Sudden Death Due to Coronary Blockade by Microfilaremia: An Autopsy Report.

Extralymphatic filarial disease has varied clinical manifestations and is largely underestimated worldwide. We report an autopsy case of extralymphatic filarial disease with coronary and pulmonary circulations being involved and causing sudden death. Such an isolated event is, perhaps, rare and has not been reported so far to the best of our knowledge. Microfilaremia on autopsy may be easily missed or overlooked due to unawareness. The present report emphasizes the importance of extensive careful scrutiny of autopsy sections.

Adult onset retinoblastoma: A diagnostic dilemma.

Retinoblastoma is the most common intraocular tumor of childhood. About 95% of retinoblastoma cases are diagnosed before the age of 5 years. Not more than 30 cases of Adult-onset retinoblastoma have been reported in literature. A 32 year old male presented with a painful blind eye. There was sudden loss of vision accompanied by severe pain and redness in right eye about 1 year ago, for which some surgery was done with neither a gain in vision nor any relief from pain. Then he was put on maximum tolerable medical therapy, later cyclocryotherapy was done. Now he presented to us with complains of extreme pain and bleeding from right eye since 2 days. There is no history of any ocular trauma. Right eye had no perception of light & showed anterior staphyloma with perforation. Right eye evisceration was done & material sent for histopathological examination, which revealed an adult-onset retinoblastoma. CECT scan revealed thickening of optic nerve throughout its entire length with contrast enhancement. He was further taken up for enucleation of residual sclera with maximum optic nerve stump removal to reconfirm the diagnosis. Histopathological examination revealed tumor deposits present in orbital soft tissue, resection margins and optic nerve cut end.Retinoblastoma presenting in adult age creates a diagnostic dilemma because of its low frequency and atypical features. We want to highlight the importance of high clinical suspicion and imaging modalities before taking any patient for evisceration with unexplained vision loss. One should send the eviscerated material for histopathological examination.

A prospective study of mucormycosis in north India: experience from a tertiary care hospital.

Mucormycosis is an emerging angioinvasive infection caused by the ubiquitous filamentous fungi of the Order Mucorales and class of Mucormycetes. We conducted a prospective study of 38 patients who were diagnosed as having mucormycosis in a tertiary care hospital during January 2010 to June 2011. The cases were analyzed regarding the site of involvement, underlying disease and species of fungi isolated, antifungal susceptibility pattern of the isolates, and outcome of therapy. The mean age of the patients was 40.43 years, with 72% male. Rhino-orbital mucormycosis (61.5%) was the most common presentation followed by cutaneous manifestations (31%), gastrointestinal symptoms (5%), and pulmonary (2.5%). Diabetes mellitus (56%) was the significant risk factor in rhino-orbito-cerebral presentation (OR = 7.55, P = 0.001). Among 23 culture isolates, Rhizopus arrhizus (37.5%) was the most common, followed by Apophysomyces variabilis (29.2%), Lichtheimia ramosa (16.7%), Rhizopus microsporus (4.2%), Rhizomucor pusillus (4.2%), and Apophysomyces elegans (4.2%). Rhizopus arrhizus was most commonly isolated from rhino-orbito-cerebral mucormycosis and Apophysomyces species were generally obtained from cutaneous mucormycosis. In vitro antifungal susceptibility showed that 16 isolates were sensitive to amphotericin B (MIC less than 1 µg/ml), while in contrast, all isolates were found to be resistant to voriconazole (MIC- 0.25 to >8), fluconazole (MIC > 32), flucytosine (MIC > 32). Treatment regimens included antifungal therapy, reversal of underlying predisposing risk factors, and surgical debridement. Combination of surgery and medical treatment with amphotericin B was significantly better (OR = 0.2, P < 0.04) than amphotericin B alone (61.5% vs. 10.3% patient survival). The awareness of fungal diseases amongst clinicians is required to decrease the fatal outcome of disease.

Changing Epidemiology of Mucoralean Fungi: Chronic Cutaneous Infection Caused by Mucor irregularis.

