Plasmablastic lymphoma of bone marrow: Report of a rare case and immunohistochemistry based approach to the diagnosis

Plasmablastic lymphoma (PBL) is a distinctly rare neoplasm believed to arise from post-germinal center, terminally differentiated, activated B cells before transformation to plasma cells; and predominantly affecting human immunodeficiency virus (HIV) infected or immunodeficient males. Here, we report a rare case of primary PBL of bone marrow in an immunocompetent male, the diagnosis of which is complicated by the overlapping morphology and immunophenotype with several large cell lymphomas and plasma cell neoplasms; and showing dramatic response to anti-CD30 monoclonal antibody based therapy. We discuss the immunohistochemistry based approach and the possible diagnostic pitfalls in such cases. The inclusion of markers of plasmablastic differentiation in the diagnostic panel of large cell lymphomas is essential to avoid misclassification of these rare lymphomas.

Angiographic predictors of success in antegrade approach of Chronic Total Occlusion interventions in a South Indian population in the contemporary era

Chronic Total Occlusion (CTO) intervention is a challenging area in interventional cardiology. Presently about 70% of CTO interventions are successful. Materials and methods This was a single center prospective study of a cohort of all patients undergoing percutaneous coronary intervention (PCI) as elective or adhoc procedure for CTO from August 2014 to June 2015. Only antegrade CTO interventions were included. In all patients the following data were recorded. Results A total of 210 (8.9% of total PCI (2353) during the study period) CTO patients were followed up. The mean age was 56.54 ± 8.9. In the study sixty nine patients (32.9%) presented with chronic stable angina and rest of the patients had history of acute coronary syndrome of which 22.9% (n = 48) had unstable angina (UA) or non ST elevation myocardial infarction (NSTEMI) and 44.2% (n = 93) had ST Elevation Myocardial Infarction (STEMI). In those with history of ACS, 64.78% (n = 92) had ACS during the previous year and remaining 35.22% (n = 49) had ACS prior to that. Single vessel CTO was seen in 89.5% (n = 188) and two vessel CTO in 10.5% (n = 22). LAD was involved in 36.7% (n = 77), RCA in 48.1% (n = 101), and LCX in 15.2% (n = 32). Procedural success in the first attempt was 68.1% (n = 143), which increased to 71.42% (n = 150) after the second attempt. CTO interventions were more frequently successful when the calcium was absent or minimal (p-0.05), CTO length was <10 mm (p < 0.01) and good distal reformation (p < 0.01).

Geographical variation in the clinical presentation of endomyocardial fibrosis in India?

Objectives To compare the clinical presentation, clinical profile and survival of two groups of endomyocardial fibrosis patients. Methods The study was a prospective cohort study, or a prospective case series, comparing all consecutive echocardiographically proven patients with endomyocardial fibrosis seen in Medical College Trivandrum with the patients seen in Medical College Hospital, Alappuzha(Alleppey) (or TD Medical College). In all patients the clinical details like age, sex, type of endomyocardial fibrosis, the presence of anaemia, eosinophilia, neutrophilia and type of rhythm(Sinus or atrial fibrillation) etc were compared by both simple X2 and by Kaplan Meier survival curves. Results The mean age and the sex distribution was same in both places Briefly the incidence of biventricular endomyocardial fibrosis was more from Trivandrum than Alleppey, 64.9% vs 14.3% (p < 0.0.001), the incidence of atrial fibrillation was more in Trivandrum 44.2% vs 16.3%. (p < 0.001)The overall survival of Trivandrum patients was poorer (p < 0.0001). The six year survival was 61% in the Trivandrum population whereas it was 91.5% in the Alleppey population. Conclusions These differences may have been due to the better nutrition of the Alleppey patients due to a higher exposure to fish compared to the Trivandrum population. Better nutrition would protect against Magnesium deficiency and prevent the absorption of Cerium in the patients from Alleppey, compared to those from Trivandrum.

Non-healing gastric ulcer associated with Candida infection.

Candida bezoars of the stomach usually occur after gastric surgery. We report a small Candida mass occurring on a non-healing gastric ulcer in a 40-year-old male non-smoker. The ulcer healed with fluconazole and withdrawal of the proton pump inhibitor.

Loss of virus specific epitopes on JE virus 'E' glycoprotein by acetone treatment.

