Discrete Lesions Research Articles

Extra-Axial Poorly Differentiated Chordoma Initially Misdiagnosed as Epithelioid Sarcoma.

Poorly differentiated chordoma is an exceedingly rare, aggressive subtype of chordoma. These tumors typically arise in the axial skeleton of young patients, most commonly the skull base, followed by the cervical spine. Herein, we present a 60-year-old patient with longstanding knee pain and nondiagnostic imaging, initially thought to be due to osteoarthritis. No discrete mass-forming lesion was identified by radiology. Synovial histology at the time of arthroplasty revealed a multinodular proliferation of epithelioid-to-histiocytoid cells with a moderate amount of eosinophilic-to-clear, vacuolated cytoplasm. Scattered cells with high-grade nuclear atypia were present. A diagnosis of metastatic carcinoma was considered due to immunohistochemical positivity for keratin and GATA3. However, a diagnosis of epithelioid sarcoma was rendered based on clinical context, morphology, and loss of immunohistochemical expression for SMARCB1 (INI1). However, upon re-review of the tumor, brachyury was retrospectively added to the immunohistochemistry panel and showed strong positivity, thus prompting amendment of the initial diagnosis of epithelioid sarcoma to extra-axial poorly differentiated chordoma. Given the rarity of this diagnosis, molecular testing was performed which revealed a unique SMARCB1 molecular profile with a single-nucleotide variant in addition to the commonly reported loss of chromosome 22q. This report of an ultra-rare sarcoma in an uncommon anatomic site highlights multiple potential pitfalls in the diagnosis of poorly differentiated chordoma, emphasizes the importance of brachyury immunohistochemistry in rendering a correct interpretation, and underscores an opportunity for further molecular analysis to better define the molecular profile of this entity.

Heterotopic High-Grade Salivary duct Carcinoma Likely Arising within Cervical Lymph Nodes

Abstract Introduction/Objective Salivary duct carcinoma arising in heterotopic salivary gland tissue is an extremely rare occurrence, with less than five cases reported in the literature. We present a unique case of heterotopic high-grade salivary duct carcinoma likely arising within cervical lymph nodes. Methods/Case Report A 56-year-old male presented with enlarged cervical lymph nodes for few months. Physical examination was unremarkable. Computerized tomography (CT) scan of head and neck showed two enlarged level 1B lymph nodes, measuring 1.0 and 1.4 cm, with unremarkable salivary glands. Patient had left cervical level II lymph node biopsy that showed metastatic poorly differentiated carcinoma. Immunohistochemically, the tumor cells were positive for GATA3, cytokeratin 903, androgen receptor, p16 (variable nonspecific), and were negative for TTF-1, p40, p63, ER, PR and NKX3.1, favoring salivary gland ductal carcinoma. Positron emission tomography (PET) CT scan showed a hypermetabolic left submandibular gland and level 2A lymph nodes. Subsequently, the patient underwent left modified radical neck dissection. Sectioning of the submandibular gland revealed no discrete lesions. Multiple, firm to rubbery lymph nodes ranging from 0.4 cm to 2.3 cm, with tan-pink cut surfaces were identified. Microscopic examination showed normal submandibular salivary gland parenchyma. However, eight out of nineteen lymph nodes were positive for metastatic high-grade salivary duct carcinoma comprising tumor cells forming nests and cords with ample eosinophilic cytoplasm, pleomorphic round to oval nuclei and numerous mitotic figures. Several benign and malignant lymph nodes in levels I, II and IV showed heterotopic salivary gland tissue. Immunohistochemical stains for androgen receptor and p40 were positive and negative respectively, supported the final diagnosis of high-grade salivary duct carcinoma. Results (if a Case Study enter NA) NA Conclusion Given the absence of carcinoma in the completely sampled submandibular gland, the origin of the intra- nodal tumor deposits was most likely to be heterotopic salivary gland tissue. This case emphasizes the importance of meticulous pathological sampling required for definitive diagnosis.

