Unusual presentation of progressive systemic sclerosis.

A female 38 years old, housewife, presented to the Department of Dermatology and Venereology, Mymensingh Medical College Hospital (MMCH) on 08.04.07 with the complaints of i) pain and reduced movement of hand, knee, shoulder and neck joints for 1 year and 9 months ii) tightness of skin over face, neck, limbs and trunk for 1 year and 6 months iii) patchy depigmentation over same areas for 1 year and 3 months iv) deformity of hands with flexion contractures for 6 months and v) dysphagia to solid food for 3 months. She had no complaints of Raynaud's phenomenon. On general examination, she was ill looking, anemic and nutritionally poor. Examination of integumentary system showed smooth, shiny, thick, hard and hidebound skin with pigmentary alteration of 'salt and pepper' appearance over fingers, hands, limbs, face, neck and trunk. Hands appear claw like but more on the right side than the left and there were no other obvious changes suggestive of digital ischaemia (atrophy, ulceration, scarring, gangrene etc). Face has got suggestive features of scleroderma. Examination of the respiratory system showed restriction of chest movement and reduced expansibility of chest wall. No other abnormality was found on examination of other systems. Laboratory investigations showed histopathology typical of scleroderma. X-ray of hands and feet showed suggestive changes, lung function test-showed restrictive lung disease. Barium swallow x-ray of esophagus in supine position showed mild dilation of lower oesophagus. But serology was non-reactive (negative ANA, Negative RA test, Negative VDRL). So, she was diagnosed as a case of progressive systemic sclerosis (PSS) with some atypicality.

Evaluation of 35 cases of abdominal lymphoma.

Abdominal lymphoma is not a common clinical entity in Bangladesh. Still, in our Clinical practice we come across such problem occasionally. Because of their rarity and variable unusual behaviour, such case may present a major challenge even to experienced clinicians. Thirty five cases are reported in this series of which 29 were male and 6 were female (M:F = 4.8:1). Cases were collected from BSMMU, DMCH, MMCH, different clinics of Dhaka. Mean age was 36.7 years. Out of 35 cases 20(57.15%) had primary abdominal lymphoma, 08(22.85%) had secondary lymphomatous involvement, 07(20%) were cases of nodal lymphomas with or without superficial lymphnode involvement. All patients presented with gastrointestinal symptoms with or without an abdominal lump. Duration of symptoms of these patients ranged from 03 months to 02 years. In only 02 patients a clinical diagnosis of lymphoma was made pre-operatively. Various operative procedures were performed according to circumstances. Most common site of involvement was small intestine followed by large intestine, mesenteric lymphnodes, rectum and stomach. Among 35 cases, 28(80%) were Non-Hodgkin's, lymphoma 05(14.28%) were Hodgkin's and lymphoma 2(5.71%) were unclassified. All of the patients were referred to oncologist. Some of the patients received chemotherapy. The patients were followed up for a variable period. This study showed that abdominal lymphoma has a good prognosis provided diagnosed and treated early.

Histopathological analysis of hysterectomy specimens.

The objective of this study was to explore the histopathological findings and the rate of removal of ovaries in hysterectomy specimens. This study took into account 328 hysterectomy specimens examined in the Department of Pathology, Mymensingh Medical College and in one private Pathology Laboratory in Mymensingh town from March to August, 2005. Formalin fixed paraffin embedded tissue sections stained with haematoxylin and eosin were examined under light microscope. Patients' age, parts of uterus examined and their histopathological findings were retrieved from laboratory records. The common histopathological findings were: chronic cervicitis (87.80%), leiomyoma (17.07%), uterine prolapse (16.72%), adenomyosis (3.96), non-specific endometritis (3.35%), squamous cell carcinoma of cervix (2.44%), endometrial polyp (2.44%), serous cystadenoma of ovary (2.44%) and endometrial hyperplasia (1.83%). Some of the specimens show more than one lesions in the body of uterus, of which coexistence of adenomyosis and leiomyoma was the most common. Neoplastic lesions in cervix were 4.27%, in body 16.92% and in ovaries 5.06%. Malignant neoplasms were found in cervix 71.43%, in uterine corpus 3.03% and in ovaries 25%. Ovaries of both sides were removed in 48.17% of total cases. Their median age was 45 years, lowest age 23 years and maximum age was 82. The rate of removal of both ovaries was found to be increasing with the increase of age. Only one case was found to be subtotal hysterectomy and others were total hysterectomy. The present study revealed that the most common histopathological cause of hysterectomy is chronic cervicitis. Most common neoplastic cause of hysterectomy is leiomyoma. The rationalities and the possible after effect of hysterectomy in sexual functions and other physiological impairment should be followed up.

