Reporting Pancreatic FNAC using the Papanicolaou System: Still a Diagnostic Challenge.

Introduction: The Papanicolaou Society of Cytopathology System for reporting Pancreaticobiliary Cytology (PSCPC) is a reliable method to classify pancreatic fine needle aspiration cytology (FNAC) smears. However, it is not without practical problems which can diminish the diagnostic accuracy of the cytological diagnosis. Aims and Objectives: To determine the diagnostic pitfalls while reporting cytomorphology of pancreatic lesions according to PSCPC on correlating FNAC findings with histopathology. Materials and Methods: Retrospective analysis of pancreatic FNAC smears received in the Department of Pathology of our tertiary care institute over a period of 2 years was done. The cytological diagnoses were classified according to the Papanicolaou Society of Cytopathology system of reporting pancreaticobiliary cytology and correlated with histopathology. The reasons of cyto-histological discordance were analyzed. Results: Out of 50 cases in which both FNAC and biopsy of pancreatic lesions were done, 34 cases were positive/malignant (Category VI), eight cases were suspicious for malignancy (Category V), three cases were neoplastic (Category IV), two cases were atypical (Category III), two cases were negative for malignancy (Category II), and one case was non-diagnostic (Category I). Out of 50 cases, histopathology was non-diagnostic due to inadequate material in six cases. The cytological diagnoses were compared with histopathology in the remaining 44 cases. Categories III, IV V, and VI were considered as positive for neoplastic pathology. The sensitivity of FNAC to predict neoplastic pathology was 97.5%, while the specificity was 25%. The positive predictive value was 92.9%. Two cases reported as atypical (Category III) turned out to be adenocarcinoma on histopathology. One case reported as neuroendocrine tumor and two cases reported as adenocarcinoma on cytology displayed features of chronic pancreatitis on histology. One case reported as neoplastic mucinous cyst (Category IV) turned out to be adenocarcinoma on histology (limited concordance). Conclusion: The cytopathologist needs to be wary of the potential pitfalls to improve the diagnostic accuracy of FNACs.

The Effect of Diabetes Mellitus on Outcomes of Patients Admitted with COVID-19: A Single - Center Experience from a Tertiary Hospital in India.

Background and Objectives: Diabetes mellitus is associated with poor clinical outcomes in patients with coronavirus disease 2019 (COVID-19). This study aimed to explore the clinical characteristics of patients with type 2 diabetes with COVID-19, and to determine the impact of type 2 diabetes on clinical outcome of patients with COVID-19. Material and Methods: This single-center, retrospective, observational study enrolled patients admitted from March 2020 to June 2021 with COVID-19. The clinical and biochemical characteristics of patients with known type 2 diabetes, newly diagnosed diabetes, type 2 diabetes with comorbidities and those who succumbed to illness were analyzed. Results: Of 4,559 patients with COVID-19, 2,090 (45.8%) had type 2 diabetes. Patients with COVID-19 with diabetes were older, more likely to receive mechanical ventilation, had higher odds of mortality from COVID-19 as compared with patients without diabetes. In addition, patients with diabetes had significantly higher levels of serum creatinine, C-reactive protein, ferritin, lactate dehydrogenase, and D-dimer. Compared with previously diagnosed patients with diabetes, newly diagnosed patients had higher mortality (33% vs. 27%, P = 0.049). Among patients with COVID-19 and diabetes, nonsurvivors had significantly higher levels of inflammatory markers and had severe impairment of cardiac, renal, and coagulation parameters as opposed to survivors. Conclusion: Patients with COVID-19 with diabetes were more likely to have severe disease and had higher mortality. Presence of chronic kidney disease and coronary artery disease in patients with diabetes with COVID-19 was associated with adverse outcome. Patients with newly diagnosed diabetes had higher odds of severe disease at presentation and had higher mortality.

Endocrine and Metabolic Manifestations of COVID-19 Patients Admitted to an Intensive Care Unit.

