Secretory meningioma: A diagnostic pitfall.

Context: Secretory meningioma is a rare subtype of meningiomas, displaying epithelial and secretory differentiation of meningothelial cells. It has unique radiological, morphological, and immunohistochemical features, but runs a benign course. Radiological picture because of the variable degrees of peritumoral edema can be confused with aggressive neoplasms. Morphologically, it is diffi cult to distinguish secretory meningioma from other tumors having a clear cell appearance and aggressive clinical behavior. Materials and Methods: Retrospective analysis over a period of 16 years (1997-2012) brought out fi ve cases diagnosed as secretory meningioma. The slides were restained and subject to special stains and immunohistochemistry and the clinical details were retrieved. Results: On histopathology, the tumors showed a characteristic vacuolated appearance due to the presence of variably sized intracytoplasmic lumina. Another unique feature was the presence of hyaline inclusions within these intracytoplasmic lumina and in the intercellular spaces. These inclusions were periodic acid-Schiff positive diastase-resistant, yellowish-orange on Elastic Van Giesson stain and strongly carcinoembryonic antigen positive. Conclusion: Owing to its rarity and unique morphology secretory meningioma poses a diagnostic challenge to the pathologists. As this tumor follows a benign course, it is crucial to correctly diagnose this entity to avoid unnecessary over treatment.

Lead-induced peripheral neuropathy following ayurvedic medication.

Lead poisoning following intake of Ayurvedic medication is one of the recent areas of concern. We report a case of a 58-year-old type II diabetic man who was stable with diet control and 30 mg pioglitazone per day. He took Ayurvedic medication for generalized weakness and developed peripheral neuropathy following its intake. He was found to have high blood and urinary lead levels and was diagnosed to have subacute lead poisoning. He was treated with d-Penicillamine for 8 weeks, following which his lead levels became normal. The use of d-Penicillamine was proved highly effective in treating a case of lead poisoning.

Rational use of glucocorticoid during pituitary surgery--a pilot study.

BACKGROUND & OBJECTIVE: The conventionally used perioperative glucocorticoid replacement protocol in patients with pituitary tumours is far from optimal. In this study we evaluated the validity of a modified protocol for perioperative glucocorticoid replacement in non-functioning pituitary macroadenomas. METHODS: A total of 24 consecutive patients with non functioning pituitary macroadenomas were included in this interventional study. Patients with a pre-operative 0800 h cortisol of > or = 350 nmol/l (> or = 12.6 microg/dl) did not receive glucocorticoid replacement during perioperative (d(0)-d-(2)) period, while those with < or = 100 nmol/l (< or = 3.6 microg/dl) received glucocorticoid replacement. Those patients with 0800 h cortisol value between > 100-349 nmol/l (> 3.6-12.6 microg/dl) required them to undergo an insulin induced hypoglycaemia (IIH). In response to IIH, patients with a peak cortisol of < 550 nmol/l (< 19.8 microg/dl) received glucocorticoid replacement. Post-operatively, patients on day 3 with 0800 h cortisol of < or = 100 nmol/l (< or = 3.6 microg/dl) received hydrocortisone 10 mg/m(2) per day; those between > 100-449 nmol/l (> 3.6-16 microg/dl) received hydrocortisone replacement only if they had symptoms of adrenal insufficiency (AI) or during stress; while patients with > or = 450 nmol/l (> or = 16.0 microg/dl) did not receive any glucocorticoid replacement. Retesting was done at 12 wk in 23 subjects based on the algorithm. RESULTS: Pre-operatively, 8 (35%) patients were hypocortisolic and received glucocorticoid supplementation, thereby sparing 15 (65%) subjects from glucocorticoid replacement. On d(3) of surgery, 13 (57%) patients were hypocortisolic, but only 6 with serum cortisol of < or = 100 nmol/l (< or = 3.6 microg/dl), had symptoms and were substituted with glucocorticoid. Remaining seven patients, with serum cortisol between >100-349 nmol/l (> 3.6-12.6 microg/dl), were asymptomatic and advised glucocorticoid support only during stress but none required. Overall, 17 (74%) patients were spared from unnecessary glucocorticoid support. At 12 wk, 13 (57%) patients were hypocortisolic and only 6 either with serum cortisol level of < or = 100 nmol/l (< or = 3.6 microg/dl) or symptomatic for AI received glucocorticoids. Post-operative complications including diabetes insipidus and CSF leak remarkably decreased. INTERPRETATION & CONCLUSION: The protocol used was safe and spared unnecessary use of glucocorticoids peri- and post-operatively. However, more number of patients are to be studied to substantiate the validity of this protocol.

Raised intracranial pressure in hepatic encephalopathy.

