Diagnostic approach to a rare case of anaplastic meningioma with osteosarcomatous differentiation and associated bone alterations

Anaplastic meningioma with osteosarcomatous differentiation is a very rare finding. We herewith present squash cytology, histopathology and immunohistochemistry findings of this rare case with systematic approach to diagnosis. A 38-year-old female presented with complaints of headache, vomiting, seizure with loss of consciousness and left side weakness. Radiologically, there was a heterogeneous hyperintense likely extra axial densely calcified solid lesion measuring approximately 4.2�1�5 cm along right high frontal convexity compressing the adjacent brain parenchyma. Histology sections revealed fibro collagenous tissue, devitalized bone, multiple vascular spaces lined by fibrous septa with giant cells, along with spindle cell and round proliferation at one end with vague whorl formation. High mitosis, (>20/10 hpf) along with malignant lacy osteoid closely abutting the highly pleomorphic cells were indicative of a malignant spindle cell neoplasm with osteosarcomatous differentiation. Systematic approach, immunohistochemistry with involvement of all the specialities involved led to the correct diagnosis and management of patient.

Inclusion of carbohydrate antigen 242 in addition to carbohydrate antigen 19.9 in serological workup of carcinoma gall bladder: a case series analysis

Background: Common antigenic pool is seen because of shared embryonic origins of gall bladder cancer (GBC) and pancreas. Hence, we analyzed the role of serum carbohydrate antigen 242 (CA242) which has been studied in pancreatic cancer, in GBC. The objectives were to identify whether serum CA242 provides added advantage in diagnosis of GBC when compared to controls and to determine its cut-off value. Methods: Serum CA 19-9 level was determined by chemiluminescent micro particle assay and CA242 by enzyme linked immunosorbent assay (ELISA) of age matched cases and controls. Results: Total enrolled patients were 83 including 10 (11.7%) healthy volunteers, 22 (25.9%) chronic cholecystitis cases, and 53 (62.4%) patients with histological evidence of carcinoma. Mean age of presentation of GBC was 51.64 SD10.88 years with F: M ratio of 5.6:1. Pain (90.6%, 48/53) accompanied with jaundice was significantly associated with GBC well reflected by significantly raised serum total bilirubin (p=0.011), direct bilirubin (p=0.008) along with alkaline phosphatase levels (p=0.001). Significantly higher median value of CA 19-9 and CA242 was observed in GBC when compared to CC and healthy volunteers (p<0.001) with a significant correlation between tumor size (>2.5 cm) and serum levels of CA242. The best cut-off limit for CA242 was 45.25 IU/ml. The specificity for carcinoma diagnosis increased to 100% when CA242 was included along with CA 19.9 in serological estimation. Conclusions: We recommend that CA antigen 19-9 may be complimented with CA242 for serological identification of malignancy in the gall bladder.

May-Thurner syndrome causing venous thromboembolism in a young female with Sturge weber syndrome and connective tissue disease

May-Thurner syndrome (MTS) is a rare condition characterized by the compression of the left common iliac vein by the overlying right common iliac artery. It is a unique causal reason for development of deep venous thrombosis (DVT) and pulmonary embolism (PE). Young females developing DVT should be examined and investigated with details as triggers can include trauma, pregnancy, autoimmunity. In this case report we report a case of a young female who had Sturge Weber Syndrome, and how a left hip pain was diagnosed as DVT which led to diagnosis of an underlying MTS and autoimmune trigger for her hypercoagulable state.

