Gas Chromatography-Mass Spectrometry (GC-MS) Metabolite Profiling of Citrus limon (L.) Osbeck Juice Extract Evaluated for its Antimicrobial Activity Against Streptococcus mutans.

Purpose The present study aimed to determine the antimicrobial nature of Citrus limon juice extract against Streptococcus mutans and to identify its metabolic profile by gas chromatography-mass spectrometry (GC-MS) technique. Materials and methods The cariogenic bacteria S. mutans were procured from Microbial Type Culture Collection and Gene Bank (MTCC), Chandigarh, India, and revived on brain heart infusion (BHI) agar. The C. limon (L.) Osbeck fruits were authenticated from the University of Trans-Disciplinary Health Sciences and Technology (TDU), Bengaluru, India. The antibacterial property of lyophilized lemon juice extract (LJE) dissolved in methanol was evaluated against S. mutans (MTCC 497) by the agar well diffusion assay. GC-MS technique was employed to identify the volatile metabolite profile of the methanolic LJE sample. The metabolite masses of the respective compounds were identified using the National Institute of Standards and Technology (NIST) library. Results The methanolic LJE sample concentration from 5 to 25 mg/ml did not demonstrate antimicrobial activity, while 30 to 100 mg/ml displayed antibacterial activity against S. mutans. Chlorohexidine (100 µg/ml) was used as the positive control, while methanol was used as the negative control. Significant antimicrobial metabolites were detected in the methanolic LJE sample by GC-MS analysis. Maleic anhydride, succinic anhydride, 6-Oxa-bicyclo[3.1.0] hexan-3-one, and 3-methyl-2,5-Furandione were the key metabolites identified in the methanolic LJE sample.  Conclusion The present study reports that C. limon is a potential candidate for the pharmaceutical industry as it possesses bioactive compounds demonstrating therapeutic properties. Further investigations are warranted to determine the individual and synergetic effects of identified metabolites in the methanolic LJE sample for its antimicrobial property. Special attention needs to be focussed on translational research for the development of anti-caries products from C. limon.

Superscan on 18F-FDG PET-CT imaging for lymphoma: How frequent is it?

This retrospective study was conducted to evaluate the frequency of PET superscan in baseline staging scans of lymphoma patients.The study was conducted at the Shaukat Khanum Memorial Cancer Hospital, Lahore, from October 1, 2018 to August 31, 2019. A retrospective review of baseline PET-CT scans of 203 lymphoma patients, performed during the period of October 1, 2017 to August31,2018, was done from the institutional database. Out of these 203 patients, PET superscan pattern was observed in 13 (6.4%) patients, 08 (61.5%) males and 05 (38.5%) females. Eight (61.5%) patients had Non-Hodgkin's lymphoma, while 05 (38.5%)had Hodgkin's lymphoma. Based on TNM staging 10 (76.9%) patients had stage IV disease, 01 (07.6%) had stage III disease, and 2 (15.4%) had stage II disease. PET-CT superscan pattern is uncommon and is not dependent on the stage of the disease. It should be recognised in clinical practice as it suggests a poor prognosis.

Recurrence Yield of Stereotactic Biopsy of Suspicious Calcifications After Breast Conservation Therapy.

Aim To analyze the histopathological outcome of stereotactic biopsies of newly developed suspicious calcifications at lumpectomy scar site in patients with breast conservation surgery (BCS) to determine the incidence of malignancy and the association of mammographic appearance of recurrent microcalcification and their distribution. We also determined the association of disease recurrence with the presence of calcifications in original tumor and lumpectomy resection margins with the risk of recurrence. Materials and methods This study is a retrospective review of mammograms of patients with breast cancer from 2010 to 2021 who underwent stereotactic biopsy of newly developed suspicious calcifications at scar site appreciated on annual follow-up mammogram after breast conservation surgery (BCS) with no mass on correlative ultrasound. The radiological and pathological features of the patients' primary tumor and new calcifications were obtained from the hospital's electronic patient record system. Results A total of 84 patients with breast cancer developed suspicious microcalcifications at the lumpectomy scar site detected on follow-up mammograms after BCS, and 28.6% showed malignant histopathological outcomes. All malignant cases demonstrated pleomorphic morphology. All amorphous (9.5%) and coarse heterogeneous (54.8%) calcifications were benign. The distribution pattern of recurrent malignant calcifications was grouped in 9.5%, regional in 2.4%, linear in 9.5%, and segmental in 7.1%. Calcifications in primary tumors were found in 20.2% of cases. Positive margins were found in 7.1% of these malignant cases. Statistically, there was a strong association between calcification morphology, calcification distribution, presence of calcifications on baseline mammogram, and tumor resection margins. The presence of calcifications in primary tumors and positive resection margins were identified as significant independent risk factors of malignant recurrent calcifications in the logistic regression model and marginal statistical significance in the multivariable logistic regression (MLR) model. Conclusion The interval development of pleomorphic calcifications after BCS with either linear or segmental pattern, positive resection margins, and associated calcifications in primary tumors was related to the increase in the risk of recurrence. Although amorphous and coarse heterogeneous morphology with grouped distribution showed benign outcomes, stereotactic biopsy is recommended to exclude disease recurrence in this high-risk patient population.

