A Rare Co-existent Case of Splenic Microfilariasis and Pancreatic Solid Pseudopapillary Epithelial Neoplasm - A Double Jeopardy!

Filariasis is a major public health concern in tropical and subtropical countries like India with Wuchereria bancrofti accounting for 90% of lymphatic filariasis. Rarely observed are extra lymphatic manifestations caused by interaction of immune system with microfilaria and their diffusible products. Among various organs involved, splenic involvement is a rare extra lymphatic manifestation of filariasis and can masquerade clinicoradiologically as metastasis when associated with a known malignancy or as a primary malignancy like lymphoma. Hereby, we present an unusual case of coincidence of splenic filariasis with pancreatic solid pseudopapillary epithelial neoplasm in a 20-year-old woman associated with peripheral blood eosinophilia.

Adequacy of sigmoidoscopy as compared to colonoscopy for assessment of disease activity in patients of ulcerative colitis: a prospective study.

Background/Aims: Patients of ulcerative colitis (UC) on follow-up are routinely evaluated by sigmoidoscopy. There is no prospective literature to support this practice. We assessed agreement between sigmoidoscopy and colonoscopy prospectively in patients with disease extent beyond the sigmoid colon. Methods: We conducted a prospective observational study at a tertiary care institute for agreement between sigmoidoscopy and colonoscopy. We assessed endoscopic activity using the Mayo Endoscopic Score (MES) and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) and histological activity using the Nancy Index (NI), Robarts Histopathology Index (RHI), and Simplified Geboes Score (SGS). Results: Sigmoidoscopy showed a strong agreement with colonoscopy for MES and UCEIS with a kappa (K) of 0.96 and 0.94 respectively. The misclassification rate for MES and UCEIS was 3% and 5% respectively. Sigmoidoscopy showed perfect agreement (K = 1.00) with colonoscopy for assessment of the presence of endoscopic activity in the colon using MES ??1 as activity criteria and strong agreement (K = 0.93) using MES > 1 as activity criteria. Sigmoidoscopy showed strong agreement with colonoscopy for assessment of the presence of endoscopic activity using UCEIS (K = 0.92). Strong agreement was observed between sigmoidoscopy and colonoscopy using NI (K = 0.86), RHI (K = 1.00), and SGS (K = 0.92) for the detection of histological activity. The misclassification rate for the detection of histological activity was 2%, 0%, and 1% for NI, RHI, and SGS respectively. Conclusions: Sigmoidoscopy showed strong agreement with colonoscopy for endoscopic and histologic disease activity. Sigmoidoscopy is adequate for assessment of disease activity in patients with UC during follow-up evaluation.

"The Innate Tail": An Unusual Cause of Rectal Bleeding in an Adult Male.

Retrorectal cystic hamartomas or tailgut cysts are infrequent congenital lesions presenting as presacral masses originating from the embryonic hindgut. They are commonly diagnosed in middle-aged women. Physicians must have a high index of suspicion to diagnose this rare tumor. We report a case of retrorectal hamartoma in a 70-year-old male presenting as rectal bleeding instead of the usual compressive symptoms. The utility of imaging modalities and the paramount importance of histopathology has been described. The treatment modality is surgical excision to prevent the potential malignant transformation.

Hamartomas císticos retrorretais ou "tailgut cysts" sao lesóes congénitas pouco frequentes que se originam do intestino posterior embrionário e que se apresentam como massas pré-sagradas. São comumente diagnosticados em mulheres de meia-idade. Os médicos devem ter um elevado grau de suspeição para diagnosticar este tumor raro. Relatamos um caso de um hamartoma retrorretal num homem com 70 anos de idade que se apresentou com retorragias e não com os sintomas mais comuns de obstrução. A utilidade dos exames de imagem e a grande importância da histopatologia foi demonstrada neste caso. A modalidade terapêutica adoptada foi a excisão cirúrgica para prevenir uma transformação maligna potencial.