Immunohistochemical appraisal of epithelial mesenchymal transition type III in gall bladder cancer

Background: Epithelial-mesenchymal transition (EMT) is the heart of invasion. EMT associated with cancer progression and metastasis is known as type III EMT. Beta-catenin, E-cadherin, and MMP9 markers of EMT are routinely employed for diagnostic purposes. Aims: We employed these markers to study EMT by immunohistochemistry (IHC) in gall bladder cancer (GBC) with respect to depth of tumor invasion, clinical outcome, and disease-free survival. Settings and Design: This was a prospective case-control study. Material and Methods: Seventy gall bladders were included (50 GBC and 20 CC). After detailed histology, immunoexpression was studied in terms of percentage and strength of expression. Statistics Analysis Used: Expression was compared between CC and GBC by Student t test and analysis of variance. Kaplan–Meier was used for survival analysis, and the extent of agreement (“Kappa”) was calculated. Results and Conclusions: The age of incidence of GBC was 49.40 (+11.6) years with female predominance (F:M = 4:1). In 88% (44/50) of GBC, the fundus was involved. Moderately differentiated adenocarcinoma was most frequent [54%; 27/50]. Significant downregulation of E-cadherin (P = 0.022) and beta-catenin (P < 0.001) and upregulation in MMP9 (P < 0.001) were seen in GBC with respect to CC with significant association among them. MMP9 expression was significantly associated with higher tumor stage but with chemotherapeutic response. Our results display that epithelial-mesenchymal transition type III plays a role in GBC invasion. MMP9 overexpression and loss of membranous beta-catenin may be considered a marker for poor clinical outcomes and advanced disease.

Clinicopathological profile of hepatoblastoma: An experience from a tertiary care center in India

Background: Hepatoblastoma is the most common primary hepatic malignancy in the pediatric population. Advances in pathological evaluation, imaging, risk stratification, neo-adjuvant chemotherapy, and surgery including transplantation have improved survival of these children in the western countries. However, a successful outcome in developing countries such as India with limited resources poses great challenges to the clinician and the family. Histology plays a major role in determining the prognosis of these patients. Methods: A retrospective study was done on 10 children diagnosed with hepatoblastoma between January 2010 and December 2015 in our institution. Clinical, laboratory, radiological, histopathological diagnoses, treatment, and outcome data were collected and analyzed. Results: The median age of these children at diagnosis was 11 months, and only 1 child was premature at birth. Most children were presented with abdominal distension. One child had lung metastasis at presentation. Elevated alpha fetoprotein levels were present in 90% of the children. The histological types were fetal, embryonal, macrotrabecular, and mixed epithelial-mesenchymal types. SIOPEL risk stratification was done, which showed 40% of the children to be of high risk. Three children had PRETEXT 1, 2, and 4, respectively. Conclusion: Our study is significant with respect to the information on PRETEXT staging, risk status, and histological favorability. In developing countries with limited resources and low-socioeconomic status, it is important to have a multidisciplinary team approach and tailor treatment to manage these patients effectively and improve the overall survival.

Impact of Migration on Epidemiology and Control of Leprosy

Migration has been a major influencing factor facilitating movement of disease between endemic and nonendemic areas. Both internal migration and global immigration contributes to spread to disease to nonendemic areas. This review discusses the findings of studies carried out all over the world regarding the role of migration in leprosy. It focuses on factors contributing to migration within the country, effect of migration on leprosy control programme, migration related factors adding to stigma and leading to administrative problems in leprosy control programmes. Migration of leprosy patients affects the opportunities to seek timely treatment at other places due lack of leprosy treatment facilities or awareness among the users. This review analyses the published studies available in PubMed and news articles related to migration in Leprosy. Out of total 2506 search results, only 18 were found to be relevant. In these studies migration has been identified as one of the important obstacles in achieving elimination of leprosy as the affected individuals may continue to spread the disease and themselves may suffer from disabilities with social consequences. The review also finds paucity of scientific studies carried out to study the role of migration in leprosy at present. There is clear need to focus on in depth studies on this aspect in the contemporary scenario for achieving the goal of world without leprosy.