6823 A Puzzling Case: Complete Regression of Pituitary Macroadenoma

Abstract Disclosure: N.T. Mazengia: None. D.R. Vangipuram: None. S.K. Majumdar: None. Introduction: The natural course of nonfunctioning pituitary macroadenomas remains poorly understood, largely because the majority are surgically treated [1]. There are a few case reports describing the spontaneous regression of nonfunctioning pituitary macroadenomas. Here we describe a case of pituitary macroadenoma which completely regressed following childbirth and two months of cabergoline therapy. Case Presentation: A 25-year-old female presented with bilateral nipple discharge and persistently elevated prolactin levels ranging from 31µg/liter to 45.9 µg/liter (NV <25 µg/L). She did not have any signs and symptoms of hypo or hypersecretion of the pituitary hormones. All her pituitary hormone levels were within normal range. Initial MRI revealed a pituitary mass measuring 9x13x9mm (AP, TR, CC). Given her lack of symptoms, the decision was made to follow up without any intervention. A repeat MRI after one year showed the size of the mass to be 11x13x11mm. Two years after her initial diagnosis, the patient had a spontaneous pregnancy, during which she remained asymptomatic with normal pituitary hormone levels. She had Cesarean delivery at term with no complication. She was lost to follow-up for about two years after childbirth then presented with breast discomfort and galactorrhea at which time, she was started on cabergoline. A subsequent MRI done two months after the start of cabergoline showed asymmetric fullness of the pituitary gland on the right with no discrete measurable lesion. Conclusion: We currently lack a comprehensive explanation for the regression observed in our patient. Silent ischemia may have played a role, particularly considering the natural increase in pituitary gland size during pregnancy. We are not sure if the regression can be solely attributed to the two months of cabergoline treatment. In asymptomatic patients diagnosed with nonfunctioning pituitary macroadenoma, tumor regression can potentially occur through either a "wait and watch" strategy or medical management using dopamine agonists, specifically cabergoline. However, the use of cabergoline as a primary treatment for asymptomatic nonfunctioning pituitary adenoma warrants further investigation. This is especially crucial given that, in most cases, nonfunctioning pituitary macroadenomas tend to increase in size during follow-up without any intervention.

8578 Papillary Thyroid Carcinoma in Autonomous Nodule with Low Risk Characteristics in Adolescent

Abstract Disclosure: A. Aponte Velez: None. M.M. Mangual Garcia: None. Thyroid nodules in children are uncommon but are known to carry a greater risk of malignancy than adult thyroid nodules. Additionally, differentiated thyroid cancer (DTC) in children is more commonly found with extrathyroidal extension and metastases which makes the approach and treatment similar but with important differences. The incidence of DTC in children is increasing, making a personalized evaluation of thyroid nodules in pediatric patients even more valuable. Guidelines recommend evaluation of nodules based on sonographic characteristics rather than size of nodule. However, not having worrisome sonographic characteristics may not be as reassuring as in adult patients. A 13 year old female patient presented with a palpable non tender right sided solid thyroid mass. She had no family history of thyroid cancer or history of irradiation. Thyroid function tests were remarkable for TSH:0.017 and positive thyroid stimulating immunoglobulin. Thyroid Ultrasound findings described heterogenous parenchyma with multiple discrete lesions on right thyroid lobe with a dominant solid isoechoic nodule at upper lobe measuring 2.1 x 3.5 x 1.9cm and a smaller nodule in lower lobe. Thyroid scan demonstrated a large functional hot nodule occupying most of right thyroid lobe with suppression of rest of thyroid parenchyma. Ultrasound guided FNA was performed of this lesion and results were negative for malignancy. Patient underwent total thyroidectomy with pathology report revealing right thyroid nodule encapsulated classical variant of papillary thyroid carcinoma. No lymph node metastases were identified. Non neoplastic thyroid parenchyma revealed chronic lymphocytic thyroiditis. Patient underwent radioiodine therapy with Whole Body Scan post radioiodine therapy demonstrating focal increased radionuclide localization at in region of neck consistent with functional thyroid tissue. There was no evidence of metastatic disease. In children, risk of malignancy is underestimated in ultrasonography and cytology. In this patient, papillary thyroid carcinoma was identified despite being stratified as having low risk of malignancy based on ultrasonography characteristics, hyperfunctioning nodule in scintigraphy study along with negative FNA results. Hyperfunctional nodules are usually reassuring for low risk of malignancy but rarely DTC can be found as in our patient. Guidelines agree that FNA is not recommended in functional nodules as surgical resection is the main therapy in children. However, surgery may be deferred if subclinical hyperthyroidism and low risk sonographic characteristics are present such as in our patient. If surgery had been deferred, based on low risk of malignancy, the risk of progression of disease would have been higher. Prognosis of DTC in children is good but the recurrence rate along with morbidity at such a young age may improve with more studies of DTC in children. Presentation: 6/2/2024

Presurgical Use of Cenobamate for Adult and Pediatric Patients Referred for Epilepsy Surgery: Expert Panel Recommendations.

