Case Report of Nasal Rhinosporidiosis in South Africa.

We describe a classic case of nasal rhinosporidiosis in a woman who resided in Johannesburg, South Africa, but originated from a rural area in Eastern Cape Province. We confirmed histologic diagnosis using PCR testing and compared details with those from records on 17 other cases from South Africa.

Placental Listeriosis: Case Report and Literature Review.

Listeria monocytogenes, a foodborne, facultative, intracellular gram-positive bacillus, is one of 17 species of the Listeria genus and was responsible for the world's largest outbreak of listeriosis in 2017-2018 in South Africa. Listeria monocytogenes tends to cause mild gastrointestinal symptoms in healthy individuals. However, pregnancy-associated listeriosis can be fatal to the fetus and can lead to serious adverse effects in the neonate. Listeria monocytogenes has an affinity for the placenta, as opposed to other nonreproductive organs. Herein, we present a case of placental listeriosis diagnosed in a 33-year-old female, parity 4, with unknown gestational age during the listeriosis outbreak in South Africa in 2017-2018. The patient presented with pregnancy-related complications and underwent a caesarean section. Morphological features demonstrated acute suppurative villitis and intervillositis with a heavy load of gram-positive bacilli, which is highly suggestive of placental listeriosis. Multiplex polymerase chain reaction confirmed the presence of L. monocytogenes.

Leiomyo-adenomatoid Tumor of the Uterus: Finding the Rare in the Routine.

Leiomyo-adenomatoid tumour (LMAT) is a rare benign neoplasm and very few cases of LMAT of the uterus are documented in the literature. Uterine LMATs are usually detected incidentally during the histopathologic evaluation of routine myomectomy or hysterectomy specimens for leiomyomata. Thorough evaluation of the morphological features and a concise immunohistochemical panel allows for accurate classification of this benign neoplasm.

HIV-associated DLBCL: Clinicopathological factors including dual-colour chromogenic in situ hybridisation to assess MYC gene copies.

INTRODUCTION: Diffuse large B-cell lymphoma (DLBCL) comprises up to 43% of non-Hodgkin lymphomas in South Africa due to the high seroprevalence of human immunodeficiency virus (HIV) infection in the southern African region. We explored the prognostic influence of an array of clinicopathological factors, including MYC gene copy numbers, within HIV-associated DLBCL. METHODS: The retrospective inclusion of 123 tumours was followed by c-MYC immunohistochemistry and dual-colour MYC and centromere 8 (CEN8) chromogenic in situ hybridisation on formalin-fixed paraffin-embedded sections. Clinicopathological data were collected, interpreted and analysed. RESULTS: HIV seropositive patients comprised 81% (93/115), mean age 42 (SD 10.8) years, with 55% males, HIV negative patients comprised 19% (22/115), mean age 57 (SD 16.7) years (p = 0.001), with 59% males and the HIV status was unknown for 8 patients. The median CD4 count was 162 (IQR 215) cells/mm3, 33% of patients presented with CD4 counts <100 cells/mm3 and the median viral load was 217 (IQR 182 981) copies/mL. There was advanced stage at presentation (i.e., III-IV, 87%), with Ki-67 proliferation indices ≥90% in 85%- and c-MYC expression (i.e., ≥40%) in 58% of tumours. Double expression of c-MYC and BCL2 was associated with a non-germinal center immunophenotype (p < 0.01). Low-level increase of MYC gene copy numbers and MYC rearrangements occurred in 57% and 12%, respectively. C8 polysomy, MYC gene clusters and concurrent MYC rearrangement/increased MYC gene copies were also detected. Inferior median overall survival (OS) occurred when the CD4 counts were <100 cells/mm3 (149 days 95% CI 44-254, p 0,04) and when IPI scores were 3-5 [155 days (95% CI 37-273), p = 0.01]. Concomitant infections negatively impacted the survival outcome, multivariate regression analysis (HR 4.01, 95% CI 1.86-12.20, p = 0.02). CONCLUSION: c-MYC protein expression, low-level increase in MYC gene copy numbers, rearrangement, C8 polysomy, MYC gene clusters and concurrent MYC rearrangement/low-level gains are present in HIV+ DLBCL. CD4 counts < 100 cells/mm3, IPI scores 3-5 and concomitant infections negatively impact the survival outcome.

