Introducing a novel histopathological scoring system to assess disease activity and chronicity in cutaneous lichen planus: A proposal.

BACKGROUND: Lichen planus (LP) is a chronic inflammatory disorder caused by an autoimmune attack by cytotoxic T-cells. The clinical course is variable, with episodes of remission and exacerbation. A clinicopathological scoring system for cutaneous LP is not available for effectively assessing disease severity and monitoring treatment response. This study was designed with the aim of proposing an objective and reproducible scoring system, comprising histopathological features of active and chronic disease, and to correlate these scores with clinical morphology groups. METHODOLOGY: This is a retrospective study of 200 cases of cutaneous LP, which were categorized into five clinical groups (I-V) at the time of biopsy. The corresponding histopathological feature was assigned a score based on feature of active and chronic disease. Individual scores were summated to calculate a histopathological index (index [AI] and chronicity index [CI]). The comparison of indices between various clinical groups was performed by Mann-Whitney U test. RESULTS: The median AI was lowest (1) for post-inflammatory hyperpigmentation (clinical group I) and highest (7) for the bullous group (clinical group IV). The median CI (7) was highest for the scarring group (clinical group V). The difference between median AI of clinical group I (post-inflammatory hyperpigmentation) and rest of the groups (clinical groups II, III, IV, and V) was statistically significant (p value <0.05). CONCLUSION: We present this clinico-histopathological scoring system as a reliable and facile method of assessing the activity and severity of LP.

Practical Approach to the Interpretation of Complete Blood Count Reports and Histograms.

Improvement in technology and inclusion of new parameters in automated hematology analyzers allows for better and faster detection of anemias. These parameters along with histograms provide details and clues that help to diagnose the etiology of anemia and help bridge the time lag in detection and treatment. Timely and expert interpretation of complete blood counts should not be limited to the pathologist but should also interest the clinician to allow for efficient patient care.

Clear Cell Variant of Squamous Cell Carcinoma of Eyelid, Mimicking Sebaceous Carcinoma: A Rare Case Report.

Clear cell variant of squamous cell carcinoma (SCC) is an extremely rare neoplasm. Here, we report a case of clear cell variant of SCC which presented as an eyelid nodule. A 56-year-old male presented with a painless, small, pedunculated nodule in the left upper eyelid. On microscopic evaluation, tumor cells were arranged in nests and lobules with few foci of necrosis. Tumor cells were polygonal in shape, having abundant clear and vacuolated cytoplasm with peripherally pushed hyperchromatic nuclei. Two main differential diagnoses considered were sebaceous carcinoma and clear cell variant of SCC. On immunohistochemistry, tumors cells were negative for androgen receptor. A final diagnosis of clear cell variant of SCC was made. In a malignant eyelid tumor with clear cell morphology, a differential diagnosis of clear cell variant of SCC should be kept in mind before making a diagnosis of sebaceous carcinoma because sebaceous carcinoma possesses a poorer prognosis.

Static smartphone images supplemented by videoconferencing for breast telepathology.

BACKGROUND: Both static images and videoconferencing by smartphone have been tried for telepathology. Combining the two approaches for telepathology might offset some of the limitations of both techniques. METHODS: A total of 150 cases of breast pathology were retrieved and were photographed by a trained junior pathologist using a smartphone camera and binocular microscope and the images were sent as Google photos attachments with email to three pathologists. The pathologists opened the emailed attachments during separate prescheduled google meet videoconferencing sessions and rendered the diagnosis verbally to the junior pathologist. The pathologists were given the option of asking for live dynamic images of the cases during the meet which were transmitted using the rear camera of the smartphone with the video option of google meet. RESULTS: The overall concordance rates for the three pathologists were 96.6%, 99.3% and 98.0% (Mean 98.0%). The reporting pathologists asked for dynamic live images in 23, 20 and 18 cases respectively. Out of these 61 cases, a discrepant diagnosis was made in 7 cases (11.4%). The reporting pathologist was satisfied with the quality of static images (Mean Likert score 4.2/5). However, concerns were raised on the consistency of video quality (Mean Likert score 2.5/5). The screen share option of Google meet was found useful to discuss specific features of the case. (Mean Likert Score 4.6/5) CONCLUSION: The combined approach to telepathology has shown some promise and it is hoped that with adequate training the discordance can be reduced.

Anastomosing Hemangioma of Ovary with Stromal Luteinization Masquerading as Sex Cord-Stromal Tumor on Intraoperative Consultation.

