Sideroblastic Anaemia-A Hitherto Unrceognized cause of unexplained Anaemia

Objective: To assess the clinicopathological heterogeneity of sideroblastic anemia disorders characterized by the presence of ring sideroblasts in the bone marrow

Study Design: Descriptive study

Place and Duration of Study: Study was conducted at department of Pathology, Combined Military Hospital Kharian, from Apr 2014 to Oct 2016

Material and Methods: A total of ten patients diagnosed as having sideroblastic anemia [SA] on cytomorphological basis were included in the study. After clinical examination of the patients, blood samples were analyzed on Sysmex KX21 Haematology analyzer. Blood and bone marrow aspiration slides were stained with leishman's stain to study red cell morphology and aspects of haematopoiesis. Assessment of iron stores was done using Perl's staining technique. Data was collected and analyzed using SPSS 16.0 version

Results: Age range of the SA patients varied from 14-65 years and male to female ratio was 1.3:1. Clinical features included weakness, malaise, easy fatigability, fever, bleeding complications, pallor, splenomegaly and syndrome specific features in 2 patients. MCV ranged from 66 fl to 94 fl. Dimorphic red cell morphology which is considered an important feature of SA was not observed in any patient. Other cytopenias were also noticed. Dysplasia was observed in 4 patients. One patient was confirmed as having secondary SA due to lead poisoning

Conclusion: Clinicopathological features of SA are variable and it is inappropriate to associate SA with any specific age group, gender, red cell indices or morphology. Prompt recognition of SA with its accurate categorization and specific treatment can avoid undue suffering of the patients as well as their relatives

Expression of Estrogen Receptors [ER], Progesterone Receptors [PR] and HER-2/neu receptors in endometrial carcinoma and their associations with histological types, grades and stages of the tumor

Objective: To study and detect immunohistochemical expression of Estrogen Receptors, Progestrone Receptors and HER-2/neu Receptors in Endometrial Carcinoma [EC] and to find their associations with histological types, grades and stages of the tumor

Methods: A cross sectional study of one year duration from January 2016 to January 2017 was conducted at Histopathology department of Army Medical College, Rawalpindi. A non-probability purposive sampling technique was used to include 56 cases of EC. The specimens were tested for ER, PR and HER-2/neu expression using immunohistochemical analysis. Data was analyzed in SPSS and the significance of association of expression of the receptors with histological types, grades and stages of the tumor was assessed

Results: Significant association of Her-2/neu overexpression with histological types and grades of EC was seen, whereas the association of ER and PR expression with histological types, grades and stage of EC was statistically insignificant

Conclusion: It is suggested that EC showing over expression of HER2/neu with immunohistochemistry may be treated with anti HER-2/neu treatment with better chances of survival and decreased post-treatment morbidity

Prevalence of metabolic risk factors in non-alcoholic fatty liver disease

Objective: To determine the frequency of factors leading to metabolic syndrome among non-alcoholic fatty liver disease [NAFLD] patients at a tertiary care hospital

Study Design: Descriptive cross sectional study

Place and Duration of Study: Department of Medicine, Combined Military Hospital, Kharian. Study was carried out over a period of six months from Jan 2015 to Jun 2015

Material and Methods: A total of 110 patients were included in this study. Past history was taken to rule out alcohol intake, viral and drug induced etiology, to determine the presence of co-morbidities like obesity, type 2 diabetes mellitus, arterial hypertension and dyslipidemia. Physical examination was carried to determine the arterial blood pressure and to determine anthropometric data that is weight, height, body mass index [BMI] and abdominal obesity by measuring waist circumference

Results: Mean age of the patients was 49.95 +/- 8.86 years. There were 72 male patients [65.5%] while 38 [34.5%] patients were female. Different metabolic factors were central obesity in 82 patients [74.5%], raised high density lipoprotein [HDL] in 19 patients [17.3%], raised cholesterol in 87 patients [79.1%], raised blood pressure in 65 patients [59.1%] and raised fasting plasma glucose in 82 patients [74.5%]. Mean BMI was 26.31 kg/m2 +/- 2.68, mean waist circumference was 109.82 cm +/- 18.41, mean cholesterol was 237.50 +/- 48.47mg/dl, mean systolic blood pressure was 148.88mmHg +/- 22.10, mean diastolic blood pressure was 90.41mmHg +/- 12.25 and mean fasting plasma glucose was 113.28mg/dl +/- 22.80. Stratification with regard to age was carried out