INTRODUCTION: The fungi pertaining to order Mucorales usually cause an acute form of clinical disease called mucormycosis. A primary chronic presentation in an immunocompetent patient is a rare form of mucormycosis. Mucor irregularis is known for causing chronic cutaneous infections geographically confined to Asia, mainly in China. We describe a case of primary chronic cutaneous mucormycosis caused by M. irregularis from a new geographical niche in India, highlighting changing aspects of its epidemiology. CASE PRESENTATION: The patient was a farmer with a history of skin lesions over the lower limb for the past 6 years. The biopsy taken from the lesions showed pauci-septate hyphae with right-angle branching on KOH wet mount as well as special fungal stains. On fungal culture, greyish-white cottony mycelial growth of Mucormycetes was obtained. The strain was finally identified as M. irregularis on macro- and microscopic features on 2 % MEA and DNA sequencing. The antifungal susceptibility was done using EUCAST broth microdilution method and was found to be susceptible to commonly used antifungal agents. The patient was started on oral itraconazole and saturated solution of potassium iodide (SSKI). While undergoing treatment for 2 months, he was lost to follow-up, however, after a year when he recently visited the hospital; the disease got completely healed with no new crops of skin lesions. CONCLUSION: Mucoralean fungi should also be suspected in cases with chronic presentation, in immunocompetent host, as there is emergence of such fungi in new endemic areas, particularly located in Asia. The role of other antifungal agents apart from amphotericin B for the treatment of chronic mucormycosis needs to be explored.

Sudden cardiac death in 2 young siblings.

Hypertrophic cardiomyopathy is a disease known for exhibiting phenotypic and genetic heterogeneity. At times, sudden cardiac death may be the first and foremost manifestation of the disease. We report 2 cases of hypertrophic cardiomyopathy causing sudden death, which were diagnosed on autopsy with special emphasis on histopathological findings of this entity. The role of a pathologist cannot be undermined as the disease is a diagnostic challenge often overlooked by the neophytes in the field due to unawareness.

Clinico-pathological Spectrum of Primary Skin Malignancies in an Indian Tertiary Care Hospital.

Background: Skin malignancies are the most common form of malignant disease in the western world, predominantly affecting older age groups. The majority of skin cancers are basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma, which account for more than 95% of total skin malignancies. However, in India, these constitute only 1-2% of all cancers. There is an increase in incidence in India over 10 years of period. There is scarcity of data on the clinico-pathological profile of these tumours from this geographical region. Materials and Methods: This was a retrospective study conducted in a tertiary care teaching hospital in which archival records and histopathology sections of all patients of skin carcinomas diagnosed over a period of 5 years (January 2016 to December 2020) were analysed. The clinical parameters and histopathological features of the cases were analysed and correlated for any possible association. Results: Out of the 230 skin malignancies studied, SCC constituted the most common type (n = 148), followed by BCC (n = 70) and malignant melanoma (n = 12). The tumour commonly presented in the 6th decade of life with slightly higher male preponderance (M: F =1.6:1). Sun-exposed areas were the most common sites, and the common presentations included non-healing ulcer, fungating/cauliflower/polypoidal growth, and hyperpigmented or nodular plaque. In SCC, previous history of diabetes and burns was noted in 10% and 3.4% of the patients, respectively. Conclusion: SCC is likely the most common histological type of skin malignancies in India. The clinico-pathological profile of skin malignancies of patients depends on multiple factors, notably the skin colour and the geographical location.

Fine-needle aspiration cytology in soft tissue tumors-5-year institutional experience.

INTRODUCTION: Fine-needle aspiration cytology (FNAC) forms one of the first-line investigations in the evaluation of tumors in modern era. Its role in diagnosing soft tissue tumors (STT) has been well established. However, the morphological overlap and biological heterogeneity of STT pose a morphological diagnostic challenge. AIMS: To evaluate the scope of FNAC in diagnosis and categorization of STT and to correlate the cytological features with histological findings wherever available, and to analyze the reasons for discordance, if any. MATERIALS AND METHODS: All FNAs of cytologically diagnosed STT during 5-year period were retrospectively analyzed. FNAC smears stained using May-Grünwald Giemsa, Pap- and hematoxylin and eosin, were evaluated and interpreted inconjunction with clinical details. Cellblock and immunocytochemistry (ICC) was done, wherever required to render the final diagnosis. RESULTS: Of the total 15,844 FNAC done in 5 years, 1319 (8.3%) cases were diagnosed as STT. Benign tumors comprised the majority (94.2%), whereas 5.8% were diagnosed to be malignant. These were further grouped according to the cytomorphological features into adipocytic (82.2%), benign spindle cell lesions (10.8%), vascular (1.4%), spindle cell sarcoma/sarcoma NOS (2.2%), myxoid (0.3%), round cell tumors (0.9%), metastatic tumors (1.9%), and others (0.3%). The cytological findings were corelated with histopathological findings, which were available in 316 cases. The specificity and sensitivity calculated for detecting malignancy was 99.2% and 95.4%, respectively. The overall diagnostic accuracy for diagnosing malignancy was 98.7%. Among the group of non-adipocytic tumors, the sensitivity, specificity, PPV, NPV calculated for diagnosing a malignant tumor (irrespective of exact sub-categorization) is 95.2%, 100%, 100%, and 96.4%, respectively. The overall diagnostic accuracy in non-adipocytic tumors is 97.92%. CONCLUSION: FNAC is a simple, cost effective, and minimally invasive method in diagnosing STT with good sensitivity and specificity. It is of utility not only in primary lesions, but also for metastatic tumors, and for the documentation of locally recurrent soft tissue neoplasms.

