Chronic Lunate Dislocation: An Unusual Cause of Carpal Tunnel Syndrome—Avoiding Diagnostic Pitfalls and Synopsis of Management Options

ABSTRACT Carpal tunnel syndrome (CTS) represents the most common compressive neuropathy of the upper limb (1). There are a myriad of causes of CTS, of which carpal fractures and dislocations are known aetiologies. Volar lunate dislocations are the most common carpal dislocations described (1). Approximately 25% of perilunate dislocations are missed on initial presentation, resulting in delayed diagnosis and likely poorer outcomes (1-3). A case of chronic lunate dislocation presenting as CTS is presented here to highlight diagnostic pitfalls and management options.

Hurthle cells in fine needle aspiration cytology of the thyroid: a potential diagnostic dilemma?

Hurthle cells are not uncommonly encountered in thyroid fine needle aspiration cytology (FNAC) smears. They are easily recognized by their distinct cytomorphology in cytological preparations, i.e. large, polygonal cells displaying uniform, rounded nuclei, often prominent nucleoli and abundant granular cytoplasm. Hurthle cells can be seen in both non-neoplastic and neoplastic thyroid lesions which can pose diagnostic dilemma to cytopathologists, especially when the lesions are focally sampled. We describe a case of solitary thyroid nodule in a 46-year-old male, whose aspirates comprised predominantly of Hurthle cells exhibiting nuclear features suspicious of papillary carcinoma, which turned out to be Hurthle cell carcinoma on subsequent histological sections. The potential diagnostic pitfalls of Hurthle cell lesions and associated conditions in thyroid FNA are discussed. The presence of Hurthle cell change in a wide variety of thyroid lesions can be diagnostically challenging. However, accurate diagnosis can still be made with careful observation of the predominant cell population, nuclear features and whether there is abundant colloid or lymphocytes in the background.

Fine-needle aspiration cytology of pleomorphic adenoma: cytologic variations and diagnostic pitfalls: a report of two cases.

Introduction: Fine-needle aspiration cytology (FNAC) of the salivary gland is a sensitive and specific technique used in the diagnosis of lesions of the salivary gland. On FNA, adequately cellular aspirates make distinction easy in most cases. However, sparse cellularity makes diagnosis difficult partly due to lack of observer familiarity with the different patterns. The diagnosis of pleomorphic adenoma (PA) can be made accurately but this common salivary gland neoplasm can be diagnostically challenging, causing pitfalls in cytodiagnosis. Material And Methods: A 26-year-old male presented with a firm, painless, mobile slowly-growing mass in the right preauricular region of three years duration. Fine needle aspiration (FNA) was done. A diagnosis of pleomorphic adenoma suspicious of malignancy was given due to the presence of isolated squamous cells, occasional cluster of basaloid cells, occasional giant cells and hyaline globules. Histology confirmed a pleomorphic adenoma with marked squamous metaplasia and keratin cyst formation without evidence of malignancy. A 52-year-old male presented with a firm, painless, mass in the right preauricular region of five months duration. FNAC smears were cellular and showed a hemorrhagic background. Numerous single anucleate and nucleate squamous cells, myoepithelial cell clusters and epithelial cell aggregates were seen. Few foamy cells, giant cells and hyaline globules were noted. Characteristic metachromatic fibrillary chondromyxoid stroma which is usually seen in pleomorphic adenoma was absent. A diagnosis of pleomorphic adenoma suspicious of malignancy was given. The patient was lost to follow up and hence details regarding the histopathological status of his preauricular swelling were not known. Results: Here we illustrate that PA with squamous metaplasia, basaloid cells and hyaline globules can be misinterpreted as carcinoma on cytology and discuss the various pitfalls of cytology. Conclusion: FNAC is a good pre-operative procedure for the diagnosis of PA. One should be aware of the cytological variations to avoid diagnostic errors. When one is uncertain about classification of a salivary gland tumour the cytopathologist should leave the diagnosis open with a few suggested differential diagnoses rather than issuing a misleading report.

Evaluation of Role of Ultra Sound Guided Fine Needle Aspiration Cytology for Diagnosis of Ovarian Lesions with Particular References to Diagnostic Pitfalls.

Background: Ovarian lesions are quite common among females of all age groups. Ovarian cancers account for 6% of female malignancy. ULTRASONOGRAPHY(USG) can help in proper identification and categorization of these lesions. Fine needle aspiration cytology (FNAC) under USG guidance can be an effective modality for early diagnosis of ovarian masses. Aims And Objectives: To evaluate the role of USG guided FNAC over ovarian space occupying lesions (SOLs) for proper categorization into non-neoplastic, benign & malignant variants and to identify possible underlying causes of cytological misdiagnosis, if any, in comparison to histopathological diagnosis. Materials and Methods: FNAC under USG guidance were performed over one hundred and sixteen cases with radiologically proved ovarian SOLs during a period of five years. Aspirated materials were interpreted as non- neoplastic, benign or malignant lesions. Histopathological study was possible in 47 of these cases. Results: Out of 116 aspirations, non neoplastic, benign and malignant diagnosis were given in 51, 42 &23 cases, respectively. During histopathological correlation 41 out of 47 cases(87.2%) show exact cytohistological parity.Rest six cases with cytological misdiagnosis were discussed in detail. Conclusion: USG guided FNAC can effectively diagnose ovarian lesions in more than 87% cases. Scrutiny about failed diagnosis will help to improve accuracy in future.

