Autopsy-based morphometric study of coronary atherosclerosis in young adults

Background & objectives: The burden of cardiovascular diseases is high in Kerala, India, and a considerable proportion of these occur in young people. The objective of this study was to estimate the severity of atherosclerosis in autopsies done for accidental and suicidal deaths in victims below 40 yr of age. Methods: Coronary arteries from 77 autopsies done for unnatural deaths in a population below 40 yr were graded, and the degree of stenosis, intimal thickness index (ITI) and the intima-media ratio (IMR) were measured. Results: There were 65 males and 12 females in the sample. The American Heart Association (AHA) type 3-6 (pathological intimal thickening) was seen in 55.4 per cent [95% confidence interval (CI): 42.5-67.7%] of males and 25 per cent (95% CI: 5.5-57.2%) of females and advanced lesions (type 4-6) in 44.6 per cent (95% CI: 32.3-57.5%) of males and 8.3 per cent (95% CI: 0.2-38.5%) of females. Types 5 or 6 lesions were seen in 32.2 per cent (95% CI: 21.2-45.1%) of males. The mean stenosis was 57.3 per cent in males and 40.6 per cent in females. More than 40 per cent stenosis was seen in 76.6 per cent cases, more than 50 per cent in 54.5 per cent cases and more than 75 per cent stenosis in 14.3 per of the sample. The mean ITI (MIT) was 1.85 and the mean IMR was 4.11. The degree of stenosis, MIT and IMR were significantly associated with male sex, overweight and smoking. Interpretation & conclusions: Morphometric data showed that the degree of atherosclerotic narrowing of coronary arteries in young non-diseased population was high. It portends a danger to the community unless preventive measures are taken up.

Bilineage T‑lymphoblastic/myeloid extramedullary blast crisis in chronic myelogenous leukemia.

The blast crisis of chronic myelogenous leukemia (CML) can be hematological or extramedullary. About 25% of these cases fulfill the criteria for mixed phenotype acute leukemia. We here report a case of a second blast crisis of CML which was extramedullary and was immunophenotypically bilineage T/myeloid.

Cutaneous manifestations of chikungunya during a recent epidemic in Calicut, north Kerala, south India.

Background: There was a recent epidemic of chikungunya (CKG) in Calicut and other northern districts of Kerala, South India, affecting thousands of people. Aims: To study the cutaneous manifestations of CKG and to have a serological and histopathological correlation. Methods: A total of 162 patients (63 males and 99 females) with cutaneous manifestations of CKG were enrolled in the study and serological confirmation was done with capture IgM ELISA for CKG. Skin biopsy was done in all representative cases. Results: Cutaneous manifestations were found more in females. There were 23 children, the youngest being 39 days old. Generalized erythematous macular rash was the most common finding. Vesicles and bullae were also common especially in infants. Localized erythema of the nose and pinnae, erythema and swelling of the pre existing scars and striae and toxic epidermal necrolysis-like lesions sparing mucosae were the other interesting findings. Different types of pigmentation were observed with a striking nose pigmentation in a large number of patients, by looking at which even a retrospective diagnosis of CKG could be made. Hence we suggest this peculiar pigmentation may be called "chik sign". There was flare up of existing dermatoses like psoriasis, lichen planus and unmasking of Hansen's disease with type 1 reaction. Serological tests were positive in 97%. Some hitherto unreported histopathologic findings like melanophages in the erythematous rashes were observed. Conclusion: A spectrum of cutaneous manifestations of CKG with a wide variety of unusual presentations with confirmed serological and histopathological evidence was encountered.

Acute eosinophilic appendicitis and the significance of eosinophil - Edema lesion.

Eight cases of a histological entity that we name 'acute eosinophilic appendicitis' (AEA) are described and compared with classical acute appendicitis and appendices, which turned out to be normal after emergency appendicectomy. These 8 cases formed part of a dataset of 128 emergency appendicectomies, which also included 78 cases of classical acute appendicitis and 42 cases of normal appendix. The clinical and pathological variables were compared between these three. Acute eosinophilic appendicitis is characterized by acute presentation and a grossly inflamed appendix, but with absence of neutrophils in the muscle layer. The histological hallmark of the entity is eosinophil infiltration of the muscularis propria with accompanying edema separating muscle fibers (the Eosinophil - Edema lesion). The duration and prevalence of symptoms, the male female ratio and the gross maximum circumference of the appendix in these 8 cases resembled classical acute appendicitis rather than those cases in which the morphology of the appendix was normal. The Eosinophil-Edema lesion was also seen in many cases of classical appendicitis in non-suppurative areas where neutrophils were sparse or absent. We hypothesize that this lesion is an allergic response and is probably an early event in the evolution of acute phlegmonous appendicitis. Acute eosinophilic appendicitis may merely be those cases that do not proceed on to suppuration.