Anastomosing hemangiomas (AHs) are benign vascular tumor with rare occurrence in the ovary and the majority being asymptomatic. We report one such case of AH with stromal luteinization. A 35-year-old female had complaints of abdominal pain and heavy menstrual bleeding for 2 years. Her lactate dehydrogenase was markedly raised. Following the clinical suspicion of germ cell tumor, exploratory laparotomy and right salpingo-oophorectomy were done. On frozen section due to extensive stromal luteinization, diagnosis of sex cord-stromal tumor was suggested. However, the case was finally diagnosed with AH with extensive stromal luteinization. This case highlighted the potential mimics of AH due to coexistent raised biomarkers and secondary changes, thereby posing a diagnostic dilemma on intraoperative consultation.

Crescents in Kidney Biopsy - What Do They Imply? A Clinicopathologic Study of 40 Cases in a Tertiary Care Center.

INTRODUCTION: Crescents in glomeruli mean proliferation of parietal epithelium of Bowman's capsule with the presence of macrophages, lymphocytes, neutrophils, fibrin, and collagen. When crescents are present in >50% of nonfibrosed glomeruli, it is called crescentic glomerulonephritis (CGN). The presence of crescents is indicative of poorer prognosis. CGN can be pauci immune (PI), immune complex mediated (ICM), and anti-glomerular basement membrane (anti-GBM) disease. AIM: The aim was to study the clinicopathological spectrum of CGN over a period of 10 years in our center. MATERIALS AND METHODS: Forty kidney biopsies with the presence of crescents over a period of 5 years were retrieved retrospectively from the histopathology records of the department of pathology. The clinical history, laboratory parameters, histopathology report, and the direct immunofluorescence (DIF) findings were analyzed. RESULTS: Totally 40 cases had crescents on light microscopy. Out of these, 17 cases qualified for CGN. The mean age of the patients was 20 years. Nephritic syndrome was the most common presentation in these 17 cases. The mean creatinine level was 3.55 mg/dL. PI (7/17, 41.1%) was the most common category, followed by ICM (6/17, 35.2%) and anti-GBM (4/17, 23.5%). Out of the ICM, two cases were of IgA nephropathy with crescents and one of lupus with crescents. CONCLUSION: PI is the most common type of CGN. DIF examination is essential for exact categorization of CGN. Kidney biopsy in these cases can guide management and benefit patients with timely initiation of aggressive therapy.

Galectin-3 and CD117 immunocytochemistry in the diagnosis of indeterminate thyroid lesions: A pilot study.

BACKGROUND: Indeterminate thyroid lesions have always been a grey zone in the field of thyroid cytopathology. Immunocytochemistry (ICC) has emerged as a promising tool to correctly classify these indeterminate thyroid lesions into benign and malignant. Hence we planned to assess a panel of immune markers in the diagnosis of indeterminate thyroid lesions consisting of Galectin-3, considered positive for malignancy and CD117 which is positive in benign follicular epithelial cells and negative in malignant lesions. METHODS: All the thyroid aspirates reported as indeterminate lesions over a period of 3 years were evaluated. Galectin-3 and CD117 immunocytochemistry was done in 50 alcohol fixed Pap stained smears of AUS/FLUS, FN/SFN and SM category lesions. The expression of both immune markers was assessed by semi-quantitative method and ICC score was calculated. RESULT: Of 50 indeterminate lesions, 29 were positive for Galectin-3 and 21 were negative. CD117 was positive in 19 cases and rests 31 were negative. With the use of this ICC panel 29/30 indeterminate lesions in which histopathological correlation was available could be recategorized correctly into benign and malignant. The combined sensitivity and specificity of Galectin-3 and CD117 for categorising the indeterminate lesions into malignant category was 100%. CONCLUSION: The combined use of positive and negative immune markers for thyroid malignancy increases the sensitivity and specificity of ICC to categorise the indeterminate thyroid lesions into benign and malignant. In cases with discordant ICC results we propose that inclusion of one additional positive and/or negative marker may resolve the diagnostic dilemma.

C3 Glomerulopathy: Diagnosis of a Rare Entity in a Resource-Limited Setting.

C3 glomerulopathy (C3G) is a rare entity that is defined by glomerular pathology characterized by predominant deposition of C3 in the glomeruli, with absent or scant immunoglobulin deposition. The aim of this study was to diagnose this rare entity, using clinical features, light microscopy (LM) and direct immunofluorescence (DIF) findings. A retrospective study was done from January 2016 to December 2018. Out of 207 kidney biopsies, eight cases of C3G were included in the study. Clinical, laboratory, and demographic data of all patients were obtained. LM and DIF findings were further evaluated. Nephrotic syndrome was the predominant clinical presentation in this study. All eight cases showed a membranoproliferative pattern on LM. DIF showed predominant mesangiocapillary staining with C3 in all eight cases. DIF plays an important role in making the correct diagnosis, which is necessary to further perform appropriate complement investigations, as these patients respond well to complement inhibitor therapy.