CONTEXT: The effects of coronavirus disease 2019 (COVID-19) on the endocrine system remain uncertain. OBJECTIVE: Our study aimed to explore the possible effects of COVID-19 on endocrine organs and to determine the impact of glycemic status, 25-hydroxyvitamin D levels, calcium levels, and thyroid dysfunction on the final outcome of patients with COVID-19. DESIGN AND METHODS: This single-center, retrospective study evaluated endocrine function abnormalities in 102 patients hospitalized with COVID-19 in the intensive care unit (ICU). RESULTS:  Of 102 patients admitted to ICU, 42 (41.2%) succumbed to illness. The most frequently observed abnormality in thyroid function tests was low free triiodothyronine (FT3) levels (56%). A thyroid profile indicating thyrotoxicosis was detected in five (4.9%) patients, and overt hypothyroidism was identified in two (1.9%) patients. New-onset diabetes was detected in five (4.9%) patients whereas diabetic ketoacidosis at presentation was found in six (5.9%) cases. Rhino-orbital mucormycosis was detected in one patient with diabetes during treatment of COVID-19 while three (2.9%) patients were diagnosed with pulmonary mucormycosis after recovery from COVID-19. Hypocalcemia was observed in 52 (51 %) patients. Out of 42 patients who died, 32 patients had low FT3, 26 patients had high glycated haemoglobin (HbA1c), and 33 patients had low 25-hydroxyvitamin D. Multivariate analysis demonstrated that low concentration of 25-hydroxyvitamin D, low FT3 and higher HbA1c levels were significantly associated with increased mortality. CONCLUSION:  New-onset thyrotoxicosis in COVID-19 patients is mostly due to subacute thyroiditis. Hypocalcemia is also frequently encountered in patients with moderate disease and those with critical COVID-19. A high index of suspicion is required to timely diagnose mucormycosis in COVID-19 patients with diabetes.

Diabetes and rhino-orbito-cerebral mucormycosis - A deadly duo.

BACKGROUND: Rhino-orbito-cerebral mucormycosis(ROCM) is an uncommon yet potentially fatal fungal infection predominantly seen in immunocompromised individuals. However, there is very limited data available from India regarding outcome of patients with ROCM and diabetes mellitus. OBJECTIVE: To ascertain clinical parameters and factors in the final outcome of patients with diabetes mellitus and ROCM. MATERIALS AND METHODS: This series included retrospective analysis of medical records of 91 patients with diabetes mellitus who were diagnosed with ROCM from january 2007 to june 2019 at a tertiary care hospital in Punjab. RESULTS: The mean age of patients was 52.6 years (range 18-82 years), with men constituting the majority (71.4 %). Ophthalmoplegia was the most frequent presenting feature seen in 77 % of patients followed by proptosis (71 %). Intracranial involvement was seen in 20 % of the patients and cavernous sinus thrombosis was diagnosed in 9(10 %) patients. Out of 91 patients, 81 patients were subjected to appropriate surgical procedure depending upon site and extent of involvement by mucorales. A total of 53 (58.2 %) patients survived while 38(41.8 %) patients succumbed. Delay in presentation to hospital, intracranial extension and loss of vision at presentation adversely affected the outcome (p < 0.05). Aggressive surgical management in the form of multiple debridements was superior to single debridement (p < 0.05). Diabetic ketoacidosis did not significantly affect the outcome (p = 0.359). CONCLUSIONS: ROCM in patients with diabetes mellitus, is a rapidly progressive disease with a high fatality rate and grave outcome unless diagnosed early and managed aggressively.

Early detection of cutaneous complications of insulin therapy in type 1 and type 2 diabetes mellitus.

BACKGROUND: Subcutaneous insulin therapy is associated with important injection site complications, which can influence insulin pharmacokinetics resulting in glycemic fluctuations above and below target levels for blood glucose. OBJECTIVE: Our objective was to assess the prevalence and risk factors of cutaneous complications including insulin derived amyloidosis in insulin-injecting diabetes patients and to study the role of ultrasonography (in comparison to gel-assisted palpation) in early diagnosis of lipohypertrophy (LH). METHODS: This was a cross-sectional study conducted at a tertiary care center in India, wherein 500 patients injecting insulin for ≥2 years were randomly enrolled and evaluated for the presence of cutaneous complications of insulin therapy through clinical examination, ultrasonography and punch biopsy of skin. RESULTS: Clinical examination detected LH in 44.6% of patients. Ultrasonography diagnosed additional 13.4% of patients with LH which were missed on clinical examination. Incorrect rotation of sites (P < 0.001) and insulin syringe reusage for more than five times (P < 0.001) significantly increased the risk of LH. Skin biopsy was performed in 100 cases, out of which two patients showed apple green birefringence and its association with insulin was confirmed by positive staining with anti insulin antibody in these two patients. CONCLUSION: Improper rotation of sites and reuse of needles were the leading causes of LH in Indian diabetic patients. Ultrasonography is more objective and reliable method of detecting LH. Insulin-derived amyloidosis may be a more common complication of insulin therapy than previously thought.