Association of Chlamydia trachomatis infection with human papillomavirus (HPV) & cervical intraepithelial neoplasia - A pilot study.

Background & objectives: Human papillomavirus (HPV) is the necessary cause of cervical cancer and Chlamydia trachomatis (CT) is considered a potential cofactor in the development of cervical intraepithelial neoplasia (CIN). The objective of this pilot study was to determine the association of CT infection with HPV, other risk factors for cervical cancer, and CIN in symptomatic women. Methods: A total of 600 consecutively selected women aged 30-74 yr with persistent vaginal discharge, intermenstrual/postcoital bleeding or unhealthy cervix underwent conventional Pap smear, Hybrid Capture 2® (HC2) testing for HPV and CT DNA and colposcopy, with directed biopsy of all lesions. Results: HPV DNA was positive in 108 (18.0%) women, CT DNA in 29 (4.8%) women. HPV/CT co-infection was observed in only four (0.7%) women. Of the 127 (21.2%) women with Pap >ASCUS, 60 (47.2%) were HPV positive and four (3.1%) were CT positive. Of the 41 women with CIN1 lesions, 11 (26.8%) were HPV positive, while two were CT positive. Of the 46 women with CIN2+ on histopathology, 41 (89.1%) were HPV positive, two (4.3%) were CT positive and one was positive for both. The risk of CIN2+ disease was significantly increased (P<0.05) by the following factors: age <18 yr at first coitus, HPV infection and a positive Pap smear. Older age (>35 yr), higher parity, use of oral contraceptives or smoking did not show any significant association with HPV or abnormal histopathology. Parity >5 was the only risk factor positivity associated with CT infection (P<0.05). Interpretation & conclusions: Our findings showed that CT infection was not significantly associated with CIN, and most of its risk factors, including HPV infection, in symptomatic women. Longitudinal studies with carefully selected study sample would be able to answer these questions.

Thoraco-abdominal mature teratoma in a left diaphragmatic hernia.

This case describes a contiguous mediastinal and retroperitoneal mature teratoma in a congenital diaphragmatic defect, a combination that is hitherto unreported in literature. It substantiates embryological chronology of events during the cephalad migration of the primordial germ cells through the developing diaphragm, prior to its closure.

Comparative evaluation of smear cytology & hybrid capture II for the diagnosis of cervical cancer.

BACKGROUND & OBJECTIVES: There is no ideal screening method for cervical cancer in India with the role of human papilloma virus (HPV) detection yet to be established. This study was undertaken to compare the diagnostic accuracy of HPV testing by hybrid capture II (HC-II) with conventional cervical smear cytology for squamous intraepithelial lesions (SIL). METHODS: This prospective study was conducted at New Delhi during 2003-2004 with patients selected from the gynaecology out patients of the All India Institute of Medical Sciences. Initial screening by a questionnaire and per-speculum examination were used to select high-risk patients. Patients, in whom conventional cytology, HC-II test and colposcopy-directed biopsy were done, formed the basis of this study. RESULTS: Of the 133 patients included in the study, incidence on biopsy of low grade SIL (L-SIL) was 6.77 per cent, high grade SIL (H-SIL) was 8.27 per cent and carcinoma was 3.00 per cent. Sensitivity and specificity of cytology for detection of H-SIL and above lesions was 93.33 and 83.49 per cent while for HC-II it was 93.33 and 90.83 per cent, respectively. HC-II had higher diagnostic accuracy of 91.13 per cent versus 84.68 per cent for cytology. Kappa for HC-II was higher (0.67) than cytology (0.52). Among patients diagnosed to have atypical squamous cells (ASC-US & ASC-H) and L-SIL, HC-II helped to select patients who had significant lesions on biopsy. INTERPRETATION & CONCLUSION: The main utility of HC-II is in the triage of patients with cytology smear diagnosis of ASC-US, ASC-H or L-SIL, for referral to colposcopic examination. HC-II alone has the best diagnostic accuracy but owing to high cost it is unsuitable for general screening in developing countries. Combining HC-II with cytology will refer smaller numbers for colposcopy,improving efficient utilization of available resources.

Diffuse multifocal chorangiomatosis of the placenta with multiple intestinal stenosis of the fetus: combination of rare causes for nonimmune hydrops fetalis.