Cenobamate has demonstrated efficacy in patients with treatment-resistant epilepsy, including patients who continued to have seizures after epilepsy surgery. This article provides recommendations for cenobamate use in patients referred for epilepsy surgery evaluation. A panel of six senior epileptologists from the United States and Europe with experience in presurgical evaluation of patients with epilepsy and in the use of antiseizure medications (ASMs) was convened to provide consensus recommendations for the use of cenobamate in patients referred for epilepsy surgery evaluation. Many patients referred for surgical evaluation may benefit from ASM optimization; both ASM and surgical treatment should be individualized. Based on previous clinical studies and the authors' clinical experience with cenobamate, a substantial proportion of patients with treatment-resistant epilepsy can become seizure-free with cenobamate. We recommend a cenobamate trial and ASM optimization in parallel with presurgical evaluations. Cenobamate can be started before phase two monitoring, especially in patients who are found to be suboptimal surgery candidates. As neurostimulation therapies are generally palliative, we recommend trying cenobamate before vagus nerve stimulation (VNS), deep brain stimulation, or responsive neurostimulation (RNS). In surgically remediable cases (mesial temporal sclerosis, benign discrete lesion in non-eloquent cortex, cavernous angioma, etc.), cenobamate use should not delay imminent surgery; however, a patient may decide to defer or even cancel surgery should they achieve sustained seizure freedom with cenobamate. This decision should be made on an individual, case-by-case basis based on seizure etiology, patient preferences, potential surgical risks (mortality and morbidity), and likely surgical outcome. The addition of cenobamate after unsuccessful surgery or palliative neuromodulation may also be associated with better outcomes.

Acute necrotizing duodenitis in diabetic ketoacidosis

Acute necrotizing esophagitis (ANE), acute necrotising duodenitis (AND), and Wishnesky’s lesions (WLs) are three peculiar upper gastrointestinal pathologies that can be seen in death from diabetic ketoacidosis (DKA). Amongst these three, AND has only been recently described. Morphologically, ANE and AND present as generalized black discoloration of the intestinal tract, and florid necrosis and inflammation. Whereas WLs are discrete black lesions in the stomach with necrosis and muted inflammation. We report a case of isolated AND with an unusual morphology not previously reported. A man in his 60s was found dead at home who died from pneumonia complicated by DKA. The gastrointestinal tract showed isolated patchy and discrete AND in which macroscopically resembled WLs, but microscopy resembled ANE with florid necrosis and acute inflammation. This case, together with the literature, documented AND can be macroscopically diffuse or discrete resembling ANE or WLs respectively but microscopically resemble ANE. Furthermore, the potential of these lesions being found in isolation in DKA raises the possibility of both general and local mechanisms playing a role on their morphology and presentation.

ST-Elevation Myocardial Infarction Due to Coronary Vasospasm Associated with Eosinophilic Granulomatosis with Polyangiitis: A Case Report.

ST-elevation myocardial infarction (STEMI) can be caused by underlying coronary artery vasospasm (CAV) with or without associated atherosclerotic disease. Coronary artery vasospasm is a rare but potentially devastating manifestation of eosinophilic granulomatosis with polyangiitis (EGPA). We describe a 54-year-old male with a known history of EGPA and coronary artery disease presenting to the emergency department with chest pain and an inferior STEMI on electrocardiogram. He was ultimately taken for coronary angiography and found to have a discrete vasospastic lesion in the right coronary artery that was treated with intra-coronary nitroglycerin and calcium channel blockers. He was continued on immunosuppressant agents (prednisone and mepolizumab) for management of EGPA and followed up with outpatient cardiology and rheumatology for vasospastic angina. This case highlights a rare cause of STEMI, discusses the nuances in treatment of STEMI due to CAV, and provides background on pathophysiology and treatment of EGPA.

Severe atypical iliac wing fracture associated with long-term bisphosphonate use.

