A 58-Year-Old Man With Hemoptysis After COVID-19 Infection.

CASE PRESENTATION: A 58-year-old man presented to us with a 1-week history of high-grade fever and progressive dry cough. Four weeks before his presentation, he was diagnosed with COVID-19 infection and needed non-ICU hospital admission with no supplemental oxygen requirements for 6 days and was treated with a 5-day course of remdesivir and 3 weeks of dexamethasone. His steroid dose was commenced on dexamethasone 12 mg bid (four times the recommended dose) for 14 days and then gradually tapered over the remaining 7 days. His history was unremarkable, except for well-controlled asthma. He did not complain of any shortness of breath, weight loss, or loss of appetite. He was never a smoker and denied any alcohol use.

Long-term outcome of adjunctive Gamma Knife radiosurgery in skull-base chordomas and chondrosarcomas: An Indian experience.

Skull-base chordomas (CD) and chondrosarcomas (CS) are locally-invasive tumors, have similar clinical presentations, while differing in their nature of growth and outcomes. In this study, we compare the long-term outcomes of Gamma Knife Radiosurgery (GKRS) as an adjunctive treatment modality for residual skull-base CD and CS. A retrospective analysis of clinico-radiological, pathological, radiotherapeutic and outcome data was carried out in patients who underwent adjunctive GKRS for residual skull-base CD and CS at P D Hinduja Hospital, Mumbai, between 1997 and 2020. All 27 patients included had either histopathologically proven CD (20 patients) or CS (7 patients). Brachyury immunohistochemistry in CD specimens gave 70.6% positivity. Total sessions of GKRS in CD and CS groups were 22 and 7, respectively. Mean tumor volume and mean margin dose in CD group were 6.53 ± 4.18 cm3 and 15.95 ± 1.49 Gy respectively, while for CS group, they were 4.16 ± 2.79 cm3 and 18.29 ± 3.15 Gy. With mean follow-up periods of 5.25 ± 4.73 years and 6 ± 2.07 years respectively, the CD and CS groups showed 5-year progression free survival (PFS) of 56.8% and 57.1%, and a 5-year overall survival (OS) of 82.1% and 100%. Sub-group analysis in both CD and CS groups revealed a better 5-year PFS with the following factors - CS histopathology, patient age < 45 years, margin dose > 16 Gy, tumor volume < 7 cm3 (p-value < 0.05), gross total resection, and brachyury positivity. Adjunctive radiotherapy for skull-base CD and CS holds promise.

Do additional colonoscopic biopsies increase the yield of Mycobacterium tuberculosis culture in suspected ileo-colonic tuberculosis?

BACKGROUND: Isolation of Mycobacterium tuberculosis on culture is vital for differentiating intestinal tuberculosis (ITB) from Crohn's disease (when histology is not diagnostic) and for diagnosis of multidrug-resistant tuberculosis. The current yield of TB culture (< 50%) from colonoscopic biopsy tissue is not satisfactory. AIM: To determine whether more colonoscopic biopsies can increase the yield of TB culture in patients with ITB. METHODS: In this prospective study, in patients who underwent colonoscopy for suspected ITB, four biopsies were taken (container 1) followed by an additional four biopsies (container 2) for TB culture, from involved regions. The culture was done using Mycobacterium Growth Indicator Tube (MGIT) 960. A final diagnosis of ITB was made if TB culture was positive, there was unequivocal histological evidence of TB, or there was unequivocal evidence of TB elsewhere in the body, in the absence of another diagnosis. RESULTS: Of 182 patients enrolled (mean age 37.5 [SD 17.2] years; 93 [51.5%] women), 70 (38.4%) were finally diagnosed to have ITB. MGIT culture was positive in 29 (41.4%), 27 (38.5%), and 37 (52.8%) of 70 patients from containers 1, container 2, and combined eight biopsies, respectively. The incremental yield of eight biopsies was 11.4% (95% confidence interval [CI] 5.1 to 21.3%) as compared to container 1 and 14.3% (95% CI 7.1 to 24.7%) as compared to container 2. CONCLUSION: Additional four (total eight) colonoscopic biopsies improved the yield of TB culture positivity over four biopsies by 11.4% to 14.3%, to 52.8%; this increase is clinically useful.

