Allo-specific immune response profiles indicative of acute rejection in kidney allografts using an in vitro lymphocyte culture-based model.

BACKGROUND: Ability to predict the manner in which a recipient's immune system would respond to a transplanted graft by analyzing cytokine profiles of the "allograft antigen sensitized" recipient lymphocytes in vitro might provide a means to identify patients at risk to adverse clinical endpoints. METHODS: Cytokine/chemokine gene expression profiles of peripheral blood mononuclear cells co-cultured with allograft antigen-pulsed macrophages were studied in 49 renal transplant recipients-12 with acute cellular rejection (ACR) with or without antibody-mediated rejection (AMR), 7 with AMR (without ACR), and 30 with stable allografts (SA). An 86-gene inflammatory cytokines and receptors PCR array was used to measure fold changes in gene expression between pulsed and un-pulsed cultures. RESULTS: On linear discriminant analysis and multivariate analysis of variance, a gene set comprising C3, CCL3, IL1B, TOLLIP, IL10, CXCL5, ABCF1, CCR3, IL10RB, CXCL1, and IL1R1 differentiated the ACR-AMR from the SA group. Similarly, a gene set comprising IL10, C3, IL37, IL1B, CCL3, CARD18, and TOLLIP differentiated the AMR from the SA group. No significant difference was found between the ACR-AMR vs AMR groups. CONCLUSION: Distinct post in vitro stimulation cytokine profiles at the time of transplantation thus correlated with the occurrence of post-transplantation rejection episodes which indicated feasibility of this in vitro model to assess the recipient's anti-graft response at an early stage.

Correlates of hematuria on glomerular histology and electron microscopy in IgA nephropathy.

BACKGROUND: Hematuria is the most important clinical manifestation of IgA nephropathy. This study was undertaken with the objective to describe the spectrum of histological changes with reference to the Oxford classification and the ultrastructural changes in the glomerular basement membrane and to correlate them with hematuria. METHODS: 66 patients who underwent renal biopsy for IgA nephropathy were evaluated histologically by the Oxford system and also subject to electron microscopic examination for glomerular immune deposits, as well as alterations in the glomerular basement membrane. RESULTS: On comparing the histological scores generated by the Oxford classification with degree of hematuria, it was found that the status of 'endocapillary proliferation' and the status of 'tubular atrophy and interstitial fibrosis showed a significant correlation. Correlation of hematuria with location of the deposits, i.e. mesangial only, and mesangial with capillary wall deposits (subendothelial and subepithelial) did not show any association. Other alterations of the GBM were seen in 12 cases. The changes included thinning alone in 4 cases, thinning and lamellar splitting in 5 cases, and lamellar splitting alone in 2 cases. CONCLUSION: At presentation, endocapillary proliferation is one histological parameter which shows close association with hematuria.

Histopathological indicators of disease outcome in class IV lupus nephritis: a revisit of various indices.

Current management guidelines for lupus nephritis (LN) do not attach importance to histological indices of disease activity or chronicity. The present study was performed to evaluate the clinical relevance of these indices in determining outcomes in patients with class IV LN. We analyzed the data of all patients with biopsy-proven class IV LN seen over a 6-year period. The histopathological findings were reviewed; the activity and chronicity indices proposed by Austin [AI (Austin) & CI (Austin)] and the renal biopsy index proposed by Hill were calculated. As immunofluorescence was not done in all patients, this was excluded from calculation of the renal biopsy index, which was referred to as the modified Hill's index (MHI), which was a composite of glomerular activity index (GAI), chronicity index (CI) and tubulo-interstitial activity index (TIAI). Pearson's correlation coefficient, multilinear regression analysis and logistic analysis were performed, and p value of <.05 was considered significant. During the study period, 114 cases of LN were evaluated, of which 64 % (73/114) had class IV LN. The mean age was 26.5 years, and 92 % were females. The mean scores of AI (Austin), CI (Austin), GAI, CI, TIAI and MHI were 8.46, 2.50, 7.54, 3.06, 4.74 and 2.23, respectively. Serum creatinine correlated significantly with TIAI, CI, CI (Austin) as well as MHI, but not with AI (Austin) or GAI. The serum creatinine level was the strongest clinical parameter determining outcome, while none of the histological indices correlated with either treatment outcome or mortality. None of the histological indices performed better than serum creatinine level in determining the treatment outcomes and mortality.