Conclusion: A considerable number of patients with NAFLD had metabolic syndrome. There was a close correlation between NAFLD and metabolic syndrome

Endoscopic findings in non ulcer dyspepsia; a new perspective

Objective: To see the pattern of endoscopic findings in patients with non-ulcer dyspepsia. Study Design: Observational cross sectional study. Place and Duration of Study: Department of Gastroenterology, Combined Military Hospital Kharian Pakistan, from Jan 2015 to Dec 2015

Material and Methods: Two hundred and seventy seven patients were included in the study. Patients presenting with dyspeptic symptoms at outpatient Gastroenterology Department were included in this study. Upper GI endoscopy was carried out and those having ulcers or any structural lesion were excluded from the study. Endoscopic findings were interpreted with IBM SPSS version 22

Results: Out of 277 patients, 146 were male and 131 female. Their minimum age was 12 and maximum age was 86 years with 44 +/- 15.5 [mean +/- SD]. Maximum numbers of patients were between ages of 31 to 50 years. Endoscopy was normal in 112 [40.4%] patients, showed mild gastritis in 118 [43.7%], moderate gastritis in 17 [6.1%], duodenitis in 19 [6.9%], and mixed findings in 8 [2.9%] patients. Bile was present in 144 [52%] and absent in 133 [48%] of the endoscopies

Conclusion: Mostly patients have either normal findings or mild gastritis on upper GI endoscopy. Gastric bile reflux was a common observation

Frequency of helicobacter pylori in histologically proven gastritis cases - a study of 100 cases

Objective: To determine the frequency of Helicobacter pylori [H. pylori] based on endoscopic of special stains in gastritis cases

Study Design: Prospective descriptive study

Place and Duration of Study: Histopathology department, Army Medical College Rawalpindi, from Oct 2016 to Mar 2017

Material and Methods: One hundred [100] cases were included in the study. Gastric biopsies of the patients histologically diagnosed as gastritis were included in the study, which were evaluated for the presence of H. pylori with the help of special stain [Modified Giemsa stain]

Results: Gastric biopsies of 100 patients, who were diagnosed as gastritis on histopathological examination were analyzed with the help of Giemsa stain for the presence or absence of H. pylori. Out of these 100 cases, 60 were males and 35 were females. Most patients were between the age group of 30-40 years. Histological examination and special stain analysis revealed presence of H. pylori in 30 cases [30%], while rest of the 70 cases [70%] showed no H. pylori. Out of 30 cases positive for H. pylori, 28 cases [93%] had chronic active gastritis, while 2 cases [7%] had no element of activity

Conclusion: Among the cases of chronic gastritis, H. pylori negative gastritis was more common than H. pylori associated gastritis. A significantly decreased frequency of H. pylori in histologically gastritis cases in our population may be due to more frequent use of complete or incomplete therapies against H. pylori by general practitioners at some stage of disease

Histopathological outcome of pancytopenia cases on bone marrow trephine biopsy

Objective: To determine the histological outcome of pancytopenia cases on bone marrow trephine biopsy and to see the frequency of various causes of pancytopenia in our population

Study Design: Descriptive study

Place and Duration of Study: Pathology department, Combined Military Hospital [CMH], Kharian [Pakistan]. One year [Jan 2015-Dec 2015]

Material and Methods: Two hundred bone marrow trephine biopsies were done in one year [2015], out of which 40 were done for evaluation of pancytopenia. The criteria for diagnosis of pancytopenia were; haemoglobin less than 10 g/dl, total leukocyte count [TLC] less than 4.0 x 109/1 and platelet count less than 100,000 x 109/1. Patients with pancytopenia secondary to drugs, chemotherapy and radiotherapy were excluded from the study

Trephine biopsies showing marked crushing and having inadequate material were also excluded from the study. Biopsies were processed, slides made and examined under light microscope by haematologist and histopathologist. Frequencies of various causes of pancytopenia diagnosed on histopathology were calculated. The findings were analyzed by using SPSS version 10.0

