Restricted Diffusion of Pus in the Subarachnoid Space: MRSA Meningo-Vasculitis and Progressive Brainstem Ischemic Strokes – A Case Report

Extra-axial restriction on diffusion weighted imaging (DWI) is an unusual finding on brain magnetic resonance imaging (MRI). Intra-axial restriction on DWI, however, is common, and can represent brain parenchymal infarction, tumor, abscess, or toxic-metabolic process. The infrequency of extra-axial DWI restriction and the paucity of clinico-pathological correlation in the literature limit its differential diagnosis. Scant case reports suggest that extra-axial DWI restriction could be a lymphoma, neurenteric cyst, or, in one patient, subdural empyema [1,2,3]. We postulate that pus formation must be excluded first, because it can provoke an aggressive meningo-vasculitis with rapidly fatal, intra-axial infarctions. Our patient was a 45-year-old man, presenting to our hospital with left facial droop and right (contralateral) arm and leg weakness. Initial MRI revealed DWI restriction in the left lateral pons, consistent with a classic Millard-Gubler stroke. Also noted was a subtle, extra-axial area of curvilinear diffusion restriction in the left cerebellar-pontine angle's subarachnoid space. Days later, the patient had a headache, and repeat MRI revealed extension of the two DWI lesions – both the intra-axial pontine infarction and the extra-axial area of restricted diffusion in the subarachnoid space. The patient became comatose, a third MRI revealed more extensive DWI restrictions, and he expired despite aggressive care. Autopsy revealed massive brainstem infarcts, a thick lymphoplasmacytic infiltrate, copious Gram-Positive cocci (likely MRSA) and arteries partially occluded with fibrointimal proliferation. This emphasizes the concept that extra-axial DWI restriction can represent pus development in the subarachnoid space – a radiographic marker to identify a patient at risk for demise due to septic, meningo-vasculitic infarctions

Online Training and Self-assessment in the Histopathologic Classification of Endocervical Adenocarcinoma and Diagnosis of Pattern of Invasion: Evaluation of Participant Performance

Histopathologic classification of endocervical adenocarcinomas (EAC) has recently changed, with the new system based on human papillomavirus (HPV)-related morphologic features being incorporated into the 5th edition of the WHO Blue Book (Classification of Tumours of the Female Genital Tract). There has also been the introduction of a pattern-based classification system to assess invasion in HPV-associated (HPVA) endocervical adenocarcinomas that stratifies tumors into 3 groups with different prognoses. To facilitate the introduction of these changes into routine clinical practice, websites with training sets and test sets of scanned whole slide images were designed to improve diagnostic performance in histotype classification of endocervical adenocarcinoma based on the International Endocervical Adenocarcinoma Criteria and Classification (IECC) and assessment of Silva pattern of invasion in HPVA endocervical adenocarcinomas. We report on the diagnostic results of those who have participated thus far in these educational websites. Our goal was to identify areas where diagnostic performance was suboptimal and future educational efforts could be directed. There was very good ability to distinguish HPVA from HPV-independent adenocarcinomas within the WHO/IECC classification, with some challenges in the diagnosis of HPV-independent subtypes, especially mesonephric carcinoma. Diagnosis of HPVA subtypes was not consistent. For the Silva classification, the main challenge was related to distinction between pattern A and pattern B, with a tendency for participants to overdiagnose pattern B invasion. These observations can serve as the basis for more targeted efforts to improve diagnostic performance

Differentiated exophytic vulvar intraepithelial lesion: Clinicopathologic and molecular analysis documenting its relationship with verrucous carcinoma of the vulva

Verruciform proliferations of the vulva unrelated to HPV infection are rare. The term differentiated exophytic vulvar intraepithelial lesion (DEVIL) was recently proposed for these lesions, which harbor recurrent PIK3CA mutations. It is still unclear whether DEVIL is related to verrucous carcinoma, a neoplasm characterized by persistence and local recurrence but nil risk of distant spread. Specimens identified using the words "verruciform" and "verrucous" were reviewed. Diagnosis of DEVIL required verruciform acanthosis, hyper and/or parakeratosis, hypogranulosis, cytoplasmic pallor, and bland nuclei. Verrucous carcinoma required, in addition, discontinuous, bulbous, puzzle-like nests in the stroma. A targeted next-generation sequencing using a custom 11-gene panel was performed. Eighteen specimens corresponding to ten patients with DEVIL and/or verrucous carcinoma were included. Median age at presentation was 66 years for DEVIL and 70 years for verrucous carcinoma. A similar spectrum of prevalent mutations was found in both lesions involving HRAS, PIK3CA, and BRAF. DEVIL preceded verrucous carcinoma and/or was diagnosed concurrently or in subsequent follow-up in five patients. In four of these, the same mutation was identified in DEVIL and synchronous or metachronous carcinoma. All cases showed wild-type 53 staining and lacked pathogenic TP53 mutations. DEVIL is a rare form of squamous proliferation characterized by prevalent PIK3CA and HRAS mutations. Its temporal relationship with verrucous carcinoma and their shared mutational profile in some patients suggest that DEVIL is a precursor of verrucous carcinoma. Moreover, given their morphologic and molecular overlap and the nil risk of verrucous carcinoma for distant spread, it is conceivable that DEVIL and verrucous carcinoma represent a spectrum of the same entity

