Sclerosing angiomatoid nodular transformation of spleen masquerading as carcinoma breast metastasis: Importance of splenic biopsy in obviating splenectomy.

Metastasis to spleen is rare and usually occurs in the setting of extensive multivisceral metastatic disease. A 60‑year‑old lady with appropriately managed early breast cancer (breast conservative surgery for Grade‑2 infiltrative ductal carcinoma [0.7 cm × 0.5 cm diameter]) in 2006, was detected to have splenic incidentaloma (1.4 cm × 0.8 cm) in November 2012, which was fluoro‑deoxy‑glucose (FDG) avid on positron emission tomography. Fine needle spiration cytology (FNAC) was normal. More than doubling of lesion size by March 2015 (3.83 cm × 3.03 cm diameter) with persistent FDG positivity lead to Tru‑Cut biopsy of spleen, which revealed multiple nodular areas of congestion and hemorrhage, composed of sinusoids (CD31+, CD8+, and CD34−), capillaries (CD31+, CD8−, and CD34+), and small veins (CD31+, CD8−, and CD34−), fibrosis, around these nodular areas along with numerous histiocytes (CD68+) consistent with diagnosis of sclerosing angiomatoid nodular transformation (SANT) of spleen. SANT is a benign, reactive vascular transformation of spleen, notorious to mimic metastasis, the cause of its 18FDG avidity due to its rich content of macrophages and myofibroblasts, usually diagnosed postsplenectomy. This report highlights the importance of splenic biopsy over FNAC is diagnosing splenic incidentalomas, which can help prevent splenectomy, and hence the associated morbidity. This is the first report of SANT in carcinoma breast mimicking metastasis

Multiple Pituitary Hormone Deficiency, Empty Sella and Ectopic Neurohypophysis in Turner Syndrome.

Background: Multiple pituitary hormone deficiency and Turner syndrome have overlapping features in peripubertal girls and is a diagnostic challenge. Case characteristics: 16-year-old girl having Turner phenotype undergoing evaluation for severe short stature and pubertal arrest. Observation: 45,X karyotype, and multiple pituitary hormone deficiency with empty sella. Intervention: Levothyroxine, growth hormone and ethinyl-estradiol replacement resulted in 11 cm height gain with attainment of puberty over 2 years Message: Patients of Turner syndrome with height <3rd percentile (Turner specific charts) warrant additional pathology evaluation.

Occurrence of osteoporosis & factors determining bone mineral loss in young adults with Graves’ disease.

Background & objectives: There is a paucity of data with conflicting reports regarding the extent and pattern of bone mineral (BM) loss in Graves’ disease (GD), especially in young adults. Also, interpretation of BM data in Indians is limited by use of T-score cut-offs derived from Caucasians. This study was aimed to evaluate the occurrence of osteoporosis in active treatment naive patients with GD and determine the factors predicting BM loss, using standard T-scores from Caucasians and compare with the cut-offs proposed by the Indian Council of Medical Research (ICMR) for diagnosing osteoporosis in Indians. Methods: Patients with GD, >20 yr age without any history of use of anti-thyroid drugs, and normal controls without fracture history, drugs use or co-morbidities underwent BM density (BMD) assessment at lumbar spine, hip and forearm, thyroid function and calcium profile assessment. Women with menopause or premature ovarian insufficiency and men with androgen deficiency were excluded. Results: patients with GD (n=31) had significantly lower BMD at spine (1.01±0.10 vs. 1.13±0.16 g/cm2), hip (0.88±0.10 vs. 1.04±0.19 g/cm2) and forearm (0.46±0.04 vs. 0.59±0.09 g/cm2) compared with controls (n=30) (P<0.001). Nine (29%) and six (19.3%) patients with GD had osteoporosis as per T-score and ICMR criteria, respectively. None of GD patients had osteoporosis at hip or spine as per ICMR criteria. Serum T3 had strongest inverse correlation with BMD at spine, hip and femur. Step-wise linear regression analysis after adjusting for age, BMI and vitamin D showed T3 to be the best predictor of reduced BMD at spine, hip and forearm, followed by phosphate at forearm and 48 h I131 uptake for spine BMD in GD. Interpretation & conclusions: Osteoporosis at hip or spine is not a major problem in GD and more commonly involves forearm. Diagnostic criterion developed from Caucasians tends to overdiagnose osteoporosis in Indians. T3 elevation and phosphate are important predictors of BMD. Baseline I131 uptake may have some role in predicting BMD.

