Primary Osteosarcoma of the Breast.

Primary osteosarcoma of the breast is an extremely rare and aggressive tumor representing 12.5% of mammary sarcomas. It is associated with early recurrence and hematogenous rather than lymphatic spread, most commonly to the lungs. We report a case of 55 year old lady with gradually increasing painless lump measuring 7 × 6 cm in upper outer quadrant of left breast of 2 months duration. FNAC smears revealed pleomorphic spindle cells admixed with osteoid and chondroid material. A differential diagnosis of metaplastic carcinoma and malignant phyllodes tumor was offered. Histopathology of the modified radical mastectomy specimen showed predominantly osteosarcomatous areas. Epithelial component was not seen even after extensive sampling of the tumor. On immunohistochemistry, vimentin, S100 and CD68 were positive while AE1/AE3, CAM5.2, ER, PR, Her2-neu and desmin were negative confirming a diagnosis of osteosarcoma. Primary osteosarcoma of breast must be differentiated from metaplastic carcinoma and malignant phyllodes tumor because of different biological behaviour and treatment approach. Immunohistochemistry plays a pivotal role in the diagnosis of this tumor.

Coexistent lymphoma with tuberculosis and Kaposi's sarcoma with tuberculosis occurring in lymph node in patients with AIDS: A report of two cases.

Although there have been a few reports of simultaneous infections and neoplasm in patients with acquired immune deficiency syndrome, no reports of coexistent lymphoma with tuberculosis and Kaposi's sarcoma with tuberculosis occurring in the same lymph node have been described. In this article, we describe coexistent lymphoma with tuberculosis in one case and Kaposi's sarcoma with tuberculosis in another case of human immune deficiency virus-infected individuals.

Right atrial appendage thrombus with atrial infarct in a case of thyrotoxicosis: An autopsy report.

Cardiac function has long been known to be altered in patients with thyrotoxicosis and atrial fibrillation occurs in patients with hyperthyroidism. In addition to its disabling symptoms, atrial fibrillation is a strong risk factor for systemic embolism, especially with regard to cerebral circulation. A right atrial appendage thrombus formation in atrial fibrillation is a rare phenomenon. In this report, we describe a case of a 30-year-old female, who suffered from hyperthyroidism and subsequently developed atrial fibrillation and a right atrial appendage thrombus with infarction of right atrial appendage.

Kaposi's sarcoma in a patient with AIDS.

We report a case of a 40 year old HIV infected male, citizen of Somalia who presented with multiple painful, livid reddish brown plaques, papules and nodules on both lower limbs and purplish red nodules on the hard palate. The cutaneous nodular lesions on biopsy showed characteristic features of Kaposi's sarcoma. This case is reported due to paucity of Kaposi's sarcoma in Indian literature.

Pathobiology of fungal infections of the central nervous system with special reference to the Indian scenario.

Ubiquitously present fungi in the environment find a nidus in the human body and adopt its metabolic machinery to be in symbiosis or become pathogenic. Immunocompromised states like human immunodeficiency virus (HIV) / acquired immunodeficiency syndrome (AIDS), systemic neoplasia and organ transplantation have enhanced the frequency of fungal infections. High-risk behavior, IV drug abuse and air travel have led to the emergence of new fungal infections hitherto geographically localized. The pathology in the central nervous system (CNS) is dictated largely by the size of the fungus - the yeast forms, by virtue of their small size enter the microcirculation to cause meningitis and microabscesses, while hyphal forms invade the vasculature to manifest as large pale or hemorrhagic infarcts. The growth kinetics of fungi, the antigenic character of the capsule. the proteases secreted by the mycelial forms and the biochemical milieu in the host also determine clinical manifestations. A hospital-based analysis of the available information from India suggests that in the non-HIV patient population, hyphal forms like Aspergillosis and Zygomycosis are the most common pathogens, while yeast forms like Cryptococcus and Candida are the prime pathogens in cases of HIV/AIDS, the altered macrophage function acting in synergy with suppressed cell-mediated immunity. In Northeastern states, systemic infection by Penicillium marneffei is reported in association with HIV though CNS involvement is not recorded. Although fungal infections of the CNS are reported from various hospitals in India, studies are limited by non-availability of relevant microbiological studies and the reported prevalence data is biased by the surgical practices, availability of postmortem and microbiology and laboratory support. Detailed clinical and mycological investigations related to the interaction between the fungus and host environment is a fertile area of research to understand the basic pathogenetic mechanisms.