Short Latency Radiation Induced Osteosarcoma Detected on 18F-FDG PET/CT Scan in Solitary Plasmacytoma.

18Fluorine-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) plays a pivotal role in the staging, restaging, and surveillance of various bone tumors, including plasmacytomas and osteosarcomas. Solitary plasmacytomas most frequently occur in the bones and are primarily treated with either surgery or radiotherapy. Radiation-induced osteosarcomas (RIOS) usually develop after a median interval of 11 years between radiation and sarcoma presentation. However, these can rarely present with a short latent period of 4 years or even lesser. In such cases, whole-body imaging plays a vital role in the early detection and management of RIOS. Herein, we present the case of a 29-year-old female patient with solitary plasmacytoma undergoing a follow-up whole-body 18F-FDG PET/CT, which revealed metastatic RIOS after a short latent period.

Encapsulated peritoneal sclerosis.

Encapsulating peritoneal sclerosis (EPS) also known as abdominal cacoon is a rare cause of acute or subacute small bowel obstruction. It is characterized by total or partial encasement of the small bowel within a thick fibrocollagenous membrane which may be formed in response to prolonged, repetitive, and severe insult to the peritoneal mesothelium. This is frequently seen in the setting of peritoneal dialysis. However other causes may include chronic inflammation. We present a case of EPS in a male with infrequent abdominal pain, nausea and fever.

Iatrogenic intra-spinal subdural haematoma: An exceptionally rare phenomenon.

Spinal subdural haematoma (SSDH) is very rare but potentially life debilitating spinal vascular condition, often developing acutely. Usually managed conservatively but may require immediate evacuation to prevent potential harm to the spinal cord. Predisposing factors can be spontaneous or iatrogenic. MRI remains the modality of choice to diagnose and see the age and extent of haemorrhage. We hereby present the case of a young child who developed iatrogenic spinal subdural haematoma.

Sonographic Evaluation of Incidental Synchronous Masses in Patients with Breast Cancer: Clinical Significance and Diagnostic Workup.

OBJECTIVE: This study aimed to evaluate the diagnostic accuracy of breast ultrasonography in classifying incidental satellite masses as benign or malignant in patients with breast cancer and to assess its effect on their surgical management. MATERIALS AND METHODS: Ultrasound-guided fine needle aspiration/biopsy was performed in 288 satellite masses of 225 patients with breast cancer. Two radiologists retrospectively reviewed the sonograms of these masses and classified them as benign or malignant and compared this feature with the results of the histopathological examination. The location of the satellite mass and type of surgery were also documented. RESULTS: Of the 288 satellite masses, 139 were located in the same quadrant, 95 in different quadrants, while 54 were in the contralateral breast. Of the 123 sonographically benign masses, 106 showed benign pathological outcome, and from 165 sonographically malignant masses, 127 were found malignant on histopathology/cytology. McNemar's chi-square was 7.27 (p-value=0.007), showing statistically significant association between sonographic features and pathological outcome of satellite masses. The sensitivity, specificity, positive and negative predictive values, and accuracy were 88.2%, 73.6%, 77%, 86.1%, and 80.9% respectively. Based on these findings, 61 patients underwent lumpectomy limited to a single tumor, 52 underwent extended resection, 78 underwent mastectomy, four underwent lumpectomy for the contralateral breast, and bilateral mastectomies were performed in another four patients. Surgery was not performed in 26 patients. CONCLUSION: Although ultrasound is an effective tool for the detection and characterization of incidental satellite masses in patients with breast cancer, biopsy is imperative to ascertain the pathological diagnosis and, therefore, select the most appropriate surgical plan.

Cranial vault lymphoma- An unusual presentation of primary disease.