Clinical profile of childhood blindness and inappropriate enrolment of children in schools for visually impaired in Uttar Pradesh, India

Purpose: To assess major causes of severe visual impairment (SVI)/blindness (BL) in children studying in schools for the blind in western Uttar Pradesh, India and the extent of inappropriate enrolment of children in blind schools. Methods: Students of five schools for the blind were examined in a tertiary care eye hospital. The anatomical sites and etiology for SVI/BL were recorded using the World Health Organization/Prevention of Blindness standard reporting form. Categorical variable were summarized using frequencies and percentages. Results: A total of 93 students were examined. Male/Female ratio was 3.4:1. The most common anatomical sites of SVI/BL were the whole globe (40.3%) and the cornea (26.4%). Postnatal or childhood causes were noted in 13.8% cases. Forty-one (56.9%) students had hereditary diseases which was most likely caused by chromosomal abnormalities. Three students were having an associated disability, one was deaf and mute, one was physically handicapped, and one was intellectually challenged. Fifty-four (58%) children were blind and 21 (22.6%) children had no visual impairment but were studying in schools for the blind. Conclusion: Schools for the blind should be screened routinely to reduce the incidence of misdiagnosed visual impairment. This will prevent inappropriate enrolment and will definitely help in reducing the social and economic burden of society and of the schools of blind too.

Posterior lenticonus with persistent fetal vasculature

A 10 year old girl present with both eyes central cataract with posterior lenticonus. Intraoperative, she was noted to have both eyes persistent fetal vasculature (PFV). To the best of our knowledge, association of bilateral posterior lenticonus and PFV has not been reported before. This supports the hypothesis that PFV has a role in pathogenesis of posterior lenticonus.

Urothelial carcinoma of urinary bladder with exclusive heterologous component of epithelioid rhabdomyosarcoma at metastatic site

Urothelial carcinoma of urinary bladder with divergent differentiation into rhabdomyosarcoma (RMS) is an extremely uncommon aggressive phenomenon. We present a case of a 74-year-old male with bladder carcinoma which metastasized to the abdominal wall as epithelioid RMS. To the best knowledge of our literature searches, an oligometastasis of exclusive heterologous component has not been described before. The clinical, radiological, and immunohistochemistry profile of the patient supported the monoclonal nature of the tumor.

Molecular characterisation of Staphylococcus aureus using spa typing as a diagnostic tool in Haryana, India

Background: Staphylococcus aureus is one of the top six most common etiologic agents of nosocomial, community and livestock acquired bacterial infections. These infections although initially were described as a major problem in hospitals have now also become a serious threat in community not only in India but also worldwide. Its prevalence varies depending on the health-care setting, country or a particular region. Thus to better understand the epidemiology of methicillin-resistant S. aureus (MRSA) in a particular geographical location, it is important to study the variations in the population using molecular tools. Methods: This prospective study was carried out in the Department of Microbiology of Shree Guru Gobind Singh Tricentenary (SGT) Medical College. Staphylococcal protein A (spa) typing was done on 250 S. aureus isolates obtained from various clinical specimens including pus, wound swabs, urine, catheters, blood and cerebrosspinal fluid from both indoor and outdoor patients of SGT Hospital, Budhera, Gurgaon. Results: The selected region of the spa gene of all 250 isolates which includes 87 MRSA and 163 methicillin-susceptible S. aureus were amplified. The spa gene was detected in 248 out of 250 isolates (99.2%), whereas in 2 isolates (0.8%), it remained undetected and referred as non-typable isolates. The 248 S. aureus isolates were typed into 39 spa types, which clustered into six different spa clonal clusters and eight singletons. Conclusion: High diversity observed within S. aureus isolates indicated that many different strains circulate in the study region or in the hospital. The results would contribute in the understanding of epidemiology related to S. aureus spread and prevention.

