Nerve Epidermal Growth Factor-Like 1 Protein (NELL-1) Expression in Mercury-Related Membranous Nephropathy: Is It a True Association or a Chance Occurrence?

Background: Neural epidermal-like growth factor-like 1 (NELL-1) is a protein kinase C binding protein expressed in osteoblasts and renal tubules. It is expressed in 5%-25% glomerular cells at the mRNA level. Membranous Nephropathy (MN) is characterized by the presence of antibodies against certain types of antigens on the glomerular basement membrane. The most common one implicated in primary MN is an antibody against PLA2R. Many newer antigens have been discovered in the recent past, which are proven to cause secondary MN, one of which is NELL-1. NELL-1 has been associated with malignancy-associated MN and also recently associated with traditional indigenous medications containing mercury. In this study, we study the expression of NELL-1 in mercury-associated MN. Materials and Methods: Records of ten cases of Mercury -associated MN were retrieved from the Institute medical archives and NELL-1 Immunohistochemistry was performed in all ten cases. Results: NELL-1 was found to be positive in 50% of the cases of Mercury associated MN. In addition, mass spectrometric studies was performed, which revealed the common Mercuric compound associated to be 'Swaskalpa', 'Sudarshana Melugu' and 'Rasagandhi Mezhugu'. Conclusion: This study highlights why it is important to diagnose mercury-associated MN by a pathologist by picking up the finer histopathological clues and by using NELL-1 immunohistochemistry, especially in PLA2R-negative patients. The former is true as most of the time a history of mercuric compound intake is missed out.

Exploring the role of Aspergillus galactomannan antigen in assessing the risk factor of acute exacerbations in chronic obstructive pulmonary disease patients: a cross-sectional study.

Chronic obstructive pulmonary disease (COPD) is characterized by permanent airflow obstruction due to abnormalities of the airways and alveoli. This study investigated the potential role of Aspergillus species in acute exacerbations of COPD (AECOPD) and evaluated the diagnostic utility of serum Aspergillus galactomannan antigen. This cross-sectional study, carried out at the Jawaharlal Institute of Postgraduate Medical Education and Research from January 2021 to June 2022, involved COPD patients aged ≥40 years. Serum galactomannan and serum Aspergillus-specific antibodies were analyzed, along with the collection of demographic details, symptoms, and comorbidities. Statistical analyses, including univariate analysis and receiver operating characteristic (ROC) curve analysis, were performed. Among the 61 recruited COPD patients, 24.5% showed serum galactomannan positivity. Significant associations were found between galactomannan positivity, hemoptysis, and previous tuberculosis. ROC analysis revealed modest diagnostic accuracy (area under the ROC=0.6027) with a sensitivity of 44.4% and a specificity of 83.7% at a cut-off of 0.5. Univariate analysis did not show any potential links between diabetes, hypertension, previous exacerbations, and severe gold stages with a risk of exacerbation. Serum galactomannan antigen showed limited sensitivity, and its routine testing may not be justified for predicting exacerbation risk. Further studies are warranted to validate these findings and explore other diagnostic methods using bronchoalveolar lavage galactomannan antigen in AECOPD.

Validation of histopathological chronicity scores in native kidney biopsies using light microscopy and digital morphometry for predicting renal outcome.

Quantitative assessment of chronicity changes in native kidney biopsies offer valuable insights in to disease prognosis, despite the strength of qualitative information. Yet, standardization and reproducibility remain challenging. The present study aims to assess and compare the prognostic utility and reproducibility of two chronicity scoring systems based on light microscopy and whole slide imaging with morphometry and also to evaluate the prognostic utility of structural measurements: cortical non-sclerotic glomerular (NSG) density and NSG area/volume. We designed a retrospective longitudinal study involving 101 adult and paediatric patients who underwent native kidney biopsies. Chronicity scoring was performed using two semi-quantitative methods: Method 1 (method proposed in PMID: 28314581) and Method 2 (method proposed in PMID: 32516862), under light microscopy as well as on whole-slide scanned images, and assessed for prognostic utility. Kidney-Failure-Risk-Equation (KFRE) was employed in combination with chronicity-scoring-methods and assessed for predictive capability. Interobserver reproducibility for the two chronicity methods was studied among three renal pathologists. Structural measurements were performed on whole-slide- scanned-images. Both the chronicity scoring methods significantly predicted decline in estimated glomerular filtration rate (eGFR) and persistent need for renal replacement therapy in follow-up. Method 1 combined with KFRE, outperformed Method 2 in predicting renal survival. Method 2 however showed higher interobserver reproducibility. Combined KFRE plus histopathological scoring methods showed better predictive accuracy. The study validates the precision of chronicity scoring using whole slide scanned images. The morphometric structural measurements showed significant correlations with follow-up eGFR, thereby providing supplementary prognostic information.

Validation of a novel alcohol-free preservative solution in comparison with conventional prefixation on quality of serous body fluid smears.