Posttraumatic Natural Killer Cell Decrease is Associated with Septic Complications.

BACKGROUND: There has been paucity in prospective studies investigating trauma-induced changes in the cellular immunity of HIV-seropositive patients and their impact on the clinical outcome after trauma surgery. The role of natural killer (NK) cells especially has not yet been fully elucidated, and the function of this lymphocyte subtype in the immune defense after trauma is still under debate. METHODS: This prospective study included patients requiring surgery for abdominal gunshot wounds. A blood specimen was obtained on admission, 48 hours after the index operation and, in case of damage control surgery, 48 hours after the first planned second look operation. The quantity and changes of T-, B- and NK cells were analyzed via flow cytometry to investigate whether these numbers had an impact on the postoperative outcome. RESULTS: A total of 62 patients were recruited in the analysis of which 38 were HIV-negative and 24 HIV-seropositive. After surgery, HIV-negative patients had a more severe decrease of their CD4+ T cells compared to the HIV-seropositive patients. Trauma resulted in a severe decrease of NK cells irrespective of the HIV-serostatus. Patients with more extensive NK cell drop had a significantly higher postoperative complication rate. CONCLUSIONS: Our data support the association of trauma-induced NK cell decrease with a subsequent significantly higher rate of septic and surgical complications and suggest that these immune cells might play an important role in antibacterial immunity. Strengthening the NK cell function or limiting their decrease in the postoperative course might be of therapeutic value in severely injured trauma patients.

CD4 + T cells are found within endemic Burkitt lymphoma and modulate Burkitt lymphoma precursor cell viability and expression of pathogenically relevant Epstein-Barr virus genes.

Endemic Burkitt lymphoma (eBL) is an aggressive B cell cancer characterized by an IgH/c-myc translocation and the harboring of Epstein-Barr virus (EBV). Evidence accumulates that CD4 + T cells might contribute to eBL pathogenesis. Here, we investigate the presence of CD4 + T cells in primary eBL tissue and their potential dichotomous impact on an EBV-infected pre-eBL cell model using ex vivo material and in vitro co-cultures. In addition, we establish a novel method to study the effect of IgH/c-myc translocation in primary B cells by employing a CRISPR/Cas9 knock-in approach to introduce and tag de novo translocation. We unprecedently document that CD4 + T cells are present in primary eBL tumor tissue. Furthermore, we demonstrate that CD4 + T cells on the one hand suppress eBL development by killing pre-eBL cells lacking IgH/c-myc translocation in vitro and on the other hand indirectly promote eBL development by inducing crucial EBV Latency III to Latency I switching in pre-eBL cells. Finally, we show that while the mere presence of an IgH/c-myc translocation does not suffice to escape CD4 + T-cell-mediated killing in vitro, the CD4 + T-cell-mediated suppression of EBV's Latency III program in vivo may allow cells harboring an IgH/c-myc translocation and additional mutations to evade immune control and proliferate by means of deregulated c-myc activity, resulting in neoplasia. Thus, our study highlights the dichotomous effects of CD4 + T cells and the mechanisms involved in eBL pathogenesis, suggests mechanisms of their impact on eBL progression, and provides a novel in vitro model for further investigation of IgH/c-myc translocation.

Feasibility of Cell-Free DNA Collection and Clonal Immunoglobulin Sequencing in South African Patients With HIV-Associated Lymphoma.