Combined occurrence of hyperthyroid Graves' and Hashimoto's thyroiditis.

A 40 years old, married Govt. servant from Sadar upazila, Mymensingh was admitted in Mymensingh Medical College Hospital on 9(th) February, 2005 with the complaints of excessive sweating for 1 year, gradual loss of weight for 6 months, swelling in front of the neck for 1(1/2) months, and hoarseness of voice for 1 month. He was nervous, irritable, emotionally labile. Thyroid gland was symmetrically enlarged, firm in consistency with scalloped surface. Palms were warm and sweaty with fine tremor in outstretched hands. Lid lag, lid retraction and proptosis were the occular manifestations. All the reflexes were exaggerated. Radioactive iodine uptake showed enlarged gland with homogenously increased radiotracer concentration, ultrasonogram findings were enlarged gland with hypoechoic parenchyma with fibrous septa, T(3), T(4), TSH values were 6.56 nmol/L, 241.09 nmol/L and 0.14 mIU/L respectively. Thyroid microsomal antibody level was 32.87%. Thyroid FNAC findings were sheets of regular follicular cells, some large cells with granular basophilic cytoplasm, macrophages, a few inflammatory cells and giant cells. All the above findings were in favour of a diagnosis of hyperthyroid Graves' with Hashimoto's thyroiditis.

Retrograde jejunogastric intussusception (JGI) with strangulation following previous gastrojejunostomy.

Jejunogastric intussusception is a rare but potentially very serious complication of gastrectomy or gastrojejunostomy. To avoid mortality early diagnosis and prompt surgical intervention is mandatory. A young man presented with epigastric pain and bilous vomiting followed by haematemesis 15 years after vagotomy & gastrojejunostomy for chronic duodenal ulcer. At presentation the patient was in shock and an emergency laparotomy was done after resuscitation. At laparotomy a retrograde type II JGI was found and managed by resection of the affected segment and partial gastrectomy and jejuno - jejunostomy with closure of the duodenal stump. Postoperative recovery was uneventful. Retrograde JGI is a rare condition and only less than 200 cases have been reported since its first report. Clinical picture of acute intestinal obstruction with suspicion about the condition in patients having a past history of gastrojejunostomy makes the elusive diagnosis definite and demands early surgery to reduce the grave consequences of the disease.

Ultrasonographic determination of amniotic fluid volume in normal pregnancy.

Ultrasonographic assessment of amniotic fluid has important implications because documentation of abnormalities of amniotic fluid volume may provide valuable information to enhance fetal health assessment. But in our country no study was conducted to establish normal values of amniotic fluid volume. So, this study was designed to find out normal values of amniotic fluid volume at various stages of gestation. The study was conducted in the department of Radiology and Imaging, BIRDEM in collaboration with the department of Obstetrics and Gynaecology, BIRDEM from 1(st) July, 2001 to 30(th) June, 2002. One hundred and twenty patients of normal pregnancy between 15 to 38 weeks' gestation were scanned by ultrasonography and their amniotic fluid volume was measured. For each gestational age between 15 and 38 weeks, 5 patients were recruited, and only one examination was done per pregnancy. Currently, the three semi-quantitative methods of assessing amniotic fluid volume include the amniotic fluid index (AFI), single deepest pocket (SDP) and two diameter pocket (TDP). Amniotic fluid volume of the study population was measured by the three methods. The values were plotted against each week in tabulated form. Thus the normal range of amniotic fluid volume in three methods (AFI, SDP, TDP) across gestational age in normal pregnancies was established. The mean value of amniotic fluid volume in AFI, SDP and TDP were 13.224 cm, 4.679 cm and 19.252 cm(2) respectively. AFI and SDP showed amniotic fluid volume increased with increasing gestational age up to early third trimester, but volume decreased thereafter. The prevalence of false positive result for oligohydramnios was 0.83% for AFI, 0% for SDP and 23% for TDP. The prevalence of false positive result for hydramnios was 1.66% for AFI, 0.83% for SDP and 0% for TDP. Thus the normal values of amniotic fluid volume for each of the three ultrasonographic techniques in the perspective of our country were obtained from the study. As the study was conducted with a limited number of patients, further study may be carried out with a large number of observations to reevaluate the results of the study.

A case of molluscum contagiosum.

