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.

A comparative study of uncomplicated acute non-A-E hepatitis with acute viral hepatitis and acute onset autoimmune hepatitis.

BACKGROUND AND AIMS: Non-A-E hepatitis (NAEH) not leading to acute liver failure (ALF) is poorly documented. The objective was to compare clinical and laboratory features of uncomplicated acute NAEH with acute viral (AVH) and autoimmune hepatitis (AIH) and histopathology in NAEH and AIH. METHODS: Cases of hepatocellular jaundice were included. These were grouped into AVH, AIH and NAEH based on clinical, laboratory and, when indicated, liver biopsy findings. NAEH and AIH were followed up at three months. RESULTS: Of 336 patients with hepatocellular jaundice, 15 (5%) were NAEH, 25 (7%) acute AIH and 45 (14%) AVH. Among NAEH patients, seven (46.7%) were males with a mean age of presentation 39 years. Jaundice (100%) was the most common presentation of NAEH. Peak bilirubin was 10.7 mg/dL. Peak aspartate and alanine aminotransferase (AST, ALT) were 512 and 670 U/L. Five (33.3%) patients had positive anti-nuclear antibody and one had anti-smooth muscle antibody. Mean immunoglobulin G (IgG) levels were 1829. On liver biopsy, all had ballooning degeneration, four (26.7%) had mild and three (20%) moderate interface hepatitis, four (26.7%) mild lymphoplasmacytic infiltrate, one (6.7%) rosette formation, bridging necrosis in none and stage 1 fibrosis in one. Comparing NAEH with AIH, AIH showed significantly older age at presentation, female predisposition, past history of jaundice, lower ALT, more autoantibodies, higher IgG, higher grade interface hepatitis, lymphoplasmacytic infiltrate, rosette formation and higher bilirubin, AST at three months. NAEH and viral hepatitis had similar features. CONCLUSION: Etiology of NAEH is unlikely to be autoimmune and is probably viral, unidentified as yet. Uncomplicated NAEH likely has self-limiting course even without specific treatment.

A Rare Cause of Acute on Chronic Liver Failure (ACLF): Bakuchi-Induced Liver Injury.

Psoralea corylifolia Linn (Bakuchi or Babchi), commonly known as purple fleabane, is a popular herb used in Ayurvedic traditional medicine. Its seeds, called Fructus Psoraleae, are traditionally used for treating leprosy, vitiligo, and psoriasis in the absence of empirical evidence. We report the first case of acute on chronic liver failure (ACLF) caused by Bakuchi, a well-documented hepatotoxic agent, in a middle-aged female. Her liver function deteriorated progressively which prompted us to go for a liver biopsy which was consistent with diagnosis of herb-induced liver injury after excluding all competing causes. Fortunately, the patient improved gradually after herb withdrawal and supportive care. Patients with underlying chronic liver disease (CLD) should be aware of risks in using untested herbal formulations. This case emphasizes the need for increased surveillance to formulate guidelines regarding the regulation and informed use of herbal supplements in patients with chronic liver disease.

A case of giant colonic lipoma removed endoscopically using a modified hybrid technique.

Colonic lipomas are benign adipose tumors and are mostly asymptomatic. They may cause symptoms when their size becomes more than 2 cm. Giant colonic lipoma (GCL) is a rare finding in endoscopy which presents with or without macroscopic ulceration and may lead to iron deficiency anaemia (IDA). The choice of treatment of symptomatic large colonic lipomas has been controversial. Here we are presenting a case of GCL presenting with occult bleeding causing iron deficiency anaemia (IDA). It was removed endoscopically using a combination of noradrenaline, endoloop ligation, and snare cautery technique (modified hybrid technique). Successful removal of the GCL lead to the resolution of IDA. This case report highlights that even GCL can be removed endoscopically, thus surgery can be prevented. Clinical Significance: GCL is an unusual cause of anemia. Modified hybrid endoscopic removal technique improves safety.

Non-variceal upper gastrointestinal bleed as first presentation of primary systemic amyloidosis - A case report.

Gastrointestinal (GI) tract manifestations of amyloid deposition include diarrhea, GI hemorrhage, steatorrhea, or constipation. Here, we report an elderly female presenting with GI hemorrhage due to gastric ulceration and 4-6 polypoidal lesions with intermittent ooze in the duodenum as a first presentation of primary systemic amyloidosis. The bleed was managed with proton-pump inhibitors and hemospray application. She received chemotherapy for multiple myeloma after stabilization. A high index of suspicion is needed to diagnose amyloidosis causing GI hemorrhage.

