Transformation of HHV-8-negative idiopathic multicentric Castleman disease into diffuse large B-cell lymphoma: A case report from Nepal.

Key Clinical Message: Idiopathic Castleman disease transforming into Diffuse Large B-cell Lymphoma has an aggressive course and can lead to mortality. Hence, early diagnosis and intervention are required. Abstract: Idiopathic Castleman disease transforming into non-Hodgkin lymphoma has an aggressive course, poor prognosis, and high mortality rate. Hence, early diagnosis and intervention are necessary. In a developing country like Nepal, where infectious diseases, particularly TB, are high, concomitant infection worsens the disease course. It also poses a diagnostic challenge as the clinical presentation may be similar.

Cystic endometriosis in a degenerated sub-serous myoma in a sub-fertile woman: A case report.

INTRODUCTION AND IMPORTANCE: Leiomyoma is the most common gynecologic tumor which may show atypical locations and degenerations. Cystic degeneration is said to be found in 4 % of all degenerations. Endometriosis, the presence of endometrial glands and stroma at extrauterine sites, is a common gynaecological condition seen in 10 % to 15 % of reproductive-age women usually being associated with various degrees of fertility problems. CASE PRESENTATION: 40 years old woman with P1L1A2, with secondary sub-fertility for 5 years, presented with chief complaints of dysmenorrhoea for 1 year initially around the menstrual cycle relieving with analgesics but later not limited to the menstrual cycle and pain not relieving with analgesics since 1 month. The patient underwent fertility-sparing laparoscopic removal avoiding a laparotomy and definitive hysterectomy. Manual morcellation was achieved. CLINICAL DISCUSSION: Cystic degeneration is rare in Leiomyoma although it is the more common gynaecological tumor in women and is associated with endometriosis probably due to retrograde menstruation. CONCLUSIONS: Laparoscopic removal of leiomyoma without laparotomy and definitive hysterectomy for a case of cystic endometriosis in a degenerated subserous myoma which to the best of our knowledge according to our search of articles on the relevant topic is the first reported case pertaining to the topic from Nepal.

The effectiveness of online team-based learning in introduction to medical ethics education for medical students at a medical college of Nepal: a pilot study.

BACKGROUND: The effectiveness of online classes is always a concern, and it can be overcome by opting for active learning strategies like team-based learning (TBL). This study was conducted to find out the effectiveness of online TBL as an active learning strategy. We also aimed to explore the satisfaction and perception of students toward TBL. METHODS: This is a mixed-method study conducted among 29 third-year Bachelor of Medicine and Bachelor of Surgery (MBBS) students of Gandaki Medical College using purposive sampling method in the duration of January to September 2021. Three two hours online TBL sessions were used for teaching introduction to medical ethics. The individual readiness assurance test (IRAT) scores were compared to the group readiness assurance test (GRAT) scores to evaluate the effect of TBL through cooperative learning. Learner reactions and satisfaction of students towards TBL were assessed using a validated questionnaire comprising of a five-point Likert scale. An open-ended question asking the participants to describe their overall experience of the TBL sessions was also included to explore their perceptions towards TBL. The data were collected using Google form and exported to Microsoft Excel and the quantitative data were then analyzed using Statistical Package for Social Sciences (SPSS) version 16.0. To check the normal distribution of the data, Kolmogorov Smirnov and Shapiro-Wilk test were used. Non-parametric tests were used for the non-normally distributed data. P value of < 0.05 was regarded as significant. Thematic analysis was conducted for the qualitative data. RESULTS: The median GRAT scores were significantly higher (p = 0.006 in TBL 1 and 0.001 in TBL 2) than IRAT scores. Learner reactions toward TBL sessions were positive as shown by the mean scores which were in the range of 3.59 to 4.66. Five themes were generated from the codes: "effective learning method", "positive experience", "gained knowledge", "expression of gratitude" and "the way of conduction of the sessions". CONCLUSION: Online TBL in medical ethics was effective as a teaching learning tool in our setting. The students were satisfied with the learning process and rated the learning strategy positively.

Sebaceous carcinoma of trunk with bilateral axillary lymph node metastasis: a rare presentation of malignant adnexal tumor in young adult.