A WhatsApp-based introductory histopathology and cytology course for first-year pathology postgraduate students.

Background The first-year pathology postgraduates can take a long time to learn the basic skills of microscopy, which can become a barrier to learning. Methods A WhatsApp group comprising all 14 postgraduate first-year students with one senior resident and one faculty as group administrators was formed. For the study, 50 routine cases (35 histopathology cases and 15 cytopathology cases) captured by using a smartphone camera and annotated using image-editing software, along with relevant descriptions and weblinks, were sent to the WhatsApp group. A pre- and post-test comprising 15 cases each was conducted and the results were compared by non-parametric Wilcoxon rank test. A feedback form about the effectiveness of this method of learning was circulated at the end of the study. Results The results of the post-test were better than the pre-test by the non-parametric Wilcoxon rank test. Both the active participants (>10 posts) and passive participants of the study group showed statistically significant improvement in the scores and posted a similar number of intellectually thought-provoking posts. The students' responses to the questionnaire also indicated that they liked the new method of instruction. Conclusion This pilot study shows that smartphone-based learning methods can supplant the traditional methods of teaching for pathology postgraduates.

Role of Direct Immunofluorescence Microscopy in Spectrum of Diffuse Proliferative Glomerulonephritis: A Single-Center Study.

INTRODUCTION: Immunofluorescence (IF) microscopy is an essential tool for the analysis of glomerular diseases. In this study, we studied the significance of the IF technique together with light microscopy (LM) and clinical details in the diagnosis of different types of diffuse proliferative glomerulonephritis (GN). We intended to evaluate the spectrum of Diffuse Proliferative Glomerulonephritis (DPGN) in our institute. MATERIALS AND METHODS: We evaluated a total of 95 kidney biopsies received in the past 10 years. All biopsies were scrutinized by LM and IF techniques. Clinical details were documented in a predesigned form. RESULTS: The predominant clinical presentation in this study was nephrotic syndrome (49.4%) followed by systemic lupus erythromatosus with suspected renal involvement (24.2%). On microscopy, lupus nephritis (LN) was the most common DPGN in the study (35.7%), followed by immunoglobulin (Ig) A nephropathy (25.2%) and postinfectious GN (PIGN) (16.8%). The majority of patients were in the <30 years age group (72.6%), with the average age of patients being 24.4 years. The dominant deposit on IF in LN was C3 and IgG (100%). A high deposit of IgA (100%) in IgA nephropathy and of IgG and C3 (100%) in membranoproliferative GN was seen. PIGN showed dominant positive staining of IgG (92.8%). CONCLUSION: The predominant clinical presentation was of nephrotic syndrome and on LM LN was the most commonly diagnosed DPGN in this study. Direct IF is vital for classifying DPGN, followed by electron microscopy, which is an essential tool. This article describes a rational evaluation of kidney biopsies with DPGN pattern on LM in a way that guides toward the logical assessment to reach the diagnosis. Using the IF technique and comparing it with LM and clinical details, we evaluated the spectrum DPGN in our center.

Clinicopathological Spectrum of Renal Amyloidosis in Young.

Amyloidosis is a complex multi-system disorder characterized by deposition of an aberrant protein in tissues with kidney being the main target organ. The age of presentation of amyloid A (AA) amyloidosis is highest among adults aged 60-80 years followed by 45-55 years. However, presentation in younger age group is rare. We aimed to study the clinicopathological spectrum of patients with biopsy-proven renal AA amyloidosis aged <35 years in the last five years. This retrospective study was done on patients admitted from January 2015 to December 2019. Nine cases of AA amyloidosis diagnosed on kidney biopsy in ≤35 years of age were included in the study. Clinical, laboratory, and demographic data of all patients were obtained. Histopathological and direct immunofluorescence findings were further evaluated. The mean age (±standard deviation) was 22.5 ± 6.7 years with a range of 14-32 years. The most common underlying disorder of AA renal amyloidosis was Tuberculosis (TB) (88.88%, 8/9) with cyclosporine induced in one of the cases (11.11%). In all nine cases, glomeruli were mostly enlarged with moderate to marked mesangial expansion with thickened arteries and arterioles due to deposition of pink hyaline acellular material. Renal amyloidosis is rare in young age and is mostly secondary in nature. The association of TB with renal amyloidosis is common in adults (3.6%-50%), but only infrequently reported in children. It is important, especially in developing countries to be aware, as successful treatment of TB can result in remission of nephrotic syndrome due to secondary renal amyloidosis.

Smartphone-assisted tele-gynepathology: A pilot study.

