Infantile pulmonary tuberculosis: the great mimic.

PURPOSE: Infantile tuberculosis is common in developing countries and rarely presents as space occupying thoracic lesions mimicking congenital malformations. This case series reviews four such infants with varied presentations and their outcome. METHODS: Four cases of infantile pulmonary/mediastinal tuberculosis that presented like congenital thoracic lesions are described. Details of demography, symptomatology, contact history, immunization status, provisional diagnosis, tuberculin testing, imaging, histopathology, final diagnosis, management and outcome were retrospectively collated and analyzed. RESULTS: They were 4-6-month males, term-born and immunized. They presented with pneumonia/hyperactive airway disease since 2-12 weeks. One had a suspect and another a close tuberculous contact. The provisional diagnosis after imaging were infected congenital lung cyst, posterior mediastinal cyst and bronchopulmonary malformation. Two were tuberculin positive; none had gastric acid-fast bacilli. One underwent a pulmonary lobectomy for necrotic lung cyst; the second had a biopsy and drainage of a posterior mediastinal cyst that contained caseating material and was densely adherent to the esophagus. Surgical biopsy showed necrotizing granulomatous inflammation in both; one with acid-fast bacilli. Both succumbed to postoperative complications. The other two with tuberculous contacts who were managed with early antituberculous therapy, responded well and recovered uneventfully. CONCLUSIONS: Infantile pulmonary/mediastinal tuberculosis may mimic congenital thoracic malformations. A review of contact history, investigations and imaging help to establish the tuberculous etiology, avoids surgical misadventures and prompts early antituberculous therapy to achieve a favorable outcome.

Embryonal carcinoma in a cryptorchid testis of a 3-year old.

The undescended testis is at an increased risk of malignant transformation. Almost all such tumours occur in the second to fourth decades of life and are usually seminomas. A case of a mixed germ-cell tumour with yolk sac and embryonal carcinoma components arising in one of the hitherto uncorrected bilateral cryptorchid testes of a3-year old child is presented.

Malignant lymphoma without lymphadenopathy.

Hepatosplenic T-Cell lymphoma (HSTCL) is a rare form of extra-nodal post-thymic T-cell non-Hodgkin's lymphoma that primarily involves liver and spleen with B symptoms, with a characteristic absence of lymphadenopathy. We report such an entity in a 65-year-old man who was diagnosed to have multiple myeloma and treated for the same for two years. A clinical diagnosis of secondary myelofibrosis was suspected and was investigated, when he developed pancytopenia and massive hepatosplenomegaly at one of his follow-up visits. The patient underwent therapeutic splenectomy with a simultaneous wedge biopsy of the liver and with their corresponding histopathological and immunohistochemical features, the diagnosis of HSTCL was clinched.

The diagnostic utility of bone marrow trephine biopsies.

The bone marrow examination is invaluable in the diagnosis of certain haematological and non haematological conditions. The diagnosis of haematological disorders is achieved mainly by the examination of peripheral blood and bone marrow aspirate smears. Although bone marrow histology can provide additional information, for many technical reasons, trephines are not so popular and their diagnostic value is overlooked. Our experiences in the role of trephine biopsies in the diagnosis are presented in this article. All the bone marrow biopsies performed at the St. John's Medical College Hospital over the last 12 years (1990-2002) were reviewed The bone marrow biopsies were grouped into 3 categories for analysis. The trephine biopsy is invaluable in cases where the aspirate fails or is a dry tap as in the case of myelofibrosis, focal marrow involvement as in granulomatous lesions, metastatic tumour and lymphomas.

Cutaneous vasculitis--a dynamic process posing diagnostic challenge.

AIM: To characterize the clinicopathologic features and to assess the therapeutic outcome in cutaneous vasculitis. MATERIAL AND METHODS: Fifty biopsy proven cases of cutaneous vasculitis seen between January 1998 and July 1999 were studied. RESULTS: The commonest presentation was palpable purpura. The site most commonly affected was the extremity, irrespective of the age (adults - 40 and children - 10) and sex. The histopathologic picture ranged from an acute to chronic process, which besides the classic picture included bullous presentation, granulomatous histology and nonspecific features. Clinical correlation and investigations including direct immunofluorescence (DIF) were required to differentiate primary from secondary vasculitis (SLE-4, dermatomyositis-2, rheumatoid artritis-1, HIV-1, septicaemia-1 and drug reaction 2). DIF was diagnostic in 13 out of 21 cases providing evidence of an immune-mediated pathogenesis. Drugs used in the treatment included dapsone, colchicine, pentoxyphiline and steroids. CONCLUSIONS: The clinical picture and outcome of primary cutaneous vasculitis were benign while the prognosis of secondary vasculitis depended on the primary disease, irrespective of the histopathological picture.

Double primary carcinoma in a renal allograft recipient.

We report a renal allograft recipient on triple immunosuppression with prednisolone, azathioprine and cyclosporine who presented with ductal infiltrating carcinoma of the right breast eight years post-transplant, followed two years later with left ovarian papillary carcinoma.

Sporadic synchronous ganglioneuromas in a child--case report and review.

An 8-year-old girl presented with a relatively asymptomatic abdominopelvic mass that was detected in the neonatal period. She harbored a presacral mass with intraspinal extension and a right posterior mediastinal mass; all were excised completely and were ganglioneuromas. The report discusses the maturation of neuroblastoma-ganglioneuromas and details the staged management of sporadic synchronous ganglioneuromas in a child, probably the first in published English literature.

Vertebral osteomyelitis with a rare etiology diagnosed by fine-needle aspiration cytology.

Invasive fungal infections are rare in immunocompromised individuals, but are not uncommon in immunologically compromised patients. Bone involvement by these infections, though exceedingly rare, may occur due to direct extension of the infection from a neighboring organ or due to hematogenous dissemination in critically ill patients. Still rarer is the invasive aspergillosis involving either the vertebral body or the intervertebral disc with extension into the extradural space as an abscess. We report one such case of vertebral osteomyelitis due to Aspergillus diagnosed by FNAC in a well-controlled diabetic patient who presented with nonspecific symptoms and in whom a clinical and radiological diagnosis of Pott's spine was considered. The present case stresses the importance of early cytologic diagnosis of vertebral Aspergillus osteomyelitis, which in conjunction with appropriate timely medical and surgical treatment, offers good recovery without much sequelae or threat to life.