Glucagon-producing mucinous tubular and spindle cell variant of renal cell carcinoma with paraneoplastic diabetes: Case report and review of literature.

Renal cell carcinoma (RCC) is known as the internist tumor because of the myriad paraneoplastic manifestations associated with it. One of the rarely described paraneoplastic manifestations associated with this malignancy is hyperglycemia. Only 11 cases in the English and Japanese literature have been reported. We report the occurrence of paraneoplastic hyperglycemia with a rare variant: mucinous tubular and spindle cell variant of RCC. To the best of our knowledge, the association of paraneoplastic hyperglycemia with this variant has not been reported earlier.

Generalised gingival enlargement as a sole manifestation of IgG4-related disease.

An 18-year-old woman presented with enlarged gingivae of 1-year duration with no history of drug consumption or systemic conditions that might explain the enlargement. Biopsy revealed hyperplastic gingival epithelium and a plasma cell-rich inflammatory infiltrate in the subepithelial connective tissue with the presence of scattered multinucleated giant cells. Immunostaining revealed the plasma cells to be positive for IgG4. Serum IgG4 levels were elevated at 3.6 g/L (reference range: 0.049-1.985). These findings led towards the diagnosis of an IgG4-related disease (RD). Other granulomatous conditions were also ruled out via series of investigations. The enlarged tissue was surgically excised. No corticosteroids were administered owing to the localised nature of the manifestations. After 3 months, the gingival size remained unchanged. This case has been reported with a relatively shorter follow-up period because of the rarity of the presentation. IgG4-RD should be considered while diagnosing a patient with gingival enlargement.

Role of CT Chest and Cytology in Differentiating Tuberculosis from Presumed Sarcoidosis in Uveitis.

Purpose: To report the role of CT chest and cytology in suspected tubercular and sarcoid uveitis. Methods: This is a retrospective, interventional case series of 376 uveitis patients with suspected ocular tuberculosis (TB)/sarcoidosis seen between January 2010 and April 2015 at the Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh. All underwent CT chest, and had following inclusion criteria: (1) Presence of active granulomatous anterior/intermediate/posterior uveitis or panuveitis; (2) a documented tuberculin skin test/QuantiFERON-TB Gold test; (3) all other causes of infectious/non-infectious uveitis ruled out. A total of 206 patients had abnormal CT chest, of which 147 patients with minimum four months follow up were studied. Based on CT findings and amenability of involved lymph nodes, conventional transbronchial needle aspiration (TBNA)/endobronchial ultrasoundguided TBNA (EBUS-TBNA) or fine needle aspiration cytology (FNAC) of peripheral nodes was performed by an interventional pulmonologist. All smears were subjected to cytopathological examination, and Ziehl-Neelsen staining for acid-fast bacilli (AFB). The detection of the underlying etiology (TB or sarcoidosis) was the main outcome measure. Results: CT chest demonstrated mediastinal/hilar lymph nodes in 123/147 (83.7%) patients. Twenty four (16.2%) patients with parenchymal involvement were diagnosed TB (n = 20) or sarcoidosis (n = 4). Sixty nine patients with subcentimetric lymph nodes that were not amenable to biopsy were diagnosed clinico-radiologically as TB (42) and sarcoidosis (27). Fifty-four patients underwent biopsy from various sites that diagnosed TB and sarcoidosis in 21 (38.2%) patients each. Five TBLB/EBUS TBNA smears and seven FNAC smears demonstrated AFB. Conclusions: In systemically asymptomatic individuals presenting with uveitis, CT chest helped to establish the diagnosis of TB/sarcoidosis in 71.43% cases (105 out of 147) using only the clinico-radiological criteria, while a confirmed diagnosis of TB/sarcoidosis was possible only in 42 cases (28.57%) by EBUS/TBNA guided cytological examination.

Successful Use of Entecavir in Hepatitis B-associated Membranous Nephropathy.

