Use of Polarized Light in the Diagnosis of "Fuzz" Granuloma in the Conjunctiva of a Child.

Synthetic fiber granulomas, also known as "Teddy Bear" granulomas or "Fuzz Ball granulomas," are usually seen in childhood. We present a case of a 5-year-old child with a "Fuzz Ball" granuloma of the conjunctiva. The resected specimen was processed routinely. The use of polarized light during microscopic examination of the resected tissue made the diagnosis evident due to the prominent birefringence of the synthetic foreign material fibers.

What's eating you? clothes moths (Tineola species).

Common household insects can be confused with ectoparasites. Understanding the basic identification and monitoring techniques of clothes moths will help the clinician identify if a patient has an infestation of the household versus his/her body. Clothes moth larvae are not parasites but are found on infested clothing and can be confused with myiasis.

Thrombotic Microangiopathy Secondary to Intravenous Abuse of Opana® ER.

Opana ER (oxymorphone) is an opioid drug available throughout the United States, and intravenous abuse of the crushed oral formulation has been associated with drug-induced thrombotic microangiopathy. In this abstract, we describe two young patients who lived together and used Opana ER intravenously. Both presented with microangiopathic hemolytic anemia that mimicked thrombotic thrombocytopenic purpura (TTP). Treating this condition poses a clinical challenge, as it is difficult to distinguish it from TTP. The role for plasma exchange is not clear but can be used while awaiting the results of the ADAMTS-13 activity, but ultimately supportive care with drug discontinuation is the recommended therapy of choice. Patients should be counseled against Opana ER's intravenous use, and users should be offered drug rehabilitation therapy.

Algorithmic and consultative integration of transfusion medicine and coagulation: a personalized medicine approach with reduced blood component utilization.

BACKGROUND: Therapy customized for the individual patient defines personalized medicine. Current transfusion therapy is performed primarily using general guidelines such as keeping the platelet count at >100,000/µL, the INR at ≤ 1.7 and fibrinogen at >100mg/dL for patients undergoing surgery. OBJECTIVE: The purpose of this report is to provide an algorithmic and consultative approach for the delivery of personalized and targeted blood component, blood derivative, and recombinant therapies in order to minimize unnecessary exposure to such therapies and to deliver an optimal risk-benefit ratio for a particular patient. METHODS: The initiative involved a step-wise process that included: 1. establishing "triggers" to alert and permit the clinical pathologist to intervene in the utilization of blood components for a given patient in the context of the blood bank inventory; 2. developing algorithms for the assessment of the patient's procoagulant/anticoagulant status so that appropriate blood component, derivative, and/or recombinant therapies could be instituted while minimizing the risk of thrombophilia; 3. a real time assessment and interpretation of the coagulation data so that dialogue between the pathologist and the patient's clinical team could be effected 24 hours a day, 7 days a week; and 4. monitoring the outcome of these efforts by comparing blood component utilization prior to or during development, early implementation and following full implementation of the program. RESULTS: "Triggers" (i.e., administration of six units of fresh frozen plasma [FFP] or ten units of cryoprecipitate or two single donor [apheresis] platelets in a 24-hour period) were approved. A diagnostic and therapeutic algorithm was constructed, with multidisciplinary input to assist in defining the coagulopathy contributing to the patient's microvascular bleeding in the adult cardiac surgery/cardiac intensive care unit (CICU) and the adult intensive care unit (AICU). Monitoring of utilization, prior to or during development, early implementation and following full implementation of this initiative, revealed a decline in the number of units of FFP, cryoprecipitate and single donor (apheresis) platelets administered. CONCLUSION: We report on the successful development of a model - based on the algorithmic and consultative integration of transfusion medicine and coagulation - that customizes blood component, derivative, and recombinant therapies appropriate for an individual patient's need, resulting in targeted transfusion therapy and associated with reduced blood component utilization.

Coagulation management of a patient with factor V Leiden mutation, lupus anticoagulant, and activated protein C resistance: a case report.

Although patients undergoing cardiac surgery often present with diverse comorbidities, those with coagulation derangements are especially challenging. The present report describes the management of a patient who presented with a Factor V Leiden mutation, lupus anticoagulant, and acquired activated protein C resistance. A 42-year-old female presented with acute shortness of breath and chest pain. She was otherwise healthy 1 month prior to admission when she presented with dysfunctional uterine bleeding, resulting in the transfusion of three units of packed red blood cells. Coagulation evaluation revealed that the patient had lupus anticoagulant, factor V Leiden mutation and an activated protein C resistance. The patient presented with an acute myocardial infarction and was found to have 90% stenosis of her left main coronary artery, moderate mitral and tricuspid regurgitation, and a left ventricular ejection fraction of 25%. An emergent off-pump coronary artery bypass procedure with placement of a vein graft to the left anterior descending artery was completed. Intraoperative thrombophilia was encountered as evidenced by both an elevated thromboelastograph coagulation index (+3.6) and an acquired antithrombin-III deficiency. Postoperatively, the patient was placed on low molecular weight heparin, but developed heparin-induced thrombocytopenia and was switched to a direct thrombin inhibitor, argatroban. The following case report describes the coagulation management of this patient from the time of admission to discharge 43 days later, and the unique challenges this combination of hemostatic defects present to the clinicians.

Intracytoplasmic filamentous inclusions in the peripheral blood of a patient with chronic lymphocytic leukemia. A bright-field, electron microscopic, immunofluorescent, and flow cytometric study.

Intracellular inclusions in lymphoproliferative disorders are not common. Multiple different types of inclusions have been reported in chronic lymphocytic leukemia (CLL), including vacuoles, crystals, and pseudocrystals. Most of the reported cases were seen in the bone marrow lymphocytes, and the majority of these on electron microscopy. We report a case of long-standing CLL with no therapy that had filamentous cytoplasmic inclusions in the peripheral blood that were readily seen by light microscopy. Electron microscopy demonstrated dilated cisternae of the rough endoplasmic reticulum filled with amorphous electron-dense material. By immunofluorescence, the material proved to be immunoglobulin G-lambda deposits. The immunophenotype had the typical CLL pattern with positive staining with CD19, CD5, and CD23, and low-density CD20 staining; however, it also had unusual staining with CD25 and intermediate-intensity staining with CD22.