central abscess formation. Twelve cases showed a wooden splinter. All cases were positive for fungal organisms, mostly septate hyphae and spores that were highlighted by special stains. Fungal pigment, ranging from yellow-brown to light brown to black, was observed in eight cases. No extension to deep tissues was noted. The clinical impression varied widely including ganglion, sebaceous cyst, giant cell tumor of the tendon sheath, and lipoma. One patient was immunosuppressed following renal transplantation. All patients were treated by simple excision. No antifungal chemotherapy was needed or administered in any of the patients. One patient had a recurrence of his lesion within 1 year as a result of inadequate initial excision. A second re-excision was curative.

CONCLUSION

Mycotic cysts are uncommonly encountered lesions that can be easily missed, especially in cases with scant fungal elements, thus requiring special stains to detect the organisms. We reported 21 cases of mycotic cyst, including eight pheomycotic cysts, with emphasis on the histopathologic recognition of this unusual entity.

Prevalence of Fragile Histidine Triad Expression in Tumors from Saudi Arabia: A Tissue Microarray Analysis

AIM

The fragile histidine triad (FHIT) gene was discovered and proposed as a tumor suppressor gene for most human cancers. It encodes the most active common human chromosomal fragile region, FRA3B. We studied the prevalence of loss of FHIT expression in various tumors and correlated its loss with various clinicopathologic features.

METHODS

To determine whether the absence of FHIT expression correlates with clinical variables such as grade, stage, and survival time, we assessed FHIT expression using immunohistochemistry. More than 1,800 tumors from more than 75 tumor categories were analyzed by immunohistochemistry in a tissue microarray format.

RESULTS

Loss of FHIT expression ranged from 19% in ovarian tumors to 67% in lung cancers. Clinical and pathologic features like grade, stage, tumor size, and lymph node metastasis showed correlation with loss of FHIT expression in some tumors. No difference was seen in the survival patterns and loss of FHIT expression in any of the tumor groups studied.

CONCLUSIONS

Loss of FHIT expression is an ubiquitous event in the multistep, multifactorial carcinogenesis process. FHIT may be altered at different stages in different types of cancers. Most of the tumors with a wider prevalence of loss of FHIT expression as an early event show a correlation with clinicopathologic features. However, in some of the tumors, FHIT expression is lost as a late event and is only seen in a fraction of the tumors.

HER2, TOP2A, CCND1, EGFR and C-MYC oncogene amplification in colorectal cancer

AIM

Recent studies had suggested substantial molecular differences between tumours from different ethnic groups. In this study, the molecular differences between the incidences of colorectal carcinoma in Saudi and Swiss populations are investigated.

METHOD

518 cases of colon cancer tumours (114 from Saudi Arabia and 404 from Switzerland) were analysed in a tissue microarray format. Fluorescence in situ hybridisation (FISH) was used to estimate frequencies of copy number changes of known oncogenes, including HER2, TOPO2A, CCND1, EGFR and C-MYC.

RESULTS

Using FISH, amplifications were mostly low level (gene-to-centromere ratio 2 to 4), which is in contrast with other tumour types with more frequent gene amplifications. The amplifications were particularly frequent for MYC (Saudi 9% and Swiss 14.2%) but unrelated to clinical outcome and pathological information. Remarkably, there were four tumours exhibiting classic high-level gene amplification for HER2 (Swiss 1.3%), a pattern often accompanied by response to trastuzumab (Herceptin) in breast cancer. Occasional high-level amplifications were also observed for CCND1 (Saudi 1/106, 0.9%; Swiss 2/373, 0.5%) and EGFR (Swiss 2/355; 0.6%).

CONCLUSIONS

Rare high-level amplifications of therapeutic target genes were found in patients with colon cancer. Although no molecular differences were found between incidences of colon cancer cases in Swiss and Saudi populations, these observations emphasise the urgent need for clinical studies investigating the effect of targeted therapies.

Hodgkin's lymphoma with concurrent systemic amyloidosis, presenting as acute renal failure, following lymphomatoid papulosis

BACKGROUND

Hodgkin's lymphoma (HL) has been reported to occur infrequently in association with lymphomatoid papulosis (LP). On the other hand, amyloidosis may also occur as a complication of lymphomas including HL but has never been reported in association with LP. We herein present an unusual case of a patient with LP who 3 years later developed concomitant HL, as well as kidney and brain amyloidosis, leading to nephrotic syndrome, acute renal failure, coma and death within 3 weeks. In our patient the simultaneous development of amyloidosis and HL suggests that amyloidosis is secondary to LP, an association never reported before.