Correlation of proteinuria with podocyte foot process effacement in IgA nephropathy: an ultrastructural study.

BACKGROUND: Proteinuria is an uncommon clinical manifestation of IgA nephropathy and is usually seen in cases with severe lesions like endocapillary proliferation. However, it is occasionally seen even with cases with mild glomerular manifestations and may even be of nephrotic range. PREDICTOR: Podocyte foot process effacement. OUTCOME: Severity of proteinuria. MEASUREMENTS: Podocyte foot process effacement was measured. Morphometric analysis was performed on transmission electron microscope images using a computerized digital photomicrograph system (BioWizard 4.2 Image analysis software, New Delhi, India). Proteinuria was measured quantitatively assigned into five grades. RESULTS: It was found that as the extent of proteinuria increased, the effacement ratio also increased, and this was most significant between "no" proteinuria and the rest of the categories. CONCLUSION: Nephrotic presentation in IgA nephropathy is a known phenomenon and in certain cases may show near normal glomerular morphology with severe foot process effacement on EM being the only significant finding to explain the proteinuria. Proteinuria in these cases shows a significant correlation with degree of foot process effacement. Renal biopsy is important in these cases because they are known to have a better prognosis and are usually steroid responsive.

Persistence of human parvovirus B19 in tissues from adult individuals: a comparison with serostatus and its clinical utility.

Human parvovirus B19 (PVB19) is linked to variety of diseases, including erythema infectiosum, transient aplastic crisis, fetal hydrops, cardiomyopathy and, recently, hepatitis and arthritis. Persistence of PVB19 in asymptomatic individuals has been reported in skin, synovium, myocardium and bone marrow. A higher level of PVB19 DNA has been observed in various tissues from cases of disease than in controls. Simultaneously, equal detection of PVB19 DNA has been shown in both cases and controls. Thus, it has become fundamental to study PVB19 DNA persistence in tissues that are unaffected by disease. This will help to better understand PVB19 DNA persistence in symptomatic and asymptomatic individuals and its possible pathogenic role in various diseases. A total of 70 adult autopsies were included and divided into seropositive (SP) and seronegative (SN) groups based on PVB19 IgG. Nested PCR for PVB19 DNA was carried out in myocardium, liver, kidney, and bone marrow. Of the 70 patients, 60% belonged to the SP group and 40% to the SN group. Seropositivity ranged from 50% in the 12 to 20 year old group to 66.7% in the 61 to 80 year old group. The viral genome was detected in 34.3% of myocardium, 20% of bone marrow, 10% of kidney and 8.6% of liver samples. There was no significant difference in the persistence rates between the SP and SN groups. The persistence of PVB19 DNA in various tissues ranged from 8.3% to 36% in the SP group and 10% to 30% in the SN group. The persistence of PVB19 DNA in all the tissues was low, and PVB19 serostatus had no influence on the persistence of PVB19 DNA.

An analysis of transplant glomerulopathy and thrombotic microangiopathy in kidney transplant biopsies.

