Heavy chain deposition disease in a case of clear cell renal cell carcinoma- A jack in the box

Renal cell carcinoma (RCC) is the most common subtype of adult renal tumors, and its detection rate in the early stages has been increased in the dawn of advanced imaging modalities. Nephrectomy is the mainstay of treatment; determination of tumor category and staging is the primary concern of oncopathologists. Non-neoplastic renal parenchyma is overlooked majority of times and thus misses the opportunity to detect concomitant medical renal diseases which also predict the renal outcome in the postoperative era. Although any kind of glomerular or extraglomerular pathology may be encountered, vascular changes in the form of arterionephrosclerosis are the commonest one. Here, we take the opportunity to report an unusual association of heavy chain deposition disease (HCDD) with clear cell subtypes of renal cell carcinoma in a 48-year-old male of Indian ethnicity.

Utility of serum anti-phospholipase A2 receptor antibody as a biomarker in membranous nephropathy: An experience from a tertiary care center of Eastern India

Background: Membranous nephropathy (MN) is a pattern of glomerular injury. Exact categorization into primary membranous nephropathy (PMN) or secondary membranous nephropathy (SMN) is essential for treatment. An endogenous podocyte antigen, M-type phospholipase A2 receptor (PLA2R) has been discovered to be involved in the pathogenesis of PMN. Aims and Objectives: In this article, we aimed to analyze renal tissue PLA2R and serum anti-PLA2R antibodies in MN cases and determined the diagnostic utility. Materials and Methods: The study was of prospective type carried out from March 2019 to August 2020. Analysis of cases of MN was performed with PLA2R paraffin immunoflourescence and serum anti-PLA2R antibody ELISA. Results: Overall sensitivity, specificity, PPV, and NPV of serum anti-PLA2R ELISA for PMN was 91.3%, 80%, 75%, and 93.3%, respectively, and of tissue PLA2R staining for PMN was 91.67%, 81.08%, 75.86%, and 93.75%, respectively. There was strong concordance between two methods. In the patients that were followed up, we found baseline serum anti-PLA2R antibody was less in complete remission group than that in non-remission group and the reduction in serum anti-PLA2R antibody was more in complete remission group than that in non-remission group. Conclusion: Routine light and immunofluorescence examination are incapable of giving exact categorical opinion regarding PMN and SMN. Serum anti-PLA2R antibody detection and renal tissue PLA2R analysis are sensitive and specific in detecting PMN. Baseline serum anti-PLA2R antibody and anti-PLA2R antibody quantification trends are related to prognosis of PMN. So they can be incorporated as additional biomarker.

Role of light and immunofluorescence microscopy to differentiate primary and secondary membranous nephropathy

Context: Membranous nephropathy (MN) causes nephrotic syndrome, mostly primary but may be associated with SLE, infections, cancer, or drug. Aims: To estimate clinical, serological, light microscopic, and direct immunofluorescence (DIF) findings to differentiate primary and secondary MN. Settings and Design: Prospective, cross-sectional, single-center study in a tertiary care hospital. Methods and Material: Total 51 cases from September 2019 to February 2020. Laboratory Data: Blood glucose, urine analysis, urea, creatinine, albumin, cholesterol, HBsAg, Anti HCV, ASO, ANA, MPO ANCA, PR3 ANCA, dsDNA, PLA2R, C3, and C4. Clinical parameters: age, sex, BP, skin lesions, arthralgia, edema, obesity. Renal biopsies examined with H and E, PAS, silver methanamine, MT stains. DIF done with IgG, IgM, IgA, C3c, C1q, kappa, and lambda. Statistical Analysis Used: Statistical software (Graph Pad PRISM 6) and Chi-square test). Results: Among 51 cases, 25 are primary and 26 are secondary MN with 22 being lupus nephritis, with 2 being post-infectious and the remaining 2 being proliferative glomerulonephritis with monoclonal immunoglobulin deposition (PGNMIDD) with kappa chain restriction. Mean age was 37 ± 12.18 and 30.69 ± 13.92 years for primary and secondary MN, respectively. Significant male preponderance in primary MN. Serum C4 significantly low in secondary MN (15.34 ± 9.59). Microscopic hematuria present in secondary MN. Mesangial and endocapillary hypercellularity are significant in secondary MN. IgG and kappa are significantly intense in primary whereas IgA, C3c, and C1q are significantly intense in secondary MN. Conclusions: Reliable differentiation between primary and secondary MN has important therapeutic implications.