Diffuse cranial vault and concurrent dural based disease involvement by primary CNS lymphoma is extremely rare. Often such presentations are overlooked initially as benign lesions and biopsy of lymph nodes elsewhere remains source of diagnosis in majority of patients. Diffuse large B-cell lymphoma is a subtype of primary CNS lymphoma with subdural involvement that is diagnosed based on imaging. Though features may overlap with invasive meningioma, MRI remains the modality of choice to help differentiate on the basis of characteristic appearances.The case of a patient with scalp swelling and unusual imaging features of primary dural lymphoma is presented.

Hepatic arterial system anomalies encountered during pancreaticoduodenectomy - our experience.

We present our experience of incidence and management of aberrant hepatic arterial anatomy encountered during pancreaticoduodenectomy (PD). Patients undergoing PD between December 2014 and November 2016 at the Shaukat Khanum Memorial Cancer Hospital, Lahore were included in this short report. Preoperative imaging and operative findings of these patients were reviewed to evaluate the hepatic arterial anatomy and classified according to Hiatt classification. Sixty-four PD were performed with aberrant arterial anatomy identified in 24 (37.5%) of the cases. Most common anomaly was replaced right hepatic artery (rRHA) arising from the superior mesenteric artery seen in seven (11%) of the patients. Aberrant vessels were recognised and preserved in 23 cases. In one patient, the rRHA was coursing through the pancreatic parenchyma needing resection and reconstruction with uneventful postoperative recovery. Hepatic arterial anomalies are common and it is possible to preserve these vessels with careful surgical dissection using artery first technique.

Hepatic Artery Variations in a Sample of Pakistani Population.

OBJECTIVE: To identify the frequency of different arterial variants of common hepatic artery (CHA) overview identified at abdominal CT angiography (CTA) performed in a large series of patients undergoing CT scans for various reasons. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Surgical Oncology and Radiology, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan, from October 2016 to September 2018. METHODOLOGY: Findings in randomly selected 1000 patients who underwent CTA were retrospectively evaluated. The pattern of aortic origin of branches of the celiac trunk and superior mesenteric arteries was analysed. The CHA anatomy was then investigated. Hepatic artery anomalies were classified by the Hiatt's method. RESULTS: There were 629 males and 371 females with a median age of 54 years. Type 1 variation (normal anatomy) was seen in 644 patients. Type 2 variation (left hepatic artery, LHA, aberrations), was seen in 135 patients. LHA was seen arising from left gastric artery or common hepatic artery (CHA) in most of the cases. One patient had a replaced LHA from superior mesenteric artery (SMA). Sixteen patients had an accessory LHA and 119 had a replaced LHA. Type 3 variation (unusual anatomy of right hepatic artery, RHA) was seen in 121 patients, 7 patients had an accessory and 114 had a replaced RHA . The replaced or accessory right hepatic artery originated anywhere from SMA, celiac trunk, aorta, CHA or gastroduodenal artery (GDA). Type 4 variation (unsual origin of both RHA and LHA) was seen in 73 patients. Type 5 variation (CHA arising from SMA) was seen in 23 patients. Type 6 variation (CHA arising directly from aorta) was seen in four patients. CONCLUSION: Arterial variations are common in our population of patients. A detailed understanding and knowledge of these variations is necessary for surgeons and radiologists to avoid any inadvertent injuries during various procedures.

The Hot Pleura: Isolated Pleural Metastases From Renal Cell Carcinoma.

Renal cell carcinoma (RCC) is the most common solid renal malignancy that metastasizes typically to lungs, bones, liver, adrenals, and lymph nodes. Isolated pleural metastases of RCC are extremely rare, with only few cases reported in the literature. We report one such case of a 60-year-old woman, a known case of RCC of the left kidney who underwent nephrectomy, and on follow-up, PET/CT scan revealed diffuse thick nodular hypermetabolic left pleural thickening, which was later biopsied and turned out to be pleural metastases from RCC. No other site of metastases was found.

High-grade B-cell Non-Hodgkin's Lymphoma Masquerading as Thyroid Carcinoma; a Case Report.