Nontuberculous mycobacterial infection of the musculoskeletal system in immunocompetent hosts.

BACKGROUND: Nontuberculous mycobacteria (NTM) were considered saprophytic organisms for many years but now are recognized as human pathogens. Although humans are routinely exposed to NTM, the rate of clinical infection is low. Such infections usually occur in the elderly and in patients who are immunocompromised. However, there has been an increasing incidence in recent years of infections in immunocompetent hosts. NTM infections in immunocompetent individuals are secondary to direct inoculation either contamination from surgical procedures or penetrating injuries rather than hematogenous dissemination. Clinically and on histopathology, musculoskeletal infections caused by NTM resemble those caused by Mycobacterium tuberculosis but are mostly resistant to routine antituberculosis medicines. MATERIALS AND METHODS: Six cases of NTM infection in immunocompetent hosts presenting to the department from 2004 to 2015 were included in study. Of which two cases (one patella and one humerus) of infection were following an open wound due to trauma while two cases (one hip and one shoulder) of infection were by inoculation following an intraarticular injection for arthrogram of the joint, one case was infection following arthroscopy of knee joint and one case (calcaneum) was infection following local injection for the treatment of plantar fasciitis. All patients underwent inaging and tissue diagnosis with samples being sent for culture, staining, and histopathology. RESULTS: Clinical suspicion of NTM inoculation led to the correct diagnosis (four cases with culture positive and two cases with histopathological diagnosis). There treatment protocol for extrapulmonary NTM infection was radical surgical debridement and medical management based on drug sensitivity testing in culture positive cases. At a mean follow up of 3 years (range1-9 years) all patients had total remission and excellent results. CONCLUSIONS: Whenever a case of chronic granulomatous infection is encountered that does not respond to standard anti-tuberculous treatment, with a history of open trauma, surgical intervention, or injection as shown in this study, a possible NTM infection should be considered and managed appropriately.

Bednar Tumor: An Uncommon Entity.

Bednar tumor is an uncommon variant of dermatofibrosarcoma protuberans. Also known as pigmented dermatofibrosarcoma protuberans, this tumor is of intermediate grade. It is seen in adults and has a predisposition to affect the shoulder region. We report a rare case of Bednar tumor in a 40-year-old female patient. The diagnosis of Bednar tumor must be considered while reporting pigmented subcutaneous spindle cell lesions.

Colorectal cancers in ulcerative colitis from a low-prevalence area for colon cancer.

AIM: To determine the incidence and risk factors for colorectal cancer (CRC) in patients with ulcerative colitis from a low prevalence region for CRC. METHODS: Our prospective database yielded a cohort of 430 patients [age: 44 ± 14.6 years; 248 men (57.7%)] with ulcerative colitis (median disease duration 6, range: 1-39 years) for analysis. Of these, 131 (30.5%) had left-sided colitis and 159 (37%) extensive colitis. Patients with histologically confirmed CRC within the segment with colitis were compared with those without CRC, to determine the risk factors for the development of CRC. RESULTS: Twelve patients (2.8%) developed CRC. The overall incidence density was 3.56/1000 patient-years of disease - 3/1000 in the first 10 years, 3.3/1000 at 10 to 20 years, and 7/1000 at > 20 years. Three of our 12 patients developed CRC within 8 years of disease onset. On univariate analysis, extensive colitis, longer duration of disease, and poor control of disease were associated with development of CRC. On multivariate analysis, duration of disease and extent of colitis remained significant. CONCLUSION: CRC occurred in 2.8% of patients with ulcerative colitis in our population - an incidence density similar to that in Western countries in spite of a low overall prevalence of colon cancer in our population. The risk increased with extent and duration of disease.

