Hysteropathological Correlation in Abnormal Uterine Bleeding in a Tertiary Care Hospital in South India.

Background: Abnormal uterine bleeding is a common problem mainly encountered in reproductive age group and post-menopausal women. Hysteroscopy is a safe, simple, well tolerated and reliable procedure for the diagnosis of AUB across all age groups. The aim of the study is to determine the association of hysteroscopy and histopathologic examination (HPE) findings in abnormal uterine bleeding. The secondary objective of the study are to enumerate the hysteroscopy findings in patients with AUB and to evaluate the pattern of AUB. Materials and Methods: Observational cross-sectional study among 60 women in reproductive and post-menopausal age group presenting with features/symptoms suggestive of abnormal uterine bleeding were studied. All patients reporting in the outpatient department (OPD) and who are eligible to participate were included in the study, after obtaining written informed consent. Detailed history, Clinical examination, Ultrasound pelvis and endometrial thickness assessment is done. Hysteroscopic findings were compared against histopathological findings. Results: The various patterns of bleeding documented in our study population were menorrhagia, metrorrhagia, menometrorrhagia, polymenorrhea, and post-menopausal bleeding. Out of these patterns, the commonest was menorrhagia at 50.0% and post-menopausal bleeding at 26.67%. In our study population, the various hysteroscopy findings were strawberry, tongue-shaped projections, pebble stones, polypoidal patterns, and cerebroid patterns. Out of these, the most common was a polypoidal pattern, strawberry pattern, and tongue-shaped projections with 45%, 31.67%, and 26.7%, respectively. The most common histopathology finding was secretory and proliferative constituting 35% and 26.67%, respectively. Carcinoma endometrium constitutes about 6.67% of the study population. The sensitivity, specificity, PPV, and NPV of strawberry appearance in hysteroscopy in comparison with secretory changes in histopathology were 52.38%, 79.49%, 57.89%, and 75.61%, respectively. The sensitivity, specificity, PPV, and NPV of tongue-shaped projections appearance in hysteroscopy in comparison with HPE findings was 60%, 76.36%, 18.75%, and 95.45%, respectively. The sensitivity, specificity, PPV, and NPV of polypoidal pattern in hysteroscopy in comparison with Endometrial hyperplasia in histopathology was 66.67%, 56.14%, 7.41%, and 96.97%, respectively. The sensitivity, specificity, PPV, and NPV of cerebroid appearance in hysteroscopy in comparison with carcinoma endometrium in histopathology were 75.0%, 100%, 100%, and 98.25%, respectively. This correlation of cerebroid pattern with carcinoma endometrium was highly significant. Among all correlations, the highly reliable was in Carcinoma endometrium followed by endometrial polyps. Conclusion: Hysteroscopy has high sensitivity and specificity in diagnosing intrauterine pathology especially endometrial cancer followed by endometrial polyps. Among the various patterns of abnormal uterine bleeding, menorrhagia was the most common. A combination of hysteroscopy and endometrial sampling was found to increase diagnostic accuracy in patients with abnormal uterine bleeding and will effectively guide us in planning the appropriate management for these patients.

Binucleate Cells in Cytosmears: What do They Signify?

BACKGROUND: Although the classic Reed-Sternberg (RS) cell is considered a diagnostic of Hodgkin's disease, RS-like cells have been noted in various benign and malignant conditions. The presence of these cells can be a diagnostic challenge. AIMS: Our aim was to see if cells morphologically resembling or identical to RS cells occur in conditions other than Hodgkin lymphoma (HL) and what proportion of cases show binucleate cells in various benign and malignant conditions. We also want to discuss the diagnostic utility of cytomorphological features in predicting HL. MATERIAL AND METHODS: This study is a retrospective analysis of 2086 cytology cases. The cytosmears were screened for the presence of binucleate cells. A detailed cytomorphological analysis of cytosmears with binucleate cells was performed, and the diagnostic utility of cytomorphological criteria in delineating HL was examined. RESULTS: Out of 2086 smears, 55 (2.6%) cytosmears showed binucleated RS/RS-like cells. Out of these 55 cases, 6 were HL, 3 cases were non-HL (NHL), 3 were sarcoma, 32 were carcinoma, and 11 were benign/inflammatory lesions. The presence of prominent eosinophilic nucleoli, granulomas, and eosinophils had good sensitivity and specificity in predicting the diagnosis of HL. CONCLUSION: A detailed cytomorphological analysis is of limited value in categorizing the RS and RS-like cells. However, few cytomorphological features such as prominent eosinophilic nucleoli, eosinophils, granulomas, and lack of clustering of atypical cells can help us in predicting HL.