Challenges and pitfalls in the diagnosis of hyperprolactinemia / Desafios e armadilhas no diagnóstico da hiperprolactinemia

The definition of the etiology of hyperprolactinemia often represents a great challenge and an accurate diagnosis is paramount before treatment. Although prolactin levels > 200-250 ng/mL are highly suggestive of prolactinomas, they can occasionally be found in other conditions. Moreover, as much as 25% of patients with microprolactinomas may present prolactin levels < 100 ng/mL, which are found in most patients with pseudoprolactinomas, drug-induced hyperprolactinemia, or systemic diseases. On the other hand, some conditions may lead to falsely low PRL levels, particularly the so-called hook effect, that is an assay artifact caused by an extremely high level of PRL, and can be confirmed by repeating assay after a 1:100 serum sample dilution. The hook effect must be considered in all patients with large pituitary adenomas and PRL levels within the normal range or only modestly elevated (e.g., < 200 ng/mL). An overlooked hook effect may lead to incorrect diagnosis and unnecessary surgical intervention in patients with prolactinomas. Another important challenge is macroprolactinemia, a common finding that needs to be identified, as it usually requires no treatment. Although most macroprolactinemic patients are asymptomatic, many of them may present galactorrhea or menstrual disorders, as well as neuroradiological abnormalities, due to the concomitance of other diseases. Finally, physicians should be aware that pituitary incidentalomas are found in at least 10% of adult population. Arq Bras Endocrinol Metab. 2014;58(1):9-22.

A definição da etiologia da hiperprolactinemia muitas vezes representa um grande desafio e um diagnóstico preciso é fundamental antes do tratamento. Embora níveis de prolactina > 200-250 ng/mL sejam altamente sugestivos de prolactinomas, ocasionalmente podem ser encontrados em outras condições. Além disso, até 25% dos pacientes com microprolactinomas podem apresentar-se com níveis de prolactina < 100 ng/mL, os quais são evidenciados na maioria dos pacientes com pseudoprolactinomas, hiperprolactinemia induzida por drogas ou doenças sistêmicas. Por outro lado, deve-se atentar às condições que podem levar a valores de prolactina falsamente baixos, particularmente o chamado efeito gancho. Este último é um artefato causado por um nível extremamente elevado de PRL e que pode ser confirmado pela repetição do exame após diluição do soro a 1:100. O efeito gancho deve ser considerado em todo paciente com grandes adenomas hipofisários e níveis de prolactina dentro da faixa normal ou apenas moderadamente elevados (p. ex., < 200 ng/mL). Um efeito gancho não detectado pode levar a diagnóstico incorreto e intervenção cirúrgica desnecessária em pacientes com prolactinomas. Outro desafio importante é a macroprolactinemia, um achado comum que precisa ser identificado visto que geralmente não requer tratamento. Ainda que a maioria dos pacientes seja assintomática devido à concomitância de outras doenças, muitos podem apresentar galactorreia ou distúrbios menstruais, bem como anormalidades neurorradiológicas. Finalmente, os médicos devem estar cientes de que incidentalomas hipofisários são encontrados em pelo menos 10% da população adulta. Arq Bras Endocrinol Metab. 2014;58(1):9-22.

Congenital lobar emphysema: Pitfalls and management.

Congenital lobar emphysema is a rare entity presenting in the first month of life. It appears with varying degrees of respiratory distress, clinical and radiological evidence of over-aeration of the upper and middle lobes, mediastinal shift and hypoxia. Its early recognition and surgical intervention can be life-saving. Even today, despite advanced diagnostic techniques, pitfalls in diagnosis and management are not uncommon and the condition may be mistaken for pneumothorax or pneumonia. This report elucidates the anesthetic management of three such cases with a review of literature.

Cytologic Findings of Cerebrospinal Fluid / 대한세포병리학회지

Cerebrospinal fluid (CSF) cytology is based on the cytopathologic findings of other body fluids. However, CSF's cytologic features are less familiar to physicians than are those of the other body fluid's cytology because of the small number of cases. The low overall diagnostic accuracy and the presence of false positivity still remain as problems. The incidence of lymphoreticular malignancies and metastatic carcinomas are rather higher than that of primary brain tumors. In this review, the characteristic cytologic findings of conventional CSF cytology are reviewed along with a brief note on the technical preparation and diagnostic pitfalls.