Introduction: High grade B-cell lymphoma and diffuse large B cell exhibiting myelocytoma (MYC) translocation with B-cell lymphoma 2 (BCL2) and/or B-cell lymphoma 6 (BCL6) re-arrangements, also known as double and triple hit lymphomas, are aggressive entities. World Health Organization update 2017 includes this cytogenetically defined category of "High grade B cell lymphoma with myelocytoma MYC and BCL2 and/ or BCL6 rearrangements" as a distinct entity on their own. We present an interesting case of an obese patient presenting with a neck mass, suspected to be an aggressive thyroid carcinoma, which eventually turned out to be a high grade B-cell lymphoma. Case Description: A 64 years-old male presented with complaints of neck pain for 10 weeks and a huge swelling in front of neck for 4 weeks. Respiratory system evaluation revealed cough, pleuritic pain and expectoration. Rest of the systemic review was unremarkable. Baseline reports showed hypothyroid status. Ultrasonography (USG) thyroid showed right upper pole Thyroid Imaging Reporting and Data Systems - 4 (TIRADS-4) nodule with bilateral cervical lymphadenopathy for which correlation with fine needle aspiration cytology (FNAC) was advised. Magnetic resonance imaging (MRI) films were submitted for review which showed overall features of locally invasive primary thyroid malignancy. Case was discussed in a multi-disciplinary team (MDT) meeting and suspicion arose of non-thyroidal origin of tumor. Patient underwent Positron emission tomography/computed tomography (PET/CT) as per MDT recommendations. PET/CT findings were highly suggestive of lymphomatous disease as opposed to thyroidal malignancy suspicion early on, which was confirmed on histopathology of cervical nodes. Practical Implications: High grade B-cell lymphoma is an aggressive entity and can be very deceptive in its presentation, as evident from this case report. Functional imaging modalities such as Fluorodeoxyglucose (F-18 FDG) PET/CT can provide crucial assistance in unmasking a deceptive disease entity masquerading as some other, thus changing the management plan completely.

The uncommon loop: Circumportal annular pancreas.

Circumportal annular pancreas (CAP) also known as portal annular pancreas (PAP) is an uncommon pancreatic anatomic variant in which normal pancreatic tissue completely surrounds the portal vein and can be mistaken for mass of pancreatic head. We present here a case of a 65 years old woman who was a diagnosed case of endometrial carcinoma, underwent CT scan for further metastatic workup which revealed this rare pancreatic variant.

Detection and characterization of Streptococcus downei, a rare bacterial species of mutans streptococci from caries-active patients.

BACKGROUND: The oral bacteria, mutans streptococci (MS), are an etiological agent of dental caries. Of MS, Streptococcus downei are rarely isolated bacteria. AIM: The aim of this study was to isolate and characterize S. downei from caries-active subjects. MATERIALS AND METHODS: In all, 65 dental plaque samples were collected from dental caries-active subjects. All the isolates were further identified and characterized using 16S rDNA sequencing, biochemical tests, antibiogram, and minimum inhibitory concentration (MIC). RESULTS: Five isolates have been identified as S. downei using 16S rDNA sequencing. Phylogenetic analysis showed that S. downei was closely related to S. sobrinus. The biotype traits of these five isolates were IV (n = 3), V (n = 1), and variants (n = 2). The study proposed one new biotype, classified as biotype VIII for the variant strain. The antibiogram tests revealed that all the strains of S. downei were susceptible to all the antibiotics used in the study with higher sensitivity to penicillin and ampicillin. The MIC of ampicillin and erythromycin against S. downei was 0.047 and 0.39 µg/mL, respectively. CONCLUSION: The study reports the prevalence of S. downei in caries-active subjects and recommends further investigations to determine its role in the disease.

Recognition of Antibiotic Resistance in Spontaneous Bacterial Peritonitis Caused by Escherichia coli in Liver Cirrhotic Patients in Civil Hospital Karachi.