Intracranial bony ball - An ossified variant of meningioma.

An ossified variant of meningioma in the intracranial region is very rare. We report a case of a 28-year-old female who presented with headache for 4 years. Imaging revealed an extra-axial calcified mass in the left parieto-occipital lobe. The differential diagnosis included osteoblastoma both intracranial and periosteal, calcifying pseudotumor of the neural axis, hyperostosis of the cranium, and ossifying fibroma. She underwent excision of the calcified space occupying lesion. Histopathology was suggestive of an ossified meningioma. At the end of 2-year follow-up, she was asymptomatic with no signs of recurrence.

Median raphe cyst of the penis: A startling diagnosis for the unaccustomed clinician.

Penile median raphe cysts are uncommon lesions occurring predominantly in the ventral aspect of the glans penis of young men. In most patients, the cysts, which are asymptomatic or unrecognized during childhood, may progress later and become symptomatic during adolescence or adulthood. A differential diagnosis must be made from other penile skin lesions such as glomus tumors, dermoid cysts, pilonidal cysts, epidermal inclusion cysts, urethral diverticula, and steatocystomas that originate in the genital region. The usual treatment is complete surgical excision. We are presenting a case of a penile median raphe cyst which presented in a middle-aged adult.

Humanities in medicine: experience at Pondicherry Institute of Medical Sciences, India.

A few institutes in India have started a programme of Humanities in Medicine (HiM) on a small scale. In 2014, the Pondicherry Institute of Medical Sciences (PIMS) decided to begin an HiM programme for undergraduate students and this has been conducted successfully for the last three years. The major strengths of the programme have been its formal integration within the curriculum and the contributions of a large number of enthusiastic, talented and motivated faculty. In this report, we wish to trace the evolution and implementation of the HiM programme in our institution.

Validating Micronucleus Score in Effusion Fluids.

BACKGROUND: Identifying malignant cells in effusion fluid is vital in staging and management of cancers. Differentiating reactive mesothelial cells from malignant cells in effusion fluid is a challenging task and there is an ongoing need for simpler and cost effective tool to aid the diagnosis. Micronucleus is an additional smaller nucleus in the cytoplasm, formed by chromosomes or chromosomal fragments formed during cell division. AIMS: The aim of this study was to assess the significance of micronucleated cell in effusion fluids to distinguish adenocarcinomatous from reactive mesothelial effusions. MATERIALS AND METHODS: Thirty cases of unequivocal malignant effusion fluids and 30 benign cases with reactive mesothelial cells as control were studied. Number of microucleated cells present per1000 well-preserved cells in Leishman-stained smears were counted. RESULTS: Mean (±SD) micronucleated score in malignant and benign effusions were 15.77 ± 9.78 and 1.87 ± 1.78, respectively. The median scores were 13 and 2, respectively. Mann-Whitney test showed that this difference was statistically significant (P < 0.001). This study revealed that there was a significant difference in micronucleus scoring between benign and malignant effusions. CONCLUSIONS: Micronucleus score can be used as an additional biomarker in the interpretation of routinely stained cytosmears.

Aneurysmal Variant of Fibrous Histiocytoma- A Rare Entity Known for Recurrence.

Aneurysmal Fibrous Histiocytoma (AFH) is a distinct and a rare clinicopathological variant of Cutaneous Fibrous Histiocytoma (CFH). It differs from the usual benign fibrous histiocytoma clinically and morphologically with high rate of recurrence. Here, we report a case of AFH with history of recurrence which presented as a polypoid swelling and showed vascular spaces with no endothelial lining which was proved negative by CD34 immunostaining. The spaces were bordered by tumour cells.