Glomerular diseases of the transplanted kidney are the most important cause of poor long- term outcome. The estimation of the magnitude of this problem and an elucidation of pathogenic mechanism is essential for improvement of graft survival. This study from the Indian subcontinent aims (i) to determine the incidence of transplant glomerulopathy (TG) and thrombotic microangiopathy (TMA) in a large cohort of indicated renal transplant biopsies, (ii) to evaluate the histological and ultrastructural features of TG and TMA, and (iii) to assess the relationship between the two glomerular lesions. Of a total of 1792 indication renal transplant biopsies received over 5 years (2006-2010), 266 biopsies (of 249 patients) had significant glomerular pathology and were further analyzed along with immunofluorescence, electron microscopy (EM), and C4d immunohistochemistry. TG is the most common glomerular lesion followed by TMA seen in 5.97% and 5.08% of allograft biopsies, respectively, which constitutes 40.23% and 34.2% of biopsies with significant glomerular lesions. Pathologic antibody-mediated rejection (AMR) is associated with both TG and TMA in 71% and 46.5%, respectively. A coexistent TG was found in 18.4% of biopsies with TMA. Endothelial swelling with subendothelial widening, a feature of TMA, is also seen in early TG by EM. Our findings support the concept that TG evolves from a smoldering TMA of various causes.

Light chain proximal tubulopathy without crystals in a case of Burkitt lymphoma presenting with acute kidney injury.

Acute kidney injury is a common manifestation of malignancies, either directly by the tumor or indirectly from anticancer therapy. The pathologic correlates of acute kidney injury in malignancies are many and can be diagnosed conclusively using kidney biopsy. We report a rare case of a patient with light chain proximal tubulopathy without crystals who presented with acute kidney injury. Kidney biopsy showed proximal tubulopathy without crystals with λ light chain restriction. Detailed investigations lead to a diagnosis of Burkitt lymphoma with surface λ light chain restriction.

Pathology and virology findings in cases of fatal influenza A H1N1 virus infection in 2009-2010.

AIMS: To describe the pathological findings, immunohistochemical localization of viral antigen and tissue reverse transcriptase polymerase chain reaction (RT-PCR) findings of different organs in cases of fatal H1N1 influenza virus infection from North India. METHODS AND RESULTS: Nine patients positive for H1N1 virus by a throat swab real-time RT-PCR (rRT-PCR) were included. Underlying risk factors included pregnancy, respiratory diseases, rheumatic heart disease, and chronic kidney disease. Pathological evidence of tracheitis, necrotizing bronchiolitis and diffuse alveolar damage was noted in all of the cases. Influenza viral antigen was observed by immunohistochemistry in the epithelium of the tracheobronchial tree, bronchial glands, gland ducts, and, less frequently, the alveolar epithelial cells. Viral particles were confirmed by electron microscopy in three autopsy cases. Tissue rRT-PCR for H1N1 viral RNA was positive in lung samples, but negative in other organs. Secondary bacterial pneumonia, cytomegalovirus infection and angio-invasive zygomycosis were detected. CONCLUSIONS: The pulmonary findings are similar to those described in past pandemics. Secondary fungal and viral infections, which have not been reported previously, were noted. Although the number of cases in this study is small, the findings reinforce the notion that changes in extrapulmonary organs are attributable to multiorgan dysfunction syndrome rather than a viral cytopathic effect, and that there is no transplacental transmission of virus.

Primary IgA nephropathy in north India: is it different?

BACKGROUND: Immunoglobulin A (IgA) nephropathy is the most common glomerulonephritis worldwide, but has a variable geographic distribution. the bulk of the disease burden is borne by asian countries. however, its exact prevalence or clinicopathologic spectrum in india is not well documented. METHODS: This cross sectional study analysed the renal biopsy findings and clinical features at presentation in 66 patients of primary IgA nephropathy diagnosed over a period of 2 years (2007-2008). The results were compared with studies from other centres in the country and elsewhere. RESULTS: IgA nephropathy comprised 8.1% of all native kidney biopsies. The mean age of the patients was 29.9 years with a male:female ratio of 4.4:1. Most patients presented with renal failure and a significant percentage (23%) also had nephrotic range proteinuria. Renal biopsies were classified by the Haas classification and were further scored by the MEST scoring system of the Oxford classification. By Haas classification, 41 cases (62%) showed advanced sclerotic lesions of class V. Active crescents (cellular or fibrocellular) were seen in 42% of cases, and 26% of cases showed endocapillary proliferation. Serum creatinine values were highest in the presence of proliferative lesions. MEST scoring of the Oxford classification was not applicable in approximately 18% of cases because of the presence of advanced sclerotic lesions. On immunofluorescence, the majority of the cases showed both mesangial and membranous positivity for IgA antisera. Electron microscopy revealed para-mesangial location of immune complex deposition in the majority of the cases. It also showed glomerular basement membrane abnormalities in two cases. CONCLUSION: Comparison of clinical and pathological features revealed that this disease presents as an advanced disease in much younger individuals in this study compared to other studies. Elucidation of the underlying factors may have immense therapeutic implications.