Osteopontin as a Tumor Marker in Ovarian Cancer.

Introduction: Ovarian cancer is associated with high morbidity and mortality. This is due to the nonspecific symptoms and no effective screening methods. Currently, carbohydrate antigen-125 (CA125) is used as a tumor biomarker for the diagnosis of ovarian cancer, but it has its own limitations. Hence, there is a need for other tumor biomarkers for the diagnosis of ovarian cancer. Objective of the study was to evaluate the diagnostic test characteristics of plasma osteopontin (OPN) in detecting ovarian malignancy and comparing its performance with CA125. Materials and Methods: This is a prospective cross-sectional diagnostic test evaluation. Women with adnexal mass detected by clinical or radiological examination were enrolled as suspected cases. Women who presented with other gynecological conditions were enrolled as controls. OPN and CA125 levels were measured in all enrolled subjects. Results: Among 106 women enrolled, 26 were ovarian cancer, 31 had benign ovarian masses, and 49 were controls. Median plasma CA125 levels were higher in subjects with ovarian cancer (298 U/ml; interquartile range [IQR]: 84-1082 U/ml vs. 37.5U/ml; IQR: 17.6-82.9U/ml; P < 0.001). CA125 sensitivity, specificity, positive, and negative likelihood ratios were 88.5%, 61.3%, 2.10, and 0.19, respectively. Median plasma OPN levels were higher in subjects with ovarian cancer (63.1 ng/ml; IQR: 39.3-137 ng/ml vs. 27 ng/ml; IQR: 20-52 ng/ml; P = 0.001). Sensitivity, specificity, positive, and negative likelihood ratios of OPN were 50%, 87%, 2.58, and 0.62, respectively. Conclusion: OPN levels were higher in ovarian cancer than in the benign ovarian mass and had better specificity than CA125. OPN can better differentiate between benign and malignant ovarian mass as compared to CA125.

Fatal cerebral phaeohyphomycosis in an immunocompetent individual due to Thielavia subthermophila.

We report the first case of fatal brain infection in an Indian farmer caused by Thielavia subthermophila, a dematiaceous thermophilic fungus in the order Sordariales, and present a review of previous infections from this order. The patient failed amphotericin B therapy combined with surgical excision despite the drug's low MICs in vitro.

Cytomorphologic features of chondroid neoplasms: a comparative study.

OBJECTIVE: To perform a comparative analysis of fine needle aspiration cytology (FNAC) features of chondroid tumors and their significance in diagnosis. STUDY DESIGN: A retrospective evaluation of 17 chondroid tumors diagnosed by FNAC was done. Cytologic features were detailed and compared among different chondroid tumor types and with available histology. RESULTS: The 17 cases comprised enchondroma (5), osteochondroma (1), chondroblastoma (2), chondromyxoid fibroma (2) and chondrosarcoma (7). Chondroblastoma and chondromyxoid fibroma were specifically diagnosed in all 4 cases by FNAC due to characteristic cytology. However, the cytologic appearance of enchondromas overlapped significantly with that of well-differentiated chondrosarcoma, but the correct diagnosis was made by interpreting cytology with clinicoradiologic correlation. The cytologic features of high chondroid fragment cellularity, irregular cell arrangement in fragments, prominent nucleoli, and moderate to severe nuclear hyperchromasia and mitotic activity were limited to chondrosarcoma. The single error consisted of a case of osteogenic sarcoma, chondroblastic type, that was interpreted as chondrosarcoma. CONCLUSION: FNAC smears interpreted in the light of clinical and radiologic findings demonstrated high diagnostic accuracy. It is important to be aware of the cytology of uncommon chondroid tumors such as chondroblastoma and chondromyxoid fibroma as well as of the overlap of cytologic features between enchondroma and chondrosarcoma to avoid diagnostic pitfalls.

Mucor as a cause of surgical site infection.

Mucor is an uncommon cause of surgical site infection. We present such a case after intramedullary nailing of the femur and discuss its presentation and management.

Phaeohyphomycosis: Cytomorphologic Evaluation in Eleven Cases.