Scalds - An Epidemiological Study of Last 10 Years

Introduction: Scald is caused by hot liquids and hot vapors. Scalds are frequently seen in our institutions. Scald injuries are mainly seen in children and persons with sensory neuropathies. Most of these injuries are preventable, even after that many of the patients may, however, end with severe morbidity or even death. The aim is to evaluate the epidemiological data of scald at tertiary health centre of central India in last 10 years and correlation between them. Materials and Methods: A retrospective study starting from January 2006 to December 2016 of scald burns was carried out at N.S.C.B. Medical College, Jabalpur, to outline different age, sex, percentage of burns, seasonal variations, and outcome in terms of patient discharged (cured) and expired. Result: Total number of scald patients was 749, out of which male were 492 (65.68%) and female were 257 (34.31%). Scald in age group 0–10 years was most common with 555 patients of total 749. In male of 0–10 years - 354 (71.95%), 11–40 years - 118 (23.98%), 41–60 years - 20 (4.06%), and >60 years - 0 (0%), in female of 0–10 years - 201 (78.21%), 11– 40 years - 41 (15.95%), 40–60 years - 15 (5.83%), and > 60 years - 0 (0%). Percentage of scald in male 0–20% - 314 (63.82%), 20–40% - 147 (29.87%), 40–60% - 19 (3.86%), and >60% - 12 (2.43%), in female 0–20% - 156 (60.70%), 20–40% - 74 (28.79%), 40–60% - 18 (7%), and >60% - 9 (3.5%). Scald in different seasons in winters (November–February) - 285 (57.92%) (in male) and 139 (54.08%) (in female), in summers (March–June) - 88 (17.88%) (in male) and 48 (18.67%) (in female), and in rainy season (July–October) - 119 (24.18%) (in male) and 70 (27.23%) (in female). Scalds in male discharged - 453 (92.08%) and expired - 39 (7.92%) and in female discharged - 235 (91.5%) and expired - 22(8.5%). Conclusion: Majority of the scalds are in pediatric age with less percentage of burn body surface area so can be treated well with less mortality. Scalds are preventable burns just by waring parents and educating people it can be reduced further as prevention is better than cure.

Management of Hemorrhoids.

This article discusses the pathophysiology, risk factors, classification, clinical evaluation and current nonoperative and operative treatment of hemorrhoids. Hemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushions. The most common symptom of hemorrhoids is rectal bleeding associated with bowel movement. The abnormal dilatation and distortion of the vascular channel, together with destructive changes in the supporting connective tissue within the anal cushion, is a paramount finding of hemorrhoids. It appears that the dysregulation of the vascular tone and vascular hyperplasia might play an important role in hemorrhoidal development, and could be a potential target for medical treatment. In most instances, hemorrhoids are treated conservatively, using many methods such as lifestyle modification, fiber supplement, suppository-delivered anti-inflammatory drugs and administration of venotonic drugs. Nonoperative approaches include sclerotherapy and, preferably, rubber band ligation. An operation is indicated when nonoperative approaches have failed or complications have occurred. Several surgical approaches for treating hemorrhoids have been introduced including hemorrhoidectomy and stapled hemorrhoidopexy, but postoperative pain is invariable. Some of the surgical treatments potentially cause appreciable morbidity such as anal stricture and incontinence. The applications and outcomes of each treatment are discussed.

Clinical & immunological profile of newly diagnosed patients with youth onset diabetes mellitus.

Background & objectives: There has been a rise in the incidence of diabetes mellitus in the younger population of India. There are limited data available on the immunological profile of youth onset diabetes mellitus (DM) especially in type 2. Therefore, this study was undertaken to evaluate the clinical and immunological profile of youth onset DM in north India. Methods: Fifty one consecutive patients of 8-35 yr of age with diabetes mellitus attending the Lok Nayak Hospital, Maulana Azad Medical College, New Delhi, and Hormone Care and Research Center at Ghaziabad, Uttar Pradesh, India, were included in the study. All subjects were tested for glutamic acid decarboxylase (GAD), an islet cell antigen ICA512/IA2, and insulin antibodies. GAD and ICA512/IA2 were done by ELISA and insulin autoantibodies were tested by radioimmunoassay (RIA) method. These patients were also screened for hepatitis A to E, cytomegalovirus (CMV) and Epstein-Barr virus (EBV) as trigger factors for onset of type 1 DM. Results: of the total 51 patients, 38 were men and 13 were women. The mean age and BMI of the subjects was 19.7 (±7) years and 21 (± 5) kg/m2, respectively. Twenty patients were below the age of 18 yr and their height was more than 75th percentile of Indian standards. All patients were symptomatic and 12 of these presented with ketoacidosis. only 48 per cent (n=24) were positive for GAD, 14 per cent (n=7) for ICA512/IA-2, and 28% (n=14) were positive for insulin antibody. Five of these patients had evidence of hepatitis E virus infection. None of the subjects had evidence of active CMV or EBV infection. Interpretation & conclusions: About half of the youth onset diabetes mellitus patients from north India had presence of pancreatic autoimmunity in the form of GAD, ICA512/IA2, and insulin antibodies or a combination of antibodies suggestive of having type 1 DM. Further studies need to be done on a large sample size in different parts of the country.