Malignant adnexal tumors of skin are rare. Sebaceous carcinoma-a rare and aggressive cutaneous tumor-is frequently located in the periorbital region. Malignant adnexal tumors of sebaceous carcinoma type on trunk with axillary lymph node and distant metastasis in young adult is rare. The incidence of extraocular sebaceous carcinoma has been expected to be 0.06 per 100 000 person-years with an increased incidence in elderly patients and men. With a note of mimicking benign dermatologic conditions, definitive diagnosis of sebaceous carcinomas is often hindered, increasing morbidity and mortality for patients. Herein, we present a case of a 35-year-old man with a large ulcero-proliferating lesion of trunk region previously resected for a small swelling and eventually presented with the recurrent lesion and diagnosed as sebaceous carcinoma of trunk with bilateral axillary lymphnode and distant bone metastasis demonstrating several diagnostic and management challenges.

Efficacy of iron-folic acid treatment for reducing anemia prevalence and improving iron status in women of reproductive age: A one-year longitudinal study.

BACKGROUND: Anemia control has hitherto been through prophylaxis with weekly iron folic acid (IFA) in Indian women of reproductive age (WRA). Recently, a more precise approach has been proposed, that uses a 'screen and treat with IFA' approach for anemic WRA, combined with continued prophylactic IFA in non-anemic WRA. The efficacy of this approach was assessed in Indian WRA, along with changes in iron status biomarkers. METHODS: Young WRA (n = 470), aged 17-21 y, were screened for their venous blood hemoglobin (Hb) and treated with IFA for 90 days according to their grade of anemia, or if non-anemic, administered prophylactic IFA, per Indian policy guidelines, and then followed-up for an additional 9-months. Their Hb, plasma ferritin (PF), transferrin receptor, hepcidin and C-reactive protein concentrations were measured at baseline, during treatment and further follow-up. Anemia was diagnosed using Hb (<12 g/dL) and iron deficiency (ID) using PF (<15 µg/L) cut-offs after adjustment for inflammation. Co-existence of anemia and ID was labelled iron deficiency anemia (IDA). RESULTS: At baseline, in the whole group anemia, ID and IDA prevalence was 69.6%, 68.7% and 62.4%, respectively. At 90 days, IFA treatment or prophylaxis significantly reduced anemia by 40 percentage points (pp), from 69.6% at baseline to 29.8%; ID by 47.3 pp, and IDA by 48 pp. Moreover, significant treatment effects persisted at 365 days of follow-up. CONCLUSION: The 'screen and treat with IFA' approach is efficacious in reducing the prevalence of anemia in general among WRA, with persistent and significant effects after 9 months of follow-up. TRAIL REGISTRATION: CTRI No:2019/02/017806, http://ctri.nic.in/.

Orbital Lymphoma Masquerading as Orbital Cellulitis.

BACKGROUND: Orbital lymphomas are primarily non-Hodgkin type and can originate from the eyelids, extraocular muscles, soft tissue orbital adnexa, conjunctiva, or lacrimal glands. Orbital malignancies often represent a diagnostic dilemma for clinicians given their varying and atypical presentations. OBJECTIVE: To report a case of orbital lymphoma mimicking orbital cellulitis. CASE: A 66-year-old male patient presented with sudden onset of painful proptosis with visual impairment in the left eye for 15 days. On ocular examination, best-corrected visual acuity was 6/12 in the right eye and 2/60 in the left eye, abaxial proptosis with hypertropia, swollen and erythematous eyelids, restricted extraocular movement in all cardinal position of gaze, conjunctival congestion with chemosis and tortuous vessels, sluggish pupillary reaction, and chorioretinal folds in the inferior quadrants. The case was diagnosed as left eye orbital cellulitis, and the patient was treated with broad-spectrum intravenous antibiotics and oral steroids. No clinically discernible response was noted despite 7 days of antibiotics and steroids. Contrast-enhanced computed tomography (CECT) orbit showed features suggestive of orbital lymphoma involving the ipsilateral maxillary and ethmoid sinuses. ENT consultation with diagnostic nasal endoscopy and biopsy was done. Histopathological reports showed features of non-Hodgkin lymphoma. CONCLUSION: Orbital malignancies masquerading as orbital cellulitis can pose a diagnostic dilemma. A multidisciplinary approach involving ENT consultation, radiological investigation, and pathological sampling can help achieve a timely diagnosis and appropriate management.

