Phaeohyphomycotic cyst

Phaeohyphomycosis is a term used for a rare opportunistic infection caused by a group of dematiaceous fungi which contains melanin in their cell walls. In 1974, the term phaeohyphomycosis was first coined by Ajello for an entity caused by pigmented fungi.1 Four clinical forms of phaeohyphomycosis exist: i) cutaneous, ii) subcutaneous, iii) systemic, and iv) cerebral. Among these, the subcutaneous form (phaeohyphomycotic cyst) is the most common subtype which usually presents as nodular swelling mainly over the distal extremities, which may be misdiagnosed as epidermal inclusion cyst, ganglion or lipoma. These fungi are present in the soil, where they infect mostly farmers and persons working in fields and farms. It was also highlighted that these infections are seen mostly in immunocompromised individuals and are byproducts of antimicrobial, steroid, and immunosuppressive therapy for various illnesses, including cancer, autoimmune diseases, and transplant cases.1 The pigment giving the characteristic brownish-black appearance to the fungi is melanin, which prevents phagocytosis and hence acts as a virulence factor.2 This group has more than 120 species and 70 genera.3 They have a broad spectrum of clinical manifestations, including superficial and deep fungal infections, sinus involvement, and disseminated forms, including lung and brain abscesses. The incidence ranges from 1-3.1 per 100,000 patients.4 The gold standard method for diagnosis is histopathological examination and culture. Fontana-Masson stain is of immense help in identifying these dematiaceous fungi in tissue as it highlights the melanin pigment in the cell walls. Figure 1 refers to a 59-year-old farmer man who presented with nodular swelling over the dorsum of the left hand for the last 9 months. Initially, the swelling was of peanut size, which gradually progressed to the present size of 5x3x2cm. The lesion was painless, well-defined, and freely mobile. The joint was not affected. He is on medication for type II diabetes mellitus and hypertension. He underwent Whipple's surgery for periampullary carcinoma. He was treated for proximal sensory-motor axonal neuropathy and tuberculosis three years back. Because of isoniazid-induced hepatitis, the patient received a modified anti-tuberculous regime for 9 months, after which he developed gastric ulceration with hematemesis and melena. On endoscopic biopsy, he was found to have chronic active gastritis with Helicobacter pylori infection. In addition, the patient had severe iron deficiency and hypoalbuminemia due to malabsorption. After treatment, he completely recovered at the time of hospital discharge. Figure 1 Phaeohyphomycotic cyst. A - A well-encapsulated and unilocular cyst measuring 4.5x2.2x1.8cm in size (scale bar = 2.5cm); The cyst lumen contains homogenous and translucent gelatinous soft material; B - Multinucleated giant cells showing fungal profile with septate, branching and globose swelling (H&E; x200); C - Periodic Acid-Schiff stain showing bright magenta positivity (PAS stain; x200); D - Fontana Masson stain giving brownish black color due to melanin in the fungal cell walls (x200).: Thus, the nodular swelling was wholly excised and sent for histopathological examination. Grossly, a well-encapsulated mass measuring 4.5x2.2x1.8 cm was submitted for histological analysis (Figure 1A). The external aspect appeared intact, yellowish-white, and congested. A unilocular cyst was identified on serial slicing with a capsular thickness of 0.1-0.2cm. The cut surface was soft in consistency with homogenous and gelatinous translucent material within the lumen. On light microscopy, an outer thick fibrous capsule layer was identified. Just beneath this capsular layer was the vascularized granulation tissue, proliferating fibroblasts, numerous multinucleated foreign and Langhan’s giant cells, and variable lymphoplasmacytic cell infiltrate. Also, abundant basophilic mucoid material with a background of many degenerated cells. These giant cells engulfed pigmented fungal profiles that depicted branching, septate and globose swelling (Figure 1B). Periodic Schiff-Acid stain gave bright magenta color to these fungi (Figure 1C), whereas Fontana Masson stain gave brownish black color due to melanin in the fungal cell walls (Figure 1D). Given the morphology, a diagnosis of a phaeohyphomycotic cyst was rendered. On follow-up, the patient is doing well, and has not received any antifungal agent. The leading treatment choice in non-invasive subcutaneous phaeohyphomycosis is local excision

Worsening of unrecognized tumour-induced osteomalacia with inadvertent use of recombinant human parathyroid hormone

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GCM2 Silencing in Parathyroid Adenoma is associated with Promoter Hypermethylation and Gain of Methylation on Histone 3