Endoscopic ultrasound-guided-fine-needle aspiration/fine-needle biopsy in diagnosis of mediastinal lymphadenopathy - A boon.

BACKGROUND/OBJECTIVES: Evaluation of mediastinal lymphadenopathy (MLA) is a great diagnostic challenge considering the myriad of causes. In recent years, the role of endoscopic ultrasound (EUS) has been greatly extended in evaluation of MLA due to its safety, reliability, and accuracy. The present study details the role of EUS-guided-fine-needle aspiration/fine-needle biopsy (EUS-FNA/FNB) in MLA of unknown origin. METHODS: Seventy-two patients (34 men) with MLA of unknown etiology were studied. Mediastinum was evaluated with linear echoendoscope and FNA/FNB was performed with 22-G needle and sent for cytology, histopathological, and mycobacterial growth indicator tube/GeneXpert evaluation. EUS-FNA/FNB diagnosis was based on cytology reporting by pathologists. Patients tolerated the procedure, and insertion of needle into the lesion was always successful without any complications. RESULTS: EUS-FNA/FNB established a tissue diagnosis in 66/72 patients in first sitting, while six patients underwent repeat procedure. EUS-FNA diagnoses (after second sitting) were tuberculous lymphadenitis in 45/72 (62.5%), metastatic lymph nodes 12/72 (16.7%), reactive lymphadenopathy 6/72 (8.3%), sarcoidosis 4/72 (5.6%), and lymphoma 2/72 (2.8%), while it was nondiagnostic in 3/72 (4.1%) patients. Final diagnosis was based on combined clinical presentation, EUS-FNA/FNB result and clinicoradiological response to treatment on long-term follow-up of 6 months. CONCLUSION: EUS echo features along with EUS-FNA/FNB can diagnose MLA and surgical biopsy can be avoided.

Metastasis of carcinoma of buccal mucosa to small intestine causing ileal perforation.

Oral cancers rarely metastasize to the small intestines. In a previously operated case of squamous cell carcinoma of buccal mucosa without any known preoperative distant metastases, we report a case of solitary ileal perforation 3 months after the surgery. The edge of the ileal perforation was positive for squamous cell carcinoma on histopathology. It is important to remember metastases as a cause of acute abdomen in the prior history of oral malignancies.

Occult medullary carcinoma of thyroid with lymph node metastases: a case report.

BACKGROUND: Occult thyroid malignancies presenting with secondary neck masses as the first clinical manifestation is well known. Although rare, medullary carcinoma serves a potential source for lymph node metastases. The characteristic cytomorphology of medullary thyroid carcinoma (MTC) should clinch the diagnosis. Further, fine needle aspiration cytology (FNAC) of the ultrasonography-detected occult nodules in thyroid serves as a useful preoperative diagnostic tool. CASE: A 22-year-old man presented with left-sided neck masses of 1 year duration. FNAC smears of the neck masses revealed cytomorphology characteristic of MTC. Ultrasonography of the thyroid led to ruling out the presence of an occult nodule and detected an 8-mm nodule in the left thyroid lobe. Ultrasound-guided FNAC of the nodule showed features similar to those with FNAC of the neck masses. Surgical resection of thyroid and neck masses further confirmed the diagnosis of a primary occult MTC with lymph node metastases. CONCLUSION: FNAC smears of lymph node masses showing the distinct cytomorphology of MTC should prompt suspicion for occult primary in thyroid. Ultrasound-guided FNAC of these occult nodules, if detected, further serves a diagnostic tool for accurate preoperative diagnosis when metastasis presents as the first clinical manifestation of an occult primary.

Lipoid proteinosis in a 12-year-old child: a report from west India.