Utilization pattern of antihypertensive drugs among chronic kidney disease patients in a tertiary care hospital

Background: Chronic kidney disease (CKD) exists both as a common cause of hypertension and also a complication of uncontrolled hypertension. This complex interplay of hypertension and CKD further increases the risk of adverse cardiovascular and cerebrovascular outcomes in patients with compromised renal function. Aim and Objectives: The present study tried analyze the characteristics of hypertensive CKD patients and the current antihypertensive treatment pattern in CKD patients in a tertiary care set up in Eastern India. Materials and Methods: A prospective and observational study included adult currently diagnosed CKD patients along with hypertension. Basic demographics along with medical history, blood pressure (BP) measures treatment details, and laboratory information were retrieved for each included patient, noted and analyzed statistically. Results: Around 47% patients were taking two antihypertensives, followed by 19.7% on three and 17.97% on one antihypertensive, respectively, and over 50% patients demonstrating high normal BP, followed by 25% having Grade I hypertension and around 20% having Grade II hypertension. Various classes of antihypertensives prescribed in the present study included calcium channel blockers, beta-blockers, angiotensin receptor blocker, angiotensin-converting enzyme (ACE) inhibitors, centrally acting drugs, alpha-blockers, and diuretics. Beta-blockers were found to be the most prescribed antihypertensives, being prescribed in 92.69% CKD patients. This was followed by calcium channel blockers, centrally acting drugs, alpha-blockers, angiotensin receptor blocker, diuretics, and ACE inhibitor. Utilization pattern of antihypertensive drugs among CKD patients helps with a better glimpse on the status of BP control and related renal outcomes in hypertensive CKD patients. Conclusion: Considering the interplay of hypertension and CKD, it is imperative to essentially treat hypertension robustly to ensure better cardio and renoprotection in these CKD patients. Utilization pattern of antihypertensive drugs among CKD patients helps with a better glimpse on the status of BP control and related renal outcomes in such patients. A rational multidrug antihypertensive regime can help achieve better patient outcomes in hypertensive CKD patients.

An outpatient-based observational study on demography, self-medication practice, and prescribing pattern in dermatophytosis at a tertiary care teaching hospital in Eastern India

Background: Appropriate use of drugs is essential in dermatophytosis to reduce morbidity and associated financial burden to the sufferers. Aims and Objectives: To explore the demographic characteristics along with the prescription pattern, self-medication practice, and price variability of the prescribed brands in the treatment of the dermatophytosis patients. Materials and Methods: Newly diagnosed consented dermatophytosis patients were enrolled in this cross-sectional observational study. Their baseline demographic characteristics were documented in the case report form along with the prescription details with self-medication history and Maximum Retail Price of each prescribed brand of drug. Results: Among total of 114 subjects (68 males, 46 females), majority were young (56.14%, <33 y). Most common diagnosis was tinea cruris followed by combination of tinea cruris and corporis. Average monthly family income was 11469.29 ± 10027.5 INR. Brand prescription was (74.15%), higher than generic (25.84%). Oral formulations were more prescribed (54.83%) than topical (45.16%) whereas individually luliconazole (cream) topped (23.18%) in the list. No topical or systemic steroid was prescribed. The commonest drug regimen was capsule itraconazole, luliconazole cream, and cetirizine or levocetirizine tablet with or without ketoconazole soap or tea tree body wash (71/114, 62.28%). About 39.47% subjects practiced self-medication, topical steroids (37.20%) mostly used. Price variability (percentage) among brands of the same drug was highest in ketoconazole soap (138.66%), followed by terbinafine tablet 250 mg (89.50%) followed by itraconazole capsule (83.33%). Conclusion: Luliconazole cream, itraconazole (capsule/tablet), terbinafine (tablet) and ketoconazole soap were the highly prescribed antifungal agents whereas topical steroid was mostly preferred as self-medication. Prescription of generic drugs should be promoted as well as inappropriate use of self-medication should be discouraged among the prescribers and the patients respectively.