Non-immune causes of hydrops fetalis are rare but frequently fatal. Identification of the cause for hydrops fetalis is essential to institute therapy. Chorangiomatosis and intestinal stenosis have not been previously reported as aetiological factors for the development of hydrops. We report a fetus born with hydrops associated with both of these conditions. A 1575 gms preterm neonate was born to a multigravida at 31 weeks of gestation. Emergency caesarean section was performed after detection of hydrops by prenatal ultrasonography. Baby had generalized edema at birth and died after 3 days due to progressive heart failure. At autopsy there was generalized edema and effusions. There were multiple stenotic segments in the intestine. Placenta showed numerous chorangiomas varying from 0.2 to 3 cm in diameter, hence diagnosed as diffuse multifocal chorangiomatosis. Examination of the placenta at neonatal autopsy is an essential part of assessment for hydrops fetalis. Chorangiomatosis is a rare and under reported condition which can cause prematurity, intrauterine growth retardation, pre-eclampsia and rarely hydrops fetalis.

Value of scoring system in classification of proliferative breast disease on fine needle aspiration cytology.

Fine-needle aspiration (FNA) cytology is successful in identification of benign and malignant breast lesions, but its role in proliferative breast lesions which increase cancer risk is poorly defined. We have analyzed the cytomorphologic features of proliferative breast lesions in conjunction with cytologic scoring system proposed by Masood et al and with histopathology. Sixty two patients (14 cases of fibroadenoma, 15 cases of fibroadenoma with atypia, 11 cases of proliferative breast disease (PBD), 8 cases of PBD with atypia and 14 cases of carcinoma) diagnosed on routine FNA were subjected to scoring following Masood's criteria. All cases with the cytologic diagnosis of fibroadenoma were confirmed on histology. Of 11 cases of PBD on FNA, 10 were PBD without atypia on histology. One case, which showed atypical hyperplasia on histology, was missed by both the scoring system and cytomorphology and one case was over-diagnosed as PBD with atypia by the scoring system. FNA cytology correctly identified all the carcinoma cases, while the scoring system under-diagnosed 2 cases as PBD with atypia. Hence, in cases not suspected to be atypical or confirmed to be cancer on routine cytology, scoring added no information over and above cytomorphology and was not useful. All fourteen cases of fibroadenoma with atypia suspected on routine cytology were fibroadenoma on histology. Scoring system correctly placed 11/14 of these cases as PBD without atypia. Similarly 3/8 cases thought to be PBD with atypia were correctly placed as PBD without atypia by scoring. Only 2/8 cases thought to be PBD with atypia on cytology were confirmed to have atypical hyperplasia on histology. Scoring improved the diagnostic yield to 2/5. Hence, in cases of fibroadenoma or PBD, suspected on FNAC to have cytological atypia, Masood scoring gives additional information by eliminating benign cases and improving diagnostic yield. Application of scoring in a step-wise manner, on atypical aspirates, can help in selection of cases suitable for biopsy.

Diagnosis of Pneumocystis pneumonia by bronchoalveolar lavage cytology: experience at a tertiary care centre in India.

BACKGROUND: Diagnosis of Pneumocystis pneumonia requires morphological demostration of P. carinii (now re-named as P. jiroveci). Although bronchoalveolar lavage (BAL) fluid cytology constitutes a formidable tool for detecting this infection, few studies on the utility of BAL cytology in diagnosing PCP are available from India. The present study reports the clinical spectrum, cytomorphological features and the utility of BAL cytology in diagnosing Pneumocystis infection from a tertiary care centre in India. METHODS: Retrospective study of 13 patients with PCP, diagnosed on examination of BAL fluid. RESULTS: The mean age of the patients was 41.2 years. One patient had human immunodeficiency virus (HIV) infection, while the other 10 were renal transplant receipients on immunosuppressive therapy. The immune status of two patients was unknown. Fever, cough and shortness of breath were the main presenting symptoms. Radiological diagnosis of Pneumocystis pneumonia was offered in only one case. Foamy alveolar casts were present in all cases. Silver methanamine stain enhanced the rounded, helmet or cleft forms of sporozoites. Inflammatory infiltrate was mainly polymorphonuclear. CONCLUSIONS: BAL cytology, thus, constitutes a useful diagnostic modality for morphological documentation and reliable diagnosis of Pneumocystis pneumonia in an immunocompromised host. Pneumocystis pneumonia appears to be a common opportunistic infection in renal transplant receipients in India.