Whipple's disease.

A 74 year old male patient with weight loss, diarrohea, loss of appetite, anemia, thrombocytopenia and culture negative endocarditis was diagnosed to have Whipple's disease. We are reporting this case, as it is a rare disease with fewer than 1000 validated cases reported in literature.

Osteoarticular tuberculosis--diagnostic solutions in a disease endemic region.

BACKGROUND: We conducted a study of osteoarticular tuberculosis in patients from private and public settings in a disease endemic area. Our objective was to assess the role of mycobacterial culture and polymerase chain reaction (PCR) in the diagnosis of osteoarticular tuberculosis (TB) in settings where only clinical and imaging diagnosis form the basis for treatment. METHODOLOGY: Ninety-three consecutive specimens collected from clinically suspected patients of osteoarticular TB were screened for bacterial culture, mycobacterial culture and in-house nested PCR. In addition, specimens were examined by imaging and histopathology. Ten specimens collected from patients suffering from other bone diseases were included as negative controls. RESULTS: Of the 93 clinically suspected TB patients, mycobacterial culture was positive for Mycobacterium tuberculosis (MTB) in 47 (51%) patients who were confirmed as definite TB cases. Of the remaining patients, 16 (17%) were diagnosed as probable, 19 (20%) as possible, and 11 (12%) as only clinically suspected TB cases. In-house nested PCR was positive in 65 (70%) cases. Fifteen patients were resistant to one or more anti-tuberculous drugs; twelve patients were multi-drug resistant, two of whom were extensively drug resistant. CONCLUSION: Mycobacterial cultures using liquid media with susceptibility should form the backbone of management of osteoarticular TB. Nested PCR enhances the sensitivity if performed in addition to culture.

Gamma knife radiosurgery in jugular foramen endolymphatic sac adenocarcinoma.

A 41-year-old male presented to us with a history of right-sided temporal headache and ear discharge. MRI revealed an extra-axial space-occupying lesion in the region of the right jugular foramen. The patient was operated upon and a radical excision of the tumor was performed. Histopathology revealed an adenocarcinoma, probably of endolymphatic sac origin. The patient had a recurrence of tumor at 2-year follow-up and was subjected to gamma knife radiosurgery. The patient was subsequently asymptomatic at a 2.5-year follow-up and imaging revealed regression of the tumor size. Stereotactic radiosurgery in recurrent endolymphatic sac tumors involving the jugular foramen has not been reported previously. We review the literature on this novel treatment protocol for this rare skull base tumor.

Hermansky-Pudlak syndrome.

We present a rare disease condition Hermansky-Pudlak syndrome in a 33-year-old male. He was born of a consanguineous marriage, had occulo-cutaneous albinism, nystagmus, decreased visual acuity, refractory errors, pulmonary fibrosis and granulomatous inflammation of the colon. In spite of all the classical features of this genetic disorder he was labeled to have disseminated tuberculous infection with a drug resistant strain for many years till the actual diagnosis was made on the basis of a strong clinical suspicion. We report this rare condition which might be misdiagnosed as tuberculosis.

Acanthamoeba encephalitis in patient with systemic lupus, India.

We report a fatal case of encephalitis caused by Acanthamoeba in a 24-year-old woman from India with systemic lupus erythematosus. Diagnosis was made by identification of amebas in brain sections by immunofluorescence analysis and confirmed by demonstrating Acanthamoeba mitochondrial 16S rRNA gene DNA in brain tissue sections.

Hepatic tuberculosis in absence of disseminated abdominal tuberculosis.