Perinatal and Fetal Autopsies in Neuropathology: How I do it

Fetal and perinatal autopsies are useful to identify the accurate cause of death and in the process recognize disorders which may require counselling for future pregnancies. Abnormalities of the CNS are an important cause of fetal loss and perinatal deaths. Most of these are structural abnormalities of the CNS, however a smaller portion show changes pertaining to prematurity, infections and even congenital tumors. In this review we evaluate CNS abnormalities of the fetus and the newborn as detected in autopsy series. We also describe our experience in a tertiary care hospital with a specialized neonatology unit over the last 8 years and discuss some of the newer methods like virtual autopsy.

Establishing and testing a multiple regression equation to predict body fat from height, weight, waist circumference, and hip circumference

Background: Body fat measurement requires a dedicated device and careful preparation of the subjects concerning food and water intake, exercise, precautions about alcohol intake, or any other condition that may change the hydration status of the subject. If simple anthropometric parameters can be used to estimate body fat that may help clinicians to know the body without measuring it. Aim and Objectives: The aim of the study was to find a regression equation to estimate body fat from height, weight, waist circumference (WC), and hip circumference (HC). Materials and Methods: First, we measured the height, weight, WC, HC, and body fat of 80 individuals with proper care for bioelectric impedance analysis. Then, this data were used to find multiple regression equation. Then, the equation was tested with 20 individuals where we measured the height, weight, WC, and HC and put those data into the equation to estimate body fat. Results: The mean age of participants was 28.12 ± 3.45 years. The height, weight, WC, and HC all contributed statistically significantly to the prediction of body fat, F (4.75) = 31.17 P < 0.0001. The established regression equation was: Body fat = 40.134 - (height in cm × 0.271) + (weight in kg × 0.412) + (WC in cm × 0.052) + (HC in cm × 0.067). During the test of the equation, measured mean fat (36.79 ± 2.64%) was not statistically different (P = 0.75) from estimated body fat (36.6 ± 3.23%). Conclusion: A multiple regression equation was formulated to estimate body fat from the height, weight, WC, and HC of an individual. This equation successfully estimated body fat from the anthropometric parameters. A further large-scale study is needed to find a more generalized estimation equation.

A giant retroperitoneal liposarcoma with hemoperitoneum: A rare tumor with unusual presentation

Retroperitoneal liposarcoma (RPLS) is a rare mesenchymal tumor which accounts for 0.02–0.7% of all malignancy. The presentations of these tumors are non-specific and early diagnosis is often missed. We are reporting a rare case of 17-year-old girl who came to us with complaints of abdominal distension and other non-specific symptoms but after few hours of admission, she had acute abdomen with hemodynamic instability. She underwent emergency laparotomy and found to have a giant 25 × 20 × 10 cm ruptured retroperitoneum tumor causing hemoperitoneum. The tumor involved left ovary and fallopian tube as well. Complete resection of tumor with left salpingooophorectomy was done. The patient was kept in intensive care unit and discharged in good health after 15 days. This presentation of RPLS has not been reported yet and may demand early diagnosis and management of these tumors. The histopathology revealed dedifferentiated liposarcoma with rhabdomyosarcomatous differentiation. The patient is completely fine at 16 months of follow-up while writing this report. Again, heterologous dedifferentiation of liposarcoma with spindle cell component is a rare morphologic spectrum. Liposarcomas can have various histologic types. In dedifferentiated types, the line of differentiation needs to be identified to decide further line of treatment. Therefore, thorough histopathological analysis and immunostaining is needed. Treatment includes complete surgical resection. Role of radiotherapy and chemotherapy is debatable and is still under trial. Dedifferentiated RPLS with rhabdomyosarcomatous differentiation is a rare tumor and its presentation as acute abdomen and hemoperitoneum has never been reported previously

Xylometazoline Induced Isolated Left Medial Cerebellar Peduncle Infarct: A Rare Case Report