Deeper Sections: Its Frequency and Diagnostic Utility in Histopathology of Noncutaneous Small Biopsy Specimen in a Tertiary Hospital in Nepal.

BACKGROUND: Biopsy is an important tool for accurate diagnosis of disease in histopathology which can be examined at multiple levels during microscopic examination. The initial sections may not be representative of the entire biopsy, which leads to frequent request for deeper sections. This study assessed the frequency and diagnostic utility of deeper sections in noncutaneous small biopsy specimens at a tertiary hospital. Material and Methods. All the formalin fixed noncutaneous small biopsy specimens received were processed for grossing followed by tissue processing and embedding. The paraffin-embedded blocks were cut into 3-5 µm sections, fixed in a glass slide, deparaffinised, and then stained with hematoxylin and eosin (H&E) stain as per the standard protocol. Deeper sections were instructed based on microscopic findings of initial slides. The overall frequency of deeper section, its levels of cutting, tissue survival, and outcome were assessed and interpreted for the final diagnosis. RESULTS: A total of 125 cases (26.9%) from 464 samples received were requested for deeper sections. The most frequent deeper sections were from cervix (72 cases) followed by stomach (18 cases) and endometrium (17 cases). The deeper sections were performed most frequently at 4 levels (17.8%) followed by 5 levels (14.8%) and 6 levels (13.3%). Deeper sections revealed nondiagnostic additional features in 28.2%, while 2.2% showed additional diagnostic features. Likewise, 2.2% had tissue segment loss. The overall mean level showing additional features was 6 levels. Tissue survival increased in 13% cases and 1.5% had decreased survival. The most common reason for requesting deeper section was to enhance sensitivity and diagnostic accuracy of disease. CONCLUSIONS: Deeper sections often contribute to final diagnosis. Therefore, deeper sections on biopsies that cannot readily be diagnosed on routine levels are recommended regardless of size of the lesion and there should be uniformity in the practice of deeper sections across the globe.

Male Breast Cancer: A Rare Entity.

Male breast carcinoma is a rare malignancy (<1% of all breast carcinomas, 0.2% of all male malignancies). Its common histopathological type is infiltrating carcinoma, not otherwise specified. Three male patients aged 56 (stage -IIIB), 64 (T4bN0M0) and 78 (T2N0MO) years presented with a breast lump within a year. Their hematological and biochemical parameters were within normal limits. Two of them had palpable regional lymph nodes. Male breast carcinoma occurs in older males as in our cases. Two cases showed infiltrating ductal carcinoma, not otherwise specified on histopathological evaluation, and one showed special type with apocrine differentiation. Their two-year follow-up was uneventful after modified radical mastectomy and chemotherapy. Male breast carcinoma is associated with risk factors different from and overlapping with female breast carcinoma. Male breast carcinoma differs from female breast carcinoma on clinical presentation, biological behaviour and prognosis. Male breast carcinoma as a separate clinical entity with its own biological behaviour is manageable by surgery and chemotherapy. Keywords: female breast carcinoma; infiltrating carcinoma; male breast carcinoma.

Dentigerous Cystic Changes in the Follicles Associated with Radiographically Normal Impacted Mandibular Third Molars.

OBJECTIVE: To assess the incidence of dentigerous cystic changes in the follicles of radiographically normal impacted mandibular third molars. METHODS: One hundred and thirteen follicles obtained after surgical removal of impacted mandibular third molars with radiolucency of less than 2.5 mm in the radiograph were sent for histopathologic evaluation to evaluate pathologic changes. RESULTS: The incidence of dentigerous cystic changes observed was 15.9%, that is, 18 out of 113 patients (51 males and 62 females), with the maximum incidence of cystic changes seen in the follicular space size of 0.5 mm. The mean age of the patients included was 27.8 ± 8.1. The most common indication for extraction among the patients in this study was recurrent pericoronitis (95%). There were no statistically significant differences in occurrence of cystic changes based on age, gender, angulation, relation to ramus, depth, side of impaction, and follicle size (P > 0.05). CONCLUSION: Dental follicles obtained from surgically removed impacted mandibular third molars should be submitted for histopathologic examination irrespective of the radiographic size of the follicle.

