Profile of Nonresolving Pneumonia in a Tertiary Care Center in South India: A Prospective Study

Introduction: Nonresolving pneumonia (NRP) or slowly resolving pneumonia is a major concern among clinicians. The definition and approach toward diagnosis and management are unclear. Herein, we conducted a prospective observational study to analyze the comorbidities, etiology, and mode of diagnosis of NRP at our center. Methodology: All subjects admitted with a diagnosis of NRP (who received at least 2 weeks of antimicrobial therapy without any clinical improvement) were enrolled in the study. Patients with poor general condition, hemodynamic instability, and uncooperative patients were excluded from the study. After noting clinical and demographic details, contrast-enhanced computed tomography (CT) scan was done for all patients. All subjects were assessed to undergo flexible bronchoscopy, image-guided sampling, surgical lung biopsy, or pleural fluid analysis based on the imaging findings on CT scan. The details of the mode of diagnosis and the yield of procedures were noted. Results: We included 102 subjects; an infective etiology was diagnosed in 64 (62.7%) of the cases and 38 (37.2%) were diagnosed to be of noninfective etiology. Among the infections, pulmonary tuberculosis [21 (20.6%)] and invasive fungal diseases [20 (19.5%)] were the most common diagnoses. Diabetes mellitus (57.8%) and recent COVID-19 (26.5%) were the common comorbid conditions predisposing to infection. Among the noninfectious etiology, pulmonary adenocarcinoma was the most common diagnosis seen in 14 (13.7%) cases. Flexible bronchoscopy was most instrumental in obtaining the diagnosis as seen in 71 (69.6%) cases, followed by image-guided biopsy in 17 (16.6%) and surgical lung biopsy in 7 (6.9%) patients. Overall yield of bronchoscopy in our study population is 77.2% (71/92) and image-guided sampling is 94.4% (17/18). The infectious group had shorter disease duration, more comorbid illnesses, mucopurulent secretions on bronchoscopy, and higher mortality at 1 month as compared to noninfectious group. After adjusting the covariates, the presence of fever [odds ratio (OR) 12.75; 95% confidence interval (CI), 2.74–59.26] and recent history of COVID-19 (OR 12.29; 95% CI, 1.43–105.6) were independently associated with infectious etiology. Conclusion: Infections, particularly tuberculosis and invasive fungal diseases, are the major causes of NRP. Diabetes mellitus is the predominant underlying comorbid illness, and recent infection with COVID-19 is an emerging risk factor for NRP. Flexible bronchoscopy and image-guided sampling, when used in rational approach, are helpful in establishing the diagnosis of NRP

Ovarian serous carcinoma: A retrospective study of clinicopathological findings and postchemotherapy changes

Abstract Background: Ovarian carcinoma represents 30% of all cancers of the female genital tract, of which high-grade serous carcinomas (HGSCs) are predominant, accounting for 70%. Aims and Objectives: To study the clinicopathological findings and to analyze the postchemotherapy changes in tumors treated with neoadjuvant chemotherapy (NACT). Materials and Methods: All cases diagnosed as ovarian serous carcinoma between 2015 and 2017 at our institute were retrospectively reviewed. Clinical and gross findings were collected, microscopic findings were reviewed, and tumor grade was reassessed as per the World Health Organization 2014 criteria. Chemotherapy response score (CRS) was assessed in cases which received prior chemotherapy. Results: Among malignant ovarian tumors, serous carcinoma was the most common, accounting to 38 cases (44.7%). Of these, six were low-grade serous carcinoma and 32 were HGSC. Among HGSC, six (18.75%) cases showed serous tubal intraepithelial carcinoma. Among 18 (47.4%) cases with prior NACT, CRS-1 was seen in six cases, CRS-2 in seven cases, and CRS-3 in five cases. Cancer antigen (CA)-125 levels were markedly raised in all cases. In six cases postchemotherapy, CA-125 levels were below normal with a CRS-2–3. Omental deposits were seen in 15 (39.47%) cases and showed lesser response to prior NACT compared to tumor in the ovary. Conclusion: HGSC is the most common ovarian serous carcinoma. There is correlation between the biochemical and morphological response to chemotherapy in our study. Pathologists should be well aware of postchemotherapy morphological changes in ovarian serous carcinoma.</jats:p

Clinicopathological study of non-granulomatous necrotizing lymphadenopathies

Non-granulomatous necrotizing lymphadenopathy (NGNL) is not a specific entity. It is seen in various conditions like Kikuchi-Fujimoto disease (KFD), Systemic Lupus Erythematosus (SLE), tuberculosis, lymphoma/metastasis and lymph node infarction. These conditions mimic each other histologically but it is necessary to identify the correct pathology as the treatment differs significantly. To highlight the subtle morphological features which lead to the etiological diagnosis in NGNL. The lymphnode biopsies (N=198), reported in our institute as NGNL, over 4½ year study period, were retrieved. Of these, the benign cases were 64 in total, with 40 cases of KFD and 8 cases of SLE. H&amp;E, special stains and immunohistochemistry slides were reviewed by two pathologists. Histomorphological features like amount of necrosis, apoptotic debris, vasculitis, presence of neutrophils, eosinophils, histiocytes, plasma cells, hematoxylin bodies, Azzopardi phenomenon and thrombus formation were studied. Logistic regression analysis was performed to identify the most significant histopathological parameter with each disease. Kendall’s Tau matrix plot analysis was used to measure the correlation between the disease and the histopathologic variables. Features like vasculitis, hematoxylin bodies and Azzopardi phenomenon showed strong correlation with SLE and inverse correlation with KFD. Apoptotic debris, paucity of neutrophils and eosinophils had a strong positive association with KFD. The histological features help in differentiating the various entities associated with NGNL. It is necessary to correlate with clinical details and various laboratory parameters to reach a conclusive diagnosis because these conditions have varied treatment modalities.</jats:p