Molluscum contagiosum is a benign contagious disease caused by a poxvirus. The virus proliferates within keratinocytes and forms intracytoplasmic Molluscum bodies. Though it is a common clinical condition, histologically is not yet reported from this region of Mymensingh. We received a skin biopsy specimen in a pathology laboratory for histological examination. The Haematoxylin and Eosin stained sections revealed typical intracytoplasmic Molluscum bodies in keratinocytes. The lesions were in the trunk, which is a common site for Molluscum Contagiosum (MC). As the diagnosis of Molluscum contagiosum is easy by histological examination, every patient suspected to be this disease is recommended to be examined histologically to exclude other similar types of lesions.

Histopathological types of malignant lesions of esophagus and stomach.

Upper part of gastrointestinal tract is common site of malignancy. Histological types of malignancy of esophagus and stomach may vary in different countries and also in different regions in the same countries. To find out the frequencies of different histological malignancies in Mymensingh region of Bangladesh, we analyzed the histopathological reports of 259 biopsy specimens examined in one pathology laboratory in Mymensingh town during the period from 6th January 2002 to 29th April 2004. Endoscopic biopsies were 234 (90.35%) and surgical biopsy specimens were 25 (9.35%). Male patients were 193 (72.52%) and female patients were 66 (25.48%). Specimens of esophagus were 73 (28.19%) and of stomach were 186 (71.81%). Out of 69 (94.53%) adequate samples of esophagus 46 (74.19%) were squamous cell carcinoma and 16 (25.81%) were adenocarcinoma. Adequate samples of stomach were 177 (95.16%) in which malignancies were found in 119 (67.23%). All the malignant tumor of stomach were in adenocarcinoma of which 82 (68.91%) were intestinal type, 17 (14.29%) were diffuse type and 20 (16.81%) mixed type. Intestinal type of gastric adenocarcinoma was found to be significantly associated with male patients (p < 0.005). From the present study it is suggested that in the Mymensingh region the common form of malignant lesion of esophagus may be squamous cell carcinoma followed by adenocarcinoma. Adenocarcinoma is the most common type of gastric malignancy of which intestinal type is more common

Sensitivity of splenic and bone marrow aspirate study for diagnosis of kala-azar.

Fifty adult patients of kala-azar were included in this prospective study from Medicine Unit-I of Mymensingh Medical College Hospital. Splenic and bone marrow aspiration were done simultaneously to compare the sensitivity and other related merits and demerits of each procedure. Splenic aspiration appeared to be more sensitive procedure than bone marrow aspiration. Leishman - Donovan (LD) bodies were found in 90 percent and 72 percent of the spleen and bone marrow aspirates respectively. Splenic aspiration was found more acceptable to patients (96%) as it was less painful. Both the procedures were hazardless. There was no major complication except mild pain after splenic aspiration; even a few patients had history of epistaxis. Splenic aspiration was also more acceptable by the physicians because of an easy and reliable diagnostic procedure.

Ultrasound guided fine needle aspiration cytology for diagnosis of mass lesions of liver.

The therapeutic and prognostic evaluation of malignant neoplasia of liver depends mostly on morphologic diagnosis. Ultrasound guided fine needle aspiration cytology (FNAC) of liver has been proved to be a rapid, reliable and cost-effective method for cytological diagnosis of hepatic mass lesions. This study was undertaken to find out the frequency of different benign and malignant space occupying lesions (SOL) of liver from patients attending for FNAC in Mymensingh. Ultrasound guided FNAC was performed on 108 patients with hepatic mass lesions from September 2, 2001 to August 19, 2003. There were 67 (62.0%) males and 41 (37.96%) females with a mean age 53 year (SD +/- 14) ranging from 2 to 83 years. Samples were adequate in 101 (93.5%) and inadequate in 7 (6.5%). Out of 101 adequate samples only one was benign (liver abscess) and 100 were malignant. Of the malignant lesions hepatoblastoma was in 1 (1%), hepatocellular carcinomas in 8 (8%), metastatic adenocarcinomas in 73 (73%) and unclassified malignancies were in 18 (18%). Most of the hepatocellular carcinomas occurred in males (7 in 8). The frequency of metastatic adenocarcinoma was more in males (39 vs. 34) but the difference is not significant (p > 0.05). Ultrasound guided FNAC of liver is a rapid, reliable and cost-effective diagnostic method. It can be practice in any centres where ultrasound facility and specialist pathologists are available.

Studies on clinical pattern of glomerulonephritis.

A prospective study of primary glomerulonephritis covering two and half years period was done at Dhaka Medical College Hospital & IPGMR, Dhaka from June 90 to July 92. A total of 100 cases were included in this study. All of the patients were of 13 years and above, clinically diagnosed, and by laboratory investigations, the diagnoses were established. In this study, we have tried to find out age incidence, sex ratio, possible aetiological factors, common clinical presentation, biochemical parameters and histological typing of primary glomerulonephritis.

