A clinicopathological study of peripheral lymph nodes in HIV-infected patients with special reference to CD4+ T-cell counts: Experience from a tertiary care institution in Darjeeling (India).

BACKGROUND: HIV/AIDS is a major health burden worldwide. India bears the third highest HIV-patients load globally. In the Darjeeling district, HIV-prevalence is >1% with very little known about the profile of HIV-lymphadenopathy. The aim of this study was to identify the different causes of peripheral lymphadenopathy among HIV-infected patients in this region, correlate them with CD4+ T-cell counts and formulate some common clinico-haematological parameters as potential predictors of CD4+ T-cell count. METHODS: In the present study, 76 cases were evaluated. Fine Needle Aspiration Cytology (FNAC) was performed as an out-patient procedure in the Department of Pathology. Smears were stained routinely with Haematoxylin-Eosin and Leishman stains. ZN stains were done when indicated by the cytological findings. Immediate CD4+ T-cell count was obtained by referring the patients to the Anti-retroviral therapy centre. RESULTS: Cytological diagnoses included tuberculosis (82.9%), reactive hyperplasia (6.6%), nonspecific granulomatous lesions (3.9%), non-Hodgkin lymphoma (2.6%), histoplasmosis (2.6%) and simultaneous filariasis with toxoplasmosis (1.3%). Statistically, the opportunistic infections and lymphomas significantly concurred with a CD4+ T-cell count <350/µl. Likewise, the number of enlarged lymph nodes and absolute lymphocyte count (ALC) were found to be useful predictors of CD4+ T-cell counts. CONCLUSIONS: Lymph node cytology in HIV-infected patients is essential to identify opportunistic infections from neoplastic lesions and; to enable therapeutic strategies. Correlation of lesions with mean CD4+ T-cell count predicts personal immunity, stage of disease and disease activity. Furthermore, enlarged lymph node numbers and ALC can be surrogate markers of CD4+ T-cell count for monitoring the severity of the immune suppression in under-resourced countries like India.

Pigmented malignant teratoid medulloepithelioma of ciliary body - An extremely rare intraocular tumor in adult.

Malignant teratoid medulloepithelioma of ciliary body is an extremely rare tumor usually occurring in children younger than 5 years of age and is usually amelanotic. Here, we report a very rare case of pigmented malignant teratoid medulloepithelioma in a 20-year old male patient who presented initially with pain, redness and proptosis of right eyeball. The right eyeball was enucleated. A histopathological diagnosis of orbital teratoma was made and no further treatment was given. Four months later, the patient developed another swelling in the same area. A review of the previous histopathology slides revealed a pigmented malignant teratoid medulloepithelioma. No nerve involvement was seen. MRI did not show any intracranial extension. The mass along with rest of the orbital tissue was removed. No adjuvant chemotherapy or radiotherapy was given due to the lack of intracranial extension. The patient was symptom free at 2-year follow-up and the repeat MRI also showed no evidence of recurrence.

Clinicohaematological profile of aplastic anaemia in a rural medical college of Northern West Bengal.

There is a scarcity of clinical data in the field of aplastic anaemia from rural India. Present study was conducted in North Bengal Medical College to find out the clinicohaematological profile and the possible aetiological factors in patients with aplastic anaemia. The study population (n = 83) included 21 children with male to female ratio 4.93:1. Weakness was present in all cases and pallor was present in 74.70% cases. Fever, bleeding episodes and localised infection were found in 55.42%, 48.19% and 27.71% cases respectively. There was no difference in clinical manifestations between children and adult except occurrence of fever (p = 0.0365). We identified possible aetiological factors in 32.53% cases as relevant drug intake in 10.84%, exposure to chemicals in 13.25% and hepatitis in 8.43% cases. We found low mean haemoglobin (3.81 +/- 1.71 g/dl), leucocyte and platelet (3.05 +/- 1.3 and 37.30 +/- 35 x 10(3)/cmm), neutrophil (30.28 +/- 21.76%) and high lymphocyte (67.27 +/- 22.50%) in peripheral blood. At the time of presentation, aplastic anaemia was moderate in 59.04% cases, severe in 48.19% cases and mild in 4.82% cases. We estimated the prevalence of aplastic anaemia in 4 districts of West Bengal including tea garden areas was 2.98/million populations per year. It was concluded that aplastic anaemia is a major non-malignant haematological disease in this part of India, and an increasing use of chemicals in agricultural and tea garden areas might be the responsible factor. Larger population based study is suggested.

Primary hydatid cyst of the neck diagnosed by aspiration cytology.

Primary hydatid cyst of the neck is of extremely rare occurrence even in endemic regions. Clinically mimicking a cold abscess, we report such a case which was diagnosed by fine needle aspiration cytology. The lesion was removed surgically and at 6-month follow-up visit, the patient was a symptom-free.

Clinicopathologic profile of non-Hodgkin's lymphoma in a rural medical college.

A prospective study was done at North Bengal Medical College, Sushrutanagar, Darjeeling, West Bengal over a period of two years. All patients diagnosed as non-Hodgkin's lymphoma were analysed for clinical presentation, classified according to the Working Formulation and staged according to Ann Arbor staging system. A lower median age (39.94 years) of onset and higher male to female ratio (3.22:1) as compared to western countries were observed. We found neck swelling was the commonest presenting symptom (65.79%) and peripheral lymphadenopathy was the commonest sign (94.74%). "B symptoms" were noted in 63.16% cases. Cervical lymph nodes were commonly involved (78.95%), followed by axillary (55.26%). Thoracic lymph nodes were enlarged in 31.58% cases and abdominal lymph nodes in 18.42% cases. We found diffuse mixed variant was the commonest (31.58%) followed by diffuse large cell (18.42%). At presentation most of the cases were of intermediate grade (55.26%) and in stage III (44.74%). We conclude that there is a distinct geographical pattern of non-Hodgkin's lymphoma in respect of age, sex, grade and stage of the disease which is distinctly different from those of western countries.