Pericardial Haemangioma: A Common Tumour in an Unusual Location: Case Report and Review of Literature.

Overall incidence of primary cardiac tumour ranges from 0.0017% and 0.27% at autopsy. Cardiac haemangiomas are rare, and account for 2.8% of benign cardiac tumours. Pericardial haemangiomas, in particular are extremely rare. Pericardial haemangiomas are reported to present with a variety of symptoms such as dyspnea, palpitation, atypical chest pain. Other symptoms like obstruction of blood vessels, cardiac tamponade, or pericardial effusion may result due to compression of surrounding structures. Here, we report a case of pericardial haemangioma in a patient who presented with breathlessness and cough.

Ovarian Leiomyoma Along with Uterine Leiomyomata: A Common Tumour at an Uncommon Site.

Ovarian leiomyoma is one of the rarest benign tumours of the ovary, mostly seen in women of reproductive age group. Here we report a case of ovarian leiomyoma as an incidental finding in a patient of 38-year-old woman with uterine leiomyomata. Peroperatively, her left ovary appeared bulky & she underwent total abdominal hysterectomy with left salpingo-oophorectomy. Macroscopically, in addition to uterine leiomyomata, a grey-white solid mass was seen entirely within the ovary without any capsular breach. Microscopically, the ovarian mass resembled its uterine counterpart without any evidence of atypia or necrosis. Masson trichrome stain & immunohistochemistry for desmin positivity confirmed the smooth muscle origin of the tumour cells. Despite its rarity, ovarian leiomyoma has to be considered as one of the differential diagnosis of ovarian spindle cell tumours. In difficult cases, immunohistochemistry aids the diagnosis.

Subcutaneous Fungal Cyst Masquerading as Benign Lesions - A Series of Eight Cases.

BACKGROUND: Subcutaneous fungal infections are caused by penetration of the causative fungi into the subcutaneous layer and are usually localised. We present a series of eight cases with subcutaneous fungal cystic lesions masquerading as benign lesions. MATERIALS AND METHODS: A retrospective study was conducted on subcutaneous fungal infections seen between January 2007 to July 2014 in the Department of Pathology. Eight patients with biopsy proven subcutaneous fungal infection were included. We collected and analysed their demographic, clinical and histopathological details. RESULTS: Among eight patients, six were male and two were female. The mean age was 47 years (Range: 21-70). All the eight patients presented with non-tender cystic swelling. The size of the swellings varied from a minimum of 3x3 cm to maximum of 10x4 cm. Out of eight, hand was involved in three, forearm in one, elbow in two, leg in one and foot in one. On H&E staining, all the cases showed fibro collagenous cyst wall, lined by histiocytes, granulomatous reaction, foreign body type of giant cells with acute and chronic inflammatory infiltrate containing fungal elements. Six were identified as hyalohyphomycosis and two were identified as phaeohyphomycotic cysts based on pigmentation of hyphae. CONCLUSION: Fungal infection should be suspected in all subcutaneous cystic lesions. Excised tissue should always be sent for culture and histopathology.

Correlation of narrow band imaging endoscopy and histopathology in the diagnosis of nonerosive reflux disease.