Liver involvement in tuberculosis in absence of miliary tuberculosis is rare. This study was performed to analyse the spectrum and response to treatment of hepatic tuberculosis in the absence of miliary abdominal tuberculosis. Retrospective analysis of seven cases of hepatic tuberculosis without miliary abdominal tuberculosis who presented at the single tertiary referral center were analyzed. All patients presented with fever and hepatomegaly. Five of them had pain in upper abdomen and vomiting. HIV serology was positive in one patient. All patients had normocytic normochromic anaemia, raised erythrocyte sedimentation rate (Mean 65). Mild elevation of liver enzymes and low albumin (Mean 2.4 gm%) with reversal of albumin globulin ratio (Mean 0.6) were seen in all. Two had jaundice. Prothrombin time was normal in all and lactate dehydrogenase values were elevated in all (Mean 794 IU/L). On ultrasonography, 2 had multiple hypodense lesion, 1 had coarse echotexture of liver, 1 had hyperechoic pattern and 3 had just hepatomegaly. Complete resolution of liver lesions on treatment with 4-drug anti-tuberculosis drug chemotherapy was seen. In conclusion, liver tuberculosis has protean manifestations with nonspecific alteration of liver function tests and is best diagnosed on liver biopsy. Overall response to therapy is satisfactory.

Co-existence of peri-ampullary carcinoma with peripancreatic tuberculous lymphadenopathy.

CONTEXT: Pancreatic tuberculosis and peripancreatic tuberculous lymphadenitis are rare, mimicking various pathologies of the pancreas. The coexistence of peri-ampullary malignancy with peripancreatic tuberculous lymphadenitis has not been reported. CASE REPORT: We present the case of a young woman who had been operated on with a preoperative diagnosis of peri-ampullary adenocarcinoma in whom a frozen section of regional lymph nodes revealed tuberculosis. The final pathology confirmed the co-existence of tuberculosis with malignancy. The patient made an uneventful recovery. CONCLUSION: In countries with high endemicity for tuberculosis, the co-existence of malignancy and tuberculosis should be considered and resection, which is the only chance for cure, should not be abandoned due to observations based solely on frozen sections.

Autoimmune hepatitis: a study of 50 patients.

INTRODUCTION: Autoimmune hepatitis (AIH) is a well-defined entity in the West but there are sparse Indian data on this disease. AIM: To study the clinical profile and response to treatment of Indian patients with AIH. METHODS: This is a part retrospective and part prospective study of 50 patients (median age 48 years, range 11-82; 43 women) seen between 1995 to 2001, diagnosed to have AIH as per the revised scoring system. Clinical and laboratory profile, response to treatment, and complications of treatment were analyzed. RESULTS: AIH accounted for 6% of all patients with liver disease seen during the period. The presenting symptoms were gastrointestinal in 43 and non-gastrointestinal in 7, with median symptom duration of 6 months (range 2 weeks to 40 years). Forty patients (80%) had chronic liver disease. Associated illnesses were present in 28 patients. Twenty-six patients were classified as definite and the rest as probable AIH. Forty-nine patients had Type 1 AIH. Five patients had overlap syndrome. Forty-five patients (90%) received immunosuppressive therapy. Twelve of 18 patients receiving only prednisolone and 21 of 27 patients receiving prednisolone and azathioprine combination responded. Thirteen (26%) patients had therapy-related complications (infectious 5, non infectious 8) with two treatment-related deaths. CONCLUSION: Type 1 AIH was the predominant type of AIH. The majority of patients with AIH presented with chronic liver disease. There was good response to immunosuppressive therapy. Therapy-related complications occurred in one-fourth of patients.

AIDS-associated Kaposi's sarcoma in a heterosexual male--a case report.

A 39 year old married heterosexual male presented with extensive purpuric macules, papules, and lichenoid plaques scattered over his skin and mucocutaneous surfaces for one year. The lesions were larger in both his groins, and were associated with lymphedema of his penis and scrotum. His serology for the HIV-1 virus was positive. Biopsies from multiple lesions confirmed the diagnosis of Kaposi's sarcoma. Histochemistry was positive for the HHV-8 virus. He subsequently developed pulmonary and peritoneal effusions and died 3 months later of cardiopulmonary arrest.