OBJECTIVE: Phaeohyphomycosis caused by phaeoid fungi is a type of mycosis emerging worldwide which causes a wide variety of clinical manifestations. STUDY DESIGN: A retrospective analysis of 11 cases diagnosed with fungal inflammation on cytology over a period of 6 years (2013-2018) was done along with culture/histopathologic confirmation. RESULTS: Of the total of 11 cases, 9 cases presented with subcutaneous swellings and 1 case each with brain and lung lesions. The age range was 30-83 years (mean: 53.6); 8 patients were male and 3 were female. Cytologic smears showed fungal profiles with septate tortuous hyphae, as well as swollen and narrow, yeast-like swellings with an irregular breadth of the hyphae in all cases. The fungal profiles were visualized on a Masson-Fontana stain. The background showed inflammatory cells, giant cells, and necrosis in variable proportions. Five cases were diagnosed as phaeohyphomycosis on cytology, whereas 3 cases were misdiagnosed as aspergillus and 2 as candida. In 1 case, typing of the fungus was not done. Histopathology was available in 5 cases, and in all these a diagnosis of phaeohyphomycosis was reached. Ten of the 11 cases had confirmation on fungal culture. CONCLUSIONS: Phaeoid fungi are rarely seen in routine cytologic practice. Careful evaluation of cytologic smears and an awareness of the characteristic morphologic features of phaeohyphomycosis are helpful in arriving at a correct diagnosis. Fine needle aspiration cytology provides a rapid diagnosis, enabling prompt therapy.

Fine needle aspiration in retroperitoneal Castleman's disease: a case report.

BACKGROUND: Castleman's disease is a rare disorder of lymphoid tissue that occurs chiefly in the mediastinum and less commonly at other sites, including the retroperitoneum. Few cases of fine needle aspiration (FNA) findings of this lesion have been reported. CASE: A 21-year-old man presented with left-side abdominal pain of 2 months' duration. A solid, well-defined pelvic mass measuring 7.2 x 4.3 x 5.3 cm displacing the urinary bladder and blood vessels was seen on ultrasonography. Ultrasound-guided FNA was performed; smears consisted predominantly of clusters of mature lymphocytes in hemorrhagic background showing crashing at places and closely intermingled with a distinct population of large follicular dendritic cells. Many clusters were seen traversed by capillary fragments. Cell block preparation showed concentric rings of mature lymphocytes surrounding lymphocyte-poor centers with vascular proliferation and follicular dendritic cells. Immunohistochemical staining of cell block sections showed leukocyte common antigen and CD20 positivity in small lymphocytes. A diagnosis of Castleman's disease was rendered, taking into consideration cytologic features and cell block findings. Subsequent histopathology confirmed the diagnosis. CONCLUSION: A definitive diagnosis of Castleman's disease on FNA is possible by a combination of cytologic features and cell block technique with an appropriate use of immunohistochemistry.

Cytologic features and differential diagnosis in a case of extraskeletal mesenchymal chondrosarcoma: a case report.

BACKGROUND: Extraskeletal myxoid chondrosarcoma (EMC) is an uncommon tumor. On fine needle aspiration (FNA) it has to be distinguished from other benign and malignant soft tissue lesions. CASE: FNA was done on an 85-year-old man with painful swelling of the forearm. Smears showed fragments comprised of polygonal cells with eccentric nuclei and peripheral fine cytoplasmic vacuoles embedded in a dense, metachromatic matrix. Cell block showed similar cells in a chondromyxoid stroma. The cells were positive for S100 and negative for cytokeratin. CONCLUSION: FNA is a useful tool in the diagnosis of EMC in conjunction with radiology. A preoperative diagnosis can be made due to its distinct cytologic and immunohistochemical features, obviating the need for a biopsy.

Fungal Suppurative Otitis Media (Histopathology) Among Patients in North India.

Chronic suppurative otitis media (CSOM) has a substantial worldwide prevalence and is a major cause of hearing impairment. In cases of CSOM unresponsive to local antibiotics, superimposed fungal infection should be suspected. The aim of the present study was to study the spectrum of cases with fungal otitis media. The study was conducted over a period of 12 years (2006-2017). Fifteen cases of CSOM clinically not suspected to be of fungal etiology that underwent surgery with identification of fungal organisms on histopathology were included in the study. Age of the patients ranged from 12 to 75 years (mean age: 37.1 ± 22.7 years). Of 15 cases, 9 (60.0%) were males and 6 (40.0%) were females. It was a unilateral presentation in all. The complaints observed were ear discharge in all followed by itching (86.7%), pain (46.7%), decreased hearing (26.7%) and blocking sensation (13.3%). Histomorphologic typing of fungus was possible in 13/15 patients. Isolated aspergillus was identified in eight patients while mucor alone was seen in three patients. Mixed infection with Aspergillus + Candida and Aspergillus + Mucor was seen in one patient each. Categorization of fungus could not be done in rest of the two patients due to paucity of fungal profiles. Histopathological identification of fungal organisms in otomycosis provides a quick and fairly reliable diagnosis. Culture is considered the gold standard but it may not always be available or fruitful. Less turnaround time and accurate diagnosis facilitates prompt and optimal therapy in fungal otitis media thus preventing adverse outcomes.

