Dysplastic Pulmonary Valve Infective Endocarditis With an Atrial Septal Defect-A Black Swan Event: When Rarity Brings Clarity.

ABSTRACT: A case of infective endocarditis of a dysplastic pulmonic valve along with atrial septal defect has been described. Right-sided endocarditis has now increased in frequency because of cardiac invasive procedures and intravenous drug abuse. Although the tricuspid valve usually bears the brunt of right-sided endocarditis, there have now been increasing reports of pulmonary valve infective endocarditis.

An Autopsy Study of Cerebrovascular Atherosclerosis in the Elderly.

Background: Stroke is an important cause of mortality with intracranial atherosclerosis as an important risk factor. Geographical variation in the pattern of atherosclerosis is well documented with various studies in stroke patients showing that African Americans and Japanese people tend to have intracranial vascular occlusion, whereas Caucasians more often have extracranial atherosclerotic lesions. Methods: This is a prospective study of 50 cases of Indian elderly patients over 60 years of age where we have studied the CNS vasculature in detail including intracranial atherosclerosis with regards to its incidence, severity, distribution, plaque composition and associated risk factors. We compared the atherosclerotic pathology in the intracranial vessels and the extracranial vessels including the carotids. Results: Out of 50 cases 31 showed intracranial atherosclerosis. Anterior circulation was more commonly affected. A total of 87 of the intracranial arteries showed atherosclerotic plaques, most common nature of the plaques being fibrofatty. Majority of the intracranial vessels showed mild stenosis and multiple vessels were involved in 15 cases while single vessel involvement was seen in 16 cases with the middle cerebral artery being the most common single vessel involvement. Infarcts were seen in 7 cases and all these cases had history of hypertension. Cerebral atrophy was seen in 28 cases. All cases showing frontoparietal and generalized atrophy had carotid artery stenosis. Of the 100 carotid arteries studied (2 per case) 59 showed atherosclerosis. Majority of the carotid arteries showed mild degree of atherosclerosis and the content was predominantly fatty. Conclusion: This study concludes that the pattern of atherosclerosis is different in the Indian population as compared to the western literature. Intracranial atherosclerosis is more common in Indian population with the anterior portion of circle of Willis being more commonly affected.

Pathology of pulmonary tuberculosis: has the tiger changed it's stripes?

Background: India accounts for the highest number of TB cases globally (almost one-fifth of the global burden and almost two-thirds of the cases in South East Asia. Furthermore, the development of drug resistance of varying levels such as multi-drug resistant TB (MDR-TB), extensively-drug resistance TB (XDR-TB) and total-drug resistant TB (TDR-TB) has been on the increase, and now India also features in the 27 high-MDRTB-burden countries. Almost parallel to these developments, in the last few years, we have been encountering less common morphological forms of pulmonary TB (PTB) at autopsies. With these less common manifestations of the disease, we undertook this study to examine the changing trends in the morphological pattern of pulmonary TB over the recent years. Methods: In this 3-year retrospective study, adult autopsy cases of PTB (that significantly contributed to the final cause of death) were studied in detail. HIV-positive cases were excluded from the study. The clinical details, gross appearances of the pulmonary lesions, microscopic pattern and Ziehl-Neelsen (ZN) staining were studied. Extrapulmonary involvement and causes of death were documented. Results: Pulmonary tuberculosis as a cause of death at autopsy was seen in 130 adult patients over 3 years. The age range was between 12 to 70 years. Anti-tuberculous therapy had been administered in 33 of them, but only one patient had taken complete therapy. Dyspnea was the commonest respiratory symptom seen in 51 cases (39.2%). Tuberculous bronchopneumonia was the commonest lesion (45.3%), miliary lesions (including localized miliary) accounted for 26% while fibrocavitary lesions (including the ones not involving apex) were seen in 13% cases. Other morphologies included nodular forms of TB (13%), localized miliary lesions (11.9%), and fibrocavitary lesions, not necessarily involving the apex (11.7% of all fibrocavitary cases), and predominant pleuritis with underlying lung involvement by TB in 1 case. Many cases of TB bronchopneumonia had a bronchocentric pattern of distribution (14.7%). On microscopy, caseating granulomas were seen in 93% cases, only caseation necrosis was seen in 4.6% cases, and necrotizing granulomas with abscess-like reaction in 11.5% cases. ZN staining was positive in 92 cases (70.7%). All the extrapulmonary lesions showed caseating granulomas histologically. The final cause of death was found to be primarily tuberculous in 106 cases (81.5%), whereas in 24 cases (19.5%) pulmonary TB was attributed to the secondary cause of death. Conclusion: The typical apical involvement of secondary TB was not seen in most of our cases. This could indicate a difference in the morphology and the pattern of lung involvement in recent years. The difference in gross morphology does not affect the pattern of involvement of the lung. In our study, we have observed both; a change in morphology, i.e., more cases of TB bronchopneumonia, and a change in the pattern of involvement like nodular forms, localized miliary forms, and fibrocavitary lesions not necessarily involving the apex. We postulate that this less common manifestation of pulmonary TB is closely related to the development of multi-drug and microbial resistance posing serious medical challenges.

