'Lateral Aberrant Thyroid Carcinoma' or 'Thyroglossal Duct Cyst Carcinoma Metastasizing to Neck Node': Can we Decide in this Interesting Case Report?

Lateral aberrant thyroid(LAT) belongs to subset of ectopic thyroid, mostly presenting as asymptomatic lateral neck swelling and are challenging to diagnose without histopathological examination. Malignant transformation in LAT is even rare and is best managed by surgical excision. Here, we report a case of papillary carcinoma of LAT, but with an unusual post-operative finding, revealing papillary carcinoma of thyroglossal duct cyst.

Bronchoscopic lung cryobiopsy for the diagnosis of pulmonary alveolar proteinosis in a hypoxemic patient.

Pulmonary alveolar proteinosis (PAP) is a rare disorder characterized by the intra-alveolar accumulation of surfactant due to macrophage dysfunction or the production of abnormal surfactant. Diagnosis is usually confirmed by lung biopsy either bronchoscopically or by video-assisted thoracoscopic surgery. Bronchoscopic lung cryobiopsy (BLC) is increasingly being utilized for the histopathological diagnosis of diffuse parenchymal lung diseases; however, it has rarely been reported for PAP. We report a case of 59-year-old male who presented to our center with gradually worsening breathlessness and cough of 1-year duration. Chest radiograph revealed bilateral extensive pulmonary infiltrates and high-resolution computerized tomography scan revealed extensive bilateral ground-glass opacities with areas of sparing. BAL and transbronchial lung biopsy failed to confirm the diagnosis; hence, BLC was done which revealed pathologic findings suggesting PAP. BLC appears to be a promising diagnostic tool for the diagnosis of PAP and offers several diagnostic advantages compared to conventional techniques.

Flagellar antigen based CI-ELISA for sero-surveillance of surra.

Trypanosoma evansi causes a disease known as 'surra' in wide range of domesticated and wild animals including cattle, buffaloes, horses, camels etc. The disease is transmitted through the bites of haematophagous tabanid flies and is characterized by undulating fever, chronic progressive weakness, and hypoglycemia leading to low productivity in animals. In the present study, monoclonal antibodies (MAbs) have been produced (IgG3 sub-type) against purified flagellar (FLA) protein of T. evansi and its immunoreactivity was evaluated by serological tests. MAb and purified protein were then exploited in the development of CI-ELISA and the diagnostic potentiality of the new ELISA test has been evaluated using 1230 sera samples from field animals including cattle, buffaloes, camels, horses and donkeys. The statistical analysis of the data showed optimum combination of sensitivity and specificity at 95.8 and 94.4, respectively. The positive-negative cut off percentage inhibition (PI) value was found to be >55, with a Cohen's Kappa value of 0.83. The study showed that the new assay has potential for application in sero-diagnosis as well as sero-surveillance of surra.

Transient Loss of Vision after Coronary Angiogram - A Case Report.

A 50-year old, diabetic, hypertensive patient with post-CABG status developed complete loss of vision about one hour after coronary angiogram (CAG). Thorough ophthalmological and neurological examination as well as magnetic resonance imaging of brain especially of the occipital region revealed no abnormality. The patient had complete recovery of vision about 48 hours later. We could not document any specific cause or mechanism for the visual loss, although the selective vulnerability of occipital lobes to contrast agent toxicity (Cortical blindness) was the most likely underlying mechanism.

Development of an enzyme immunoassay using recombinant invariant surface glycoprotein (rISG) 75 for serodiagnosis of bovine trypanosomosis.

Trypanosomosis or surra is caused by the haemoflagellate parasite, Trypanosoma evansi and is an important disease of animals, including domestic and wild herbivores and carnivores, in tropical countries. The invariant surface glycoproteins (ISGs) are blood stream stage specific and are uniformly distributed over the entire surface of the trypanosomes. In the present study, the extracellular domain (ED) region of ISG-75 from T. evansi, consisting of 1320 nt, encoding a polypeptide of 440 amino acids, has been heterologously expressed in Escherichia coli. Further, the immunoreactivity of recombinant ISG-75 (rISG-75) was characterized in immunoblot and ELISA using T. evansi hyper immune sera raised in experimental animals. The protein was found immunoreactive when compared with a panel of antigens (VSG RoTat 1.2 and whole cell lysate) using bovine serum samples from field. The diagnostic potential of rISG-75 was evaluated in ELISA with large number of bovine field serum samples. The optimum sensitivity and specificity were 98.47 and 99.1, respectively. The present finding showed that the expressed protein has potential use in the serodiagnosis of trypanosomosis.