Bisphosphonate use is associated with atypical non-traumatic fractures, which are most commonly seen in the femur. We report a 63-year-old postmenopausal woman who presented acutely with progressively worsening lumbar pain radiating to her left hip for 10days. There was no antecedent trauma. On examination, the patient could not bear weight on her left leg due to the severity of the pain. Radiography and computed tomography of the pelvis demonstrated an iliac wing fracture which was treated conservatively. The patient had a significant past medical history of breast cancer and intense bisphosphonate use for several years which was discontinued 3years previously. No discrete bone lesion was seen at the fracture site on computed tomography, and there was no evidence of metastatic disease elsewhere. A dual-energy X-ray absorptiometry scan showed the lowest bone mineral density T-score of - 1.2. A diagnosis of an atypical fracture related to long-term bisphosphonate therapy was made. To the best of our knowledge, this is the first reported case of an isolated iliac wing fracture associated with long-term bisphosphonate therapy in the literature. Whilst the incidence of such fractures is exceedingly rare, it is an important differential in patients with atypical fractures on long-term bisphosphonates.

Efeitos do uso prolongado de meloxicam em equinos hígidos: achados clínicos, laboratoriais, gastroscópicos e eletrocardiográficos

Non-steroidal anti-inflammatory drugs are extensively used in veterinary practice. COX-2 inhibitors are considered to be safer than non-selective inhibitors; however, there are few studies address of their long-term use in equine species. The goal of this study was to identify the possible adverse effects of meloxicam (a preferential COX-2 inhibitor) in healthy horses, administered at a dose of 0.6 mg/kg, orally, once a day, for 28 days. A paired test was performed with seven animals, and the clinical, hematological, biochemical, and gastroscopic parameters, as well as bleeding time, were evaluated in five timepoints and an electrocardiogram at three timepoints. No relevant adverse effects were observed in terms of the parameters evaluated. Significant differences were found in heart rate, AST and P wave duration, segmented neutrophils (%), and the levels of erythrocytes, hemoglobin, hematocrit, and MCH, compared with these parameters at T0; however, no animal manifested clinical alterations. Gastroscopy revealed discrete lesions (Grade 1) in the squamous gastric mucosa on day 14 of treatment in all animals; however, at the end of the study (day 28) these lesions had regressed to grade 0 in three of the horses and remained at grade 1 in the other four animals. Based on these results, we conclude that the use of meloxicam at a daily dose of 0.6 mg/kg, orally, for 28 consecutive days, did not cause relevant adverse effects in healthy horses.

NFS-09.NF1 MUTATION IN OLIGODENDROCYTE PRECURSOR CELLS LEADS TO PRENEOPLASTIC LESION FORMATION IN THE BRAIN

Abstract Oligodendrocyte precursor cells (OPCs) are progenitor cells that give rise to central nervous system oligodendrocytes throughout life. Transcriptomic and lineage tracing studies suggest that OPCs may be the putative cell of origin for many glioma histologic subtypes. While children with the neurofibromatosis type 1 (NF1) cancer predisposition syndrome are prone to low-grade gliomas following bi-allelic NF1 loss, the cellular and molecular etiologies underlying tumorigenesis remain incompletely elucidated. Using a unique collection of genetically engineered Nf1 mouse strains, we identified discrete hyperdense lesions composed of OPCs. The OPCs within the lesions display a transient increase in proliferation and hypercellularity (hyperplasia). This phenotype was not observed following heterozygous mutation in other tumor suppressors (Trp53, Pten, or Rb1). OPC-specific heterozygous Nf1-mutant mice harbored similar lesions, suggesting an OPC-intrinsic phenotype. OPC-specific Nf1 loss resulted in increased OPC density throughout the entire brain, suggesting that the lesions in heterozygous Nf1-mutant mice represent spontaneous OPC Nf1 loss-of-heterozygosity events. Mechanistically, monoallelic KRAS hyperactivation phenocopies OPC hyperdensities in the brain of Nf1+/- mice; however, KRAS hyperactivity is not necessary for lesion formation or expansion. When the brains of mice engineered with heterozygous NF1 patient-derived Nf1 mutations were examined, the development of hyperdense OPC lesions reflected RAS-independent dysregulated PI3K-AKT signaling. Collectively, our study reveals a potential mechanism driving the development of preneoplastic lesions in the brains of individuals with NF1.