Cytopathological dilemma of anaplastic sacral chordoma with radiological and histological corroboration.

Chordoma is a relatively rare locally invasive and potentially malignant tumor of fetal notochord origin, affecting the axial skeleton. Cytopathological diagnosis of chordoma is favored by the presence of characteristic physaliphorous cells, bearing abundant foamy cytoplasm dispersed in a myxoid matrix. Anaplastic chordoma or dedifferentiated chordoma, an even rarer variant, can cause a diagnostic confusion with chondrosarcoma from the cytopathological point of view, with similar chondromyxoid matrix and atypical cells. Hence, chordoma bearing anaplastic features needs to be identified and should be distinguished from chondrosarcoma on aspiration cytopathology. We present a case of anaplastic sacral chordoma in a man 59 years of age, causing extensive destruction of sacrum and invading the paravertebral tissues as evidenced by radiology. Fine needle aspiration cytopathology revealed few large pleomorphic hyperchromatic cells, admixed with characteristic physaliphorous cells and myxoid matrix. The cytopathological diagnosis has been confirmed by histopathology and immunohistochemistry. Since anaplastic chordoma bears an unfavorable prognosis, it should be suspected on preoperative aspiration cytopathology. Clinicoradiological correlation along with histopathological and immunohistochemical confirmation is necessary subsequently.

Hodgkin's and Non-Hodgkin's lymphomas in an indian rural medical institution: comparative clinicopathologic analysis.

In this prospective, hospital-based two year study, we comparatively evaluated clinicopathologic features of Hodgkin's lymphoma (HL, n = 48) and Non-Hodgkin's lymphoma (NHL, n = 76) in an Indian rural medical institution. A lower median age of onset (28.1 versus 39.9 years) and and higher male to female ratio (3.8:1 versus 3.2:1) were noted for HL compared to NHL. The commonest symptom was neck swelling (58.3% versus 65.8%) while peripheral lymphadenopathy was the commonest sign (83.3% versus 94.7%). The commonest lymph-node group involved was cervical (79.2% versus 79.0%). Bone marrow involvement was lower in HL (8.33% versus 18.4%). The commonest histological subtype was mixed cellularity (45.8%) in HL and diffuse mixed variant (31.6%) in NHL. Most cases presented at advanced stage (54.2% in HL, 71.1 % in NHL). Hence a distinct clinicopathologic profile was noted in HL and NHL that are comparable to other Indian studies but different from Western studies. Recognition of such characteristic features should assist in providing appropriate diagnosis and suitable management in rural communities having limited access to sophisticated medical services.

Clinicohaematological analysis of aplastic anaemia among children of northern districts of West Bengal.

Though aplastic anaemia in children is an important haematological disorder, not many studies have been undertaken in India and especially in the northern districts of West Bengal. The present study was carried out at North Bengal Medical College and Hospital to find the occurrence, clinical and hematological profile of children with aplastic anaemia. All the children (less than 15 years) having relevant history and clinical features underwent a complete blood count and bone marrow aspiration study (smear and histological sections) and trephine biopsy. Total number of children diagnosed were 21 (M = 17, F = 4), having an age range of 6-14.5 years (mean 11.36). Relevant aetiological factors were noted in 10 cases (47.61%), including history of exposure to insecticides, fungicides and fertilisers in 5 cases (23.81%). The common symptoms were due to anaemia (weakness, pallor in all cases), leucopoenia [fever in 16 cases (76.19%)] and thrombocytopenia [bleeding in 10 cases (47.61%)]. Severe and moderate aplastic anaemia were noted in 7 (33.33%) and 12 (57.14%) cases respectively. The calculated occurrence of aplastic anaemia is 1.96/million population of children/year in the four northern districts of West Bengal. The bone marrow aspiration was satisfactory in all cases. Histological sections of aspirated marrow particle produced better architectural relationship among different components. Aplastic anaemia is a major hematological problem among the children of northern districts of West Bengal. Simultaneous examination of smear and histological sections of marrow particles is a satisfactory method for detection of aplastic anaemia.

Clinico-pathologic profile of Hodgkin's lymphoma in a rural medical college.

PURPOSE OF STUDY: A prospective study was done at North Bengal Medical College and Hospital (NBMCH), Darjeeling, West Bengal, which caters predominantly to the rural and hilly population. All patients diagnosed as Hodgkin's lymphoma (HL) were analyzed for clinical presentation, histological classified and staging. RESULTS: Total of 48 cases reported for HL were studied (n=48). A lower median age of onset (28.1year) and higher male to female ratio (3.8:1) as compared to western countries were observed. We found neck swelling was the commonest presenting symptom (58.28%) and peripheral lymphadenopathy was the commonest sign (83.33%). "B symptoms" was noted in 79.17% cases. Cervical lymph nodes were commonly involved (79.17%), followed by inguinal (45.83%) and axillary (29.17%). Thoracic lymph nodes and abdominal lymph nodes were enlarged in 29.17% of the cases and 25% of the cases respectively. Eosinophilia was noted in 29.17% of cases. Marrow involvement by neoplastic process was observed in 8.33% of cases and reactive changes in the marrow were observed in 12.5% of cases. We found mixed cellularity subtypes was the commonest (45.83%) followed by nodular sclerosis subtypes (33.33%). At presentation 54.17% of cases were of advanced stage of disease (stage III and IV). CONCLUSION: We noticed a distinct geographical pattern of HL in respect of age, sex, presentation, histological typing and staging of the disease, which is comparable to some other Indian studies but is noticeably different from patterns noted in Western countries.