Role of fine needle aspiration cytology in the diagnosis of pulmonary lesions.

Fine needle aspiration cytology (FNAC) is a rapid, reliable and cost-effective method in the diagnosis of lung lesions. Cells are collected from the lesions usually under fluoroscopic or CT-guidance for cytological examination. Due to lack of these highly sophisticated radiologic imaging techniques in our institute we performed this test under X-Ray film guidance. This study was carried out in 59 patients, who underwent FNAC of lung lesions in the department of Pathology, Mymensingh Medical College, Bangladesh to find out the specimen adequacy and frequency of both benign and malignant lesions of the lungs in our areas. Out of 59 cases 54 were males and 5 were females with age ranged from 20 to 82 years. Adequate samples were obtained in 50 (84.75%) cases of which 35 (70%) were malignant, 10 (20%) were benign and 5 (10%) were suspicious for malignancy. Malignant lesions comprised of squamous cell carcinoma in 20 (57.14%), adenocarcinoma in 1(2.86%), large cell carcinoma in 8 (22.86%) and small cell carcinoma in 6 (17.14%) cases. All the benign lesions were inflammatory in nature, which included abscess in 6 (60%), tuberculosis in 3 (30%) and chronic non-specific inflammation in 1 (10%) case. Majority of the malignant lung lesions were encountered in the 6th decade of life. As the method is simple, rapid, cost-effective and without major complications, so it can be practiced in any centres in our country where specialised radiologists and pathologists are available.

Thoracic actinomycosis.

Thoracic actinomycosis represents about one-fourth of all cases of the disease. Isolated pleural effusion due to Actinomycosis is rare. We report a case of right sided pleural effusion with discharging sinus in the right anterior chest wall. Actinomycosis was suspected and confirmed by microscopic identification of "sulfur granules" in the discharge of the sinus tract and also identification of gram-positive filamentous bacteria in the specimen of discharging sinus. The patient improved clinically and radiologically after treatment with intravenous penicillin G followed by oral penicillin and aspiration of pleural fluid.

Immunochromatographic (rK39) strip test in the diagnosis of visceral leishmaniasis in Bangladesh.

Immunochromatographic strip test (ICT strip test) for the diagnosis of visceral leishmaniasis was evaluated in this study in the context of a case-control study. A total sixty consecutive cases of kala-azar admitted in all four Medicine Units of Mymensingh Medical College Hospital during the period of May 2002 to February 2003 was included here. Parasitological confirmation was done by demonstration of leishmania donovani bodies in bone marrow or splenic aspiration in all cases. A total 120 controls was taken of which sixty were asymptomatic endemic controls with no previous history of kala-azar and sixty were admitted patients suffering from diseases other than kala-azar (malaria, tuberculosis, enteric fever and chronic liver disease). ICT strip test for kala-azar was done in all cases and controls. Only 2 of the confirmed kala-azar cases were negative and the remaining 58 cases were positive for ICT strip test which gives the sensitivity of this test 96.6%. Among the controls, 118 were negative for ICT strip test and two of the asymptomatic controls were positive for this test with no clinical evidence of kala-azar. So, the estimated specificity of ICT strip test is 98.3%. The predictive value for a negative result was 98.3% and for a positive result was 96.6%. The ICT strip test is easy, quick, requires no technical facilities with higher sensitivity and specificity entails it to be the ideal test for the diagnosis of kala-azar in field level.

Hairy cell leukaemia with advanced treatment - a case report.

A case of hairy cell leukaemia (HCL), a rare leukaemia, is reported here. The patient was presented with high grade continuous fever with left upper abdominal discomfort for 6 days. He was moderately anaemic, had no peripheral lymphadenopathy with mild hepatosplenomegaly. He was anaemic (Hb-7.8 gm/dl), total leukocyte count was 20 x 109/L. Peripheral blood film showed lymphocytosis (92%) with neutropenia (8%) and absolute neutophil count (ANC) was 1 x 109/L. On review, 88% of the peripheral cells had peripheral hairy projections resembling hairy cell (HC). Bone marrow examination was consistent with HCL (morrow hairy cell = 52%) including marker studies. Tartrate resistant acid phosphatase test (TRAP) was also positive. He had opportunistic mycobecterial infection giving a positive bronchial lavage for acid fast bacilli. After controlling the infection he was advised a single dose chemotherapy of 2-chlorodeoxyadenosine (2-CDA). After that he was in partial remission and after 25 months clinical and pathological relapses occurred and a second dose of 2-CDA was given and the patient went into complete remission.