PURPOSE: Diagnosis of AIDS lymphoma in low-resource settings, like South Africa, is often delayed, leaving patients with limited treatment options. In tuberculosis (TB) endemic regions, overlapping signs and symptoms often lead to diagnostic delays. Assessment of plasma cell-free DNA (cfDNA) by next-generation sequencing (NGS) may expedite the diagnosis of lymphoma but requires high-quality cfDNA. METHODS: People living with HIV with newly diagnosed aggressive B-cell lymphoma and those with newly diagnosed TB seeking care at Chris Hani Baragwanath Academic Hospital and its surrounding clinics, in Soweto, South Africa, were enrolled in this study. Each participant provided a whole blood specimen collected in cell-stabilizing tubes. Quantity and quality of plasma cfDNA were assessed. NGS of the immunoglobulin heavy chain was performed. RESULTS: Nine HIV+ patients with untreated lymphoma and eight HIV+ patients with TB, but without lymphoma, were enrolled. All cfDNA quantity and quality metrics were similar between the two groups, except that cfDNA accounted for a larger fraction of recovered plasma DNA in patients with lymphoma. The concentration of cfDNA in plasma also trended higher in patients with lymphoma. NGS of immunoglobulin heavy chain showed robust amplification of DNA, with large amplicons (> 250 bp) being more readily detected in patients with lymphoma. Clonal sequences were detected in five of nine patients with lymphoma, and none of the patients with TB. CONCLUSION: This proof-of-principle study demonstrates that whole blood collected for cfDNA in a low-resource setting is suitable for sophisticated sequencing analyses, including clonal immunoglobulin NGS. The detection of clonal sequences in more than half of patients with lymphoma shows promise as a diagnostic marker that may be explored in future studies.

MYC status in HIV-associated plasmablastic lymphoma: dual-colour CISH, FISH and immunohistochemistry.

AIMS: We utilised chromogenic and fluorescence in-situ hybridisation (CISH and FISH) to evaluate MYC gene copy numbers and rearrangements within HIV-associated plasmablastic lymphomas (PBLs). Thereafter, clinicopathological features were explored retrospectively. METHODS AND RESULTS: Sixty-seven (n = 67) patients were included and the HIV seropositive status was confirmed in 98% (63 of 64) with a median viral load of 55 587 (IQR 273 582) copies/ml and median CD4 count of 170 (IQR 249) cells/µl. The mean age was 41 ± 10.1 years and females comprised 54%. PBL was documented predominantly at extra-oronasal topographic regions. Starry-sky (SS) appearance was evident in 33% in association with monomorphic morphology (P-value 0.02). c-MYC protein was expressed in 81% and latent EBV infection was detected in 90%. EBER ISH-positive status and MYC rearrangement occurred in 67% of HIV PBL. MYC aberrations included MYC rearrangement (70%), low-level increase in MYC gene copy numbers (43%), concurrent MYC rearrangement and increased MYC gene copy numbers (49%) as well as low-level chromosome 8 polysomy (6%). MYC aberrations in HIV PBLs were significantly associated with SS appearance (P -0.01), monomorphic morphology (P - 0.03), c-MYC protein expression ≥40% (P - 0.03) and mortality (P - 0.03). There was advanced stage (Ann Arbor III/IV) at presentation (77%) and the median overall survival for HIV PBL was 75 days (95% CI 14-136). CONCLUSION: Majority of the HIV-associated PBL tumours harbour MYC aberrations. Due to the persistently inferior survival outcome of HIV-associated PBL in the era of antiviral treatment, targeted and/or intensified therapy of oncogenic MYC may need to be explored in future.

Compromised Gut Associated Lymphoid Tissue is a Risk Factor for Postoperative Septic Complications in HIV-Seropositive Trauma Patients.

BACKGROUND: The gut associated lymphoid tissue (GALT) is an important part of the immune system and compromised in HIV treatment-naïve as well as in HIV-seropositive patients on antiretroviral treatment (ART) due to HIV-induced changes. The influence of the impaired GALT on the postoperative complication rate after surgery for penetrating abdominal trauma has not been investigated and the hypothesis that the HIV-induced changes of the GALT contribute to septic complications postoperatively was tested. MATERIAL AND METHODS: This prospective study included patients who required a small bowel resection due to abdominal gunshot wounds. A bowel specimen was obtained in the index operation, and the T-lymphocytic quantity in the specimen was analyzed via immunohistochemistry to scrutinize whether these lymphocyte numbers had an impact on the postoperative outcome. Septic and postoperative complications were documented during the in-hospital course and the first month after discharge. RESULTS: In total, 62 patients were included in the study of which 38 patients were HIV-seronegative and 24 were HIV-seropositive. HIV-seropositive patients had a significantly lower quantity of CD4 + T cells in the GALT compared to the HIV-seronegative patients (p = 0.0001), which was also associated with a significantly higher rate of septic complications in the postoperative course. In the HIV-seropositive group, no significant differences were detected for T-lymphocytic quantity in the GALT between the HIV-treatment naïve and antiretroviral treatment groups. CONCLUSION: The compromised GALT in HIV-seropositive patients may predispose these patients to postoperative septic complications. Antiretroviral therapy does not result in an adequate immune reconstitution in this tissue.

