Transbronchial lung cryobiopsy : a novel confirmatory tool to diagnose asbestos-related pulmonary fibrosis

Asbestosis is diagnosed with a combination of historical, clinical and radiological findings in the absence of another cause. Histology is required when uncertainty exists, with lung biopsy via VATs being gold standard. Transbronchial cryobiopsy is becoming increasingly popular for diagnosing interstitial lung disease and may provide sufficient lung sample to demonstrate asbestosis. A 73 year old man presented with dyspnoea on a background of rheumatoid arthritis, previous methotrexate use and asbestos exposure. Examination revealed fine crackles in the mid and lower zones bilaterally without signs of pulmonary hypertension. The presence of pleural plaques and basal interstitial reticulation on HRCT was suggestive of asbestosis but histology was required to differentiate this from rheumatoid or methotrexate associated ILD. Samples of lung tissue were obtained via transbronchial cryobiopsy, demonstrating fibrosis and asbestos fibres consistent with asbestosis. Transbronchial cryobiopsy appears effective in obtaining sufficient parenchymal lung samples to diagnose asbestosis when clinical uncertainty exists

Health-related quality of life during chemoradiation in locally advanced rectal cancer : impacts and ethnic disparities

Aims: There is limited data on health-related quality of life (HRQoL) in locally advanced rectal cancer. We assessed HRQoL before, during and after neoadjuvant chemoradiation, correlated this to corresponding clinician-reported adverse events (CR-AEs) and explored disparities between patients of Asian ethnicity versus Caucasians. Correlation between HRQoL and treatment response was also assessed. Methods: A consecutive sample of patients was recruited. HRQoL was assessed with the EORTC QLQ-C30 before chemoradiation, week three of chemoradiation and one-week pre-surgery. Clinical variables including CR-AEs were recorded at these time-points. Patients self-reported socio-demographic variables. Treatment response was assessed by the tumour regression grade. HRQoL data were analysed with multilevel models. Results: Fifty-one patients were recruited. HRQoL completion rates were ≥86%. Cognitive and role functioning worsened significantly during treatment. Emotional, role and social functioning improved significantly at pre-surgery. Fatigue and nausea/vomiting worsened during treatment while fatigue, appetite loss, diarrhoea and financial difficulties improved from treatment to pre-surgery. Almost 30% of the cohort were Asian ethnicity. Differences were found in multiple HRQoL domains between Asians and Caucasians, with Asians faring worse. Significant differences were evident in physical, role and cognitive functioning, and in seven out of the 8 symptom scales. The correlation between patient-reported outcomes and clinician-reported outcomes was weak, with diarrhoea having the strongest correlation (r = 0.58). Vomiting during treatment correlated with poor response, whilst baseline constipation correlated with good response. Conclusion: Chemoradiation for locally advanced rectal cancer affects multiple HRQoL domains. Our findings highlight the importance of psychological aspects of treatment. Significant differences were identified between the Asian and Caucasian populations, with Asians consistently performing worse. Poor correlations between patient and clinician reporting strongly support the inclusion of patient-reported outcomes in clinical studies. HRQoL domains of vomiting and constipation are potential biomarkers of treatment response

Cutaneous crystal storing histiocytosis : a report of two cases

Crystal storing histiocytosis (CSH) is a rare condition where crystals accumulate in the cytoplasm of macrophages and is usually associated with a lymphoplasmacytic neoplasm producing a monoclonal immunoglobulin with kappa light chain. CSH with primary manifestation in the skin is extraordinarily rare and limited to four case reports in the literature. Here we present two cases of cutaneous CSH. One case is that of an 80 year old woman who presented with bilateral periorbital oedema with yellow discolouration. Skin biopsy showed dermal CSH in association with a neoplastic lymphoplasmacytoid infiltrate showing IgM kappa light chain restriction. Subsequent work up led to the discovery of Waldenstrom's macroglobulinemia. She had an indolent clinical course but died 6 years later from transformation into a diffuse large B cell lymphoma in the bone marrow. The other case is that of a 52 year old man who was recently diagnosed with multiple myeloma and developed a pruritic rash on his back during chemotherapy. Skin biopsy showed Grover disease (transient acantholytic dermatosis) and crystal storing macrophages in the superficial dermis. He died 4 years later after a protracted clinical course involving multiple cycles of chemotherapy and numerous complications. In both patients cutaneous CSH occurred early in the course of their lymphoplasmacytic malignancy and its development did not herald rapid clinical decline

Paediatric melanoma : challenges in diagnosis and management

Paediatric melanoma, although relatively rare, is the most common cutaneous malignant tumour of childhood. It is often not suspected at initial presentation. It may be misdiagnosed due to poor correlation of conventional ABCDE criteria and ambiguous histopathological features. This younger patient group is more likely to have thicker tumours and positive sentinel lymph node biopsy compared with adult melanoma patients at diagnosis. Despite this, melanoma-specific death rates are lower than those in adults. This suggests different biological behaviour of paediatric compared to adult melanomas. Significant psychosocial issues may exist in the patient and their family. These may delay diagnosis and affect the compliance with management and so should be closely monitored, and intervention arranged if warranted