The TACRD association is distinct from VACTERL association--a case report.

Tracheal agenesis is a rare malformation. A case of tracheal agenesis with associated ventricular septal defect, gastric hypoplasia, hiatus hernia, duodenal atresia, isomerism of the lungs, hypoplastic spleen with polysplenia, Meckel's diverticulum and fused crossed ectopia of the kidneys is presented. This case fits into a newly proposed TACRD association, an extremely rare condition composed of tracheal agenesis, cardiac, renal and duodenal malformations. It is distinct from the more common VACTERL association of which tracheo-esophageal fistula and not tracheal agenesis is a part. TACRD association has complex internal malformations and lacks the external skeletal manifestations of VACTERL association. Awareness amongst pathologists conducting neonatal autopsies is necessary for correct identification of this condition.

Xanthogranulomatous pancreatitis: mass lesion of the pancreas simulating pancreatic carcinoma--a report of two cases.

Xathogranulomatous inflammation is well known in the gall bladder and kidney. Xanthogranulomatous pancreatitis has not been previously described. We report two cases of this new clinicopathologic entity. The first was a 50 years old male with cholelithiasis and progressive obstructive jaundice for 5 months. Radiology was suggestive of carcinoma head of pancreas and a Whipples procedure was performed. The second was a 36 years old male with choledocholithiasis and features of chronic pancreatitis. During pancreaticojejunostomy, a mass was found in the tail of pancreas, which was excised with a suspicion of carcinoma. Gross examination of both specimens showed firm grey white masses, demarcated from the surrounding pancreas but with infiltrative margins, and were thought to be carcinoma. Histopathological examination showed localized inflammation with numerous foamy histiocytes along with dilated ducts and microabscesses. A diagnosis of xanthogranulomatous pancreatitis was made in both instances. In view of clinical, radiological, operative and gross appearances of our cases simulating carcinoma, recognition of xanthogranulomatous chronic pancreatitis as a distinct clinicopathological entity seems important, analogous to similar lesions of the kidney and gall bladder.

Rapid staining using toluidine blue: a reliable method for quick diagnosis in ultrasound-guided aspiration cytology.

Rapid staining of ultrasound guided aspirates is an accepted procedure for evaluation of adequacy and rapid diagnosis (RD). We have assessed the reliability of Toluidine blue stain in this regard, which has not been previously reported. 295 ultrasound guided aspirates performed over a 13 month period were studied. 59 aspirates were inadequate for RD. 103 cases were called malignant on RD of which 101 were confirmed, and 2 cases were considered highly suspicious on final diagnosis. Of 34 cases considered suspicious on RD, 32 were either signed out as malignant or considered highly suspicious while 2 cases were benign. Of 56 cases considered benign on RD, 49 were confirmed, 2 were suspicious for malignancy and 5 cases had inadequate material on final diagnosis. All 43 inflammatory lesions on RD were confirmed. The overall sensitivity for a malignant/suspicious for malignancy diagnosis was 98.54% on RD while specificity was 97.99%. Sensitivity and specificity for an inflammatory condition was 100%. Toluidine blue staining is not only a reliable method for rapid staining and diagnosis, it also permits preservation of cytological material by destaining and restaining with permanent stains.

Focal segmental glomerulosclerosis in childhood: histology, glomerular morphometry, electron microscopy and immunofluorescence findings in biopsies performed early in the course of the disease.

The histological evolution of Focal Segmental Glomerulosclerosis (FSGS) is poorly documented due to variation in the time at which the biopsy is taken. We looked at patients presenting with steroid resistant nephrotic syndrome (SRNS) in which the first biopsy was performed within 3 months of presentation. FSGS lesion was demonstrable in 68.5% of cases in the first biopsy. Glomerular size was increased in 86% of patients indicating that is an early event in the course of the disease. The group was heterogenous with respect of mesangial cellularity, mesangial matrix, position of FSGS lesion in the glomeruli, glomerular size, lamina densa thickness and immunofluorescence findings. No association of morphological features was seen permitting subclassification of this group on morphological grounds. Thus, both the FSGS lesion and glomerular enlargement occur early in the evolution of idiopathic FSGS presenting with SRNS.