Xylometazoline, a sympathomimetic available as over the counter drug, acts as a nasal decongestant and has been reported as an independent risk factor for hemorrhagic and ischemic stroke. The chronic use of xylometazoline leads to either increased release of more potent vasoconstrictor norepinephrine in the presynaptic region, or acts directly on central adrenoreceptors which leads to dysfunction resulting in chronic progressive vasculopathy that manifests as an ischemic stroke. Sympathomimetics also activate 12-lipoxygenase pathways which induce proliferation and migration of vascular smooth muscle cells. 12-lipoxgenase also plays a significant role in regulating the degree and stability of platelet activation, as its activation significantly strengthens platelet activation and uncontrolled platelet activation, which may lead to myocardial infraction and stroke. The present case reports a rare case of young adult suffering from isolated left medial cerebellar peduncle infarct related to the chronic use of xylometazoline. Acute cerebellar stroke is rare, especially in young adults and represent only 3% of total ischemic and hemorrhagic strokes. Clinical symptoms, patient age at the onset of stroke, and lesion size had no significant effect on the clinical outcome. Symptoms are frequently underestimated and misdiagnosed which further lead to serious complications and poor functional outcomes.

Eosinophilic Gastroenteritis: An Unclear Etiology of Ascites and Dramatic Response to Steroids Can be a Diagnostic Key

Eosinophilic gastroenteritis disorder is an uncommon inflammatory disorder of the gastrointestinal tract, affecting predominantly, stomach and small intestine. Subserosal inflammation is a major source of minor?to?moderate ascites. We present the case of an 8?year?old girl child who was brought to the hospital with complaints of chronic abdomen pain and mild ascites. There was a remarkable finding of eosinophils in ascitic fluid. Other differential diagnosis was excluded. Treatment abdomen with deflazacort gave significant resolution of symptoms over the time.

Drug-Induced Erectile Dysfunction: Two Interesting Cases

Erectile dysfunction (ED) is the inability to achieve or maintain an erection that is required for satisfactory sexual performance, and affects a considerable proportion of men around the globe at least occasionally. Although roles for nonendocrine and endocrine pathways have been propose, presence of comorbidities, psychogenic factors may contribute to its development. Large number of published reports link many commonly prescribed drugs with sexual dysfunction. Many common drugs such asanti-hypertensive, anti-psychotic, and anti-histaminic are linked with iatrogenic ED. On the other hand, psychogenic ED may be wrongly perceived to be of iatrogenic origin. While dealing a subject with ED it is important for the clinicians to take a detailed medical, surgical, sexual and drug/substance abuse history. In this article, we have described two such cases which would reflect the importance of determining the cause of ED before initiating treatment.

Aggregates Characterization and Its Associated Organic Carbon in Two Contrasting Lowland Rice Soils of West Bengal

Aims: The present study investigated the effect of lowland rice soils of two regions viz. new alluvial and red-laterite on aggregate characterization and their associated organic carbon (SOC). Study Design: Randomized block design (RBD). Place and Duration of Study: New alluvial soils were collected from Jangipara block of Hooghly, West Bengal and Red-laterite soils were collected from Raghunathpur block of Purulia, West Bengal during 2017-18. Methodology: For each soil types (New alluvial and Red-laterite) five locations were identified and soil samples were collected from three depths i.e. 0-10, 10-20 and 20-30 cm. The aggregate characteristics i.e. water-stable aggregates (WSAs), mean weight diameter (MWD), aggregate stability and aggregate size fractions along with the distribution of carbon in those aggregate size fractions were critically studied. Results: The aggregate size as well as the stability decreased with increasing soil depth from 0 to 30 cm in both soils. New alluvial soils showed higher aggregate stability than red-laterite soils. Mean weight diameter (MWD) values of new alluvial soils were 34, 29 and 87% more than red-laterite soils at 0-10, 10-20 and 20-30 cm depth, respectively. Presence of higher amount of clay and organic matter in new alluvial made the difference in structural coefficient. The surface soil (0-10 cm) had more coarse aggregate (Cmac A >2000μ) fraction, however, microaggregates (<250μ) were dominant in lower depths in both soils. Water stable aggregates (WSA) in surface soils of new alluvial and red-laterite were 57 and 36%, respectively and were decreased with depth. Red-laterite produced higher micro aggregates as compared to new alluvial soils. Coarse macro aggregate fractions (>2000μ) retained maximum amount of soil organic carbon in both soils however, coarse micro aggregate associated carbon (Cmic AC<250μ) was captured in lower depths. New alluvial soils yielded aggregates with higher in diameter and stability coefficient that is due to higher amount of carbon stored in aggregates. Conclusion: The abundance of macro aggregate of New alluvial soils indicates better soil physical quality than Red-laterite soil which was dominated in higher micro aggregates leads to poor in structure and susceptible to water erosion.