Result: Out of 40 cases of pancytopenia, male to female ratio was 3:2. The age range was between 1 year to 75 years. Histopathological analysis of bone marrow trephine biopsies revealed megaloblastic anaemia as the most common cause of pancytopenia [30%], followed by aplastic anaemia [25%] and hypersplenism [15%]

Conclusion: Megaloblastic anaemia is the most common cause of pancytopenia in our population as compared to aplastic anaemia mentioned in most of the international studies. This indicates prevalence of nutritional deficiency in our population and megaloblastic anaemia must be kept at top of list while evaluating pancytopenia cases. Early diagnosis and treatment of megaloblastic anaemia will prevent any further complication of this disease

Hepatitis B leading to megaloblastic anemia and catastrophic peripheral thrombocytopenia

Hepatitis B virus [HBV] typically causes chronic hepatitis, cirrhosis, and hepatocellular carcinoma. It is associated with a variety of extrahepatic complications. We herein, present a rare extrahepatic complication of HBV infection. A 32-year man presented with melena, bleeding from gums and fever. Peripheral blood examination revealed anemia, macrocytosis and severe thrombocytopenia. His hepatitis B surface antigen [HBsAg] was positive but deoxyribonucleic acid [HBV DNA] by polymerase chain reaction [PCR] was negative. Other hepatitis, human immune deficiency virus [HIV], dengue, and autoimmune serology were negative. Bone marrow examination revealed megaloblastic erythropoiesis. There was mild to moderate reduction of megakaryocytes in bone marrow, which was not compatible with severe peripheral thrombocytopenia. His response to cyanocobalamin and folic acid was remarkable for myeloid cell lines and moderate for erythroid cell lines, but poor to platelet counts. Platelet counts gradually improved to safe limits with eltrombopag, likely reflecting autoimmune pathogenesis for thrombocytopenia. This case report highlights multiple targets of HBV infection with associated multiple pathogenetic mechanisms

Histopathological analysis of gastric mucosal biopsies in non ulcer dyspepsia

Objective: To find out the pattern of gastric mucosal histopathological findings in gastric biopsies of patients with non ulcer dyspepsia

Study Design: Prospective descriptive study

Place and Duration of Study: Histopathology department Combined Military Hospital [CMH] Kharian Pakistan from Jan to Dec 2015

Material and Methods: One hundred patients presenting at outpatient gastroenterology department with dyspepsia having no endoscopic lesion were included in the study. Two gastric mucosal biopsies from antrum and two from corpus were taken. The specimens were processed and examined histologically to see the changes

Results: Gastric biopsies of 100 patients including 65 males and 35 females presenting with non ulcer dyspepsia were studied. Most of the patients were between the age group of 31-50 years. Histological examination of gastric biopsies revealed 70% of patients having histological features of gastritis, while 30% having no significant histological finding. Chronic inflammation was seen in 70 cases [70%], activity in 15 cases [15%], glandular atrophy in 2 cases [2%] and intestinal metaplasia in 2 cases [2%]. H.Pylori were identified in 25 cases [25%] based on haematoxylin and eosin [H and E] staining and modified giemsa staining

Conclusion: Most the cases of non ulcer dyspepsia show histological evidence of gastritis, however a significant number of patients showed no gastric mucosal histological abnormality. A significantly low frequency of H. Pylori in gastric biopsies noted in non ulcer dyspepsia cases may be due to more frequent use of antibiotics and acid suppressant drugs used by general practitioners at some stage of disease

Higher frequency of cholelithiasis in eosinophilic cholecystitis - an unusual finding