Ocular Inflammatory Myofibroblastic Tumor in the Left Eye with Phthisis Right Eye: A Rare Occurrence in a Child.

Inflammatory myofibroblastic tumor (IMT) is a benign pseudoneoplastic inflammatory condition with the potential for persistent local growth and recurrence that rarely affects the orbit. We report a very rare case of anterior orbital IMT in a child who presented with gradually progressive mass in left eye for 16 months. Ocular examination showed a cauliflower like exophytic mass at 360 degrees of the perilimbal area covering the entire cornea and obscuring the visualization of anterior and posterior segments. The right eye was phthisical. CT scan showed a lobulated exophytic soft tissue mass in the preseptal region and along the anterior portion of the left globe extending from medial canthus to the lateral canthus. Enucleation of the left eye was performed and the histopathological examination confirmed the diagnosis of IMT. This report aims to raise awareness about this rare ocular entity and emphasizes its early treatment as delay can result in loss of the eye.

Rare location of primary non-Hodgkin's lymphoma in the rectum.

Lymphomas of the gastrointestinal tract are usually secondary. Primary rectal lymphoma is very rare by virtue of its location. We present here a 60 years old lady diagnosed as primary rectal diffuse large B-cell Non-Hodgkin's lymphoma managed operatively. The optimum management of this entity is still much debated.

Fine needle aspiration cytology in diagnosis of pure neuritic leprosy.

Leprosy is a chronic infection affecting mainly the skin and peripheral nerve. Pure neuritic form of this disease manifests by involvement of the nerve in the absence of skin lesions. Therefore, it can sometimes create a diagnostic problem. It often requires a nerve biopsy for diagnosis, which is an invasive procedure and may lead to neural deficit. Fine needle aspiration cytology (FNAC) of an affected nerve can be a valuable and less invasive procedure for the diagnosis of such cases. We report five suspected cases of pure neuritic Hansen's disease involving the common and superficial peroneal, ulnar, and median nerve, who underwent FNAC. Smears revealed nerve fibers infiltrated by chronic inflammatory cells in all cases, presence of epithelioid cells granulomas, and Langhans giant cells in three cases, and acid fast bacilli in two cases. In conclusion, FNAC is a safe, less invasive, and time saving procedure for the diagnosis of pure neuritic leprosy.

Diagnosis of sternomastoid tumor of infancy by fine-needle aspiration cytology.

Sternomastoid tumor of infancy, also known as fibromatosis colli or muscular torticollis, is a benign fibroblastic lesion of the sternocleidomastoid muscle presenting as a firm, fusiform, non-tender neck mass of 1-3 cm in greatest dimension in the perinatal period. Various modalities are used for the diagnosis including radiographic studies, fine-needle aspiration cytology (FNAC), and open biopsy. We report eight cases of sternomastoid tumor of infancy diagnosed by FNAC. The objective of the study is to present the role of FNAC in the diagnosis of sternomastoid tumor with its cytomorphological features. FNA was done by using 23-guage needle and 10 ml disposable plastic syringe. The wet smears were fixed in 95% ethanol and processed for Papanicolaou stain. The dried smears were stained with May-Grünwald-Giemsa stain. The smears were studied for cytomorphologic features. The age of the patients ranged between 2 and 10 weeks. Male: Female ratio was 1.6:1. Six of eight had history of prolonged labor, two had history of breech presentation, and three had history of forceps assisted vaginal delivery. Cytologic findings included singly scattered and loose clusters of benign fibroblasts with moderate amount of unipolar to bipolar cytoplasm and plumped, ovoid nuclei. Many multinucleated giant cells consistent with atrophic muscle fibers were also seen. FNAC is a reliable, safe, and cost-effective method and can provide a rapid and reliable diagnosis of sternomastoid tumor of infancy.