Tumor Budding and Worse Pattern of Invasion Can Predict Nodal Metastasis in Oral Cancers and Associated With Poor Survival in Early-Stage Tumors.

The management and prognosis of oral squamous cell carcinoma (OSCC) depend on tumor stage and lymph node (LN) metastasis status. Early-stage (T1/T2 N0M0) OSCC comprises a heterogeneous group. We evaluated the role of histological parameters including worst pattern of invasion (WPOI) and tumor budding to determine the risk of LN metastasis in cases of OSCC and to determine the risk of recurrence and death in early-stage OSCC in north Indian patients. All cases of buccal mucosa and tongue SCC which underwent excision over 4 and half years were reviewed for histological parameters including histologic grade, WPOI, tumor budding, lymphovascular emboli (LVE), perineural invasion (PNI), depth of invasion (DOI), host lymphocyte response, and stromal response and compared to LN metastasis. Clinical follow-up of early-stage tumor was obtained and compared. A total of 126 cases of OSCC were included, of which 48 showed LN metastasis. Histological grade, WPOI, tumor budding (≥3/×40 field), LVE, and PNI were significantly associated with risk of LN metastasis. On multivariate analysis, WPOI and tumor budding were 2 most significant factors. Among the early-stage tumors with available follow up (n = 48), DOI, WPOI, tumor budding, and LVE were associated with a shorter overall survival, although it was not statistically significant. To conclude, WPOI and tumor budding are important risk factors for predicting LN metastasis in all stages of OSCC and associated with a poorer outcome in early-stage tumors. These are easy and reliable prognostic factors and should be included in the histopathological reporting guidelines.

Cutaneous plexiform schwannoma of the finger not associated with neurofibromatosis.

Plexiform schwannoma is a rare, benign, peripheral nerve sheath tumor that occurs as an uncommon nodular variant of schwannoma. It is important to recognize this tumor because it can be misdiagnosed as plexiform neurofibroma. In contrast to the latter, however, plexiform schwannoma is not associated with neurofibromatosis (von Recklinghausen disease). We report a case of plexiform schwannoma located on the index finger of a 20-year-old male patient with no signs of neurofibromatosis.

Adenoid cystic carcinoma: A study of 19 cases of salivary and extra-salivary tumours diagnosed by fine needle aspiration cytology.

BACKGROUND: Adenoid cystic carcinoma (ACC) arises at sites where seromucinous or sweat gland epithelium is present and commonly affects the salivary glands. Rarely it can occur at extra-salivary locations. METHODS: A retrospective analysis of 19 cases of ACC diagnosed on fine needle aspiration cytology (FNAC) over a period of 15 y (2002-2016) was made. RESULTS: Of 19 total cases, there were 10 salivary and 9 extra-salivary ACCs. Extra-salivary tumours were seen in 2 cases each in trachea, tongue and in one case each in bronchus, lung, subcutaneous tissue, maxillary antrum, and external auditory canal. The age ranged from 14-80 y (mean: 49.5 y), 10 patients were male and 9 were female. The smears were highly cellular in 11 cases, moderately cellular in 5 cases while 3 cases were paucicellular. Multilayered dense clusters, tissue fragments, dispersed cells and cup-shaped fragments were seen. Relatively uniform cells with high nuclear: cytoplasmic ratio, hyperchromatic nuclei, irregular margins, and nuclear moulding were observed. Variable sized hyaline globules, finger-like hyaline material, hyaline cylinders, and hyaline cords were noted. The cytologic diagnosis of ACC was rendered in 13 cases while in 6 cases it was one of the differential diagnosis including monomorphic adenoma, membranous variant of basal cell adenoma, adnexal tumour, polymorphous adenocarcinoma, and pleomorphic adenoma (PA). CONCLUSIONS: Cytologists must be aware of varied locations where ACC can occur. A diagnosis of ACC must not rely exclusively on the occurrence of hyaline globules but necessitates a close scrutiny of cellular and nuclear features to avoid diagnostic pitfalls.