To determine the frequency of cholelithiasis in eosinophilic cholecystitis in our population. Prospective descriptive study. Histopathology department, Combined Military Hospital [CMH], Peshawar [Pakistan] from Dec 2011 to Nov 2014. Eighteen hundred [1800] cholecystectomy specimens were included in the study. The specimens which were properly fixed in 10% formalin were included in the specimen, while poorly fixed and autolysed specimens were excluded. The specimens were examined grossly, measured and block selection was done. The slides made were examined under light microscope by one histopathologist and findings were analyzed. Out of 1800 cholecystectomy specimens, 25 cases [1.38%] were diagnosed as eosinophilic cholecystitis. Out of these 25 cases, 20 [80%] were females having an age range of 30-50 years, while 5 [20%] were males with an age range of 35-55 years. Out of these 25 cases of eosinophilic cholecystitis, 22 [88%] were having cholelithiasis, while 3 [12%] were acalculous eosiniophilic cholecystitis. Eosinophilic cholecystitis in our population is mostly calculous which is very significant finding contrary to data given in western literature, where most of eosinophilic cholecystitis is aclculous. This needs further evaluation to determine any genetic, geographic, environmental, dietary, microbiological or any other factor responsible in etiopathogenesis of calculous eosinophilic cholecystitis in our population, which could be helpful in prevention and management of this disease

Calretinin expression in the differential diagnosis of ameloblastoma and keratocystic odontogenic tumour

To determine calretinin expression by immunohistochernistry in ameloblastoma and keratocystic odontogenic tumors [KCOT] and to document the use of calretinin as a differentiating marker between the two lesions. A cross sectional study conducted on previously diagnosed cases of ameloblastoma and Keratocystic odontogenic tumour. Armed forces Institute of Pathology, Rawalpindi Pakistan and duration was one year. [Sep 2009 - Aug 2010]. Twenty cases each of Ameloblastoma and KCOT were retrieved from the record files along with their paraffin embedded blocks. Histological features of all the cases were reviewed on freshly prepared slides and a fresh diagnosis made regardless of the previous diagnosis. The immunohistochemical marker, Calretinin, was applied on both types of cases using the avidin-biotinylated peroxidase complex method.The results were interpreted. In the cases of Ameloblastoma the epithelial tumour nests showed positivity for Calretinin expression. In 85% cases; intense and diffuse staining was observed in more than 80% of the stellate reticulum like cells while 15% cases showed focal and moderate staining patterns. On the other hand KCOT showed contrary results as none of epithelial lining expressed positive staining for Calretinin, [p<0.001]. Calretinin can be used as a useful marker for Ameloblastoma and can be used to differentiate KCOT from Ameloblastoma

Second-opinion histopathology - a study of 142 cases at armed forces institute of pathology [AFIP], Rawalpindi, Pakistan

To assess the histopathological diagnosis made on the cases sent for second opinion to the Department of Histopathology. A descriptive study. Department of Histopathology AFIP, Rawalpindi, Pakistan from July 2010 to April 2011. During the study period, 142 cases were received for second opinion by the department. The demographical details of the patients were entered in a profroma. After initially seeing the H and slides, immunohistochemical and special stains were applied where required. The initial diagnosis and review diagnosis were then analysed. During the study period, 142 cases were analysed, 81 were male and 61 female patients. There was wide age range, from 2 months to 90 years. Out of the total 22 [15.5%] were reviewed for benign conditions and 120 [84.5%] were malignant. Majority of cases were from lymphoreticular system. In 72 [50.7%] cases diagnosis was changed on review out of which 9 were benign conditions and rest malignant. Out of the 63 malignant 27 cases and 3 out of 9 benign cases, were those where change in diagnosis was such that it changed the treatment pattern. In 12 cases the review diagnosis was changed from benign to malignant and vice versa. Getting second opinion on surgical biopsy material is very important part of treatment, particularly in our set up, where all the laboratories are not fully equipped.

Role of immunohistochemistry [IHC] in diagnosis of ovarian malignancies - is there any change from before?

Ovarian malignancies account for about 3% of all cancers in women. After the development of immunohistochemishy, it is now considered an essential part in diagnosing malignant ovarian tumours, including metastatic tumours. To compare between the frequencies, histological patterns and histogenesis of malignant ovarian tumours before and after the advent of immunohistochemistry. This descriptive cross sectional study was conducted at department of histopathology, Armed Forces Institute of Pathology [AFIP] Rawalpindi from 1[st] Jan 2010 to 10[th] Dec 2011. A total of 128 cases of malignant ovarian tumours were included. After gross and histological examination, a panel of immunohistochemistry markers was applied and tumours were classified according to WHO classification. Most frequent malignant tumours were surface epithelial tumours [54.8%] followed by metastatic tumours [12.7%]. Frequency of metastatic tumours was higher in our study as compared to other studies. Immunohistochemistry plays an important role in correct diagnosis of malignant ovarian tumours and also in identifying metastatic tumours.