We report the case of a 7-year-old unimmunized boy who presented with generalized anasarca for the first time, along with nephrotic-range proteinuria, hypoalbuminemia, microscopic hematuria and hypertension. Special investigations revealed ELISA test to be positive for hepatitis B surface antigen (HBsAg) and hepatitis B envelope antigen (HBeAg); hepatitis B viral DNA load (HBV DNA) level (real-time polymerase chain reaction) was 54 360 903 IU/ml. For hepatitis B virus (HBV)-related glomerulopathy, he was started on enalapril and lasilactone, and percutaneous renal biopsy was performed, which revealed membranous nephropathy (MN). A diagnosis of MN secondary to HBV infection contracted via horizontal transmission was made. The patient was started on peginterferon alfa-2b (50 µg/week) for 24 weeks. He failed to attain remission and seroconversion after interferon (IFN) therapy. Then, oral therapy with entecavir was started, and he attained remission as well as seroconversion after 3 months of therapy. He maintained his seroconversion status at his 6-month and the recent 12-month (quantitative HBV DNA level was 373 IU/ml) follow-up visit. Entecavir seems a promising drug for HBV-related glomerulopathy, especially in IFN-resistant cases.

Changes in gastric environment with test meals affect the performance of 14C-urea breath test.

BACKGROUND: (14)C-urea breath test (UBT) is considered to be an accurate diagnostic test for the detection of active Helicobacter pylori infection. Various test meals are used in (14)C-UBT to slow down gastric emptying, and to enhance the gastric distribution, in order to increase the time and area of contact between microorganisms and the tracer substrate. The aim of the present paper was to evaluate the effect of gastric environment on the performance of (14)C-UBT using an alkaline and an acidic liquid test meal having gastric emptying retardant effect. METHODS: The comparison of (14)C-UBT was done with liquid test meals (200 mL water) comprising (i) plain drinking water (PDW); (ii) 1.3 g or 3.0 g citric acid (CA); and (iii) 3.0 g trisodium citrate (TSC). Eighteen patients (37 +/- 12 years, range 18-57 years) with complaints of dyspepsia participated in the study. The status of H. pylori was confirmed by histology and rapid urease test. A total of 93 kBq of (14)C-urea (0.5 mL) in a gelatin capsule was orally administered along with liquid test meals to the overnight fasting subjects. Breath samples were collected and radioactivity measured. Results were expressed as (14)CO(2)/mmol exhaled CO(2) as percentage of administered radioactive urea. RESULTS: Higher acidic gastric environment (pH approx. 2.0) with CA was found to increase the exhaled (14)CO(2) level in a dose-dependent manner as compared to PDW and TSC meal (P < 0.05) at all time points. With TSC test meal, the expired (14)CO(2) level decreased in the lower acidic gastric environment (pH approx. 5.3). The peaks of exhaled (14)CO(2) with TSC test meal were observed at the same time points as that with PDW and CA test meals. The (14)C-UBT with TSC was found to be positive in 77% of patients (10/13). CONCLUSION: Better interaction between the microbial urease and (14)C-urea, caused by a test meal that retards gastric emptying and that changes gastric pH, plays an important role in hydrolysis of the administered (14)C-urea by H. pylori urease.

The high incidence of BK polyoma virus infection among renal transplant recipients in India.

BK polyoma virus causes allograft dysfunction as a result of tubulo-interstitial nephritis in 2% to 5% of renal transplant recipients. The incidence of BK virus infection among renal transplant recipients in India is unknown. We used routine histologic examination, immunohistochemistry, and electron microscopy to retrospectively screen for BK polyoma virus in 414 renal allograft biopsy specimens from 321 transplant recipients presenting with allograft dysfunction. All patients had received a combination of cyclosporine, azathioprine, and prednisolone. A total of 30 biopsy specimens (9.3%) were positive for BK polyoma virus, suggesting a high incidence of this infection in Indian transplant recipients. BK virus infection coexisted with acute rejection in a majority of patients. This is the first report of this infection among Indian renal transplant recipients.