Intracranial hypertension secondary to cerebral edema is the cause of death in 50%-80% of patients with fulminant hepatic failure (FHF). This is rarely seen in chronic hepatic failure. The genesis of cerebral edema in FHF is poorly understood. The grade of encephalopathy and coagulopathy are the most important predictors of outcome in FHF. However, it is important to emphasize that intracranial pressure (ICP) may not reflect clinical course. Decerebrate posturing may be seen with ICP recording of 16 mmHg, while a quarter of the patients may have brain damage without clinical signs of raised ICP. ICP monitoring is therefore vital. The gold standard for ICP monitoring is the intraventricular method. Non-invasive methods like computerized tomography scan and magnetic resonance imaging have poor correlation with ICP. Other methods like transcranial Doppler and jugular venous oximetry measurement of brain metabolites need evaluation. The main indications for ICP monitoring in FHF are (a) patients in grade III or IV encephalopathy and (b) patients undergoing liver transplantation. Generally, patients with an ICP >40 mmHg with cerebral perfusion pressure <50 mmHg for over 2 hours are poor subjects for liver transplant.

Suprasellar malignant mixed germ cell tumour presenting as craniopharyngioma.

A 15 year old boy presented with diminution in vision of both eyes, diabetes insipidus and hypopituitarism. MRI was suggestive of a large suprasellar and retrosellar craniopharyngioma with stretching of the optic chiasma. Histopathological findings on the first surgical specimen were interpreted as a craniopharyngioma. He was reoperated on account of clinical deterioration and increase in tumour size. Histological examination this time revealed derivatives of all three germ cell lineages along with areas of embryonal carcinoma, and yolk sac tumour besides squamous cysts, establishing the diagnosis of malignant mixed germ cell tumour. Serum and CSF were strongly positive for alpha foetoproteins.

A mathematical outcome prediction model in severe head injury: a pilot study.

103 patients of head injury, with a Glasgow coma scale (GCS) score of 8 or less, were studied prospectively. GCS score, brain stem reflexes, motor score, reaction level scale, and Glasgow Liege scale were evaluated as prognostic variables. Linear logistic regression analysis was used to obtain coefficients of these variables and mathematical formulae developed to predict outcome in individual patients.

Detection of HIV seropositivity during an outbreak of Japanese encephalitis in Manipur.

An epidemic outbreak of Japanese encephalitis (JE) occurred during mid 1995. Sixteen serum samples from patients with history of febrile headache, convulsions, mental confusion, neck rigidity etc. were sent to the Department of Virology, School of Tropical Medicine, Calcutta, in August, 1995. Twelve (75%) showed HIV antibody against JEV. Out of these 12 sera showing HIV antibody titre between 1:40 and 1:160, eight (66.6%) showed IgM antibody, giving the presumptive diagnosis of recent JEV infection. Five of these 16 sera showed HIV seropositivity (31.25%). Concomitant JEV and HIV infection could be detected in 3 cases. However, in 2 sera HIV titre were less than 1:20. This is probably the first documentation of concomitant JEV and HIV infection in the eastern India.

HCV activity in Calcutta--a serological study.

HCV infection, a global public health problem is quite prevalent in India. In the present study conducted during February-July 1996 a total of 153 samples of different age groups and of both sexes were tested by ELISA for detection of Anti-HCV antibody. Anti-HCV was found in 13% of multi-transfused cases and in 8.8% cases with multiple needle-stick injury. Maximum seropositivity (20%) could be observed amongst males between 31-40 yrs. age group. HCV activity was noted more in males (13%) than in females (8.2%) and more relatively in subjects without a history of jaundice (11.5%) than those having the features of jaundice (10.5%). An increasing trend has also been observed amongst the multi-transfused cases in Calcutta.

An in vitro qualitative assay for the detection of antibodies to HIV type 1/2 contained in human saliva.

There is ample evidence that saliva contains secretory antibody against most infections. Therefore, saliva has been recommended as a non invasive, safe and effective alternative to serum, for HIV antibody testing. The present study attempted comparative evaluation of antibody detection by serum and saliva specimens in laboratory by ELISA and Western Blot for diagnosis of HIV infection in the Indian situation. From a study of 42 test sera it is concluded that test apart from its simplicity and reproducibility, is almost free from any false positive and false negative reactions.

An institutional outbreak of hepatitis E--reported first time from Calcutta city.

A sudden outbreak of hepatitis occurred in a micro-epidemic form, amongst the staff members of the School of Tropical Medicine, Calcutta, during May-June, 1995. A total of 21 persons developed jaundice, out of whom 11 members who attended the Virology Department and were tested for detection of different serological markers of hepatitis by ELISA. All the sera (N = 11) showed evidence of non-A, non-B infection by process of exclusion and 9 of the above sera showed evidence of anti-HEV when tested specifically. This is the first documented outbreak of viral hepatitis in respect of Calcutta.

Febrile episode among a floating population of C.R.P.F. Jawans stationed at Calcutta.