Epidemiological characteristics of sixty five cases of Kala-azar attending to a laboratory in Mymensingh.

To find out the epidemiological characteristics of the patients with Kala-azar attending to a pathology laboratory at Mymensingh we studied retrospectively in a total of 65 patients. These patients were suspected to be Kala-azar as they were suffering from usually chronic fever, anaemia and splenomegaly. They were referred for serological detection of anti-k39 Leishmanial antibody by Immunochromatographic test (ICT) method. ICT positive cases were included for study. Majority cases were suffering from fever of more than 3 months (40%). Out of 65 patients 43 (66.15%) were males and 22 (33.85%) were females with a M:F ratio 2:1. Patients of 10 or less then 10 years of age were 17 (26.15%), in 11-20 years 23 (35.38%), in 21-30 years 13 (20.00%), in 31-40 years 5 (7.69%), in 41-50 years (6.15%) and in more than 50 years 3 (4.62%). Distribution of patients in different districts were: Mymensingh 54 (83.08%), Tangail 5 (7.69%), Jamalpur (4.62%), Netrokona 1 (1.54%) and Kishorgonj 1 (1.54%). In Mymensingh district patients were distributed as following Upazilla:Trishal 22 (40.74%), Fulbaria 11 (20.37%), Mymensingh Sadar 7 (12.96%), Gaforgaon 7 (12.96%),Bhaluka 5 (9.96%), Fulpur 1 (1.85%) and Nandail 1 (1.85%). Patients were found to scattered among different Unions of the affected Upazillas. The details addresses of the Kala-azar patients are recorded in authors computer databases. This may help in the further study regarding pathogenesis, reservoir and vectors of Leishmania in endemic areas. It may also helps in the community based study of Kala-azar. Present study supports that Kala-azar is still prevailing in the south-western region of greater Mymensingh in Bangladesh of which males and the adolescents are more affected.

Frequency of abortion in different seasons and age groups.

During the routine histopathological examination of the specimens in the department of Pathology, Mymensingh Medical College, the investigators observed variation in the frequency of abortion in different months in comparison to other cases. This is a descriptive study and was designed to find out the frequency of abortion in comparison to other cases in different seasons and mothers' age groups. A total of 1382 specimens were examined histologically in one year period from July 2000 to June 2001, of which 130 (9.41%) were histologically diagnosed as abortion i.e. retained products of conception (RPOC). The frequency of abortion cases was highest in May (18.98%) followed by June (17.31%). The frequency of abortion was lowest in September (1.69%). Abortion cases were significantly associated with relatively hot season (March-August) than that of cold season (September to February; p < 0.01). The frequency of abortion was found to be highest in age group of 26 to 30 years. Management facilities of abortion should be readily available during the high frequency of abortion i.e. relatively hot season especially April, May and July, to reduce maternal mortality from complications of abortion.

Evaluation of fine needle aspiration cytology (FNAC) of lymph node in Mymensingh.

Fine needle aspiration cytology (FNAC) is widely accepted as the accurate, sensitive, specific and cost-effective procedure in the diagnosis of lymphadenopathy. The purpose of the study was to evaluate the results of FNAC of lymph nodes in our institutions comparing with results of histopathology. We performed 117 FNAC of lymph node in a period between November 2001 to April 2002, of which, histological results were available in 81 (69.23%). Cervical lymph nodes were 102 (87.18%) and axillary lymph nodes were 15 (12.82%). Male to female ratio of the patients was 1:0.65. Patients' age ranged from 3-80 years with a median age of 23 years. FNAC diagnosis was found to be as follows: granulomatous inflammation 46 (40.35%), reactive hyperplasia 31 (27.19%), metastatic carcinoma 20 (17.54%), Non-Hodgkin's lymphoma 6(5.26%), tubercular lymphadenitis 4(3.51%), acute non-specific lymphadenitis 3(2.63%), Hodgkin's lymphoma 3(2.63%) and chronic non-specific lymphadenitis 1(0.88%). Out of 81 cases of FNAC 71(87.65%) were consisted with histopathological diagnosis of granulomatous lymphadenitis. In the malignancy of lymph node sensitivity and specificity of FNAC were 82.76% and 97.92%, respectively. So, the investigators reasonably conclude that before resort to surgical intervention FNAC may be a helpful procedure in the diagnosis of both neoplastic and non-neoplastic lesion of lymph nodes.