METHODS

A 74-year-old man with a 3-year history of LP presented with oliguria. He was found to have acute renal failure and 37 g of proteinuria. The patient had had a right nephrectomy performed 27 years before because of a small nonfunctioning kidney. He was found to have paraaortic and mesenteric lymphadenopathy that were biopsied percutaneously. Despite supportive dialysis the patient continued to do poorly, went into coma and died.

RESULTS

Biopsy of his single left kidney showed enlarged glomeruli completely replaced by amyloidosis confirmed by Congo red stain and electron microscopy. His paraaortic lymph nodes exhibited classic HL with CD30- and CD15-positive Reed-Sternberg cells in a background of mixed inflammatory cells including prominent eosinophils. A CT scan of the brain was negative; however, the MRI showed multiple periventricular parenchymatous lesions and changes of cerebral amyloid angiopathy.

CONCLUSION

In this case, the concomitant presentation of systemic amyloidosis and HL post-LP suggests that amyloidosis is a late sequela of LP, an association that has never been reported before.

Colorectal carcinoma from Saudi Arabia. Analysis of MLH-1, MSH-2 and p53 genes by immunohistochemistry and tissue microarray analysis

OBJECTIVE

To document the incidence and role of p53 and DNA mismatch repair proteins in colorectal carcinomas, and to evaluate the relative frequency of major molecular pathways in colorectal cancers from Saudi Arabia.

METHODS

We collected the formalin fixed, paraffin embedded tissues from 154 colorectal tumors (83 patients from King Faisal Specialist Hospital and Research Centre and 71 from Saudi Aramco Dhahran Health Centre) between January 1989 and December 2003. We analyzed the p53 and mismatch repair gene expression (hMSH-2, hMLH-1) by immunohistochemistry in tissue microarray format.

RESULTS

Expression loss of at least one mismatch repair gene was found in 33.8% of cases and significantly associated with the right-sided tumor location (p=0.0047). The p53 positivity was observed in 57.5% of tumors, and was inversely linked to expression loss of mismatch repair genes (p=0.0102).

CONCLUSION

The strong confirmation of the previously established associations between tumor phenotype, and mismatch repair gene alteration provided strong evidence for the validity of our experimental approach. Together with the higher incidence of right sided location in Saudi (46.6%) than in Western colon cancers (34.9%), the observed high prevalence of mismatch gene expression loss in Saudi tumors argues for a higher importance of microsatellite instability in this population. If confirmed, it will be interesting to see whether an increased level of familial or sporadic microsatellite instability cases is causing this variation.

Acute placental infection due to Klebsiella pneumoniae: report of a unique case

A 40-year-old woman, gravida 9, with seven healthy children and a history of one abortion (p 7 + 1), presented at 18 weeks of gestation with fever and malodorous vaginal discharge. Ultrasound revealed a macerated fetus. The placenta showed acute chorioamnionitis and acute villitis with microabscess formation. Blood and vaginal cultures both grew Klebsiella pneumoniae. This is the first reported case in English literature of Klebsiella pneumoniae causing suppurative placentitis leading to fetal demise.

CD44 loss in gastric stromal tumors as a prognostic marker

BACKGROUND

The adhesion molecule CD44 (CD44s; CD44H) and its isoforms (CD44v3-6 and v9) are preferentially expressed by different cell types. These transmembrane glycoproteins are involved in cell-cell and cell-matrix interactions and in cell trafficking and, thus, may play a role in tumor metastasis and/or local invasion. The expression pattern of CD44s and variant isoforms, particularly CD44v6 and CD44v9, of some neoplasms, including soft tissue tumors, correlates with clinical course and outcome. The clinical behavior of gastrointestinal stromal tumors (GIST) is site specific; however, other reliable predictors of clinical outcome have not been identified. Thus, the prognostic value of CD44s and isoform expression in GIST were evaluated by immunohistochemistry of tissue microarrays.

DESIGN

Paraffin-embedded formalin-fixed tissue cores (129: 103 GIST and 26 normal stomach smooth muscle) from 33 patients with clinical outcome data were collected and used for the construction of the tissue microarrays. One to five tissue cores from each patient specimen were evaluated (mean = 3 tissue cores/patient). Array slides were stained with anti-CD44s (CD44H) and with antibodies to v3, v4, v5, v6, and v9 isomers. CD44s and isoform expression and staining intensity were scored semiquantitatively without knowledge of patient identity or outcome: 0 = no; 1 = weak; 2 = moderate; 3 = moderate to strong; 4 = strong. The scores of multiple cores from the same GIST were averaged; the nonneoplastic smooth muscle was similarly graded. CD44s and isoform expression and intensity were compared with outcome.