Evidence for eosinophil degranulation in acute appendicitis.

Finding of increased numbers of eosinophils in the muscle in cases of acute appendicitis has led to the hypothesis that it may have an allergic origin. This study aimed to measure the eosinophil degranulation resulting in a rise in the serum of eosinophil granule proteins that would be expected in such cases. The levels of serum eosinophil cationic protein (ECP) measured by chemiluminescence assay in acute appendicitis were compared, with those of appropriate controls. Mean (95% CI) serum ECP (microg/L) levels were: acute appendicitis 45.3 (27.7-63.0); normal appendix 22.7 (16.0-29.3); asthma 24.2 (4.6-43.8); and healthy volunteers 13.2 (8.3-18.1). In cases of acute appendicitis, there is an inverse relationship between duration of symptoms and serum ECP. However, this was not statistically significant. Significant local eosinophil activation and degranulation occurs in acute appendicitis, enough to cause a rise in serum levels of eosinophil chemotactic protein.

Testicular choriocarcinoma with gastric metastasis presenting as hematemesis.

We report a 28-year-old man who presented with hematemesis due to choricarcinoma of testis metastatic to the stomach. Gastroscopy showed a polypoidal lesion. Testicular wedge biopsy confirmed mixed germ cell tumor, the choriocarcinomatous portion alone getting metastasized to the stomach. He was initiated on chemotherapy with actinomycin-D, etoposide and methotrexate, but died due to multiple metastases to the lung and brain.

Hepatobiliary phaeohyphomycosis with secondary biliary cirrhosis.

We report a case of systemic phaeohyphomycosis in a 13-year old girl. The clinical presentation was with fever, weight loss, cholestatic jaundice with hepatosplenomegaly and generalized lymphadenopathy. The patient was diagnosed initially as tuberculous adenitis and was on antituberculous therapy, but with worsening of symptoms. Lymph node and liver biopsy showed granuloma with fungal hyphae suggestive of phaeohyphomycosis. The patient responded to antifungal therapy. Later she developed secondary biliary cirrhosis with cholangitis due to long stricture of the common bile duct and common hepatic duct requiring biliary stenting. To the best of our knowledge, this is the first report on phaeohyphomycosis causing biliary cirrhosis in the English lilterature.

Risk factors for mortality in patients with leptospirosis during an epidemic in northern Kerala.

BACKGROUND: Epidemic leptospirosis is increasingly being reported from northern Kerala during the monsoon months. We investigated the risk factors for mortality during the 2002 epidemic. METHODS: Three hundred and forty patients suspected to have leptospirosis during the epidemic were studied by clinical examination, laboratory investigations and Leptospira serology (microscopic agglutination test). Two hundred and eighty-two seropositive cases were analysed for the clinical and laboratory profile, and risk factors for mortality using univariate and logistic regression analysis. RESULTS: Of the 282 seropositive cases, 58.9% were men. No significant association with occupational risk factors was seen; 62.9% had wounds on the feet. The majority had Weil syndrome with hepatic (69.8%) and renal (56.3%) involvement. Thrombocytopenia (65.8%) was common. Transient hyperglycaemia was observed in 10.3% of cases. Pulmonary haemorrhage (4.7%) and meningism (4.3%) were less common. Jaundice occurred in 46% of cases in the first week. The mortality rate was 6.03%. Hyperkalaemia (OR= 27.3), meningism (OR= 10.6), oliguria (OR=8.2), haemoptysis (OR= 5.4), bilirubin > 15 mg/dl (OR= 5.4), disorientation (OR=5), tachycardia (OR=4.1) and muscle tenderness (p=0.03) were the predictors of high mortality in univariate analysis. Only involvement of the lung and central nervous system were significant predictors of death in logistic regression. CONCLUSIONS: Leptospirosis is no more a mere occupational hazard in Kerala. Early occurrence of complications such as hepatitis mandates caution in the primary care setting. Lung and central nervous system involvement are significant predictors of mortality.

Liver adenomatosis.

A 27-year-old man presented with 2 months' history of right hypochondrial pain, fever and mild transient pruritus. On examination, he had firm, nontender and nodular hepatomegaly. Imaging modalities showed multiple heterogeneous lesions of varying size in the liver. Liver biopsy was consistent with hepatocellular adenoma.