Serum vitamin-D predicts insulin resistance in individuals with prediabetes.

Background & objectives: Patients with diabetes and vitamin-D insufficiency have increased insulin resistance. Similar observations among individuals with prediabetes are not well documented. The aim of this study was to find the occurrence of vitamin-D insufficiency/deficiency among individuals with prediabetes and to evaluate the relationship between vitamin-D status and insulin resistance. Methods: One hundred fifty seven individuals with prediabetes who fulfilled all the inclusion and exclusion criteria underwent clinical examination, anthropometric measurements (waist circumference, waist-hip ratio, waist-height ratio) and blood sampling after overnight fast for estimation of fasting blood glucose, fasting insulin, 25(OH)vitamin-D, intact parathyroid hormone (iPTH) and lipid profile. One hour post 75 g glucose (1hPG) blood glucose during oral glucose tolerance test was measured. Results: Vitamin-D deficiency/insufficiency was found in 115 (73.25%) individuals with prediabetes. Severe vitamin-D deficiency (<10 ng/ml) was seen in 14.65 per cent individuals. Individuals with the lowest vitamin-D levels (<10 ng/ml) had the highest insulin resistance (HOMA2-IR: 2.04 ± 0.67). Serum 25(OH)D had a statistically significant inverse correlation with insulin resistance (HOMA2-IR; r=-0.33; P=0.008), and positive correlation with insulin sensitivity (QUICKI; r=0.39; P=0.002), after adjusting for BMI and HbA1c. There was no correlation between vitamin-D status and estimated beta cell mass (HOMA-β). The mean waist-height ratio among individuals with prediabetes was 0.57 (normal<0.5) indicating a high risk of cardiovascular morbidity. Individuals with elevated 1hPG>155 mg/dl had significantly higher BMI and worse insulin resistance, and 1hPG correlated well with 2 hour post glucose blood glucose (r=0.57; P<0.001). Interpretations & conclusions: Vitamin-D deficiency/insufficiency may have some role in the development/worsening of insulin resistance in individuals with prediabetes in our country who have a high cardiovascular risk. Prospective studies on a large group of individuals need to be done to confirm the findings.

Quality of life assessment of patients with chronic liver disease in eastern India using a Bengali translation chronic liver disease questionnaire.

Aims The aim of this study was to translate and validate chronic liver disease questionnaire (CLDQ) into Bengali using a standard protocol and use it to assess the impact of socioeconomic factors, etiology, disease severity and complications on the quality of life of patients. Methods Formal translation of CLDQ to Bengali was done. Cronbach’s alpha and test-retest was performed for reliability analysis. Patients with clinically stable chronic liver disease (CLD) without significant associated co-morbid states were administered Bengali CLDQ in the Liver Clinic. The clinical, biochemical and disease parameters were recorded for analysis. Results Bengali CLDQ was administered to 100 patients with CLD. Cronbach’s alpha of overall scores was 0.90 and test-retest correlation coefficient of average CLDQ was 0.86 (P<0.001). Patients with history of decompensation (96.51 vs. 109.61; P=0.039) and Child’s C status (92.24 vs. 105.71; P=0.028) had significantly lower CLDQ scores. CLDQ scores showed a moderate inverse correlation with Child’s status (r=−0.35) and a poor correlation with MELD score (r=−0.09). Conclusion Bengali translation of CLDQ was found to be reliable. History of decompensation, Child’s C status was associated with worse CLDQ scores. Child’s status may have some role in predicting quality of life of patients with CLD. MELD score had poor predictability of quality of life.