P.085 Characterizing molecular alterations in glioma growth and progression

Background: High grade gliomas (HGG) are incurable, aggressive brain malignances that carry poor prognoses. Significant scientific advances have uncovered many of the features of these diseases; however, it remains unclear how mutations and transcriptional changes drive glioma growth and progression. Methods: We used a Nestin-Cre mouse model in combination with an extrinsic chemical mutagen (N-ethyl-N-nitrosurea, ENU), to model HGG. We combined our mouse model with live animal in vivo magnetic resonance imaging to track tumor growth over time, and sample discrete lesions during premalignant, early stage tumor, and end stage tumor phases. Results: We show that the somatic mutations, copy number changes, and transcriptional profiles of tumors vary depending on the stage of growth, and that the Raf/Ras pathway is key for tumor growth with a recurring Braf mutation occurring in early stage lesions. Gene set enrichment analysis (GSEA) shows that end stage tumors have increased immunogenic/inflammatory activity, and increased signaling through Raf/Ras. Conclusions: The combination of genetic and nongenetic insults results in activating mutations in early lesions, which continue to be biologically active and underlie key differences between early and end stage tumors. Overall, this work sheds light on important differences between early and late stage tumors.

Impact of Contact Force on Pulsed Field Ablation Outcomes Using Focal Point Catheter.

Conventional focal radiofrequency catheters may be modified to enable multiple energy modalities (radiofrequency or pulsed field [PF]) with the benefit of contact force (CF) feedback, providing greater flexibility in the treatment of arrhythmias. Information on the impact of CF on lesion formation in PF ablations remains limited. An in vivo study was performed with 8 swine using an investigational dual-energy CF focal catheter with local impedance. Experiment I: To evaluate atrial lesion formation, contiguity, and width, a point-by-point approach was used to create an intercaval line. The distance between the points was prespecified at 4±1 mm. Half of the line was created with radiofrequency energy, whereas the other half utilized PF (single 2.0 kV application with a proprietary waveform). Experiment II: To evaluate single application lesion dimensions with a proprietary waveform, discrete ventricular lesions were performed with PFA (single 2.0 kV application) with targeted levels of CF: low, 5 to 15 g; medium, 20 to 30 g; and high, 35 to 45 g. Following 1 week of survival, animals underwent endocardial/epicardial remapping, and euthanasia to enable histopathologic examination. Experiment I: Both energy modalities resulted in a complete intercaval line of transmural ablation. PF resulted in significantly wider lines than radiofrequency: minimum width, 14.9±2.3 versus 5.0±1.6 mm; maximum width, 21.8±3.4 versus 7.3±2.1 mm, respectively; P<0.01 for each. Histology confirmed transmural lesions with both modalities. Experiment II: With PF, lesion depth, width, and volume were larger with higher degrees of CF (depth: r=0.82, P<0.001; width: r=0.26, P=0.052; and volume: r=0.55, P<0.001), with depth increasing at a faster rate than width. The mean depths were as follows: low (n=17), 4.3±1.0 mm; medium (n=26), 6.4±1.2 mm; and high (n=14), 9.1±1.4 mm. Using the same focal point CF-sensing catheter, a novel PF ablation waveform with a single application resulted in transmural atrial lesions that were significantly wider than radiofrequency. Lesion depth showed a significant positive correlation with CF with depths of 6.4 mm at moderate CF.

Chronic myeloid leukemia presenting with disc edema: A case report

The aim is to report a case of chronic myeloid leukemia (CML) in a 20-year-old female who initially presented with bilateral optic disc edema and headaches, and to raise awareness of uncommon causes of disc edema that could potentially be life-threatening. The patient first presented in June 2022 with blurry vision in the left eye, headache, and neck pain of 6 months duration. Initial examination revealed a young woman in no acute distress, with a blood pressure of 100/60 mm Hg and a body mass index of 26.98. Her pinhole visual acuity was 6/9 in both eyes, extraocular motility was full bilaterally, and both pupils were briskly reactive. However, she had bilateral optic disc edema. Both brain and orbital magnetic resonance imaging (MRI) revealed normal findings. Serological tests for syphilis and human immunodeficiency virus were negative. Based on these and the clinical features, an initial diagnosis of idiopathic intracranial hypertension was made, and the patient was started on acetazolamide tablets. She was followed up for approximately 1 year without resolution of symptoms. At a follow-up visit in December 2023, she was found to have developed dilated tortuous vessels with discrete retinal lesions. A peripheral blood film result showed that the patient had CML. In conclusion, a high index of suspicion should be entertained when managing a patient with unexplained bilateral disc swelling with normal brain MRI study. A complete blood workup, including a peripheral blood film, should be included as a part of the routine investigation of these patients so that diagnosis and treatment could be instituted early.