Eccrine spiradenoma in knee.

Eccrine spiradenoma is an uncommon benign adnexal tumor of the eccrine sweat glands. Although it can occur at any age, it is most common in young adults without any sex predilection. Malignant transformation is rare, presenting as rapid increase in size of a long-standing lesion. Here, we report a case of eccrine spiradenoma in a 35-year-old man who presented with swelling over the right knee, with cytological atypia but no recurrence until date.

Thoracic cord compression by extramedullary hematopoiesis in thalassemia.

Extramedullary hematopoiesis (EMH) refers to hematopoiesis occurring outside the medulla of bone. It may be physiologic or due to pathological conditions like hematopoietic disorders. EMH can involve liver, spleen, thorax, and lymph nodes. It can involve paraspinal tissues with extension and involvement of spinal canal. In our case, the diagnosis was confirmed by the history of the patient stating underlying hematological condition and by magnetic resonance imaging (MRI) findings showing large soft tissue masses in paraspinal areas with involvement of spinal canal and leading to cord compression.

Post exertional hematuria.

The incidence of exercise-induced hematuria is reported to be between 5% and 25% and available literature suggests that it lasts for a few hours to a maximum of 3 days. We analyzed the urine sediment of healthy participants between the age of 20 and 50 years before and after a 5 km run. Anyone with abnormal pre-exercise sediment was excluded from the study. Of 491 participants, 59 (12%) developed post exercise hematuria when the run had to be completed in allotted time. However, when the run was completed without time limit, only 1.3% (4 of 316) developed hematuria (p < 0.001). We found that the younger participants (age < 30 years) had a significantly higher incidence of hematuria as compared to their older compatriots (p = 0.019). The mean duration of hematuria was 1.98 ± 1.89 days and 81% of the participants cleared their hematuria within 3 days. In 12% it lasted between 3 and 7 days and in 7% it continued beyond 7 days. Three individuals had persistence of hematuria beyond day 14 and all these were found to have primary glomerular disease on renal biopsy [two had IgA nephropathy and one focal segmental glomerulosclerosis (FSGS)]. We conclude that exercise-induced hematuria can last up to a fortnight. However, if it persists beyond a fortnight, it is unlikely to be functional and an underlying cause is likely. Hematuria following exercise seems to be related to the intensity of effort during exercise rather than its duration.

PCR based diagnosis of trypanosomiasis exploring invariant surface glycoprotein (ISG) 75 gene.

The invariant surface glycoprotein (ISG-75) gene of Trypanosoma evansi buffalo isolate from Karnataka state in India was sequenced and analyzed to elucidate its relationship with other isolates/species. The sequenced ISG-75 gene was also explored to device a polymerase chain reaction (PCR) strategy for the diagnosis of trypanosomiasis in carrier animals. The six cloned ISG gene sequences revealed the open reading frame (ORF) of 1572 and 1527 nucleotide (nt) encoding a polypeptide of 523 and 508 amino acids (aa) respectively and belongs ISG-75 gene family. Sequence analysis revealed 91-100% and 65-99% similarity at nt and aa levels, respectively with other isolates/species and belongs to the RoTat 1.2 strain. The diagnostic PCR based on ISG-75 sequence amplifies a 407 bp product specifically from the different T. evansi isolates and could detect 0.04 pg and 1.2 ng of DNA from purified trypanosomes and T. evansi infected rat blood samples respectively. Subsequently the PCR detected 0.02 and 0.27 trypanosomes ml(-1) respectively, from purified trypanosomes and T. evansi (buffalo isolate) infected rat blood. By the developed PCR assay trypanosomal nucleic acid was detected in experimental rats and buffalo on 24 h post infection (p.i.) and 3rd day post infection (d.p.i.), respectively. The developed ISG-75 gene based PCR assay could be useful in detection of carrier status of trypanosomiasis in animals.

Idiopathic hypertrophic cranial pachymenigitis - A long follow-up needed.

Idiopathic hypertrophic cranial pachymenigitis is a rare clinical condition caused by localized or diffuse inflammatory thickening of dura matter. Described here is a person having diffuse thickening of dura matter of base of skull and he was on follow-up treatment for 5 years with us. Diagnosis was done by excluding other conditions and with biopsy. The patient responded to steroid and the MRI picture, which is given serially, shows improvement.

Desmoplastic trichilemmoma of the facial region mimicking invasive carcinoma.