Acute respiratory distress syndrome: A study of autopsy findings.

CONTEXT: In this autopsy study, the various morphological patterns of acute respiratory distress syndrome (ARDS) have been analyzed and compared along with their etiopathogenesis. AIMS: We aimed to study the prevalence and clinicopathological correlation of ARDS based on age, gender, hospital stay, symptoms, clinical diagnosis, gross, and microscopy findings. SUBJECTS AND METHODS: Total 130 cases of ARDS were studied over a period of 5 years. Age, gender, hospital stay duration, symptoms, clinical diagnosis, gross and microscopic lung finding, clinicopathological correlation, and cause of death were documented and analyzed. Special stains were done whenever required. STATISTICAL ANALYSIS: This is an observational study, and simple statistics such as mean, median, and standard deviation have been used for continuous variables. RESULTS: The prevalence of ARDS among the adult autopsy was 6.05%. Majority of the cases were in the age group of 18-30 years (36.9%), with a male: female ratio of 1.7:1. Chief complaints were fever (71%), breathlessness (54.6%), and chills (43.8%). The main clinical diagnoses were ARDS (41.6%), sepsis (28.3%), acute febrile illness (17%), and lower respiratory tract infection (12.5%). Most of the patients had a hospital stay of <1 day. Associated conditions mostly included chronic alcoholism (16.1%), pregnancy (16.1%), and chronic smoking (10.7%). Major findings on gross examination were intrapulmonary hemorrhage (38.5%), ARDS (33%), pulmonary edema (13%), and pneumonia (15.3%).On microscopy, major findings were hyaline membrane (84.6%), intrapulmonary hemorrhage (76.1%), pulmonary edema (75.3%), organizing fibrin (55.3%), and bronchopneumonia (36.2%). CONCLUSION: Infections were one of the major predisposing causes of ARDS. Due to the short interval, the underlying cause for ARDS often goes undiagnosed.

A perplexing primary novel hilar lesion: Remember the pneumonic PPNHL!

A 60-year-old female presented with dyspnea, cough, and chest pain with a left hilar mass lesion. In our case, clinicoradiological correlation, bronchoscopy, and computed tomography-guided biopsy revealed the diagnosis of primary pulmonary non-Hodgkin's lymphoma (PPNHL) on histopathology and immunohistochemistry. We discuss the approach to hilar masses. PPNHL is a rare malignant lymphoma most common being mucosa-associated lymphoid tissue lymphoma. Various therapeutic options are available. The chemotherapy regimen consisting of CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) is preferred.

An Unusual Schwannoma.

Mediastinal masses are commonly encountered and have multiple differentials. Although histopathological examination is gold standard, the location of the mass narrows the diagnosis. While thyroid, thymus, germ cell tumour or lymph node related masses are common in superior mediastinum, vascular or pleuro-pericardial masses are seen in middle mediastinum. Posterior mediastinal masses are commonly neurogenic tumours, schwannoma being the commonest. We discuss a case of cystic schwannoma presenting as superior mediastinal mass.

Bednar Tumor: An Uncommon Entity.

Bednar tumor is an uncommon variant of dermatofibrosarcoma protuberans. Also known as pigmented dermatofibrosarcoma protuberans, this tumor is of intermediate grade. It is seen in adults and has a predisposition to affect the shoulder region. We report a rare case of Bednar tumor in a 40-year-old female patient. The diagnosis of Bednar tumor must be considered while reporting pigmented subcutaneous spindle cell lesions.

Pancardiac tuberculosis - a case report.

Tuberculous involvement of the heart though not common has been reported in literature. Pericardium is commonly involved followed by the myocardium. Endocardial involvement is rare. We would like to report a case of a 14-year-old female with florid and extensive involvement of all the layers of the heart by tuberculosis.

Miliary Adenocarcinoma of the Lung with Lepidic Pattern: A Morphological Conundrum. Infiltrating bilateral pulmonary miliary adenocarcinoma with predominantly lepidic pattern.

Miliary multi-focal bilateral pulmonary adenocarcinoma with lepidic predominant pattern is an unusual morphological presentation and is seen in females who are non-smokers. This gross morphology can be confused with infectious diseases, like tuberculosis, histoplasmosis or with pulmonary metastasis.