Gynecologic pathology : a volume in the series Foundations in diagnostic pathology /

"Now fully revised to include recent advances in the field, the second edition of Gynecologic Pathology, a volume in the Foundations in Diagnostic Pathology series, is an essential foundation text for residents and pathologists. The popular template format makes it easy to use, and new information throughout brings you up to date with what's new in the field, including key molecular findings. Practical and affordable, this resource by Drs. Marisa R. Nucci and Esther Oliva is ideal for study and review as well as everyday clinical practice. Coverage of neoplastic and non-neoplastic conditions of the female reproductive tract to equip you to meet a wide range of diagnostic challenges"--Publisher's description."A volume in the series Foundations in diagnostic pathology."Includes bibliographical references.Inflammatory diseases of the vulva -- Squamous neoplasms of the vulva -- Extramammary Paget disease and vulvar melanocytic lesions -- Mesenchymal lesions of the vulva and vagina -- Nonneoplastic diseases of the vagina -- Neoplastic lesions of the vagina -- Nonneoplastic lesions of the cervix -- Neoplastic lesions of the cervix -- Nonneoplastic lesions of the endometrium -- Endometrial glandular neoplasia -- Mesenchymal and miscellaneous lesions of the uterus -- Diseases of the fallopian tube and broad ligament -- Nonneoplastic lesions of the ovary -- Epithelial neoplasms of the ovary -- Sex cord-stromal tumors of the ovary -- Germ cell neoplasms of the ovary -- Metastatic and miscellaneous primary neoplasms of the ovary -- Diseases of the peritoneum -- Gestational trophoblastic lesions -- Immunohistochemistry and molecular diagnostics in the differential diagnosis of female genital tract pathology -- Cytology in the practice of gynecologic pathology."Now fully revised to include recent advances in the field, the second edition of Gynecologic Pathology, a volume in the Foundations in Diagnostic Pathology series, is an essential foundation text for residents and pathologists. The popular template format makes it easy to use, and new information throughout brings you up to date with what's new in the field, including key molecular findings. Practical and affordable, this resource by Drs. Marisa R. Nucci and Esther Oliva is ideal for study and review as well as everyday clinical practice. Coverage of neoplastic and non-neoplastic conditions of the female reproductive tract to equip you to meet a wide range of diagnostic challenges"--Publisher's description.Description based on online resource; title from resource home page (ClinicalKey, viewed April 21, 2020).Elsevie

Giant Condyloma of the Cervix: An Uncommon Entity Associated With Low-risk Human Papilloma Virus Infection.

"Giant Condylomas" of the cervix are very uncommon, and have not been fully characterized in the English literature. We report 4 cases of cervical giant condyloma seen in our practice. Patients were predominantly young and presented with a cervical lesion producing bleeding or a mass effect. Biopsy/excision revealed a uniformly bland, exophytic squamous epithelial proliferation with viral cytopathic changes and absence of stromal invasion. Human papilloma virus types 6 and 11 were detected in all cases. Follow-up was uneventful without recurrence or spread. Giant condylomas of the cervix as defined in this report signify a benign albeit extensive variant of low-risk human papilloma virus infection. This term is proposed as a specific descriptor for such lesions and should be considered in the setting of any large well-differentiated exophytic cervical squamous lesion in young or immunosuppressed women. The term "giant condyloma of Buschke and Loewenstein" should be discontinued given the lack of specificity

A case of placental site trophoblastic tumor managed in a low resource setting

Placental trophoblastic site tumor (PSTT) is a rare type of gestational trophoblastic neoplasia (GTN). PSTT has a higher mortality than other types of gestational trophoblastic disease (GTD), with a rate of 16.1%, due to its relatively unpredictable behavior and reduced response to chemotherapy. Its diagnostic and management are very challenging in Low resources settings particularity in Haiti where MRI, PET Scan and IHC are not available. Further, the follow-up is very difficult because of social, political, and economic issues limiting the capacity of our patients to be present at all scheduled visits. No case of PSTT has been publicly described yet the Haitian experience in the literature in the management of such case compared to the developed world. We present a case of PSTT successfully diagnosed and managed at Mirebalais University Hospital (MUH) in Haiti with the support of telepathology and intentional partners while highlighting the difference that we observed compare to the developed world

INTESTINAL CANDIDIASIS: An Uncommon Cause of Necrotizing Enterocolitis (NEC) in Neonates

Candida albicans produces intestinal perforation and necrotizing enterocolitis (NEC) in preterm newborns. We reviewed pathology files in neonates with a diagnosis of NEC (10-year period), gathered history, and reviewed histological materials. Of 249 autopsies, two (0.8%) had systemic candidiasis. From 66 surgical cases with a diagnosis of NEC, five cases (7.5%) had intestinal candidiasis. Candida albicans grew in pre- and post-mortem blood, lung, or peritoneal fluid in all cases. Histologically, the small bowel revealed fungi, sometimes intravascular. Systemic candidiasis with intestinal involvement is an important complication of prematurity and a prevalent cause of sepsis. The presence of intraluminal fungi with associated vascular occlusion may lead to bowel ischemia, necrosis, and perforation