RESULTS

The 33 patients with gastric GIST, 0.8 to 30 cm in size, were followed for 1 to 111 months with a median follow-up of 7 months (mean 17.5 months). The overall median survival was 25 months. Nine of the 33 (27%) patients had metastases, 9 (27%) had recurrent disease, and 9 (27%) died of disease (9-111 months; mean 39 months; median 23 months). All 18 patients with GIST CD44s expression > 2+ were alive at last follow-up (1-62 months; median 3.5 months; mean 11 months). More than half (53%) of patients with GIST CD44s expression < or = 2+ died (9-111 months; median 23 months; mean 38 months); the median follow-up of the surviving patients with CD44 expression < or = 2 was 5 months (2-22 months; mean 6.5 months; log rank P = 0.07). The majority of tumors were variably positive CD44v3 and CD44v4, but there was minimal staining (number of cases and/or expression level) with antibodies directed against the v5, v6, and v9 isomers.

CONCLUSION

These preliminary results suggest that although gastric GISTs variably express CD44s and variants, only the expression of CD44s correlates with clinical outcome with loss of CD44s positivity correlating with poor clinical outcome.

CD5-negative, CD10-negative small B-cell leukemia: variant of chronic lymphocytic leukemia or a distinct entity?

CD5- and CD10-negative chronic lymphocytic leukemias are quite uncommon as compared to the CD5-positive CLL. We reviewed 250 sequential cases of peripheral blood lymphocytosis to characterize cases of small B-cell lymphoproliferative disorders, submitted with a clinical diagnosis of chronic lymphocytic leukemia exhibiting a non-classic immunophenotypic profile. Six cases of CD5-, CD10-negative chronic lymphocytic leukemias and no tissue involvement were identified that revealed high-density surface-membrane immunoglobulin and CD20 expression, with variable expression of CD11c, CD23, and CD25. Most had a profound leukocytosis (mean WBC 180 x 10(9)/L) with proliferation of mature-appearing lymphocytes. Subsequent bone marrow biopsies showed diffuse infiltration by neoplastic cells in all evaluated patients. The clinical course appeared indolent, with follow-up revealing three patients alive (survival time 38-68 months), while two died of unrelated causes and one was lost to follow-up soon after diagnosis. These cases may represent somewhat unusual chronic lymphoproliferative disorders, with morphologic features and immunophenotypic profile not readily classifiable, but which are certainly atypical for classic chronic lymphocytic leukemia. Some of these features are reminiscent of those seen in marginal-zone lymphoma. However, it is most unusual for this known to be tissue-based disease to present primarily as leukemia rather than lymphoma.

Lipoadenoma: is it arising from thyroid or parathyroid? A diagnostic dilemma

Fat-containing lesions of endocrine organs are rare. Distinguishing lipoadenomas of the thyroid gland from lipoadenomas of parathyroid glands can be challenging during intraoperative consultation. Our patient had a well-circumscribed tan-pink nodule present on the surface of the thyroid gland, exhibiting abundant fat interspersed between the cells, with ample eosinophilic cytoplasm arranged in trabeculae and solid sheets. Immunohistochemistry showed strong positivity for thyroglobulin confirming the origin of the nodule to be thyroid. Only few cases of lipoadenomas of the thyroid and parathyroid have been reported in the literature. There is considerable histologic overlap between the two, making it difficult to determine the site of origin. We briefly discuss the features that may be helpful in this distinction.

ANCA-associated crescentic IgA glomerulonephritis in pregnancy

Only a few reports have documented the presence of crescentic IgA nephropathy associated with antineutrophil cytoplasmic antibodies (ANCA), suggesting an overlap that has therapeutic significance as regards the patients' response to treatment. We report a case of rapidly progressive glomerulonephritis with P-ANCA, with biopsyproven crescentic IgA glomerulonephritis in an 11-week pregnant woman who responded very well to cyclophosphamide and prednisone. Her 24-h urine protein dropped from 5400 mg/day to 516 mg/day and serum creatinine from 2.7 mg/dL to 1.4 mg/dL. To the best of our knowledge, this is the first such case reported in pregnancy. Eighteen months after her initial presentation, she has no significant clinical problems and her laboratory work-up shows stable results.