Sudden death due to cardiac toxoplasmosis.

The recognition of cardiac toxoplasmosis has increased in patients with acquired immunodeficiency syndrome. The functional consequences of toxoplasmosis of heart vary considerably depending on the intensity of inflammatory reaction, the extent of involvement of myocardial muscle fibers by necrosis and intramyocytic presence of tachyzoites of Toxoplasma gondii. This report describes a case of toxoplasma myocarditis that lead to fatal cardiac arrest. To the best of our knowledge, this is the first reported case of cardiac toxoplasmosis in the Indian literature, which has manifested as sudden death.

Recurrent Kimura's disease: excellent response to cyclosporine.

Kimura's disease is a chronic inflammatory disorder involving the skin, subcutaneous tissues and lymph nodes, predominantly in the head and neck region. Though surgery, intralesional or systemic steroids or radiation therapy have been the mainstay of treatment recurrence is a common problem. On the basis of occasional case report of Kimura's disease responding to cyclosporine, we attempted oral cyclosporine in our patient with dramatic improvement.

Kaposi's sarcoma with thrombocytopenia in a heterosexual Asian Indian male.

A 45-year-old heterosexual male patient with retroviral disease since 12 years presented with hyperpigmented lesions, misdiagnosed initially as purpura due to an associated thrombocytopenia, but was biopsy proven to be Kaposi's sarcoma (KS). Bone marrow examination revealed excess megakaryocytes. Low CD4 count and absence of platelet specific IgG reduced the likelihood of immune thrombocytopenia (ITP). However after 6 weeks of antiretroviral therapy the patient's lesions have reduced and platelet counts are improving, possibly suggesting a sequestration thrombocytopenia in the abnormal tumor vessels of KS.

The natural history of human immunodeficiency virus infection among adults in Mumbai.

BACKGROUND: Natural history studies of untreated HIV infection are useful for clinicians, public health experts and policymakers to improve and monitor care, plan services and control, and to model the epidemic. Several natural history studies on homosexual men and intravenous drug users have been published from developed countries. A few studies have emerged on heterosexual populations from Africa. With an emerging epidemic, a similar study was required in India. This study was designed to determine the progression of HIV disease in a prevalent cohort of adult HIV-seropositive patients. METHODS: A prevalent cohort of 1009 patients comprising 488 asymptomatic HIV-seropositive persons, 259 with AIDS-related complex (ARC), and 262 with acquired immunodeficiency syndrome (AIDS) were recruited for the study at Sir J.J. Hospital, Mumbai. A case-control study was conducted to determine the correlation of clinical features and other factors with disease progression. Disease progression was determined from the asymptomatic stage to that of ARC and AIDS using time series analysis. The incubation period from HIV to AIDS was also determined, using Weibull curves. RESULTS: The median incubation periods for progression were: HIV to AIDS-7.9 years and ARC to AIDS--1.9 years. The median survival after developing AIDS was 19.2 months. A comparison of progressors and non-progressors revealed that disease progression correlated with clinical features such as chronic fever (OR 5.6), persistent generalized lymphadenopathy (OR 4.7), persistent cough for >1 month (OR 3.5), chronic diarrhoea (OR 3.3), oral candidiasis (OR 3.2), >10% loss of body weight within 1 month (OR 2.9), incident tuberculosis (OR 2.8) and herpes zoster (OR 2.5). The annual incidence of active clinical tuberculosis was 86/1503 person-years (5.7/ 100 person-years), the median time to occurrence of active tuberculosis was 21.6 months and the annual incidence of mortality was 96/2009 person-years (4.8/100 person-years, 95% CI 3.4, 6.2). CONCLUSION: Progression to AIDS and death was faster among the heterosexual cohort in Mumbai than that reported for homosexual men and haemophiliacs in the USA and Europe. Strategies need to be developed to prevent the occurrence of tuberculosis among HIV-infected patients because that would help to reduce the morbidity and mortality. This is the first large study from the Indian subcontinent of a longitudinal follow up of HIV-infected persons. The findings will be useful for advocacy and assessing the impact of antiretroviral therapy (ART) in India.