A 12-year-old male child born of non-consanguineous parents presented with multiple skin lesions, hoarseness of voice, and episodes of epilepsy since early childhood. The findings of characteristic beaded eyelid margins, patchy alopecia of the scalp, hoarseness of voice, and epilepsy were consistent with a rare clinical diagnosis, lipoid proteinosis. Skin biopsies obtained from representative skin lesions were subjected to histology and electron microscopy. Light microscopy demonstrated PAS-positive diastase-resistant material in the papillary dermis of skin. Ultrastructure revealed granulo-filamentary aspect of the accumulated material. Although this rare autosomal recessive disorder has been described in the literature, its occurrence is rare in India.

Angiodysplasia of cardia of stomach--a case report.

Angiodysplasia of gastrointestinal tract is still thought to be an entity of unknown aetiology. This lesion is most commonly observed in elderly patients presenting with severe and persistent iron deficiency anaemia, following occult blood loss or acute episodes of haematemesis. In the stomach antral vascular ectasia is the most common presentation. We report an autopsy case of vascular ectasia in the cardia of stomach in a young patient with clinical symptoms of anaemia as the presentation and an associated secondary hemosiderosis of liver.

Small Intestinal Obstruction with Intussusception due to Acute Myeloid Leukemia: A Case Report.

Myeloid sarcoma is known to precede the development of acute myeloid leukemia (AML) and can be the only clinical manifestation. Gastrointestinal involvement by AML is rare with the commonest site being small intestine. Patients present with vague abdominal pain and/or obstruction. Prognosis is usually poor as most of them rapidly progress to AML. We report a case of 25-year-old man with complaints of abdominal pain and vomiting of one-year duration. OGD scopy revealed infiltration of lesser curvature of stomach. Subsequently patient came back within a week with signs and symptoms of acute intestinal obstruction for which an ileal resection was done. Although the histology of stomach biopsy and ileal segments showing similar features were thought to be non-Hodgkin's lymphoma, immunohistochemistry confirmed the diagnosis of myeloid sarcoma. Bone marrow investigations confirmed involvement by AML. Patient succumbed to the disease due to extensive involvement of AML. This case highlights the primary gastrointestinal manifestation of AML which can often prove to be a diagnostic difficulty clinically and histologically. Prompt diagnosis is essential to hasten the management.

Intussusception due to intestinal metastasis from lung cancer.

Intestinal metastasis from lung primary is very uncommon and seen at the terminal stage of the disease. Clinically, patients present as perforation or bleeding and rarely as intussusception. We report the case of a 78-year-old man who came with sudden onset of abdominal complaints of four to five days duration. A computerized tomography (CT)--scan abdomen showed mural thickening of short loop of jejunum with ileoileal intussusception. Resection-anastomosis revealed two separate nodules in the small intestine. The patient, a diagnosed case of primary carcinoma of lung seven months ago, had been treated with one cycle of chemotherapy. Histopathology of the small intestinal nodules showed features of adenocarcinoma consistent with the known primary lung cancer. We present this case to arouse a clinical suspicion of intestinal metastasis in known cases of primary lung cancer presenting with the sudden onset of abdominal complaints. Early diagnosis and management improves the survival of these patients.

Intradiploic primary epithelial inclusion cyst of the skull.

Intradiploic inclusion cyst of the skull presenting as a calvarial defect is fairly uncommon in the neuroscience practice. They are benign in nature, slow to grow, and clinically difficult to differentiate from other causes of calvarial defects. We present a case of a healthy 55-year-old woman who presented clinically for an asymptomatic lump over the right parieto-occipital region of the scalp of 4-month duration. The radiological features were suggestive of presence of a large intradiploic solitary cyst and additional multiple lytic defects with sclerotic borders, destroying the underlying bone. The gross and histomorphological features of the right parieto-occipital craniectomy specimen received were pathognomic of an intradiploic primary epithelial inclusion cyst of the skull bone. The importance of its benign nature, embryogenic origin, and differentiation from other cystic lesions with similar histology is stressed. We report this case for its unique histomorphology and first of its kind in the Indian literature.