Drug-Induced Liver Injury from Herbal Liver Detoxification Tea.

The increasing consumption of unregulated herbal and dietary supplements has presented clinicians with new challenges in assessing and managing acute liver injury. Patients may present in various ways ranging from asymptomatic transaminitis to acute liver failure. Several natural products have been found to mitigate drug-induced liver injury, which has led to the creation of numerous registries to outline all its aspects further. We describe the case of a 36-year-old female who developed a clinically significant acute liver injury with a cholestatic pattern due to an over-the-counter herbal liver detox tea. This is the first case reported of a hepatotoxic effect from any of these compounds or ingredients in the detox tea: burdock root, stinging nettle leaf, cleavers herb, dandelion root, lemon peel, and lemon myrtle leaf (Backhousia citriodora). Idiosyncratic drug-induced liver injury (DILI) remains poorly understood; however, recognizing potential toxins is imperative to understanding toxicogenomics and identifying those at risk.

A Rare Case of Systemic Sarcoidosis in a Middle-Aged Female with a Solitary Thyroid Nodule.

Sarcoidosis is a multisystem inflammatory disease characterized by the presence of noncaseating granulomas. Sarcoidosis can affect any organ of the body, the lung being the most affected. Sarcoidosis rarely affects the thyroid gland, and only a few cases of thyroid-related sarcoidosis have been reported in the literature. Herein, we report a case of systemic sarcoidosis with multiple organ involvement in a patient with a solitary left thyroid nodule and benign Fine Needle Aspiration (FNA) findings. The patient was eventually diagnosed with thyroid sarcoidosis using a core needle biopsy of the thyroid nodule. With this case report, we highlight the limitations of the FNA. This case report has the objective to encourage clinicians to include thyroid sarcoidosis in the differential diagnosis of thyroid nodules in patients with systemic sarcoidosis even with unremarkable FNA findings.

It smells and tastes like cancer but it's not cancer: A case report of aggressive benign lung neoplasm.

Desmoid tumors are rare, locally aggressive benign tumors with a high rate of recurrence even after complete resection. Only twenty percent are intrathoracic and they are often painless or minimally painful with slow growth. Rarely they can grow quite rapidly, mimicking a malignant tumor. Here we present a rare case of a rapidly growing, intrathoracic desmoid tumor mimicking lung malignancy in an elderly male ex-smoker. This case demonstrates the importance of including desmoid tumors in the differential diagnosis of lung masses, raising awareness of benign tumors mimicking malignant behavior, and emphasizing the potential benefit of timely follow-up and early diagnosis.

Operable synchronous ampullary carcinoma and hepatocellular carcinoma: a case report and review of the literature.

We report a rare case of synchronous double primary malignancies of the liver and ampulla. A 70-year-old white female was diagnosed with ampullary and hepatocellular carcinoma. The management and outcome of this rare case of synchronous double primary hepatic and periampullary malignancies, amenable to surgical resection is discussed.

Site-specific mesenchymal control of inflammatory pain to yeast challenge in vulvodynia-afflicted and pain-free women.

Fibroblast strains were derived from 2 regions of the lower genital tract of localized provoked vulvodynia (LPV) cases and pain-free controls. Sixteen strains were derived from 4 cases and 4 controls, age and race matched, after presampling mechanical pain threshold assessments. Strains were challenged with 6 separate stimuli: live yeast species (Candida albicans, Candida glabrata, Candida tropicalis, and Saccharomyces cerevisiae), yeast extract (zymosan), or inactive vehicle. Production of prostaglandin E2 (PGE2) and interleukin 6 (IL-6) were proinflammatory response measures. Highest IL-6 and PGE2 occurred with vestibular strains after C albicans, C glabrata, and zymosan challenges, resulting in the ability to significantly predict IL-6 and PGE2 production by genital tract location. After C albicans and C glabrata challenge of all 16 fibroblast strains, adjusting for dual sampling of subjects, PGE2 and IL-6 production significantly predicted the presampling pain threshold from the genital tract site of sampling. At the same location of pain assessment and fibroblast sampling, in situ immunohistochemical (IHC)(+) fibroblasts for IL-6 and Cox-2 were quantified microscopically. The correlation between IL-6 production and IL-6 IHC(+) was statistically significant; however, biological significance is unknown because of the small number of IHC(+) IL-6 fibroblasts identified. A low fibroblast IL-6 IHC(+) count may result from most IL-6 produced by fibroblasts existing in a secreted extracellular state. Enhanced, site-specific, innate immune responsiveness to yeast pathogens by fibroblasts may be an early step in LPV pathogenesis. Fibroblast strain testing may offer an attractive and objective marker of LPV pathology in women with vulvodynia of inflammatory origin.

Comparison of cancer-associated genetic abnormalities in columnar-lined esophagus tissues with and without goblet cells.