INTRODUCTION: Traditional telepathology techniques like whole slide imaging require expensive equipment and are currently out of reach of the developing countries. However, the improvements in smartphone camera resolution and availability of faster internet have made smartphone-assisted telepathology possible. METHODS: A total of 186 cases pertaining to gynecologic pathology reported by single consultant (NT) were retrieved from the records of the histopathology department. A trained histopathologist then photographed representative areas of each case by using the smartphone camera. After a wash off period of 6 months, the images along with the clinical details were sent by Whatsapp Messenger to the same reporting pathologist. The reporting pathologist replied with the diagnosis of each case by using Whatsapp. RESULTS: The smartphone diagnosis was concordant in 179/186 (96.2%) cases. The intraobserver concordance rates varied with the organ involved - it was highest for endometrial and myometrial pathology (123/126, 97.6%) lowest for ovarian lesions (08/10, 80%). For cervical pathology, it was 97.2% (35/36) and for fallopian tube pathology it was 92.9% (13/14). CONCLUSION: Although the initial results of this pilot study are encouraging, there is a long way to go before smartphone-assisted telepathology can be put to routine use for the second opinion. More experience of the pathologists with this technique and faster internet and better smartphone cameras will further improve the concordance of smartphone-assisted telepathology diagnosis with conventional microscopy diagnosis.

Plasmodium Vivax Malaria: Usual Illness with Dysregulated Immune Profile.

Afebrile Plasmodium vivax disease is believed to be extremely rare; and so is the association of a secondary immune thrombocytopenia due to Plasmodiun vivax malaria. This is a case of malaria presenting in an atypical manner. A middle aged male (31 years) came with occasional bleeding around gums, small petechial haemorrhages over chest and abdomen, and blood in stools for a few months, but no fever. In addition, the cervical lymph nodes were slightly enlarged. Spleen was 3 cm below costal margin. Platelets were found to have markedly decreased with clusters of megakaryocytes in the bone marrow. A possibility of Immune thrombocytopenic purpura was considered and immunoglobulin started intravenously, however platelet counts remained low. Later, in a follow up smear, trophozoites of P. vivax were discovered. Antimalarial drugs (Artesunate) were administrated for the patient along with IV immunoglobulins, to which he responded. It was revealed by flow cytometry that the ratio of helper to cytotoxic cells was reversed (0.9). This highlighted a rare case of afebrile malaria in association with immune dysregulation. Accordingly, malaria, though uncommon, could trigger immune thrombocytopenia.

Smartphone-Assisted Telecytopathology: An Intraobserver Concordance Study.

INTRODUCTION: Telecytology is the practice of cytology at a distance. The images captured by a camera are sent to the cytopathologist at a different location who views the images and reaches a diagnosis. Recently, smartphone-assisted telepathology has been evaluated for different subspecialities of pathology including cytology for second opinion. MATERIALS AND METHODS: For the purpose of the study, a total of 151 cases of fine needle aspiration and 10 cases of urine cytology reported by a single pathologist were retrieved from the records. The images of all the cases were captured by a trained pathologist using the primary camera of a smartphone from the ocular of a binocular microscope. The images were sent by WhatsApp to the same pathologist who had made the conventional microscopy diagnosis. The images were viewed on the smartphone screen by the pathologist who replied with the diagnosis after analysing all the images with or without digital zoom. RESULTS: A total of 154 cases out of 161 were correctly diagnosed on smartphone-assisted telepathology (overall intraobserver concordance of 95.6%). For head and neck swellings, the concordance was 65/70 (92.9%), for breast lesions, it was 23/24 (95.8%), and for miscellaneous swellings, it was 57/57 (100%). For urine cytology, the concordance rate was 9/10 (90%). CONCLUSION: Though the results of this study are encouraging, further improvement in the smartphone camera resolution and internet connectivity would enhance the utility of smartphone-assisted telecytopathology.

Genetic stability assessment of plants regenerated from cryopreserved embryogenic tissues of Dioscorea bulbifera l. Using RAPD, biochemical and morphological analysis.

Embryogenic tissues of Dioscorea bulbifera were cryopreserved using the encapsulation-dehydration technique. Genetic stability of plants regenerated from cryopreserved embryogenic tissues was assessed using molecular, biochemical and morphological analysis. The random amplified polymorphic DNA (RAPD) analysis of 60 cryopreserved-derived and 20 in vitro grown (control) plantlets showed that 10 primers produced 62 clear reproducible DNA fragment profiles. The amplification products were monomorphic for all the plantlets except one. A total of 4960 DNA fragments were obtained from this study showing no variation in RAPD profiles. The diosgenin content of cryopreserved-derived plants, analyzed using HPLC, was similar to that of control plants. Morphology and the ability to form microtuber were also found to be unaltered in cryopreserved embryo-derived plantlets. Thus, the D. bulbifera plants regenerated from cryopreserved embryogenic tissues were genetically stable at the molecular, biochemical and morphological levels.