Revisiting the histopathologic spectrum of congenital pulmonary developmental disorders.

A retrospective analysis of lobectomy, pneumonectomy, cystectomy specimens (10 years) and stillbirth/neonatal autopsies (5 years) was carried out to analyze the histologic spectrum of congenital pulmonary developmental disorders/malformations. The autopsy data was analyzed to identify the lesions that are more diffuse and not amenable to surgical management. A total of 166 cases of pulmonary developmental disorders/ malformation were found. Out of 2,155 stillbirth/neonatal autopsies, there were 105 cases of pulmonary hypoplasia, 2 cases of congenital pulmonary lymphangiectasis, 2 cases of extralobar sequestration, and 3 cases of congenital pulmonary airway malformation (CPAM). Among the surgical specimens, there were 21 cases of CPAM, 11 cases of intralobar sequestration, 5 cases of congenital lobar emphysema and 17 cases of bronchogenic cyst. All these malformations have been described in reference to the latest updated classification of developmental disorders/malformations.

Case reports: Persistent hiccup as an atypical presentation of COVID-19 infection in a vaccinated subject.

Introduction: and Importance: COVID-19 have wide array of clinical manifestation involving both respiratory and non-respiratory symptoms including neurological symptoms. Hiccups is the involuntary and spasmodic movement of the diaphragm and the intercoastal muscle that leads to the closure of the glottis and limitation of breathing in air. Case presentation: We present a case of a 72-year old SARS COV-2 positive male with hypertension who have persistent hiccup. The patient is a vaccinated subject with 2 dose of Vero cells. Clinical findings and investigations: Vitals were stable.Mild dehydration was present.Bilateral Diffuse wheeze was present on Respiratory examination. No other abnormalities were detected during systemic examination.Imaging of his chest revealed bilateral mid-lung opacities and air bronchogram. Interventions and outcome: Perisitent hiccup was treated with metoclopramide. The hiccups reduced as the patient required less oxygen supplementation and inflammatory indicators decreased. Relevance and impact: This case report tends to provide information and awareness among physicians regarding this atypical presentation of the disease.

Tapia's syndrome in post-operative patient following orotracheal intubation.

Introduction: Tapia's syndrome is a rare condition that manifest due to unilateral extracranial nerve extension of cranial nerve 10 and 12 which occurred as a rare complication of Orotracheal Intubation in patient undergoing Laparoscopic appendectomy. Case presentation: A 30 year old male, a known case of normal variant Right bundle branch block and Gilbert syndrome underwent orotracheal intubation prior to general anesthesia for emergency laparoscopic appendectomy. Postoperatively while assessing the patient there was deviation of tongue on left side. Clinical findings and investigations: On examination of throat, atrophic and deviated uvula toward the right side was found. While protruding his tongue, tongue was deviated towards left side.Neurological examination revealed sluggish Gag Reflex. Brain Ct was done, which showed normal scan. Interventions and outcome: Tablet Prednisolone and logopedic therapy in combination helped in early recovery; which is almost 8 weeks. Patient was completely recovered in 2 month with gradual improvement of phonation, tongue tone and mobility. Relevance and impact: The intent of this report is to show how important it is for anesthesia providers and surgeons to understand Tapia's syndrome, its causes, and the fact that it can occur despite seemingly normal airway care and neck posture. We believe that by raising awareness of this uncommon issue, practitioners will be able to early identify this complication.