BACKGROUND: We describe a novel alcohol-free preservative composed of glucose, mannitol, disodium hydrogen orthophosphate, thymol, and distilled water (glucose-mannitol-disodium dihydrogen orhtophosphate-thymol [GMDT] preservative) in appropriate proportion as an alternative to alcohol prefixation (APF) of body fluids. OBJECTIVES: To assess the cytomorphologic preservation and staining quality of serous body fluid smears generated by GMDT preservative and compare it with smears processed by standard 50% APF. METHODOLOGY: The study comprised 151 effusion samples. Each sample was equally divided into four tubes. Equal volumes of APF and GMDT preservatives were added to the first two tubes and left at room temperature for 24 h. Similarly, the corresponding preservatives were added to the third and fourth tubes and stored for 48 h. Two smears were prepared from the centrifuged sediments of each tube (all four tubes) and stained with May-Grünwald Giemsa and Papanicolaou (Pap) stains. Using a three-tiered scoring system, the smear examination was blinded to assess the extent of cellular preservation and the staining quality by two cytotechnologists and two cytopathologists. Statistical analysis was performed by STATA 16.0. RESULTS: Samples processed with the GMDT preservative at 24 h showed better cytoplasmic preservation and smear background, while nuclear features and staining quality showed no difference between the two preservatives. Mild cytoplasmic and nuclear degenerative changes were noted with the GMDT at 48 h, while all four parameters remained similar with APF at 24 and 48 h. CONCLUSIONS: The newly developed alcohol-free, GMDT preservative, could be a feasible and cost-effective alternative to 50% APF, preferably when samples are processed within 24 h.

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

BACKGROUND:  The presence of microvascular inflammation (MVI) characterized by leukocyte margination in the glomeruli (glomerulitis, Banff score 'g') and peritubular capillaries (peritubular capillaritis, Banff score 'ptc') is a hallmark histological feature of antibody-mediated rejection (AMR), even in the absence of circumferential C4d positivity. In this study, we assessed the efficacy of pre-transplant plasma cytokines as an ancillary screening tool to identify MVI in kidney allograft indication biopsies to facilitate better graft survival. METHOD:  This single-center prospective analytical study comprises 38 kidney transplant recipients whose peripheral blood was collected before transplant and assessed for the plasma cytokine concentrations of FOXP3, IL-6, TGF beta, and IL-17 using enzyme-linked immunosorbent assays (ELISA). Histopathological assessment was done in post-transplant indication biopsies, and Banff scores of 'g+ ptc' were calculated to categorize recipients into three MVI groups. The correlational, regression, and ROC curve analyses were used to assess the association and predictive ability of the cytokines with respect to MVI. RESULTS:  In our study cohort, 27 recipients had MVI=0, five had MVI=1, and six had MVI≥2. A significant difference in plasma cytokines was observed between these groups, and we found a strong negative correlation of FOXP3 with MVI, whereas a strong positive correlation of IL-6, TGF beta, and IL-17 was recorded with MVI. We have also assessed the predictive ability of these cytokines, FOXP3, IL-6, TGF-beta, and IL-17, through the ROC curve, which showed an AUC of 0.70, 0.76, 0.84, and 0.72, respectively. CONCLUSION:  Our findings suggest that the pre-transplant levels of cytokines FOXP3, IL-6, TGF-beta, and IL-17 could be measured to identify recipients at risk of post-transplant MVI, which could further serve as an additional tool for effective management of the kidney allograft.

The Difficulties and Ease of Diagnosing Anaplastic Large Cell Lymphomas on Cytology.

Introduction and Objectives: Anaplastic large cell lymphoma (ALCL), a unique non-Hodgkin lymphoma (NHL), is a CD30-positive neoplasm of T-cell lineage. Its distinctive yet variable cytomorphology makes diagnosing fine needle aspiration cytology (FNAC) challenging. This study was undertaken to study the cytomorphology and the utility of immunocytochemical (ICC) stains on cytology in ALCL and to discuss their morphological differential diagnosis. Materials and Methods: The present study was conducted in the Department of Pathology of a tertiary care center. A retrospective review was done from January 2017 to July 2022, and all histopathologically and immunohistochemically (IHC) diagnosed cases of ALCL were taken and correlated with the cytological diagnosis. Results: Twenty-one cases of histopathology examination and IHC-proven cases of ALCL were retrieved from the departmental archives and reviewed. The ages ranged from 3 to 80 years (median age 28 years). Commonly noted cytomorphologic features included singly dispersed large pleomorphic cells, hallmark cells, and Reed-Sternberg-like cells. CD15, CD30, epithelial membrane antigen, and anaplastic lymphoma kinase-1 were some of the ICC stains used in this study. All 21 cases had cytology correlation. Fourteen cases had concordant cyto-histological correlation. Seven cases of histopathologically proven ALCL were reported as Hodgkin lymphoma (HL) in three, ALCL/anaplastic diffuse large B-cell lymphoma, HL/ALCL, poorly differentiated carcinoma, and NHL in one case each on cytology. Conclusion: ALCL has a reasonably distinct cytomorphologic appearance and ICC staining pattern, and a careful interpretation of both helps arrive at a reliable FNAC diagnosis.