Trichilemmoma is a hamartomatous proliferation arising from cells of hair follicle. Its desmoplastic variant simulates an invasive carcinoma. In this tumor, the cell of origin seems to be located in the superficial level of the hair follicle just below the basement membrane at the sebaceous gland level. We present a similar case which presented with an asymptomatic nodular lesion in the region above the upper lip on left side. Fine needle aspiration cytology raised the cytological possibility of a malignancy for which the lesion was excised. On histopathology the lesion was diagnosed as desmoplastic trichilemmoma. The case highlights the difficulty encountered in differentiating a benign adnexal tumor from malignant lesion based on cytology alone. Moreover, the extensive desmoplasia on histopathology raises the suspicion of invasive malignancy which requires to be carefully excluded. The superficial features of trichilemmoma and lack of cellular atypia is a useful diagnostic clue in such a situation. Positivity of CD34 can also be used to differentiate from basal cell carcinomas. The case reported here had a solitary lesion, but follow up is required for development of more lesions or multiple hamartomas in other organs as a part of Cowden's disease.

Gangliocytic paraganglioma: a rare presentation as intestinal intussusception.

Gangliocytic paragangliomas are rare benign neoplastic lesions of neuroendocrine origin occurring primarily in peri-ampullary region. Commonly occurring as small submucosal lesions, presentation as a large polyp with acute ileo-ileal intussusception in a 62-year-old woman is rare and is described in this case report.

Superficial temporal fascia pedicled v-y advancement flap for scalp reconstruction.

Repair of scalp defects using local hair bearing scalp is technically challenging. Transposition or rotation of local flaps to close the defect has its own disadvantages. Reconstruction of scalp defect using superficial temporal fascia pedicled V-Y advancement flap using both frontal and parietal branches of superficial temporal artery following the excision of a benign and a malignant pathology is reported here. It is possible to reconstruct the defect with hair bearing scalp in a single stage along with primary closure of the donor site using this technique.

Valvular regurgitation and stenosis: when is surgery required?

Valvular heart disease is a growing public health problem, with an increasing prevalence due to an ageing population. Despite advances, the medical management of symptomatic valvular heart diseases remains suboptimal, necessitating surgical correction. The challenge remains in identifying an asymptomatic or mildly symptomatic patient who will benefit from timely surgery before irreversible changes in cardiac function have occurred. The potential risks of surgery versus watchful expectancy require careful decision-making. This review is a focused update on the existing guidelines and identifies the knowledge gaps and avenues of future research in the management of patients with valvular heart diseases.

Descending thoracic aortic aneurysm presenting as left sided hemorrhagic pleural effusion.

Aneurysm of descending thoracic aorta, in majority of cases is diagnosed either by chance in routine chest imaging for some other reasons or rarely due to it's symptomatic presentation like chest pain and other mediastinal compression symptoms. In this case report we present a case of 69 year old smoker who presented with cough, hemoptysis and left sided massive painless hemorrhagic pleural effusion. Further investigation revealed a large aneurysm of descending thoracic aorta which infiltrated the left lung. We suggest descending thoracic aneurysm be included in the differential diagnosis of this sort of clinical presentation which otherwise imperative with the clinical scenario of bronchogenic carcinoma.

Ultrasound quantification of anterior soft tissue thickness fails to predict difficult laryngoscopy in obese patients.

Morbid obesity is associated with difficult laryngoscopy and intubation. In the general population, bedside indices for predicting difficult intubation (i.e. Mallampati classification, thyromental distance, sternomental distance, mouth-opening and Wilson risk score) have poor-to-moderate sensitivity (20-62%) and moderate-to-fair specificity (82-97%). In the obese population, although the risk of difficult intubation after a positive Mallampati test is 34%, it is still not sufficient to be used as a single predictive test. An abundance of pretracheal soft tissue anterior to the vocal cords, as quantified by ultrasound, was a better predictor of difficult laryngoscopy than body mass index (BMI) in Israeli patients. Obesity is a growing problem in the United States: therefore we sought to confirm this finding in the obese population in the United States. We used ultrasound to quantify the neck soft tissue, from the skin to the anterior aspect of the trachea at the vocal cords, in 64 obese patients (BMI > 35). We assessed thyromental distance, mouth-opening, jaw movement, limited neck mobility, modified Mallampati score, abnormal upper teeth, neck circumference, confirmed obstructive sleep apnoea, BMI, age, race and gender as predictors. Twenty patients were classified as difficult laryngoscopy; they were older (47 +/- 9 vs 42 +/- 1 years; P = 0.048; mean +/- SD) and had less soft pretracheal tissue (20.4 +/- 3.0 vs 22.3 +/- 3.8 mm; P = 0.049) than did easy laryngoscopy patients. Multivariate regression indicated that none of the factors was an independent predictor of difficult laryngoscopy. We conclude that the thickness of pretracheal soft tissue at the level of the vocal cords is not a good predictor of difficult laryngoscopy in obese patients in the United States.