PURPOSE: Glial cells missing 2 (GCM2), a zinc finger-transcription factor, is essentially required for the development of parathyroid glands. We sought to identify if the epigenetic alterations in the GCM2 transcription are involved in the pathogenesis of sporadic parathyroid adenoma. In addition, we examined the association between promoter methylation and histone modifications with disease indices. EXPERIMENTAL DESIGN: mRNA and protein expression of GCM2 were analyzed by RT-qPCR and immunohistochemistry in 33 adenomatous and 10 control parathyroid tissues. DNA methylation and histone methylation/acetylation of GCM2 promoter were measured by bisulfite sequencing and ChIP-qPCR. Additionally, we investigated the role of epigenetic modifications on GCM2 and DNA methyltransferase 1 (DNMT1) expression in PTH-C1 cells by treating with 5-aza 2\u27deoxycytidine (DAC) and BRD4770 and assessed for GCM2 mRNA and DNMT1 protein levels. RESULTS: mRNA and protein expression of GCM2 were lower in sporadic adenomatous than in control parathyroid tissues. This reduction correlated with hypermethylation (P\u3c0.001) and higher H3K9me3 levels in GCM2 promoter (P\u3c0.04) in adenomas. In PTH-C1 cells, DAC treatment resulted in increased GCM2 transcription and decreased DNMT1 protein expression, while cells treated with the BRD4770 showed reduced H3K9me3 levels but a non-significant change in GCM2 transcription. CONCLUSION: These findings suggest the concurrent association of promoter hypermethylation and higher H3K9me3 with the repression of GCM2 expression in parathyroid adenomas. Treatment with DAC restored GCM2 expression in PTH-C1 cells. Our results showed a possible epigenetic landscape in the tumorigenesis of parathyroid adenoma and also that DAC may be promising avenues of research for parathyroid adenoma therapeutics

Bilateral breast abscesses due to Salmonella Enterica serotype typhi

Focal infection is an uncommon complication of Salmonella septicemia, particularly in immunocompetent patients. The localization of Salmonella infection to breast tissue is regarded as a rare event. We report a case of bilateral breast abscesses due to Salmonella enterica serotype Typhi in a nonlactating female and highlight the fact that Salmonella spp. should be included in differential diagnosis of abscesses in individuals coming from endemic areas with the history of recent typhoid fever and should be treated accordingly

Effect of perioperative glutamine administration on C-reactive protein and liver function tests in patients undergoing hepatic resection

Hepatic resections are commonly associated with high morbidity and mortality. Nutrition plays an important role in reducing postoperative complications besides improvement in intensive care and perioperative management. The aim of the study was to evaluate the role of glutamine as an immunonutrient in patients undergoing hepatic resection. Material and methods. The study included 22 patients who underwent hepatectomy. Patients were randomized into two equal groups wherein group A patients received perioperative glutamine whereas group B patients served as controls. Primary outcome measures were level of serum albumin, C‑reactive protein (CRP), liver function tests and absolute neutrophil counts in the postoperative period while secondary outcome included post operative complications. Results. Glutamine decreased the CRP response in liver resection in a statistically significant manner (p=0.028) on the fifth post operative day. This may signify that glutamine decreases the post operative inflammatory response associated with liver resection. Glutamine did not have any significant effect on liver function tests. Postoperative morbidity was less in patients who received glutamine. Conclusion. Glutamine successfully blunted the CRP response in patients who received glutamine postoperatively. Decrease in morbidity following glutamine administration is an attractive area of prospective research and requires further consideration involving larger patient groups

Stentowanie wewnętrzne przez pankreatojejunostomię i główny przewód trzustkowy po pankreatoduodenektomii

Wprowadzenie: Pooperacyjna przetoka trzustkowa (POPF) wiąże się z wysoką zachorowalnością i śmiertelnością. Badania wykazały, że wewnętrzne stentowanie pankreatojejunostomii (PJ) może zmniejszyć POPF, ale metoda ta nadal budzi kontrowersje. Cel: W niniejszej pracy porównano wyniki zastosowania stentowania wewnętrznego przez PJ w celu zmniejszenia POPF po pankreatoduodenektomii (PD) i opisano technikę zakładania stentu wewnętrznego przez PJ do głównego przewodu trzustkowego. Materiały i metody: Do badania włączono 50 pacjentów poddanych elektywnej PD. Zrandomizowano ich do jednej z dwóch grup: Grupa A (n = 25) bez stentowania wewnętrznego przez PJ i Grupa B (n = 25) z wewnętrznym stentowaniem PJ. Pierwszorzędowym punktem końcowym było wystąpienie POPF. Wyniki: Obie grupy były porównywalne pod względem: danych demograficznych, chorób współistniejących, patologii, struktury trzustki i średnicy przewodu trzustkowego. Spośród 50 badanych pacjentów, u 23 (46,0%) rozwinęła się POPF – u 10 (40%) w grupie A i 13 (52%) w grupie B (p = 0,156). U 13 chorych (32%) rozwinęła się przetoka pooperacyjna trzustki stopnia A, a u 7 (14%) – stopnia B. W grupie A u 6 chorych rozwinęła się przetoka pooperacyjna stopnia A, a u 4 stopnia B. W grupie B u 10 chorych rozwinęła się przetoka pooperacyjna trzustki stopnia A, a u 3 stopnia B. Nie stwierdzono przetoki stopnia C. U wszystkich osób uzyskano zadowalający powrót do zdrowia po leczeniu zachowawczym. U 8 pacjentów (16%) wystąpiło opóźnienie opróżniania żołądka (5 w grupie A i 3 w grupie B; p = 0,366). U 6 pacjentów pojawiło się powierzchowne zakażenie miejsca operowanego (2 w grupie A i 4 w grupie B; p = 0,445). Długość pobytu w szpitalu była porównywalna w obu grupach. Nie odnotowano zgonów. Wnioski: Wewnętrzne stentowanie PJ nie zmniejsza częstości występowania POPF po PD