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

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

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

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

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

INTRODUCTION: Owing to certain inherent limitations of earlier reporting systems, "The Paris System for Reporting Urinary Cytology (TPS)" was implemented in 2015 to standardize reporting urine cytology with more stringent cytomorphologic criteria. We share our post-TPS experience, comparing it with the conventional system (CS). AIM: To assess and compare the cyto-histopathologic/cystoscopic agreement between the conventional and the Paris systems (CS and TPS) for reporting urine cytology. MATERIALS AND METHODS: It is a cross-sectional study involving urine samples from 170 patients divided into two groups (CS and TPS). Of the 170 cases, 85 were reported according to the CS, and 85 were reported according to TPS with all the relevant clinical, radiologic, and cystoscopic findings. Using the kappa statistics, both groups were statistically analyzed for sensitivity, specificity, predictive values, and agreement. RESULTS: The sensitivity and specificity for high-grade urothelial carcinoma (HGUC) as per TPS were 83.33% and 94.59%, respectively, while they were 73.47% and 80.56% for the conventional system. The agreement for HGUC with TPS was 87.06% with a kappa value of 0.7416, while it was 76.5% with a kappa value of 0.53 for the CS. Implementing the TPS minimized usage of the atypical urothelial cells (AUC) category, increasing the clarity in detecting HGUC. CONCLUSION: TPS provides better agreement with histopathology than the CS for diagnosing HGUC, which is attributable to stringent TPS criteria that prompt cytopathologists to look more diligently for morphologic and numeric criteria.

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

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

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

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

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

BACKGROUND: Burkitt lymphoma (BL) is an aggressive high-grade B-cell non-Hodgkin lymphoma commonly diagnosed in young age and is known to involve extra nodal sites. But the involvement of body fluids by BL is an uncommon presentation. Rapid diagnosis of BL is vital to prevent complications like tumour lysis syndrome. Cytological examination of body fluids continues to be an indispensable tool for rapid diagnosis of BL. OBJECTIVES: In this study, we aim to study the clinical, cytomorphological and immunophenotypic characteristics of BL involving serous effusions and other fluids. MATERIALS AND METHODS: In this retrospective study, 17 cases reported as BL in fluid cytology from 2016 to 2022 were collected and reviewed. We performed a comprehensive analysis of the clinical data, cytomorphological features, immunophenotyping data along with the haematological workup of these cases. We have also compared with the histopathological diagnosis for those cases where biopsy was available. RESULTS: BL more commonly involved ascitic fluid (52%), followed by pleural fluid (4 cases) and cerebrospinal fluid (CSF; 4 cases). Primary diagnosis of BL in fluid was done in 88% of the cases. Bone marrow involvement was noted in two cases. Cytological smears showed discrete monomorphous population of medium-sized atypical lymphoid cells with frequent apoptotic bodies. Classic cytoplasmic punched out vacuoles were observed in 88% of the cases. Immunophenotyping data was available for 12 cases in which tumour cells showed positivity for CD20 (100%), CD10 (4 of 7 cases), BCL6 (3 of 5 cases) and cMYC (7 of 7 cases-100%) and were negative for Terminal deoxynucleotidyl transferase (TdT) (11 of 11 cases). Mean Ki67 labelling index was 95%. Histopathological diagnosis was available for 9 cases, and there was 100% agreement between cytological and histopathological diagnosis in 7 cases. CONCLUSION: Precise diagnosis of BL can be rendered in body fluids by identification of classic cytomorphological features and by performing supportive ancillary tests in fluids for immunophenotyping.

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

Background: Lung cancer is the most common malignancy in both gender. Early diagnosis is needed to reduce morbidity and mortality. There is a debate about the most accurate investigating modality for the diagnosis of lung cancer. Methods: It is a retrospective cohort analysis to determine whether an approach of combined contrast-enhanced computed tomography (CECT) thorax with bronchoscopy method has higher sensitivity and specificity than combined CECT thorax with sputum cytology method. Records of patients with lung cancer who had visited the hospital within the last 6 months were retrospectively analyzed for their diagnostic modality. SPSS version 19 software was used for statistical analysis of the data. CECT scan thorax, bronchoscopy, and sputum cytology for lung cancer patients were analyzed. The CECT thorax plus bronchoscopy method was compared with the CECT thorax plus sputum cytology method. Their sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in diagnosing lung cancer were analyzed. Results: Sixty-two patients were considered, including 62.9% males with a mean age of 55.5 years. In patients diagnosed with lung cancer, CECT thorax combined with bronchoscopy method was found to have a sensitivity of 96.67% than CECT thorax combined with sputum cytology method with a sensitivity of 90% and the difference in sensitivity between all individual approaches as well as the combined method was statistically significant with a P = 0.00001 and Chi-square value of 86.5909 owing to the low sensitivity of sputum cytology. CECT thorax combined with sputum cytology approach had a better specificity than CECT thorax combined with bronchoscopy. Conclusion: Combined CECT thorax with sputum cytology method has a better specificity in diagnosing lung cancer than combined CECT thorax with bronchoscopy method.

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

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

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

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