Primary pancreatic tuberculosis with a duodenal fistula in an immunocompetent young man.

Tuberculosis (TB) is a common disease in developing countries that can virtually affect any organ in the body. The abdomen is one of the most common sites for extra-pulmonary tuberculosis. Primary Pancreatic tuberculosis (PPTB) is rare and can be clinically elusive. It is commonly encountered in immunodeficient individuals in regions endemic for TB. However, it is extremely rare in immunocompetent individuals with very few case reports in the literature. We describe a case of PPTB in an immunocompetent young man complicated with duodenal fistula. There was complete resolution of symptoms and the fistulous tract with a significant reduction of the size of the lesion on imaging after 6 months of anti-tubercular therapy (ATT).

Incidental Gall Bladder Carcinoma in Patients Undergoing Cholecystectomy: A Report of 7 Cases.

BACKGROUND: Carcinoma gall bladder accounts for 98% of all the gall bladder malignancies and is the sixth most common malignancy of the gastrointestinal tract worldwide. Incidental gall bladder carcinoma (IGBC) is an incidental finding of carcinoma diagnosed during a laparoscopic cholecystectomy or on histopathological examination of gall bladder specimen removed for benign gall bladder diseases. The incidence of IGBC is around 0.19 - 3.3% in the literature. OBJECTIVES: The aim of the present study was to report our experience with gall bladder cancers which were incidentally diagnosed during histopathological examination of cholecystectomy specimens done for benign gall bladder disease and follow up of the cases. MATERIAL AND METHODS: This study includes 270 cholecystectomy specimens which were removed, during June 2010 to July 2011 in a tertiary care hospital. The clinicopathological findings of cases with incidentally detected gall bladder cancers were recorded; age, sex, presenting symptoms, presence of gall stones and histologic grade and staging of tumours were included. Exclusion criteria included preoperative suspicion of malignancy before cholecystectomy. American joint committee on cancer (AJCC) staging system was used for staging incidental gall bladder carcinoma. RESULTS: In our study laparoscopy or open cholecystectomy was attempted in 270 cases during the one year period. Incidental gall bladder carcinomas were diagnosed in 7 cases (2.59%), with mean age of 50 years. Pain, vomiting, and dysphagia were the presenting complaints. USG revealed thickened gall bladder in 6 cases, and polyp in one case. Gall stones were seen in 6 cases. Histopathology showed moderately differentiated adenocarcinoma in all the cases. AJCC staging of gall bladder carcinoma revealed 6 cases in pT2 stage and pT1 a stage in one case. On follow up at 22 months, 6 cases were alive while one expired due to tumour metastasis. CONCLUSION: Prognosis of incidental gall bladder carcinoma is better, if diagnosed in early stages.

Cardiac findings in leptospirosis.

BACKGROUND/AIM: In leptospirosis, although cardiac involvement in the form of ECG changes and myocarditis is known, it is not considered to be significant. This study analysed cardiac changes in leptospirosis. METHODS: Twenty-four hearts from patients who had died from leptospirosis were studied. Detailed gross and light microscopic examination was carried out. RESULTS: Myocarditis was noted in 96% of cases. Endocardial inflammation was seen in 50% of cases. This endocardial inflammation correlates with vasculitis, which is the principal pathogenetic mechanism of the disease. CONCLUSIONS: There is definite cardiac involvement in leptospirosis, which even though not symptomatically evident, may add to the morbidity or be contributory to the mortality associated with the disease. In addition, a possibility of dilated cardiomyopathy as a delayed consequence of severe myocarditis remains, and may need evaluation.

Solid pseudopapillary tumor of the pancreas.

Solid pseudopapillary tumor of the pancreas is considered to be a rare pancreatic tumor. These tumors are typically present in women in their third decade of life. The tumors have a low malignant potential. We report a case of 22-year-old female who presented with intermittent abdominal pain of 3 years duration. Distal pancreatectomy with splenectomy was done as a definitive treatment. The importance of accurate diagnosis and treatment is emphasized.

Atypical stromal cells in inflammatory pseudopolyps--a case report.

Atypical stromal cells have been reported in inflammatory lesions of the gastrointestinal tract. We report a case of ulcerative colitis with pseudopolyps, histology of which showed bizarre stromal cells. These atypical stromal cells simulate malignant cells and pose a diagnostic problem for surgical pathologists. It is therefore important to recognize these benign stromal cells as reactive thereby reducing unnecessary surgery.