UNLABELLED: Background /Aim: Narrow band imaging (NBI) is a novel, innovative high-resolution endoscopic technique, which utilizes spectral narrow band filter for the visualization of mucosal patterns and microvasculature. Nonerosive reflux disease (NERD) is a type of gastroesophageal reflux disease (GERD) and it is characterized by reflux symptoms without mucosal breaks on white light endoscopy (WLE). Biopsies from distal esophagus of GERD patients show group of histologic features such as basal cell hyperplasia, elongation of lamina propria papillae, and inflammatory cells. The present study was undertaken to evaluate diagnostic utility of NBI endoscopy and biopsy study in NERD patients and also to correlate NBI endoscopy findings with histologic features of GERD. PATIENTS AND METHODS: A total of 71 cases of NERD having symptom score more than 10 and those not having erosion on WLE were recruited prospectively and underwent NBI endoscopic examination. Two mucosal biopsies were taken at 3 cm above the squamocolumnar junction. RESULTS: Histologic features of GERD were seen in 50 (70.4%) out of 71 cases. No significant correlation between NBI endoscopic findings with histologic features of GERD was found. CONCLUSION: The present study showed that histopathologic evaluation of distal esophageal mucosa has promising diagnostic value over NBI endoscopy in NERD patients. Use of newly introduced NBI technique requires tremendous familiarity for the detection of the cases of NERD, which show histologic features of GERD.

Jejunal diverticulosis with perforation - a challenging differential diagnosis of acute abdomen: case report.

Multiple diverticulosis of the jejunum represents a very rare entity. Jejunal diverticula are found to be the rarest of all small bowel diverticula. The disease is usually asymptomatic and often becomes clinically relevant when complicated. This rarity makes it a difficult differential diagnosis. Related complications such as diverticulitis, perforation, and bleeding and/or intestinal obstruction appear in about 10-30% of the patients which increase the morbidity and mortality rates in such individuals. Here, we present a case of jejunal diverticulosis with perforation who presented with symptoms of acute abdominal pain, vomiting and fever along with a brief review of literature.

Bone marrow granuloma in typhoid Fever: a morphological approach and literature review.

Typhoid fever is one of the few bacterial infections in humans where bone marrow evaluation is routinely recommended. However, the morphological aspect of typhoid fever in bone marrow has been rarely described in the literature. We describe a 25-year-old male patient who presented with prolonged fever suspected to be of tubercular etiology. Bone marrow examination showed well-formed histiocytic and epithelioid granulomas and erythrophagocytosis; and the bone marrow aspirate culture grew Salmonella typhi A. In view of potential clinical implications, typhoid fever should be considered as a differential diagnosis to tuberculosis in the evaluation of prolonged fever; especially in high prevalent areas. We suggest that erythrophagocytosis may serve as a morphological marker in typhoid granulomas in the bone marrow; and bone marrow culture should be submitted in every suspected case for appropriate patient management.

Disseminated Histoplasmosis in an Immunocompetent Patient Diagnosed on Bone Marrow Aspirate - A Rare Presentation from a Non-Endemic Area.

Histoplasmosis causing systemic fungal infection is commonly seen in endemic areas. In India, disease prevalence is more in eastern part of the country and there have been very few reports from southern part of India. The occurrence of disseminated histoplasmosis in immunocompetent individual is rare. We report a case of disseminated histoplasmosis in an immunocompetent individual with no underlying risk factors. The disease was not suspected clinically and was diagnosed by bone marrow aspirate incidentally.

Endoscopic (video) demonstration of hookworm infestation of the stomach.

Hookworm infestation is common in southern India. The adult worms normally reside in the duodenum, graze the intestinal mucosa with their large buccal cavities and ingest the intestinal epithelial cells and blood. Depending on the number of worms the infection may be either asymptomatic or can cause iron deficiency anaemia due to chronic blood loss. Adult worms live in the small intestine and are not usually seen in the stomach. There are only very few case reports in the literature reporting hookworm infestation of the stomach. In this case report we present an endoscopic (video) demonstration of hookworm infestation of the stomach in a woman who presented with chronic anaemia.

Amoeboma: resurfacing of a vanishing illness.

Amoeboma is a rare manifestation of intestinal amoebiasis. More than 90% of patients with intestinal amoebiasis have a history of diarrhoea. This report describes the case of a 60-year-old patient who presented with a right iliac fossa (RIF) mass with normal bowel habits and was eventually diagnosed with an amoeboma. In developing countries, a traditional differential diagnosis for an RIF mass is an amoeboma, but its incidence is declining. Hence this treatable condition is often overlooked in the differential diagnosis of an RIF mass. This case report emphasises that amoeboma still exists and should be considered in a patient with an RIF mass.