Bcl-2 protein expression in mucoepidermoid carcinoma of salivary glands: a single institution experience

Mucoepidermoid carcinoma is the most common salivary gland tumor with varying behavior among different histopathological grades. The objective of this study was to determine the expression of Bcl-2 protein in mucoepidermoid carcinoma [MEC] and to correlate with histological grades. The records of 40 cases of MEC were collected from the histopathology department. Fresh slides were prepared and fresh diagnoses were made using the grading criteria for MEC. Immunohistochemical markers for Bcl-2 were applied and the results analyzed using the chi-square test. Of 40 cases, 20 were males and 20 were females. The range in age of the patients was 6 to 67 years mean [SD] was 42.6 [1.85] years. Twenty-two were low grade [55%], 11 high grade [27.5%] and 7 [17.5%] were intermediate grade MEC. Among these 40 cases, Bcl-2 expression was positive in 24 cases and negative in 16 cases. In 22 cases of low-grade MEC, 19 were positive while only 3 were negative. In high-grade tumors, all 11 cases were found to have a negative expression of Bcl-2 protein. In intermediate-grade MEC, 5 cases showed positive expression while only 2 cases showed negative expression. Bcl-2 protein expression showed positive expression in low-grade and negative expression in high-grade MEC. Intermediate grade showed more than 50% positive results for Bcl-2. Correlation between grades of MEC and expression of Bcl-2 is statistically significant and can be used for the depicting the prognosis of MEC along with other prognostic and clinico-pathological parameters

Clinicopathdlogicai of Clinicopathological study of extranodal Non-Hodgkin Lymphoma [NHLS] at Armed Forces Institute of Pathology [AFIP] Pakistan

To evaluate the Clinicopathological analysis of extranodal Non-Hodgkin Lymphoma [NHLs] reported in Armed Forces institute of Pathology [AFIP] Rawalpindi, Pakistan. Record of a total of 206 cases of extranodal NHLs diagnosed between January 2009 to December 2010 was retrieved from AFIP tumour registry. Basic epidemiological data regarding each case was collected from the request forms. The specimens were received in 10% formal saline. Gross examination of surgical specimens was performed arid recorded on a proforma. The material was processed under standardized conditions for paraffin embedding. The sections were stained with hematoxylin and eosin [H/E]. Immunohistochemistry panel was applied for the categorization of the lymphomas according to the 2008 WHO guidelines. Data was entered and analysed on SPSS version 14. Out of 206 cases, 147 [71.3%] were males and 59 were females [28.6%]. Male to female ratio was 2.4:1. The age ranged between 7-99 years. The most commonly affected age group was the 5[th] decade with 40 cases [19,4%], The most commonly involved site was head and neck, 85 cases [41.2%], followed by the GIT, 61 cases [29.6%]. Diffuse large B-cell lymphoma [DLBCL], was the most common histologic type, 165 cases [80%].Diffuse large B-cell lymphoma is the most common extranodal Non Hodgkin lymphoma, in our population

Histomorphological analysis of oral white lesions

To histomorphologically analyze the oral white lesions. Descriptive, cross-sectional study. Department of Histopathology, Armed Forces Institute of Pathology [AFIP], Rawalpindi. From May 2011 to May 2012. A total of 54 patients presenting with oral white lesions were included. Age, gender, site and size was recorded. The biopsy sample was fixed in 10% formalin and after standardized processing, slides were prepared, stained by Hematoxyline and Eosin, with special stains when required. The histopathological diagnosis of lesion was recorded. Mean and standard deviation were calculated for quantitative variable. Frequency and percentages were calculated for qualitative variables. Out of total 54 patients 28 were male and 26 females. The age range was 17-80 years with mean age 49.70 years. Majority of the patients were between 50-60 years. Buccal mucosa was affected in majority of the cases [63%], followed by lip mucosa and tongue. Histologically Lichen Planus was the most common lesions [33%], followed by non specific inflammation [14.8%], keratosis without dysplasia [11%], keratosis with dysplasia [7.4%], Pemphigus Vulgaris [6%] and Squamous cell carcinoma [1%].Lichen Planus is the most common cause of white lesion in our set up. Biopsy of an intact epithelial lesion should be considered if the lesion does not resolve in due course of time