Role of Rabeprazole on Chest Discomfort of Uncertain Origin.

Chest discomfort is a common challenge to clinicians; conditions vary from benign to life threatening. The differential diagnosis includes and overlaps cardiovascular, respiratory, gastrointestinal, neuromusculoskeletal & psychiatric problems, all requiring careful history and thorough investigations. However, a significant number of cases remain undiagnosed despite meticulous investigations and thus require empirical therapy (Fagring et al, 2005; Thomas, 2012). The present study was aimed to find the effect of one of the Proton-pump inhibitors (PPIs; Rabeprazole) on patients having non-traumatic, non severe chest discomfort, diagnosis of which could not be confirmed. Forty eight eligible patients were divided into 2 groups: PPI group and placebo group. Before and after 4 weeks of therapy, they were studied with visual analog scale for pain and its frequency, duration and intensity. Rabeprazole treated patients responded much better than the placebo group. Seventy five percent were pain free or had appreciable relief in pain intensity after 4 weeks. In contrast to Rabeprazole group, in placebo group none became pain free; 45 % had marginal relief while 55 % derived no benefit. Proton-pump inhibitors are of value in the treatment of non specific chest discomfort.

Pulmonary hydatid disease with coexistent aspergillosis: An incidental finding.

There are only a few case reports in the literature on the coexistence of aspergillosis and echinococcosis. We report a case of a 45-year-old immunocompetent patient who presented with a history of intermittent fever and cough with haemoptysis. Chest x-ray and CECT showed a large cystic lesion in right lower lobe with multiple floating membranes. Histopathological examination of cyst wall revealed the laminated membrane of hydatid cyst along with infiltration of its wall with septate fungal hyphae with acute angle branching suggestive of aspergillosis.

Fenofibrate: A novel approach in treating uncomplicated neonatal hyperbilirubinemia.

Fenofibrate is one of the commonest drug to treat hyperlipidemia in adults (Marshall et al, 2011). However, apart from its hypolipidemic action, it also has the ability to induce bilirubin conjugation. The present study was aimed to find its effect on uncomplicated neonatal hyperbilirubinemia. The study was conducted on 40 normal term newborns who were admitted for uncomplicated jaundice at R.D. Gardi Medical College & Hospital, Ujjain from March 2010 to October 2010. The data included: age, sex, weight, serum bilirubin level, and duration of hospitalization. All newborns enrolled in this study, received phototherapy. The cases were divided into two groups viz. Fenofibrate group (B) consisting of 14 boys (70%) and 6 girls (30%) and a control group (A) with 11boys (55%) and 9 girls (45%). There were no statistical overt differences between the two groups regarding sex distribution, age, weight and total serum bilirubin level at the time of admission. Mean values for total serum bilirubin in Fenofibrate group at 12, 24, 36, and 48 hours after starting of phototherapy were significantly lower than those for control group (p<0.00l). The mean time needed for phototherapy was also shorter in Group B than Group A. Fenofibrate appears to be an effective drug for neonatal hyperbilirubinemia. This decreases the duration of phototherapy and thus reduces the length of hospital stay.