Hemophagocytic lymphohistiocytosis: critical reappraisal of a potentially under-recognized condition.

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon, potentially life threatening, hyper inflammatory syndrome of diverse etiologies. Cardinal signs include prolonged fever, organomegaly, and persistent unexplained cytopenias. In spite of the well known diagnostic criteria put forth by HLH society, this continues to pose great diagnostic challenge in both pediatric and adult intensive care settings. We describe 4 adult (2 males, 2 females, aged 19, 29, 40, and 17 years) and 3 pediatric (2 males, 1 female, aged 1 month, 6 months, and 12 years) patients with secondary HLH who satisfied the HLH-2004 diagnostic criteria. Definite evidence of hemophagocytosis was noted in 4 patients on initial bone marrow examination. The underlying etiologies were as follows: Rickettsia tsutsugamushi (case 1), autoimmune disorder (case 2), systemic onset juvenile idiopathic arthritis (sJIA) (case 3), unknown bite (possibly a venomous snake) (case 4), Plasmodium vivax (case 5), Cytomegalo virus (case 6), and Mycobacterium tuberculosis (case 7). In one patient, hemophagocytosis was presumed to have been exacerbated by administration of granulocyte monocyte colony stimulating factor (GMCSF) for severe neutropenia. Two patients died with disseminated intravascular coagulation (DIC) and multi organ failure within few days of HLH diagnosis. Immunosuppressive therapy was started in 3 patients, and etoposide was started in one patient only. Due to lack of specificity of diagnostic criteria, diagnosing and differentiating HLH from its closest mimickers like sepsis/septic shock may be quite challenging in critically ill patients. Therefore, increasing awareness among physicians is essential for early diagnosis and effective therapy to reduce the mortality.

Isolated deletion of the long arm of chromosome 20 [del(20q12)] in myelodysplastic syndrome: a case report and literature review.

Isolated deletion of the long arm of chromosome 20 [del(20q12)] is a rare abnormality in patients with de novo myelodysplastic syndrome. It is characterised by refractory thrombocytopenia, minimal haematological dysplasia and a lower risk for progression to acute myeloid leukaemia. Its distinction from chronic autoimmune thrombocytopenia, although clinically and morphologically difficult, is critical. We report a case of refractory cytopenia and unilineage dysplasia in an elderly woman with isolated del(20q12), identified via fluorescence in situ hybridisation analysis of her bone marrow. In order to avoid a misdiagnosis, we suggest that cytogenetic analysis be performed on all patients suspected to have myelodysplastic syndrome with predominant thrombocytopenic presentation.

Predictive value of micronucleus count in cervical intraepithelial neoplasia and carcinoma.

OBJECTIVE: A micronucleus is a small additional nucleus formed due to chromosomal loss or fragmentation. The aim of this study was to assess the utility of micronucleus count as a screening tool in cervical cancer. MATERIAL AND METHOD: A total of 132 cases consisting of 42 pre-neoplastic and neoplastic cases and 90 non-neoplastic cases were studied. Only routine Papanicolaou-stained cervical smears were used. In each smear, the number of micronucleated cells and binucleated cells were counted under oil immersion and expressed as a count per 1,000 cells. The micronucleated and binucleated cell counts in pre-neoplastic, neoplastic and non-neoplastic categories were compared for statistical significance. The counts were also correlated with age, duration of marital life, number of pregnancies and abortions. RESULTS: The micronucleus count and the binucleated cell count were significantly higher in the high -grade squamous intraepithelial lesion (HSIL) and invasive carcinoma categories compared to low -grade squamous intraepithelial lesion (LSIL) and non-neoplastic cases. Receiver operating characteristic (ROC) curve analysis revealed that micronucleus count and binucleated cell count possess a high degree of sensitivity and specificity for identifying HSIL and invasive carcinoma. CONCLUSION: Our results reveal that micronucleus evaluation in routine Pap smears is a very useful biomarker in cervical cancer screening. The binucleated cell count increases the predictive value of this simple test.