OBJECTIVE: To determine and compare the frequency of cancer-associated genetic abnormalities in esophageal metaplasia biopsies with and without goblet cells. BACKGROUND: Barrett's esophagus is associated with increased risk of esophageal adenocarcinoma (EAC), but the appropriate histologic definition of Barrett's esophagus is debated. Intestinal metaplasia (IM) is defined by the presence of goblet cells whereas nongoblet cell metaplasia (NGM) lacks goblet cells. Both have been implicated in EAC risk but this is controversial. Although IM is known to harbor genetic changes associated with EAC, little is known about NGM. We hypothesized that if NGM and IM infer similar EAC risk, then they would harbor similar genetic aberrations in genes associated with EAC. METHODS: Ninety frozen NGM, IM, and normal tissues from 45 subjects were studied. DNA copy number abnormalities were identified using microarrays and fluorescence in situ hybridization. Targeted sequencing of all exons from 20 EAC-associated genes was performed on metaplasia biopsies using Ion AmpliSeq DNA sequencing. RESULTS: Frequent copy number abnormalities targeting cancer-associated genes were found in IM whereas no such changes were observed in NGM. In 1 subject, fluorescence in situ hybridization confirmed loss of CDKN2A and amplification of chromosome 8 in IM but not in a nearby NGM biopsy. Targeted sequencing revealed 11 nonsynonymous mutations in 16 IM samples and 2 mutations in 19 NGM samples. CONCLUSIONS: This study reports the largest and most comprehensive comparison of DNA aberrations in IM and NGM genomes. Our results show that IM has a much higher frequency of cancer-associated mutations than NGM.

Cutaneous sarcoidosis in a woman with chronic hepatitis C and interferon therapy: a case report.

BACKGROUND: Sarcoidosis is an autoimmune disease of unknown origin characterized by the presence of noncaseating epithelioid cell granulomas in multiple organs. Sarcoidosislike lesions have been reported in patients who have a history of chronic hepatitis C with interferon treatment. CASE: A case of cutaneous sarcoidosis, clinically presenting with multiple skin nodules, occurred in a woman with a history of relapsed chronic hepatitis C with interferon therapy. Fine needle aspiration biopsy and excisional biopsy showed ill-defined, noncaseating granulomas. On further investigation, the patient was found to have systemic sarcoidosis. Special stains for infectious etiologies were negative. These findings were compatible with morphologic and clinical features seen in sarcoidosislike lesion induced by interferon. CONCLUSION; A nonnecrotizing granulomatous lesion in subcutaneous tissue might have many differential diagnoses, particularly in a cytology specimen. In this condition, understanding of clinical manifestations is critical for diagnosis. It helps practicing cytopathologists to be aware of this phenomenon of cutaneous sarcoidosis occurring in patients with chronic hepatitis C and interferon or antiviral therapies.

The diagnostic value of endobronchial ultrasound-guided needle biopsy in lung cancer and mediastinal adenopathy.

Endobronchial ultrasonography (EBUS) has emerged as a new diagnostic tool that allows the bronchoscopist to see beyond the airway, including pulmonary and mediastinal lesion. The real time EBUS-guided transbronchial needle aspiration (TBNA) has advanced the diagnostic yield in primary lung pathology and mediastinal lymph node staging of lung carcinoma. Sixty-four patients (36 males, 28 females, ages ranging from 16 to 86 years) with peribronchial lung lesions and mediastinal and/or hilar lymph node lesions underwent EBUS-TBNA. All patients had intraoperative cytological assessment by smears on aspiration samples or touch preparation on needle core biopsies.The cytological final diagnoses were categorized as negative, suspicious/positive, and non-diagnostic. Forty-nine samples were obtained from lymph node lesions and 15 samples were obtained from lung lesions. In cytology specimens, 32 patients had suspicious/positive diagnoses and 32 patients had negative diagnosis. In follow-up histology specimens, 35 patients had malignant diagnoses, including 18 adenocarcinomas, 8 small cell carcinomas, 6 squamous cell carcinomas, 1 metastatic hepatocellular carcinoma, 1 metastatic melanoma, and 1 lymphoma. Twenty-nine patients had negative diagnoses. Sensitivity and specificity were 88.9% and 96.4%, respectively. Positive and negative predictive values were 97.0% and 87.1%, respectively. Diagnostic accuracy was 92.2%. EBUS-TBNA is an efficient and effective technique for diagnosis of intrapulmonary and mediastinal/hilar lymph nodes. It becomes significantly invaluable on clinical management for staging in those patients with lung cancer of other metastatic malignancies. This technique enables us to obtain tissue samples for quick diagnoses beyond central airway with minimal complications.

Characterization of the lymphoid stroma in Warthin's tumor of salivary gland by immunohistochemistry, heavy chain gene and Bcl-2 gene rearrangement.

Warthin's tumor is rarely associated with malignant lymphoma. Only 18 cases were reported in the literature so far. In most cases the latter is a low grade process, including Marginal zone/Mucosa associated lymphoid tissue (MALT) type lymphoma, follicular lymphoma, and rarely diffuse large cell lymphoma which may arise de novo or secondary to low grade lymphoma. This study was conducted to determine the prevalence of occult B cell monoclones and genetic alterations in Warthin's tumor. Fourteen cases of Warthin's tumor were stained with antibodies to CD3, CD20, kappa and lambda light chains. On six cases of randomly selected Warthin's tumor, polymerase chain reaction (PCR) of IgH gene rearrangement (IgH-GR) was performed on genomic DNA extracted from formalin-fixed paraffin embedded tissue. One case of primary salivary gland indolent B-cell lymphoma and 3 cases of sialadenitis were analyzed by the same methods for comparison. In all Warthin's tumor and sialadenitis cases most of lymphoid stroma was B cell phenotype and concentrated in germinal centers. T cells were mostly located between germinal centers. No light chain restriction was demonstrable by kappa and lambda immunostains. Molecular genetic studies failed to show IgH-GR by FISH and showed polyclonal by IgH PCR. In contrast, the lymphoma case showed a diffuse proliferation of small B cells with light chain restriction and a minor component of reactive T cells. FISH showed IgH-GR and bcl-2 gene translocation with monoclonality by IgH PCR. Our study concludes that the lymphoid stroma of Warthin's tumor is reactive.