First report of Cryptostroma corticale causing sooty bark disease in California and first worldwide report of silver maple as a host.

In November 2022 and February 2023, CAL FIRE tree health experts examined four maples (Acer spp.) planted decades earlier in a residential setting in Elk Grove, Sacramento Co., California (USA). Three of the trees were silver maples (Acer saccharinum ) and one was a Norway maple (A. platanoides); both species are exotic to California. The trees were in an irreversible state of decline, with the canopy substantially thinned and browning. Extensive bark cankers elongating longitudinally along the stem were visible on all trees (Fig. S1). Cankers were filled by fungal stromata protruding through the bark and producing masses of elliptical dark brown conidia (Fig. S2), approximately 5.5 x 3.7 um in size, giving the cankers a sooty appearance. The cankered bark could be peeled off easily, revealing dark and discrete lesions in the phloem and xylem. Samples from the three trees were shipped to the U.C. Berkeley Forest Pathology and Mycology Laboratory and to the CDFA PPDC in Sacramento, CA. In the laboratories, small wood chips were taken from the margins of the lesions, surface sterilized by dipping them for 30 seconds in 70% Ethanol, rinsed for 30 seconds in sterile water and plated onto 2.5% Malt Extract Agar amended with 0.3g/L Streptomycin or onto one-half strength acidified potato dextrose agar (APDA). Two morphologically identical cultures were obtained, one (T2) from a silver maple and one (T6) from the Norway maple. Cultures were then grown in liquid 2.5% malt extract broth and, after one week, DNA was extracted using the Qiagen Plant DNeasy DNA extraction kit. The ITS sequences are diagnostic for this fungus (Li et al. 2021) and those of the two cultures (GB OR064033 and OR933565) were 100% homologous to GenBank sequences of Cryptostroma corticale ( e.g. GB OP474010-11). The RPB2 sequence of T2 ( GB OR992132) was 100% homologous to that of C. corticale (GB HG934116.1). The isolate obtained from silver maple was inoculated in four potted silver maples by removing a bark disk 50 mm in diameter with a cork borer in three spots staggered at different heights and sides on the stem, placing a colonized agar plug of C. corticale in contact with the phloem, replacing the bark disk and wrapping with parafilm. Two control trees were mock inoculated using sterile agar plugs. Trees were in 57 L pots, had an average stem caliper of 2.7 cm, an average height of 3.5 m and were kept in a lath house at average high temperatures of 18-24 degrees C. After ten weeks, average lesion length was 15.4 cm (SE= 4.6) and 4.3 cm (SE=2.3) in the fungus-inoculated and control trees, respectively. An ANOVA test, nesting lesions sizes within tree, determined lesions lengths were different between inoculated and mock trees (P= 0.04). The fungus was reisolated from all points in all inoculated trees but never from control trees. C. corticale was first described in the UK from sycamore maple (Acer pseudoplatanus) (Gregory et al. 1949) and is an emerging problem in Europe (Muller et al. 2023). In North America, it has been reported from A. negundo, A. campestre, A. macrophyllum and Cornus nuttallii (Worral 2020), and it appears to be present in the Pacific Northwest (Brooks et al. 2023, Goree 1969). Norway maple is included in the European Plant Protection Organization list of hosts for C. corticale (EPPO 2023), however our finding of C. corticale on silver maple is a first report of this host worldwide and of this pathogen in California. This report is noteworthy, given that C. corticale is also a human pathogen infecting the respiratory system (Braun et al. 2021).

Drug Induced Rowell’s Syndrome: A Rare Presentation

Rowell’s syndrome (RS) is a rare disorder characterized by Erythema multiforme (EM)-like lesions in a patient with lupus erythematosus, either systemic lupus erythematosus (SLE) or cutaneous lupus erythematosus (CLE). A 35 years old female presented in our dermatology outpatient department (OPD) with complaint of hemorrhagic crusting of lips and multiple discrete targetoid lesions over the chest, upper limb, and gluteal region. Investigations revealed a speckled pattern of antinuclear antibody (ANA), anti-Smith antibody, anti-ds DNA antibody, and strongly positive anti-Ro antibody. According to the clinical evaluation and investigations, the diagnosis of drug induced RS was made. The likely role of proton pump inhibitors, namely esomeprazole as a triggering factor is discussed. After stopping esomeprazole and starting medications with oral steroids and hydroxychloroquine, her good response to treatment was noted.