Subtype specific biomarkers associated with chemoresistance in epithelial ovarian cancer

In spite of the advent of many high throughput technologies, tumor tissue biomarkers are still the gold standard for diagnosis and prognosis of different malignancies including epithelial ovarian cancer (EOC). EOC is a heterogeneous disease comprised of five major subtypes which show distinct clinicopathological features and therapy response. Acquirement of chemoresistance toward therapy is a major challenge for successful treatment outcome in EOC patients. Several markers have been tested by immunohistochemical method to evaluate their prognostic merit to predict clinical outcome. However, a vast majority of such markers have been assessed for high-grade serous and clear cell ovarian cancer, among all subtypes of EOC. The current review elaborates upon those biomarkers that can potentially predict chemoresistance with subtype specificity.

Thoracopagus: Autoptic and radiologic study of 2 cases

Conjoined twins are a very rare complication of monozygotic twinning, most common being thoracopagus. Here we report about two cases of thoracopagus male twins illustrating the autopsy details of one case and the prenatal magnetic resonance imaging (MRI) details of another case. While the first case was misdiagnosed as separate twins on antenatal USG, only to be later confirmed as thoracopagus twins after birth, the antenatal MRI done in the second case helped in accurate detection of thoracopagus twins. Bilateral peripheral cortical cysts with dysplasia was noted in one of the twins of the first case, which has not been reported earlier in conjoint thoracopagii. Early prenatal diagnosis of conjoined twins is essential for better counselling of parents regarding post natal surgical management or termination of pregnancy. Importance of prenatal MRI for accurate detection of these cases is thereby highlighted.

Cyberbullying among late adolescent: A cross-sectional study in two higher secondary schools of Kolkata, West Bengal

Cyberbullying is a newer phenomenon which is becoming more prevalent among adolescent students with the use of information technology. The objective of the study was to determine the prevalence of being cyberbullied among late adolescent and to study the behavior and the attitude on cyberbullying. It was a cross-sectional study conducted on 254 school students (15� years). Data were collected by self-administered questionnaire, and results were analyzed using SPSS version 20. About 210 (82.7%) students were using any form of social networking site and out of which 22 (10.5%) students were cyberbullied. Among those who were cyberbullied, the majority (16 [72.7%]) had no opinion and more than half (15 [68.2%]) sought their friends' help. Cyberbullying is emerging as a newer social problem in our country, where students' lack of awareness and understanding of it results in underreporting of cyberbullying incidents.

Glomerulocystic disease, a rare cause of renal cysts in infants: A series of three cases

Glomerulocystic kidney disease (GCKD) is an uncommon type of cystic renal disease affecting children. It has both sporadic and familial occurrence and is characterized by cortical microcysts associated with dilatation of Bowman's spaces. In some instances, GCKD is an early manifestation of autosomal dominant polycystic kidney disease. Here, we present three cases of GCKD, two in infants and one in a perinatal postmortem. The first one is a case of GCKD with unilateral involvement, diagnosed on surgical biopsy. GCKD is a morphological expression of several hereditary and nonhereditary disorders that differ vastly in their management and long-term outcome. Hence, accurate morphological diagnosis of this entity is important for prognostication and genetic counseling.

Frequency & predictors of pancreatitis in symptomatic primary hyperparathyroidism