Cerebral Aspergillus arteritis with bland infarcts: A report of two patients with poor outcome

Two patients with cerebrovascular aspergillosis, in the form of arteritis, thrombosis and bland infarcts are reported. One patient had systemic lupus erythematosus with disseminated aspergillosis in lungs, kidneys and brain. The other patient was immunocompetent and had sphenoid sinusitis. Both the patients were diagnosed at autopsy only, despite extensive imaging and laboratory studies. High index of clinical suspicion and early aggressive antifungal therapy are required since definite diagnostic modalities are not available

Cerebral Aspergillus arteritis with bland infarcts: A report of two patients with poor outcome

Two patients with cerebrovascular aspergillosis, in the form of arteritis, thrombosis and bland infarcts are reported. One patient had systemic lupus erythematosus with disseminated aspergillosis in lungs, kidneys and brain. The other patient was immunocompetent and had sphenoid sinusitis. Both the patients were diagnosed at autopsy only, despite extensive imaging and laboratory studies. High index of clinical suspicion and early aggressive antifungal therapy are required since definite diagnostic modalities are not available

Isolated cerebral Aspergillus granuloma with no obvious source of infection

Background: Intracranial fungal granulomas occur by extension from contiguous structures or by hematogenous dissemination from lungs. Isolated granulomas without any obvious source of infection are extremely uncommon. Objective: To describe isolated intracerebral Aspergillus spp. granuloma without any obvious source of infection. Materials and Methods: We analyzed clinical, radiological and pathological features of isolated intracerebral aspergillus granulomas diagnosed in our institution between 1986 and 2006. The chest X-ray and paranasal sinus (PNS) X-rays were reviewed. Fungal stainings were done on histological sections. Results: We identified eight patients with Aspergillus spp. intracerebral granulomas (six males, two females). There were no predisposing risk factors. The chest and PNS X-rays were normal. On computerized tomography all were heterogeneously enhancing lesions with perilesional edema. Pre or perioperative diagnosis was never made. Histological studies revealed granulomas with minimal fibrosis and giant cells and septate hyphae of Aspergillus spp. on fungal stains. Two patients died of postoperative complications and two patients relapsed. Conclusion: Isolated intracerebral aspergillus granulomas are rare and pose a diagnostic challenge. Fungal granulomas should be considered in the differential diagnosis of intracerebral inflammatory pathologies

Isolated malakoplakia of inguinal lymph node: A rare case report

Malakoplakia is rare chronic inflammatory disorder which commonly affects urinary tract. Though it has been reported in several sites outside the urinary tract, isolated lympnode involvement is extremely uncommon. Herein we present a case of 20 year old male with right inguinal lymphnodal mass. Histological findings including special stains and immunohistochemistry findings were characteristic of malakoplakia. This case is being presented to create awareness for inclusion of this entity in the differential diagnosis of lymphadenopathy

Diagnostic utility of melanin production by fungi: Study on tissue sections and culture smears with Masson-Fontana stain

Background: Dematiaceous fungi appear brown in tissue section due to melanin in their cell walls. When the brown color is not seen on routine H and E and culture is not available, differentiation of dematiaceous fungi from other fungi is difficult on morphology alone. Aims and Objective: To study if melanin production by dematiaceous fungi can help differentiate them from other types of fungi. Materials and Methods: Fifty tissue sections of various fungal infections and 13 smears from cultures of different species of fungi were stained with Masson Fontana stain to assess melanin production. The tissue sections included biopsies from 26 culture-proven fungi and 24 biopsies of filamentous fungi diagnosed on morphology alone with no culture confirmation. Results: All culture-proven dematiaceous fungi and Zygomycetes showed strong positivity in sections and culture smears. Aspergillus sp showed variable positivity and intensity. Cryptococcus neoformans showed strong positivity in tissue sections and culture smears. Tissue sections of septate filamentous fungi (9/15), Zygomycetes (4/5), and fungi with both hyphal and yeast morphology (4/4) showed positivity for melanin. The septate filamentous fungi negative for melanin were from biopsy samples of fungal sinusitis including both allergic and invasive fungal sinusitis and colonizing fungal balls. Conclusion: Melanin is produced by both dematiaceous and non-dematiaceous fungi. Masson-Fontana stain cannot reliably differentiate dematiaceous fungi from other filamentous fungi like Aspergillus sp; however, absence of melanin in the hyphae may be used to rule out dematiaceous fungi from other filamentous fungi. In the differential diagnosis of yeast fungi, Cryptococcus sp can be differentiated from Candida sp by Masson-Fontana stain in tissue sections