Trauma results in immune cell-induced intestinal epithelial damage with subsequently increased sepsis rate.

BACKGROUND: The detrimental effect of trauma on the immune system has been a subject of interest for decades. The gut-associated lymphoid tissue (GALT) of the bowel that encompasses different lymphocyte subpopulations may be an important pillar of human immunity in the context of trauma. Neither the short-term histological trauma-induced changes in the GALT nor its impact on the outcome after trauma surgery has been investigated. METHODS: This prospective, longitudinal proof-of-concept study included patients who required damage-control surgery after abdominal gunshot wounds with small bowel involvement. Bowel specimens were obtained during the index and relook operations, and the T-lymphocytic quantity therein was analyzed via immunohistochemistry. We scrutinized how the lymphocyte structure and numbers of the GALT altered, and whether the extent and nature of these changes had an impact on the postoperative outcome with regard to septic and surgical complications. RESULTS: A total of 31 damage-control patients were recruited for the study. The main histological changes between the index and relook specimen was a shift of CD8+ T cells from the lamina propria (LP) into the epithelium and a decrease of T lymphocytes in the LP. The significant increase of the intraepithelial CD8+ T cells was associated with a more extensive enterocyte apoptosis, and correlated significantly, positively with the number of postoperative septic complications. CONCLUSION: Our data support that trauma induces an immune cell-driven impairment of the intestinal epithelium, as well as an increased apoptosis of lymphocytes in the LP, which is associated with a worse clinical outcome. The underlying mechanism suggests that a therapeutic approach to minimize apoptosis in the intestine may impact the outcome of severely injured trauma patients. LEVEL OF EVIDENCE: Therapeutic/care/management, level lV.

Endometriosis: Three-year histopathological perspective from the largest hospital in Africa.

BACKGROUND: Endometriosis refers to the presence of ectopic endometrial tissue outside the uterus, that may result in infertility or recurrent implantation failure. AIMS: We aimed to document the number of histopathologically confirmed cases of endometriosis at the largest hospital in Africa during a three-year timeframe. Age, topographic site, pathological components, CD10 immunohistochemistry, metaplasia and associated neoplasms were documented. METHOD: A retrospective, descriptive cross-sectional review of confirmed cases of endometriosis was conducted. RESULTS: Thirty-four (n = 34) patients were confirmed to have endometriosis within 43 topographic sites. More than one topographic site of involvement was documented in 5 patients. The age range was 24 to 58 years [median age 36.4 ± 8.03; mean 34.5 ± 8.03 yrs]. The most frequent diagnostic combination was the triad of endometrial glands, stroma and chronic haemorrhage as confirmed in 53% of the cases. The most frequent topographic site of involvement was the ovary (27.9%) followed by the fallopian tubes (16.7%), umbilical region (13.9%), and abdominal wall (11.6%). Endometriotic cyst was reported in 10 cases (29.4%) and the ovary was the most common site in which endometriotic cysts occurred (p < .01). Endometrioma was only confirmed at the abdominal wall of one patient. CD10 immunochemistry was requested in 5 cases and confirmed the presence of endometrial stroma in all cases tested. Ciliated metaplasia was common (62%). Endometriosis was documented incidentally in context of two cases of neoplasia (pre-invasive and invasive). CONCLUSION: Endometriosis is diagnosed predominantly, but not exclusively, in women of child-bearing age. Ovarian involvement has a propensity to develop endometriotic cysts. CD10 immunohistochemistry has diagnostic value when endometrial stroma is limited or inconspicuous.

Metachronous or synchronous male breast and prostate cancers a duality to lookout for.