Case report: A case of undiagnosed cannabinoid hyperemesis syndrome in rural part of Nepal.

Introduction: and importance: Cannabinoid, a widely used recreational drug worldwide. In Nepal, it is found easily and has multiple used as well as misused as a psychoactive substance. Despite having anti emetic property of Marijuana, chronic use of the substance can lead to cyclic vomiting syndrome due to effect in central nervous system and gastrointestinal system. Case: we present a case of 28 year old man presented frequently with severe vomiting and abdominal pain which improved with hot showers and stopping use of cannabinoid. Clinical findings and investigation: Patient abdomen was tender but all other physical examinations were within normal limits. His lab investigations were within normal limit except of Total leukocyte count and urine analysis. Intervention and outcome: The patient was hospitalized and treated for dehydration, nausea and vomiting, and abdominal pain. The patient was diagnosed with cannabinoid hyperemesis syndrome and was discharged from the hospital two days later with the advice to stop using cannabis completely.

LXR-α selectively reprogrammes cancer cells to enter into apoptosis.

There exists a general recognition of the fact that LXR-α, being a member of the nuclear receptor family, plays a crucial role in the biological process that connects inflammation, cholesterol homeostasis, and cellular decisions. In this context the present study was addressed to understand the role of LXR-α gene in the selective and specific reprogramming of cancer cells into a state of apoptosis leaving the normal cells unaffected. The results of this study revealed that LXR-α gene when activated in cancerous cells of diverse origin results in the regulation of genes coding for Bcl-2, AATF, and Par-4 in a fashion, forcing these cells to enter into the state of apoptosis leaving the normal cells unaffected. On the basis of this study we propose that in near future LXR-α agonist (Withaferin A) may definitely find its use in the therapeutic interventions directed towards the treatment of cancer.

Utility of Direct Immunofluorescence in Cutaneous Autoimmune Bullous Disorders.

Background Autoimmune bullous disorders (AIBD) are a heterogeneous group of disorders with substantial clinical overlap associated with blistering of skin or mucosa. Aims The present study aimed to study the histopathological spectrum and evaluate the utility of direct immunofluorescence (DIF) on snap-frozen and paraffin-embedded sections in resolving the differential diagnosis of AIBD and connective tissue disorders of the skin. We also compared the efficacy of DIF on paraffin versus the snap-frozen sections in diagnosing AIBD. Methods The present study was conducted for three years (2017-2019) and included 27 biopsies. We also included a retrospective analysis that included 25 biopsies collected over three years (2014-2017). Histopathological examination and DIF were conducted on all samples. Results Pemphigus vulgaris was the most common autoimmune cutaneous disorder constituting 37% (n = 10) in prospective and 36% (n = 9) in the retrospective study. DIF showed a specificity of 81.25% in our prospective study. While on the paraffin-embedded sections, it showed a specificity of 66.6% in our retrospective study. In the prospective study, DIF on paraffin-embedded sections had a positivity rate of 43.75% as compared to 81.25% in DIF done on snap-frozen sections. Conclusion DIF is a sensitive tool for the diagnosis as well as distinguishing immune-mediated bullous disorders from other lesions primarily when performed on snap-frozen sections. The diagnostic yield is enhanced by DIF in cases that pose a diagnostic dilemma both clinically and histologically. The final diagnosis depends on all clinical, histopathological and immunofluorescence findings.

E2F-1 RNomics is critical for reprogramming of cancer cells to quiescent state.