BACKGROUND & OBJECTIVES: Some Japanese encephalitis (JE) virus strains have been placed in group II based on the loss of reactivity against Hs (H = HI positive; s = JE virus specific) group of monoclonal antibodies (MAbs) in haemagglutination-inhibition (HI) test employing sucrose acetone (SA) extracted antigens. Also acetone-fixation of cells infected with some of the virus strains results in the loss of immunofluorescence (IF) against virus specific MAbs. The present study was undertaken to elucidate the effect of acetone on virus specific haemagglutination (HA) epitopes expressed on 'E' glycoprotein of group II strains of JE virus. METHODS: Porcine kidney (PS) cells were infected with JE virus strains (2 group I Indian strains, 5 group II strains and one neutralization-escape variant of 733913 group I strain). HI and complement fixation (CF) tests were carried out employing both polyethylene glycol (PEG) precipitated and SA extracted antigens of JE virus. RESULTS: Employing PEG precipitated antigens, Indian strain G9473 showed titres ranging from 1:40 to 1:160 against all the four virus specific HsMAbs and strain 641686 (1:160) with one of the four MAbs (Hs-1) by HI test whereas their SA extracted antigens did not react at all. In contrast, CF was positive employing both SA and PEG antigens in the presence of all four HsMAbs. The reactivity shown by PEG antigens in the HI test was confirmed by blocking the HA activity with the respective MAb. SA antigens, though negative in the HI test, were positive by the blocking assay. Interestingly, some of the non-HI MAbs which were negative against SA antigens, showed positive HI reaction with PEG antigens. Also, additional epitopes on Japanese (Yoken), Sri Lankan (691004) and two Indian (755468 and 641686) JE virus strains were detected either by blocking HA or surface IF. INTERPRETATION & CONCLUSIONS: It seems that the acetone treatment might result in HA property of the antigen which is no longer inhibited by an antibody in the HI test. The characterization of such labile and conformation-dependent epitopes is currently been undertaken to elucidate their role either in protection or immunopathogenesis of JE.

An IgM monoclonal antibody to Japanese encephalitis virus recognizing a cross-reactive epitope on nuclear histones.

An IgM class of monoclonal antibody (MAb) raised against 'envelope' (E) glycoprotein of Japanese encephalitis (JE) virus, cross reacted with nuclear histones, in addition to recognizing the viral antigen present in the cytoplasm of infected cells by indirect fluorescent antibody (FA) technique. The experiments on histone depletion by the acid treatment of uninfected PS (porcine kidney) cells, revealed the loss of nuclear immunofluorescence (IF) which was regained after the reconstitution of acid treated cells with histones, prior-to reacting with MAb NHA-2. The IgM MAb recognized specifically the viral antigens expressed on the surface of JE virus infected PS cells by a modified indirect FA. The adsorption of MAb NHA-2 with calf thymus histones (type II-AS) showed a comparative higher drop in the reactivity to JE virus (54.2% reduction) as compared to that against uncomplexed histones (33.3%) by ELISA, thus indicating a higher MAb affinity to the former. In contrast, the adsorption of MAb with chicken RBC nuclei resulted in comparatively more reduction in the reactivity to the uncomplexed histones (52.4% reduction) as against JE virus (37.5%), suggesting that DNA plays some role in modifying and presenting these epitopes. The cross-linkage of epitopes by glutaraldehyde treatment of JE virus antigen and histones showed a 2-fold and higher rise in the MAb reactivity as against those with unfixed or methanol fixed antigens (no cross-linkage), suggesting that the epitope is conformation dependent. Thus, histones seem to share a partial conformational homology with 'E' glycoprotein of JE virus and immune reaction with histones might lead to an autoimmune disorder.

Complete heart block in rheumatoid arthritis.

A case of rheumatoid arthritis with complete AV heart block is reported. The relevant literature is briefly reviewed.

Beta blockers in portal hypertension--current status.

Pharmacotherapy of portal hypertension started with the use of intravenous vasopressin in the 1960s. However, the short half life of the drug and the non-availability of an oral preparation limited its use to acute variceal bleeding. It was two decades later that propranolol, a beta blocker was shown to decrease portal pressure. However, the usefulness of beta blockers in the treatment of recurrent variceal bleeding remains controversial with controlled trials showing both benefit and lack of benefit. This review is aimed to bring into perspective, current knowledge of the effect of beta blockers on the splanchnic circulation in man and animals, its clinical usefulness in portal hypertension and its place in the therapeutic armamentarium against portal hypertension.

Aortoarteritis presenting as coarctation of aorta.

An interesting case of Aortoarteritis with clinical features simulating congenital coarctation of aorta (COA) is presented. Clinical pointers of differentiation of these conditions are discussed. Relevant literature is reviewed.

Leprosy, liver and jaundice.

Nine patients of leprosy, 5 BL and 4 LL who developed jaundice during the course of disease were investigated. Two LL patients developed jaundice during ENL reaction. There was slight hepatomegaly in 5 patients and moderate splenomegaly in 3 only. There was significant alterations in liver enzymes and serum bilirubin in all patients. The abnormalities of the enzymes levels persisted for abnormally long periods even when the serum bilirubin had come down and the patients had become asymptomatic. Blood for HBsAg and anti-HAV IgM was negative in all the patients except one in whom HBsAg was positive. Drugs could not be implicated as the cause of jaundice, all patients maintained recovery even after restarting antileprosy drugs. The possibility of non A, non B viruses producing hepatitis during the course of disease is brought out. Course of prolonged jaundice in leprosy is compared with other diseases which could result in a similar situation.