Introduction: Breast cancer is well known as the stereotypical women's cancer, and prostate cancer represents the well-known stereotypical male counterpart. While prostate cancer carries the potential to metastasize to the breast, the synchronous or metachronous co-occurrence of primary breast and primary prostate cancers is quite unusual. Prostate cancer in men of African descent may have its own behavior with regards to its relationship with male breast cancer. Case presentation: Case 1: A 64 year old male presented to Chris Hani Baragwanath Hospital (CHBAH) with a 2 years history of a painless left breast lump. A core biopsy was confirmed breast carcinoma. Tamoxifen was started but, due to disease progression, he underwent left modified radical mastectomy followed by chemotherapy. Prostate biopsy was done for raised Prostate Specific Antigen (PSA) and suspicious prostate on digital rectal examination. A prostatic adenocarcinoma was subsequently diagnosed with bone metastasis on bone scan. He was started on Androgen deprivation therapy and followed up every 3 months. Case 2: A 68 year old male presented to CHBAH with a 1 year history of a painless right breast lump. A core biopsy confirmed breast cancer. Tamoxifen was started, followed by right modified radical mastectomy and chemotherapy for disease progression. A raised PSA and suspicious prostate on digital rectal examination prompted a prostate biopsy revealing a prostatic adenocarcinoma. Bone scan was negative for metastasis. He is currently on 3 monthly Androgen deprivation therapy and awaiting radiation. Conclusion: This clinical practice article not only presents this exceptionally rare duality but highlights that both cancers can coexist either as sporadic conditions, or as a result of genetic mutations. Thus, we suggest that men with prostate cancer be screened clinically, biochemically and genetically for breast cancer and vice versa.

An Expanded Spectrum of High-Grade B-Cell Non-Hodgkin Lymphomas Involving the Cervicovaginal Region.

The uterine cervix and vaginal regions are infrequently infiltrated by lymphoma. Involvement of these topographic regions may constitute primary disease or more commonly represent a manifestation of systemic lymphomatous disease. Herein, we report an expanded spectrum of high-grade B-cell non-Hodgkin lymphomas comprising plasmablastic lymphoma (with and without plasmacytic differentiation), ALK-positive large B-cell lymphoma, and diffuse large B-cell lymphoma which involved the uterine cervix and/or vagina of 6 patients at initial diagnosis. These tumors clinically mimicked carcinoma and developed predominantly, but not exclusively, in the setting of human immunodeficiency virus infection.

Kaposi's sarcoma, a South African perspective: Demographic and pathological features.

BACKGROUND: The incidence of Kaposi's sarcoma (KS) has increased dramatically since the onset of the AIDS epidemic. Of the estimated 66 200 cases of KS worldwide, 58 800 are considered to have occurred in sub-Saharan Africa. OBJECTIVES: To describe the epidemiology and pathological characteristics of KS at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa. METHODS: A retrospective cross-sectional study design was used. Nine hundred and thirty-eight histopathology reports of KS diagnosed in 901 patients at CHBAH between 2005 and 2009 were reviewed. Age, gender, topographic site, CD4 count, HIV status, KS histological stage, findings of human herpesvirus 8 latency-associated nuclear antigen 1 immunohistochemistry and concomitant pathological findings were recorded. RESULTS: The male/female ratio was 1.2:1, the mean age 37 years and the median CD4 count 128 cells/µL. Lower limb skin biopsies accounted for 49.6% of cases. Paediatric, visceral and endemic KS accounted for only limited proportions (1.4%, 1.4% and 1.3% of biopsies, respectively). There were concomitant pathological findings in 4.6% of biopsy specimens, infections and inflammatory dermatoses being the most frequent. CONCLUSION: The findings of this study highlight the need for allocation of diagnostic and treatment resources for KS. Documentation of the various demographic aspects of KS will prove to be of historical, clinical and histopathological interest as the long-term outcomes of antiretroviral therapy begin to emerge.

Variability of HHV8 LNA-1 Immunohistochemical Staining Across the 3 Histologic Stages of HIV-Associated Mucocutaneous Kaposi Sarcoma: Is There a Relationship to Patients' CD4 Counts?