The discovery of cooperativity between pRB and E2F greatly prompted various investigators to find how E2F biology contributes to oncogenesis. Although E2F family of transcription factors have been linked to proliferation, apoptosis and differentiation, yet no heed has been paid to understand the role of E2F biology in cellular quiescence. To understand the functional RNomics (regulation of gene transcription through RNA interference) of E2F-1 gene, 2 cancer cell lines, such as Jurkat exhibiting E2F-1 gene overamplification and Hela-229 exhibiting intrinsic downregulation of E2F-1 gene expression, were used in our study. E2F-1 gene knockdown via siRNA within Jurkat cells resulted in upregulation of genes characteristic of quiescence both translationally and transcriptionally, which was accompanied by downregulation of genes at both translational and transcriptional level involved in cell cycle progression and apoptosis. This genomic phenomenon also translated into ultrastructural and phenotypic features typical of quiescent state. These observed results in Jurkat cells were simulated by upregulation of E2F-1 gene in Hela-229 cells through the downregulation of miR 17-5p. This E2F-1-regulated pathway explained as to how Jurkat cells entered exclusively into quiescent state when E2F-1 was downregulated in these cells and how Hela-229 cells proliferate vigorously when E2F-1 was upregulated in such cells. Here, we propose a gene-regulatory pathway which the cell might be using in its entry into either quiescent or proliferative states. Furthermore, this pathway may be useful in designing strategies for the treatment of cancer in general and acute lymphoblastic leukemia in particular.

Posterior reversible encephalopathy syndrome in a patient with hepatitis B induced type 1 membranoproliferative glomerulonephritis.

Posterior reversible encephalopathy syndrome (PRES) is a rare complication of nephrotic syndrome and corticosteroid therapy. Here, we discuss an 18 year old man with type 1 membranoproliferative glomerulonephritis (MPGN) secondary to hepatitis B infection who developed posterior leukoencephalopathy while on therapy with lamivudine and prednisone. He developed seizures and vision loss. He also had hypertension, but no sudden elevation was recorded at any time. Magnetic resonance imaging revealed patchy areas of altered signal intensity involving cortical gray and subcortical white matter in the bilateral frontoparietal regions, occipital cortices, temporal cortices and cerebellar hemispheres, and hyperintensity on T2W and FLAIR sequences. Tapering of prednisone and controlling hypertension resulted in clinical improvement within a few days, and in a month MRI was normal. Diagnosing PRES requires a high index of suspicion when treating similarly susceptible patients. PRES as a complication during the treatment of MPGN secondary to hepatitis B has, to our knowledge, never been reported previously in the literature.

Anaplastic large cell lymphoma presenting as acute liver failure: A report of two cases with review of literature.

Primary hepatic anaplastic large cell lymphoma (ALCL) of the liver is a rare entity. We present here two cases of primary hepatic anaplastic large cell lymphoma (ALCL) of the null-cell type. Both the cases had jaundice with "B" symptoms and hepatomegaly. The serum billirubin and liver enzymes were raised in both cases. The liver showed sinusoidal infiltration by atypical lymphoid cells with marked nuclear pleomorphism, dispersed chromatin and prominent nucleoli in both the cases. These cells were positive for CD30, negative for CD3, CD20 and EMA, and diagnosed as ALCL of the null-cell type. We hereby report these cases with the review of literature on primary hepatic ALCLwith their possible etio-pathogenesis & diagnostic clues which may help in timely diagnosis & management in such cases.

An unusual cause of hoarseness in an elderly asthmatic.

Dysphonia in patients with bronchial asthma is generally ascribed to vocal-cord abnormalities or steroid myopathy secondary to inhaled corticosteroids. Herein, we report the case of a 55-year-old male patient - a diagnosed case of bronchial asthma being on inhaled corticosteroids - who presented with dysphonia and was diagnosed to be suffering from Aspergillus laryngotracheobronchitis.

Can ascending infection from bladder serve as the portal of entry for primary renal zygomycosis?

Mucormycosis is an uncommon opportunistic infection by filamentous fungi that usually develops in immunocompromised patients. Most individuals have an underlying systemic disease, such as diabetes mellitus, malignancy, uraemia, burns, renal transplant recipients and those on corticosteroid and immunosuppressive therapy. Many cases of primary renal zygomycosis with lungs serving as the portal of entry have been reported from this region. We describe two autopsy cases of renal zygomycosis where bladder appeared to be the portal of entry for the fungus.