Spectrum of dermatopathologic lesions associated with HIV/AIDS in India.

Histopatholgoical analysis of cutaneous lesions in 195 patients with HIV/AIDS was carried out between 1989 to 1997 at tertiary level public hospital in Mumbai. 104/195 (53%) cases showed infectious diseases which comprised of molluscum contagiosum (28), condyloma accuminata (18), verruca vulgaris (7), varicella zoster (5), syphilis (14), tuberculosis (13), donovanosis (4), leprosy (2), chancroid (2), bacillary angiomatosis (2), lymphogranuloma venercum (1), Norwegian scabies (3), leishmaniasis (2), demodicidosis (1), crytococcosis (1), tinea versicolor (1). In 12 (6%) cases neoplasms were observed which included squamous cell carcinoma (9), basal cell carcinoma (2) and kaposi's sarcoma (1) case. The miscellaneous conditions were observed in 66(33.5%) cases which comprised of psoriasis (21), papular urticaria (13), Reiter's disease (7) and eosinophilic folliculitis (6). The prevalence of cutaneous tuberculosis observed in this study is high as compared with western literature while the prevalence of kaposis's sarcoma is quite low as compared with reports from Africa, USA and United Kingdom.

Metastatic carcinoma in hepatic hemangioma.

Metastasis into the hepatic hemangioma is a rare occurrence. We report a unique case of metastasis of intestinal carcinoma into hepatic hemangioma in a case of 65 year old male who presented with anorexia, weakness and headache. The postmortem examination revealed adenocarcinoma in the ileocaecal region. The liver showed a subcapsular hemangioma of 1.5 cms. diameter which on microscopic examination revealed metastasis of adenocarcinoma. The is the first documentation of metastasis in hepatic hemangioma. Such cases may pose problems of diagnostic difficulties and thus may result in mismanagement.

Pneumocystis carnii pneumonia in AIDS--an autopsy report.

Pneumocystis carinii pneumonia (PCP), the most common presenting manifestation in patients with AIDS from western countries, holds the distinction for being the first opportunistic infection that was associated with AIDS. There is marked paucity of clinically diagnosed and pathologically confirmed cases of PCP in India. This case represents the first complete autopsy report of pneumocystis carinii pneumonia inpatient with AIDS from our country. A high index of clinical suspicion and microscopic confirmation is needed to avert mortality due to PCP in patients with AIDS.

Renal lesions associated with AIDS--an autopsy study.

Kidneys from 55 cases (20 with HIV infection and 35 with AIDS) were studied by routine Haematoxylin and Eosin stains and special stains (PAS, PASM GMS, ZN, Mucicarmine and Congo red) to evaluate, glomerular, interstitial and vascular pathology. Twenty-four of the 35 (68.6%) cases of AIDS showed infective aetiology which included 17 cases (48.5%) of tuberculosis, 5 cases (14.4%) of fungal infection (3 cryptococcus neoformans and 2 candida species) and 2 cases (5.7%) of CMV infection. Other lesions noted were amyloidosis and tubular calcinosis. HIV associated nephropathy (HIVAN) was not detected in any of the cases. Intravenous drug abuse was not a risk factor in our cases which probably explains the absence of HIV associated nephropathy in the present study.

Severe weight loss: the predominant clinical presentation of tuberculosis in patients with HIV infection in India.