The histologic diagnosis of Kaposi sarcoma (KS) can be confirmed with human herpes virus 8 (HHV8) latency-associated nuclear antigen (LNA)-1 immunohistochemistry, which may show variability in distribution and intensity. This retrospective study was aimed at addressing the factors that may contribute to this variability. All cases of mucocutaneous KS diagnosed in a 5-year period at the histopathology department at a tertiary hospital in South Africa with available patients' CD4 counts and HHV8 LNA-1 immunohistochemically stained slides were reviewed, and the biopsy stages of KS (patch/plaque/nodular), CD4 counts, immunohistochemistry staining method (manual vs. automated), and distribution (diffuse/focal) and intensity (strong/weak) of HHV8 LNA-1 staining were recorded. A total of 127 cases were reviewed. No relationship was demonstrated between the median CD4 count and the histologic stages of KS (P = 0.701) or the intensity and distribution of HHV8 immunohistochemical staining using either staining method. Multivariate analysis showed that method of immunohistochemical staining was a significant predictor of distribution (P = 0.006) and intensity (P = 0.044) of staining, and that stage was a significant predictor of distribution of staining (P = 0.033).

Patterns of Lymph Node Pathology; Fine Needle Aspiration Biopsy as an Evaluation Tool for Lymphadenopathy: A Retrospective Descriptive Study Conducted at the Largest Hospital in Africa.

BACKGROUND: Lymphadenopathy is a common clinical presentation of disease in South Africa (SA), particularly in the era of Human Immunodeficiency Virus (HIV) and tuberculosis (TB) co-infection. METHODS: Data from 560 lymph node biopsy reports of specimens from patients older than 12 years at Chris Hani Baragwanath Academic Hospital (CHBAH) between 1 January 2010 and 31 December 2012 was extracted from the National Health Laboratory Service (NHLS), division of Anatomical Pathology. Cytology reports of lymph node fine needle aspirates (FNAs) performed prior to lymph node biopsy in 203 patients were also extracted from the NHLS. Consent was not obtained from participants for their records to be used as patient information was anonymized and de-identified prior to analysis. RESULTS: The majority of patients were female (55%) and of the African/black racial group (90%). The median age of patients was 40 years (range 12-94). The most common indication for biopsy was an uncertain diagnosis (more than two differential diagnoses entertained), followed by a suspicion for lymphoma, carcinoma and TB. Overall, malignancy constituted the largest biopsy pathology group (39%), with 36% of this group being carcinoma and 27% non-Hodgkin lymphoma. 22% of the total sampled nodes displayed necrotizing granulomatous inflammation (including histopathology and cytology demonstrating definite, and suspicious for mycobacterial infection), 8% comprised HIV reactive nodes; in the remainder no specific pathology was identified (nonspecific reactive lymphoid hyperplasia). Kaposi sarcoma (KS) accounted for 2.5% of lymph node pathology in this sample. Concomitant lymph node pathology was diagnosed in four cases of nodal KS (29% of the subset). The co-existing pathologies were TB and Castleman disease. HIV positive patients constituted 49% of this study sample and the majority (64%) of this subset had CD4 counts less than 350 cells/ul. 27% were HIV negative and in the remaining nodes, the HIV status of patients was unknown. The most common lymph node pathologies in HIV positive patients were Mycobacterial infection (31%), HIV reactive nodes (15%), non-Hodgkin lymphoma (15%) and nonspecific reactive lymphoid hyperplasia (15%). Only 8.7% were of Hodgkin lymphoma. In contrast, the most common lymph node pathologies in HIV negative patients were nonspecific reactive lymphoid hyperplasia (45%), carcinoma (25%) and Mycobacterial infection (11%). In this group, non-Hodgkin lymphoma and Hodgkin lymphoma constituted 9% and 8%, respectively. There were more cases of high-grade non-Hodgkin lymphoma in the HIV positive group compared to the HIV negative group. FNA and lymph node biopsy had statistically significant good agreement with regard to Hodgkin lymphoma (K 0.774, SE 0.07, 95% CI 0.606-0.882, p=0.001), non-Hodgkin lymphoma (K 0.640, SE 0.07, 95% CI 0.472-0.807, p=0.001), carcinoma (K 0.723, SE 0.069, 95% CI 0.528-0.918, p=0.001), and mycobacterial infection (K 0.726, SE 0.07, 95% CI 0.618-0.833, p=0.001). CONCLUSIONS: The most common lymph node pathologies in CHBAH are malignancies, nonspecific reactive lymphoid hyperplasia, necrotizing granulomatous inflammation and HIV reactive nodes. The distribution of disease differs in HIV positive patients. Overall, adequate FNA samples of lymph nodes have been found to have good correlation with lymph node biopsy findings in our setting.