Immunohistochemical expression of protein p53 in oral epithelial dysplasia and oral squamous cell carcinoma

The study was carried out to determine the frequency of p53 protein expression in oral dysplastic lesions and oral squamous cell carcinoma and to compare them in both the lesions. Sixty cases [30 each] of oral epithelial dysplasia [OED] and oral squamous cell carcinoma [OSCC] were retrieved from the record files along with their paraffin blocks at the Armed Forces Institute of Pathology, Rawalpindi including twenty fresh/frozen sections. The immunohistochemical marker p53 was applied using Streptavidin-Biotin technique. Staining and intensity of the marker was recorded and frequencies were compared in both the lesions. Protein p53 expression was seen in 60% of oral epithelial dysplastic lesions and 67% of oral squamous cell carcinomas. The results signify the importance of p53 for the early diagnosis and early treatment of dysplastic [precancerous] lesions

Sensitivity and specificity of BerEP4 immunostaining in basal cell carcinoma cases in Asian skin

To evaluate the BerEP4 stain positive cases of basal cell carcinoma in our population [BCC]. A non-interventional descriptive study. Military Hospital and Armed Forces Institute of Pathology [AFIP] Rawalpindi from 1[st] January 2009 to 31[st] August 2009. Patients who reported to the skin department of Military Hospital Rawalpindi with clinical impression of BCC were biopsied. Only those cases which were easily diagnosed on Haematoxylin and Eosin [HandE] were included. All such sections were then subjected to BerEP4 immune marker and the intensity of staining was noted. In addition, 11 cases of straight forward squamous cell carcinoma [SCC] were also stained with BerEP4, which served as controls. The study group [BCC cases] included 17 males [59%] and 12 females [41%], who were histologically diagnosed as BCC. All such cases were subjected to BerEP4 immune staining. All the tumors showed positive staining, the intensity/staining pattern was however variable. Twenty-two out of twenty-nine cases showed diffuse [75.9%], while 7 out of 29 cases showed partial [24.2%] staining; irrespective of the histological subtype and site of tumor. All the SCCs were negative for BerEP4 staining. BerEP4 was positive in 100% of the cases. Its intensity was however variable. Nevertheless, it must be used with confidence in all difficult to diagnose cases of BCC, especially when it is difficult to differentiate from SCC

Clinicopathological aspects of malignant salivary gland neoplasms - a study of 150 cases at Afip, Rawalpindi [Pakistan]

To study the clinicopathological aspects of malignant salivary gland tumors, diagnosed at AFIP, Rawalpindi [Pakistan]. Descriptive study. Armed Forces Institute of Pathology, Rawalpindi from Jan 2005-Dec 2009. The study included all the cases diagnosed as malignant salivary gland tumors in the last five years. Records of all the tumors of head and neck region that presented during this period were analyzed and out of these clinicopathological features of malignant salivary gland tumors were studied. The data analysis included the age, gender, site of tumor and histopathological pattern. A total of 18685 malignant tumors presented in the last five years. Out of these, malignant tumors of head and neck were 2165. Total malignant salivary gland tumors were found out to be 150 with an overall frequency of 0.8% and frequency in head and neck malignancies was found out to be 6.9%. The age ranged from 6-80 years [mean 48.02 + 1.23]. Of these 150 cases, 58.7% were males and 41.3 were females with a male to female ratio of 1.4:1. The most common tumor seen was mucoepidermoid carcinoma [49.3%] followed by adenoid cystic carcinoma [31.3%]. A total of 48.7% of the tumors originated in minor salivary glands. Parotid gland was the second most commonly involved site [40.7%]. Malignant salivary gland neoplasms are a common malignancy of head and neck region and their frequency is slightly more in our population. Almost half of the tumors originated in minor salivary glands and mucoepidermoid carcinoma was the most common type of malignancy