BACKGROUND: Tuberculosis is endemic in India and its prevalence is reported to be increasing in patients with human immuno-deficiency virus (HIV) infection. Several factors, including the level of immune deficiency, influence the clinical presentation of HIV-associated tuberculosis. METHODS: Between April 1994 and April 1996, 1820 patients with confirmed HIV infection were studied for their clinical, radiological and laboratory parameters. Severe weight loss was observed as a frequent presenting complaint. Hence, a case-control analysis was performed using severe weight loss as the presenting criterion among HIV-seropositive patients. RESULTS: Of the 1820 patients with HIV infection, 410 (23%) presented with severe weight loss of > 10% of body weight within the preceding month. Of these 410 patients, 176 (43%) had tuberculosis, 94 (23%) had chronic diarrhoea, and 89 (22%) had recurrent fever. Among 176 patients with tuberculosis, the following types of HIV-associated tuberculosis were seen: 115/176 (66%) had pulmonary, 49/176 (28%) had extrapulmonary tuberculosis; of these 49 cases with extrapulmonary tuberculosis 33 (18%) had disseminated tuberculosis, and 12/176 (7%) had both pulmonary and extrapulmonary involvement. In the group as a whole, 45/176 (25%) cases had disseminated tuberculosis. Clinical features of HIV-associated tuberculosis in decreasing order of frequency were chronic fever, chronic cough, lymphadenopathy and hepatosplenomegaly. The Mantoux skin test was significantly anergic among patients with extrapulmonary and disseminated tuberculosis (p = 0.001). CONCLUSIONS: There was a significant correlation between severe weight loss and tuberculosis (RR 17.5), chronic diarrhoea (RR 12.8) and recurrent fever (RR 4.5). The diagnostic value of the Mantoux skin test among HIV-associated tuberculosis is reduced, more so among those with extrapulmonary and disseminated forms.

Pathology of the heart in acquired immunodeficiency syndrome.

The spectrum of cardiac lesions in patients with acquired immunodeficiency syndrome in India is not described. To determine the extent of involvement of the heart with this disease, an autopsy study of 52 subjects having acquired immunodeficiency syndrome was carried out. Multiple sections were obtained from different anatomical parts of each heart. Forty-eight of the 52 hearts showed subtle microscopic changes, the most common being myocardial atrophy (48 cases), lymphocytic pericarditis (38 cases), fibrinous pericarditis (1 case), pericardial fibrosis (1 case), lymphocytic myocarditis (29 cases) and myocardial fibrosis (7 cases). Cryptococcosis of the heart was noticed in two cases, while in one case toxoplasmic myocarditis was identified. In only one case clinical presentation of cardiac involvement (pericardial effusion) was noted, which indicates that in spite of the presence of significant pathology in the heart, overt cardiac manifestations are infrequently seen in patients with acquired immunodeficiency syndrome.

Systemic amyloidosis in Hodgkin's disease.

Secondary amyloidosis as a complication of Hodgkin's disease has been described as being unusual to rare in occurrence. We report a case in which the clinical picture was that of a renal failure, etiology of which could not be determined but which proved to be amyloidosis secondary to clinically unrecognised Hodgkin's disease.

Toxoplasmosis of the central nervous system in the acquired immunodeficiency syndrome.

Acute encephalitis caused by Toxoplasma gondi was diagnosed at autopsy in 10 (20.4%) of the 49 patients. All patients had under lying immunodeficiency due to AIDS and showed selective involvement of central nervous system at autopsy. Sexual promiscuity was the risk factor in nine cases while one case had a history of blood transfusion. Diagnosis of toxoplasmosis was hampered by a lack of suspicion that Toxoplasma could be the agent causing necrotising encephalitis. The large number of cases of CNS toxoplasmosis appearing in AIDs patients emphasize the necessity of including toxoplasmosis in the differential diagnosis of encephalitis of unknown aetiology.

Metastatic carcinoma in uterine leiomyoma.

Metastasis of tumours are known to occur in the rarest of sites in the human body. But one of the truly rare phenomena in surgical pathology is to find the metastasis of one tumour into another. We report one such case of metastatic carcinoma in uterine leiomyoma from an occult primary site.

Bilateral renal angiomyolipoma in association with tuberous sclerosis.

Renal angiomyolipoma with tuberous sclerosis has not yet been reported in Indian literature. We report a case of bilateral angiomyolipoma associated with tuberous sclerosis in a 25 year old man.