Background & objectives: The frequency and predictors of pancreatitis in primary hyperparathyroidism (PHPT) are not well understood. The objective of the present study was to evaluate the frequency of pancreatitis in patients with PHPT and its association with clinical and biochemical parameters of the disease. Methods: In this retrospective study all consecutive patients with PHPT registered in the PHPT registry (www.indianphptregistry.com) from the year 2004 to 2013 were included. The clinical, biochemical and radiological parameters related to pancreatitis were evaluated in histologically proven PHPT patients. Results: A total of 218 patients (63 men; mean age: 40.6±14.4 yr) underwent surgery for PHPT during the study. Pancreatitis occurred in 35 [16%, 18 acute and 17 chronic pancreatitis (CP)] patients and male:female ratio was 1:0.94. Skeletal manifestations were seen less frequently in PHPT with pancreatitis as compared to that of PHPT without pancreatitis. PHPT with pancreatitis had significantly higher serum calcium (12.4±2.0 vs. 11.7±1.5 mg/dl, P <0.05) in comparison to PHPT without pancreatitis. PHPT with acute pancreatitis (AP) had higher serum calcium (P <0.05) and parathyroid hormone (PTH) (P <0.05) levels than PHPT with CP. Curative parathyroidectomy improved the symptoms associated with pancreatitis as there was no recurrence in AP group, whereas recurrence was observed only in about 10 per cent patients of the CP group. Interpretation & conclusions: Pancreatitis was observed in 16 per cent of PHPT patients with male predominance in the study population. No recurrence of AP was observed after curative surgery. It may be proposed that serum amylase with calcium and PTH should be measured in all patients of PHPT with pain abdomen to rule out pancreatitis.

A study of spectrum of pulmonary pathology and expression of thyroid transcription factor-1 during neonatal period

Context: Neonatal period is the single most hazardous period of life. The major causes of neonatal death are prematurity and respiratory distress syndrome. We report a series of neonatal autopsies in our Neonatal Intensive Care Unit with special emphasis on pulmonary pathology. The spectrum of pathological changes in the lungs and thyroid transcription factor-1 (TTF-1) expression was studied in detail with reference to its spatial distribution. Aims: This study aims to analyze the causes of neonatal death with special attention to pulmonary pathology along with associated histopathological changes in lungs. We also evaluated the expression of TTF-1 at different levels of the airway. Materials and Methods: After taking consent and anthropometric measurements, autopsy was performed. Weights of all organs were taken, and histological sections were examined under hematoxylin and eosin stain. TTF-1 immunostaining was done on lung sections. Localization of TTF-1 was evaluated at the intrapulmonary level of terminal bronchioles (TBs), distal bronchioles, and alveoli. Results: We performed a series of 25 autopsies in neonates. In our series, most of the neonates were preterm (64%), had low birth weight (44%), and died within the first 7 days of life (80%). Majority (60%) of the neonates died due to pulmonary causes, followed by septicemia (24%), congenital anomalies (12%), and birth injury (4%). Among the respiratory causes, hyaline membrane disease (HMD) was diagnosed in maximum number of cases (32%), followed by pneumonia (12%) and pulmonary hemorrhage (12%). The TTF-1 expression in TBs, distal airways, and alveoli was significantly reduced or absent in cases of HMD compared to the control group. Conclusions: In this study, we observed that HMD is the most common cause of perinatal death among respiratory disorders, and in this disease, the expression of TTF-1 is significantly reduced in TBs, distal airways, and alveoli compared to the control group.

Stigma towards mental illness: A hospital-based cross-sectional study among caregivers in West Bengal

Background: Stigma among caregivers of people with mental illness has a serious impact on the disease outcome and lives of people with mental illness as well as other family members. Objectives: The objectives of this study were (i) To determine the level of self-perceived stigma toward mental illness, (ii) To measure perception to it among caregivers of people with mental illness, and (iii) To identify the factors associated with self-perceived stigma of caregivers. Methods: In this cross-sectional study, a structured interview was conducted among 200 caregivers of people with mental illness in the psychiatry outpatient department of a tertiary care hospital in West Bengal, India. Stigma and perception regarding mental illness were assessed with a validated 12-item Explanatory Model Interview Catalogue and 20-item perception scale, respectively. Information on their sociodemographic characteristics was also collected. Results: Average stigma score (53.3 � 13.2) was higher than 50% of maximum attainable score. Caregivers of higher age, female gender, low income, higher education, manual job, rural residence, and those who are single or widowed scored higher in stigma scale. Caregivers with female gender (P = 0.007) and rural residence (P = 0.01) were more likely to have stigma while the perception score was negatively associated (P < 0.001) with stigma score. Conclusion: The study highlighted that health-care providers can play a pivotal role to address caregivers� stigma in order to alleviate its effect on the course of illness and improve family life.