Laryngeal cleft type I: a novel method of repair using Bioplastique.

The authors report a novel treatment of a case of type I laryngeal cleft diagnosed in an adult. They describe a technique of endoscopic obliteration of the posterior commissure defect. Initially, a test implant of starch and adrenaline was used, followed by permanent staged injections of Bioplastique to the posterior commissure. This rare congenital anomaly usually presents in childhood but late presentation should be considered when adults present with lifelong dysphonia especially when associated with gastro-oesophageal reflux disease.

Transcatheter closure of congenital muscular ventricular septal defect.

The success with occlusion devices for the closure of atrial septal defects and patent ductus arteriosus prompted the transcatheter closure of single and multiple muscular ventricular septal defects (VSD). The procedure for VSD was first attempted by Lock et al. in 1988 and devices originally designed for the closure of other intracardiac defects (Rashkind umbrella device, Lock clamshell, Cardioseal, coils, Sideris buttoned device etc.) were used with a variable success rate and a residual shunt. Recently, specially designed Amplatzer muscular VSD occluder and Sideris device are in use. The Amplatzer muscular VSD occluder has been undergoing clinical trial since 1998 after the animal experiments had shown 100% occlusion and complete endothelization at 3 months. The procedure was first attempted in August 1995 using the Rashkind umbrella device and since April 1998 only the Amplatzer muscular VSD occluder has been used. Of the149 patients who underwent transcatheter closure of VSD, 50 had muscular trabecular defects in various locations: mid-muscular, anterior, posterior, or apical. All cases were selected by detailed transthoracic and/or transesophageal echocardiography (TTE) and aneurysm of the muscular septum was observed in three of them. The age range was 3-28 years and the diameter of VSD was 4-11 mm. In all but one patient, the device was deployed from the venous side. Simultaneous TTE was done for proper positioning of the device and continuous electrocardiographic monitoring was also done for any arrhythmia/conduction defects. All patients were followed up every 3 months and received 3-5 mg/kg aspirin for 6 months. The procedure was successful in all patients. The Rashkind umbrella device (17 mm) was used in two and Amplatzer muscular VSD occluder (6-14 mm) in 48 patients. Forty-four devices were delivered by antegrade transvenous approach and six by the transjugular route. None had residual shunt, new aortic regurgitation, or tricuspid regurgitation. Transient complete heart block after 24 hours was noticed in one patient. On a follow-up of 2-90 months, the device was in position in all patients. There was no embolization of the device, and no late-conduction defects, infective endocarditis, or hemolysis. Transcatheter closure of muscular VSD is safe and efficacious, and should be considered as a procedure of choice as an alternative to surgery that avoids cardiopulmonary bypass.

Carcinosarcoma of the ovary.

We report our experience in the management of patients with carcinosarcoma of the ovary, a rare but aggressive variant of ovarian cancer. Forty patients were treated at a single centre, which is the largest reported series. The median age at diagnosis was 65 years (range 45-86) and the median Karnofsky performance (KP) status was 70. Thirty-two patients (80%) presented with FIGO stage III or IV disease. Twenty-four had heterologous and 14 homologous carcinosarcoma on review of histopathology, but there was no significant difference in survival between these groups (P=0.28). Twenty-seven of the 40 patients had bulk residual disease present after surgery and this was associated with a worse prognosis (P=0.045). Chemotherapy was given to 32 patients (80%) of whom 26 (81%) received platinum-based regimens. Of these 32 patients, three (9.4%) achieved a complete response (CR), 10 (31%) a partial response (PR), five (16%) had stable disease, 10 (31%) had progressive disease and four were not assessable. Of the 19 patients who had a CR, PR or stable disease after chemotherapy or were unevaluable (stage Ic), the median survival was 29.6 months. Currently, seven patients are still alive although one has cancer. The overall censored median survival was 8.7 months after a median follow-up of 34 months, and the 1- and 5-year survival were 40 and 7.5%, respectively.

Congenitally unguarded tricuspid valve orifice with a giant right atrium and a massive clot in an asymptomatic adult.

Congenitally unguarded tricuspid valve orifice, a variant of tricuspid valve dysplasia, is a rare malformation with protean manifestations. This report describes an asymptomatic adult who, on echocardiographic examination ordered in view of an abnormal 12-lead surface electrocardiogram and plain chest X-ray, was found to have an unguarded tricuspid valve orifice with a giant right atrium (12 x 10 cm), intense spontaneous echo contrast and a large right atrial clot.