Introduction Spontaneous bacterial peritonitis (SBP) is the most common life-threatening infection in patients with ascites due to liver cirrhosis. The infection is most commonly caused by the bacterium Escherichia coli, commonly referred to as E. coli. Over the past few years, the incidence of antimicrobial resistance against E. coli has risen drastically, leading to increased morbidity and mortality. Methods This cross-sectional study was conducted to determine the pattern of resistance using variations of antibiotics against E. coli, to prevent its empirical usage and initiate an appropriate target antibiotic therapy. The data were collected from May 2017 to October 2017 and included a total of 184 patients. The patients had previously been diagnosed with chronic liver disease and had presented with E. coli-induced SBP in the medicine wards at Civil Hospital, Karachi, which is the largest tertiary care hospital in the city. All participants underwent diagnostic paracentesis, and the ascitic fluid samples were sent to labs for culture and sensitivity to antibiotics. Results The sample population consisted of 184 participants, of which two-thirds (63.6%; n=117/184) of the population consisted of males. The mean age of the participants was 47.6±10.7 years. More than half of the patients had hepatitis C (54.9%; n=101/184) while the remaining were diagnosed with hepatitis B (45.1%; n=83/184). The ascitic fluid showed varying percentages of resistance for drugs, with no resistance to imipenem and meropenem while ciprofloxacin showed the highest resistance in eradicating the bacterium, E. coli. Additionally, a statistical correlation was tested between drug resistance and factors like age, gender, duration of liver disease, and duration of ascites. Ciprofloxacin and tetracycline showed a positive correlation between the resistance of these drugs and the age, gender, and duration of chronic liver disease in the participants while trimethoprim/sulfamethoxazole, amoxicillin/clavulanic acid, and piperacillin/tazobactam showed a positive association with the duration of ascites. Conclusion A rapid diligent intervention of cirrhotic patients with complicated ascites is crucial to alleviate patient mortality. Due to the rising bacterial resistance, primarily, epidemiological patterns should be assessed and analyzed in our regional hospitals, and then, antibiotics should be prescribed meticulously.

All that glitters is not gold.

Solitary pulmonary nodules (SPN) are a diagnostic dilemma with a long list of differential diagnosis which extends to include both horizons i.e., benign as well as malignant conditions. Fortunately, there are some factors which favour benign over malignant; one such factor is presence of fat.1 We present here a case of a 40 years old male who underwent x-ray due to haemoptysis and cough which demonstrated a coin lesion; subsequently, PET-CT scan was requested for characterization of the lesion and concurrent staging which revealed mildly avid fat containing lesion in right lung diagnostic of pulmonary hamartoma.

Pearls in the Wrong Pockets: Idiopathic Scrotal Calcinosis.

Idiopathic scrotal calcinosis, also called dystrophic scrotal calcinosis, is a rare benign condition that causes superficial intradermal scrotal calcifications. We present one such case of a 40-year-old married man who underwent PET/CT scan for staging workup of lymphoma and revealed this rare entity incidentally without any other testicular pathology.

Gastric Tuberculosis.

Gastric tuberculosis is a very rare disease posing a diagnostic challenge to physicians, pathologists and radiologists. It usually occurs in females aged 25 to 45 years. Symptoms include epigastric pain, vomiting, fever, weight loss, upper gastrointestinal (GI) bleed and gastric outlet obstruction. High index of suspicion and endoscopic or endoscopic ultrasound guided biopsies may help in making an early diagnosis, particularly in patients with non-healing gastric ulcers. We report a case of gastric tuberculosis in a 55-year male, who presented with persistent vomiting, epigastric pain and significant weight loss. His upper GI endoscopy finding with histopathology results favoured the diagnosis of gastric tuberculosis. He was successfully treated with antituberculous regimen.

Diagnostic Accuracy Of Us-Fnac Of Axillary Lymph Nodes In Patients With Primary Breast Cancer Using Sentinel Lymph Node Biopsy As Standard Reference.

BACKGROUND: The advent of US guided FNAC in the investigation of adenopathy has become a suitable and commonly practiced minimally invasive procedure which is safe, simple, quick, highly cost effective and innocuous. Nowadays, in modern days FNAC is done in almost all cases due to its high specificity, Positive predictive value (PPV) and no complications resulting in fewer SNLB and directly proceeding with neo-adjuvant chemotherapy or ALND.. METHODS: A total of 160 females between ages 30-60 years who had clinical palpable breast lump, newly diagnosed cases of breast cancer with palpable axilla nodes were included. Patients who already received neoadjuvant therapy and whose biopsy does not yield enough specimens and needs repeat biopsy were excluded. All the patients were then undergoing ultrasound guided fine needle aspiration. Afterwards, all patients were gone through axillary surgery for the definite histopathology report. FNAC results were compared with pathology after SLNB. RESULTS: Mean age was 46.61±8.75 years. In 67 FNAC positive patients, 61 were True Positive and 06 were False Positive. Among, 93 FNAC negative patients, 18 were False Negative whereas 75 were True Negative. Overall sensitivity, specificity, negative predictive value, positive predictive value and diagnostic accuracy of US guided FNAC of suspicious axilla nodes in patent with primary breast carcinoma was 77.22%, 92.59%, 80.65%, 91.04% and 85.0% respectively. CONCLUSIONS: This study concluded that US guided FNAC of suspicious axilla nodes in patient with primary breast carcinoma has quite acceptable diagnostic accuracy.