Kikuchi-Fujimoto's disease: report of familial occurrence in two human leucocyte antigen-identical non-twin sisters

Kikuchi-Fujimoto's disease (KFD) is a self-limiting condition usually presenting as cervical lymphadenopathy, with fever and leukopenia, in young adult females. No specific aetiology has been identified yet, although some authors believe that KFD is a 'forme fruste' of systemic lupus erythematosus. Certain human leucocyte antigen (HLA) types have also been associated with KFD. We herein report KFD in two non-twin sisters with HLA-identical phenotype, who presented 10 years apart. Neither patient had evidence of recent infection or connective tissue disease. The familial occurrence emphasizes the possibility of genetic predisposition and calls for a more extensive search for a specific cause of KFD.

Benign chondroid syringoma: report of a case clinically mimicking a malignant neoplasm

Chondroid syringoma, or mixed tumor of skin, is an uncommon sweat gland tumor most often seen in the head-and-neck region of patients in the sixth or seventh decade. Tumors usually present as asymptomatic, slowly growing masses. Histologically, there are both epithelial and stromal components. The treatment of choice is local excision. Rare malignant examples have been reported, commonly involving the extremities. We present a case of cutaneous chondroid syringoma arising in the thigh of a 28-year-old female. The tumor grew over a 4-year period, increasing rapidly in size over the last few months with fixation and pigmentation of the overlying skin clinically mimicking a malignant neoplasm. Such cutaneous appendage tumors are uncommon, and surgeons may be unfamiliar with them.

Genetic aspects of gestational trophoblastic diseases: a general overview with emphasis on new approaches in determining genetic composition

All gestational trophoblastic tumors are derived from a fertilization event. In the hydatidiform moles, varying degrees of excess paternal DNA lead to varying histopathologic forms of these tumors. The placental site trophoblastic tumors and the choriocarcinomas may follow normal pregnancy, abortions and hydatidiform moles, and, thus evince a wide range of genetic compositions reflecting their gestation of origin. Advances in molecular biological diagnoses now allow for the determination of the gestational or non-gestational origin of trophoblastic tumors, and, may well provide fantastic new insights into the biology of these unusual tumors.

Acute monocytic leukemia (FAB M5) involving the placenta associated with delivery of a healthy infant: case report and discussion

Acute leukemia seldom presents during pregnancy, and though pregnancy may not affect the course of leukemia, fetal complications and maternal mortality are high. Documented placental involvement is rare, as are metastases to the fetus. Comprehensive review of the literature reveals only a few reports of maternal or fetal leukemia with placental involvement. We encountered a case of a 45-year-old woman who presented at 29 weeks' gestation with acute monocytic leukemia with t(9;11). She was managed conservatively. Labor was induced at 33 weeks, with delivery of a healthy male infant prior to induction chemotherapy. The baby remained well at 18 months of age. The placenta showed isolated microinfarcts and an infiltrate in the basal plate of leukemic cells confirmed by immunohistochemistry. No invasion into chorionic villi was seen. Little is known about the biological significance of placental involvement and inherent defense mechanisms of the placenta in maternal cancers. Therefore, detailed histopathologic examination of the placenta should always be performed and reported in leukemic patients, regardless of fetal outcome.

The spectrum of breast diseases in Saudi Arab females: A 26 year pathological survey at Dhahran Health Center

In an attempt to delineate the spectrum of breast diseases in Saudi Arab females, we carried out a retrospective study of all cases of breast biopsies and mastectomies accessioned in the files of surgical pathology in our laboratory for 26 years (1967-1992). A total of 915 cases were collected. Fibroadenoma was the most common lesion encountered (30.7%), followed by fibrocystic condition (21.1%), carcinoma (14.9%), acute mastitis (7.2%), duct ectasia (4.9%), lactational adenoma (4.8%), intraductal papilloma (2.6%), galactocele (2.4%) and several less frequent lesions. Pathological conditions associated with lactation such as acute mastitis, abscess, granulomatous mastitis, galactocele and lactational adenomas constituted 16.2% of the cases in this series. This high frequency is related to the high fertility rate among Saudi Arab females. The mean age of Saudi Arab females with ductal carcinoma was 47.1 years as compared to 54 years in Western countries. Many patients presented with a large size tumor, skin and/or nipple involvement, as well as a high frequency (61.7%) of axillary nodal metastases in those who underwent axillary nodal dissection. The high frequency of fibroadenoma could be related to the large number of young females in our population. A great increase in the number of cases in the last five years has been observed. This could be related to more awareness among Saudi Arab females of their health problems and the expansion of our medical services.