A virological investigation was carried out to establish the etiologic agent of a febrile outbreak amongst a floating population of C.R.P.F. Jawans, stationed at Calcutta during May-July, 1993. The illness was associated with fever, severe headache, bodyache and arthralgia which lasted for 2-4 days in most of the cases. Fifty cases were examined clinically and blood samples (both acute and convalescent) were subjected to virological study. One mouse-pathogenic agent could be isolated in suckling mice and identified as DEN-3. Sero-investigation of 50 single sera by HI & CF method revealed evidence of presumptive dengue infection in 33, while sero-conversion could be noted in 10 out of 25 available paired sera tested. Results of MAC ELISA revealed evidence of primary dengue infection in 6 out of 12 acute phase sera examined. Thus, the study shows that the episode is strongly suggestive of primary dengue infection.

Serosurvey of chikungunya antibody in Calcutta metropolis.

Since its first isolation in Calcutta, in 1963, there have been many reports about epidemis of chikungunya virus infection in different parts of India. Calcutta experienced a concurrent epidemic of dengue and chikungunya between 1963 and 1965. But after that there is no report about any chikungunya infection in Calcutta. During routine investigations it is found that chikungunya antibody is on the wane. The present survey for chikungunya antibody showed only 4.37% (n = 17) seropositivity out of 389 sera tested. The highest (12.5%) seropositivity was observed in the age group of 51-55 years and no chikungunya antibody was detected in young and young adults. The findings suggest that chikungunya virus is disappearing from the Calcutta population.

Dengue haemorrhagic fever (DHF) outbreak in Calcutta--1990.

An outbreak of Dengue Haemorrhagic Fever (DHF) occurred in Calcutta between September and December, 1990. Children and young adults were the major victims. Haemorrhagic manifestations and shocks were the main features in most of the hospitalised cases. Five mouse pathogenic agents were isolated from 105 acute cases and all were identified as DEN-3. HI and CF test with 55 paired sera revealed evidence of dengue infection in 33 (60 per cent) and flavivirus group reaction including dengue in 17 (30.9 per cent). It was for the first time, that DEN-3 was considered to be the etiologic agent for DHF in Calcutta.

Recurrent outbreaks of Japanese encephalitis in Nagaland (1985-1989)--a seroepidemiological study.

Recurrent epidemics of encephalitis in Nagaland, a North-Eastern State of India, following its first appearance in 1985, were investigated both epidemiologically and virologically. Although, no viral agent could be isolated from any of the clinical samples and mosquitoes, detection of JE specific IgM antibodies in many of the CSF and acute blood samples, together with presence of HI and CF antibodies to JE antigen in a number of acute and convalescent sera established the etiologic role of JE virus in this region. A total number of 83 clinically diagnosed cases could only be investigated virologically between 1985-89, where evidence of JE could be established in 34 (40.9 per cent) and flavivirus (including JE in majority) in 17 (21.5 per cent) cases. A limited serological survey among the close contacts of the victims in 1985 revealed JE antibody in 26.6 per cent of them. Analysis of the epidemiological and serological findings of different years revealed that while the outbreaks of 1985, 1987 and 1988 were due to JE infection, the episodes of 1986 and 1989, on the other hand, had chiefly features of high and prolonged fever with limited number of CNS involvement of undetermined origin, where the possibility of malarial infection has been a suspect apart from JE etiology.

Seroepidemiological study of Japanese encephalitis in Dimapur, Nagaland.

A seroepidemiological study of Japanese encephalitis (JE) in Dimapur, Nagaland was carried out following an outbreak of the disease between July, 1985 and February, 1986. Altogether 50 persons were affected with 30 (60 per cent) deaths. The attack and death rates per 1000 were more in Nagas viz. 0.55 and 0.34 than non-Nagas viz. 0.33 and 0.20 respectively. All ages and both sexes were affected. Of the nine mosquito species encountered Culex vishnui showed the highest density (44.5/MH). Culture of mosquito pool did not yield any viral agent. A total of 311 serum samples comprising 95 humans, 166 animals and 50 birds were tested for the presence of haemagglutination inhibition (HI) antibodies against Chikungunya and three flavirus antigens, viz. JE, WN and DEN-2. The overall flavivirus HI antibody in humans was positive in 26 (27.3 per cent) almost identical to JE antibody prevalence. The per cent positivity of HI antibodies to JE, WN and DEN-2 were 42.2 per cent, 22.2 per cent and 13.3 per cent in the affected and 14.2 per cent, 10 per cent and 6 per cent in the unaffected area. The activity of Alpha (Chikungunya) virus though very low was significantly higher (chi 2 = 5.57) in the affected area. The prevalence of JE antibody was 77.7 per cent in dogs, 52 per cent in cattle, 34 per cent in pigs and 21.1 per cent in goats. Of the five species of birds, flavivirus and JE antibodies were detected in 21.4 per cent pigeons and 22.2 per cent heron egrettes. Neutralisation test established the distinct role of JE virus over other related flavivirus antigens.