Clinical and histopathological features of cutaneous nontuberculous mycobacterial infection : a review of 13 cases

Background: The incidence of cutaneous nontuberculous mycobacterial (NTM) infection has increased in recent decades because of widespread use of immunosuppressive therapy and better detection methods. The histopathology of cutaneous NTM infection is not pathognomic and the organisms are slow and difficult to culture, making diagnosis challenging. Methods: We reviewed the clinical and histopathological features of 13 cases of cutaneous NTM infection, and performed panmycobacterial polymerase chain reaction (PCR) on the paraffin blocks. Results: The immunocompetent patients presented with localized lesions on the extremities, whereas the immunocompromised patients presented with disseminated cutaneous lesions. The histopathology in immunocompetent patients was characterized by pseudoepitheliomatous epidermal hyperplasia, intraepithelial abscesses, transepidermal elimination and dermal granulomatous inflammation accompanied by necrosis and suppuration. The immunocompromised patients showed suppurative inflammation with little granuloma formation and numerous acid-fast bacilli. Paraffin block PCR was positive in 4 of 13 cases (31%), whereas culture was positive in 11 of 13 cases (85%). Conclusion: The aforementioned histological features should help in diagnosing cutaneous NTM infection when combined with clinical and microbiological correlation. In our study, we did not find paraffin block PCR to be superior to conventional culture in detecting cutaneous NTM infection

Suppurative cribriform ulcers in one leg

An 89‐year‐old female presented with a 3‐year history of painless ulcers on right lower leg. Each lesion began as small nodules that gradually ulcerated and expanded (Figs. 1 and 2). She had similar ulcers on the same leg, which spontaneously healed over months in the past year. There was no preceding trauma or environmental water exposure. She denied fevers or systemic symptoms. Her past medical history is significant for ischemic heart disease, coronary arterial bypass, stroke, hypertension, and right lower limb venous insufficiency. Clinical examination revealed multiple superficial ulcers with an exudative base and surrounding erythema, distributed over her right distal leg from the mid shin to ankle with several erythematous nodules adjacent to the right knee. Angiotensin converting enzyme (ACE) levels, rheumatoid factor, and antineutrophil cytoplasmic antibodies were not raised. There was no hilar lymphadenopathy on chest radiography. Bone scan and Doppler ultrasonography excluded osteomyelitis and arterial disease, respectively. She reported no improvement after receiving multiple courses of antibiotic therapy. We performed multiple skin biopsies for histopathology and tissue culture (Figs. 3 and 4). Histopathology demonstrated a zone of dermal necrosis lined by granulomatous palisading epithelioid histiocytes with multinucleated giant cells undermining an acanthotic epidermis. The granulomatous reaction was associated with an inflammatory infiltrate of lymphocytes, neutrophils, and plasma cells. Special stains for organisms, including mycobacterial and fungi, were negative. Tissue cultures sent for atypical mycobacteria and fungi, as well as panmycobaterium DNA polymerase chain reaction, were negative on two separate occasions

Tiny but mighty : collision tumor of a superficial adenocarcinoma arising from a tubulovillous adenoma with associated low-grade follicular lymphoma

Collision tumors are rare and there have only been a few previously described cases between an intestinal adenoma and a lymphoma. We report the first case of a 74-year-old woman who on investigation for iron deficiency had a tubulovillous adenoma with underlying follicular lymphoma. The atypical lymphoid proliferation showed immunohistochemical positivity for cluster of differentiation 20 (CD20), B-cell lymphoma 2 (BCL2), and B-cell lymphoma 6 (BCL6). Subsequent right hemicolectomy showed a superficially invasive adenocarcinoma

Cryptococcosis presenting as upper limb cellulitis and ulceration : a case series

We report four cases of cryptococcosis presenting as upper limb cellulitis or ulceration, or both. Three of the four patients were on long-term prednisolone therapy at the time of presentation. In each case, the diagnosis of cryptococcosis was established by a biopsy of the skin. Only one of the four patients had conclusive evidence of disseminated disease. Our cases highlight the importance of skin biopsy in immunosuppressed individuals presenting with cellulitis, particularly when the cellulitis occurs in an atypical location and when the clinical condition fails to respond to standard antibacterial therapy

An unsuspected case of cerebral toxoplasmosis : case report and literature review

We report a case with problematic histopathological diagnosis of cerebral toxoplasmosis because of the patient’s unsuspected HIV status, the clinico-radiological impression of metastatic malignancy, and the compounded difficulty of identifying the typical T. gondii organisms in frozen section material. However, this case highlights the need to always contemplate a non-neoplastic infective cause as the basis for observed necrosis in brain biopsies, regardless of the clinical suspicion under which the histopathological examination has been requested

Legislative History: Joint Order, To amend the Joint Rules by amending Joint Rule 38 regarding legislative confirmation of gubernatorial appointments (SP979)

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