Adenoid cystic carcinoma of the trachea.

Primary salivary gland-type tumors of the lung and airways being unusual, they pose a diagnostic challenge on small biopsies and are usually consigned as non-small cell lung carcinomas. Since the clinical behavior of these tumors is different from the conventional lung tumors, it is important to accurately diagnose them. Among this category of tumors, adenoid cystic carcinoma (ACC) of the lungs and airways is exceedingly rare. Few large studies and maximum case reports have been reported in literature on ACC of the lungs and trachea so far. We herein report a rare case of primary ACC of the trachea diagnosed on bronchoscopic biopsy.

Sudden Death in a Case of Isolated Left Ventricular Noncompaction: An Autopsy Case Report.

We report a case of isolated left ventricular noncompaction in a 15-year-old girl, who presented with sudden death. There were no associated anomalies or history of cardiac disease.

Mesothelial/monocytic incidental cardiac excrescences of the heart - a report of three cases.

Mesothelial/monocytic incidental cardiac excrescences (MICE) are uncommon pseudotumours and may histologically mimic metastatic adenocarcinoma. They consist of nonneoplastic proliferations of mesothelial cells intermingled with foamy macrophages enmeshed in fibrin. There are only around 40 cases reported in literature, and it is important that the pathologists should be aware of this lesion especially while dealing with cardiac surgery specimens. We report a series of three cases of MICE that were incidentally discovered during valve replacement surgeries.

Idiopathic mitral valve prolapse with tricuspid, aortic and pulmonary valve involvement: an autopsy case report.

Mitral valve prolapse (MVP) is usually asymptomatic, but can be associated with complications such as infective endocarditis, mitral regurgitation, thromboembolism and sudden cardiac death. It has been very rarely reported to occur in association with other valvular involvement. A 55-year-old male patient was brought dead and at autopsy the mitral valve orifice was stenotic and the leaflets were enlarged, myxoid and bulging suggestive of MVP and chordae tendinae were thickened, stretched and elongated. Similar changes were seen in the tricuspid valve. The pulmonary and aortic valves also showed myxomatous degeneration of their cusps. Myxomatous degeneration is the most common cause of MVP and it can be associated with involvement of the other valves. Concomitant involvement of the aortic valve has been reported, however it is very rare and simultaneous involvement of the pulmonary valve has not been reported in the literature so far. We report a case of MVP associated with myxomatous degeneration of the tricuspid, pulmonary and aortic valves.

Pulmonary tumor thrombotic microangiopathy in an unknown primary cancer.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a highly fatal complication of cancer leading to acute cor pulmonale and pulmonary hypertension. We present a case of 47-year-old male patient who developed acute breathlessness and died suddenly. The pulmonary vessels at autopsy on histopathologic examination showed the presence of fibrocellular intimal proliferation, fibrin thrombi and few tumor emboli consisting of malignant adenocarcinoma cells. There was associated lymphangiosis carcinomatosis. No primary visceral tumor was found despite extensive search. The patient had died following acute cor pulmonale with sudden pulmonary hypertension due to PTTM. This entity (PTTM) must be kept as a differential diagnosis in patients presenting with acute breathlessness especially in cases of cancers.

Florid bronchial cartilage ossification: a case report with literature revisited.

Pulmonary ossification is a rare phenomenon which has been observed in the lungs of patients with chronic obstructive pulmonary disease, pulmonary fibrosis, and tuberculosis. It has also been observed as a part of aging process. Approximately 130 cases of pulmonary ossification have been reported in literature so far. We report here an unusual autopsy case of bone and bone marrow metaplasia in the bronchial wall and discuss theories related to the development of metaplastic ossification.

Contained cardiac rupture: an autopsy case.

Rupture of the myocardium due to myocardial infarction is often fatal but when such patients survive, they present with a pseudoaneurysm where the defect is sealed by the pericardium preventing the complete rupture. This is described as a 'contained myocardial rupture'. We describe here a case of left ventricular contained myocardial rupture following an acute myocardial infarction.

Evolution of antiphospholipid antibody syndrome.

Antiphospholipid antibody syndrome is a very important cause of cerebral infarction, myocardial infarction, and repeated pregnancy losses in women. We present an extremely rare case of a 44-year-old man with antiphospholipid syndrome who collapsed and died suddenly. At autopsy, he was found to have both cerebral and myocardial infarction. In all young patients with cerebral infarction, myocardial infarction, pulmonary embolism, recurrent miscarriages, and unexplained low platelet count, one must consider the strong possibility of antiphospholipid antibody syndrome.