Prevalence of clinical electroencephalography findings in stroke patients with delirium

ObjectiveDelirium is an acute cognitive disorder associated with multiple electroencephalographic (EEG) abnormalities in non-neurological patients, though specific EEG characteristics in patients with stroke remain unclear. We aimed to compare the prevalence of EEG abnormalities in stroke patients during delirium episodes with periods that did not correspond to delirium. MethodsWe retrospectively analyzed clinical EEG reports for stroke patients who received daily delirium assessments as part of a prospective study. We compared the prevalence of EEG features corresponding to patient-days with vs. without delirium, including focal and generalized slowing, and focal and generalized epileptiform abnormalities (EAs). ResultsAmong 58 patients who received EEGs, there were 192 days of both EEG and delirium monitoring (88% [n = 169] corresponding to delirium). Generalized slowing was significantly more prevalent on days with vs. without delirium (96% vs. 57%, p = 0.03), as were bilateral or generalized EAs (38% vs. 13%, p = 0.03). In contrast, focal slowing (53% vs. 74%, p = 0.11) and focal EAs were less prevalent on days with delirium (38% vs. 48%, p = 0.37), though these differences were not statistically significant. ConclusionsWe found a higher prevalence of generalized but not focal EEG abnormalities in stroke patients with delirium. SignificanceThese findings may reinforce the diffuse nature of delirium-associated encephalopathy, even in patients with discrete structural lesions.

Bilateral hypogeusia and food aversion due to lacunar infarct in the right dorsomedial pontine tegmentum

ABSTRACT A 70-year-old right-handed housewife suffered an acute loss of taste, an unpleasant change in the taste of foods and liquids, and a strong aversion to all kinds of food due to a small lacune in the right dorsomedial pontine tegmentum. Eating became so unpleasant that she lost 7 kg in three weeks. Olfaction and the sensibility of the tongue were spared. The right medial longitudinal fascicle, the central tegmental tract, or both, were injured by the tegmental lesion. A discrete right-sided lesion in the upper pontine tegmentum may cause a reversible syndrome consisting of bilateral hypogeusia which is more severe ipsilaterally.

Spotting disease disrupts the microbiome of infected purple sea urchins, Strongylocentrotus purpuratus

BackgroundSpotting disease infects a variety of sea urchin species across many different marine locations. The disease is characterized by discrete lesions on the body surface composed of discolored necrotic tissue that cause the loss of all surface appendages within the lesioned area. A similar, but separate disease of sea urchins called bald sea urchin disease (BSUD) has overlapping symptoms with spotting disease, resulting in confusions in distinguishing the two diseases. Previous studies have focus on identifying the underlying causative agent of spotting disease, which has resulted in the identification of a wide array of pathogenic bacteria that vary based on location and sea urchin species. Our aim was to investigate the spotting disease infection by characterizing the microbiomes of the animal surface and various tissues.ResultsWe collected samples of the global body surface, the lesion surface, lesioned and non-lesioned body wall, and coelomic fluid, in addition to samples from healthy sea urchins. 16S rRNA gene was amplified and sequenced from the genomic DNA. Results show that the lesions are composed mainly of Cyclobacteriaceae, Cryomorphaceae, and a few other taxa, and that the microbial composition of lesions is the same for all infected sea urchins. Spotting disease also alters the microbial composition of the non-lesioned body wall and coelomic fluid of infected sea urchins. In our closed aquarium systems, sea urchins contracted spotting disease and BSUD separately and therefore direct comparisons could be made between the microbiomes from diseased and healthy sea urchins.ConclusionResults show that spotting disease and BSUD are separate diseases with distinct symptoms and distinct microbial compositions.Graphical abstract

P17 Hepatobiliary parasitic infestation: a case report

Abstract Background Hepatic parasitic lesions can present with multiple cystic lesions that may simulate inflammatory pseudo-tumour or malignancy in appropriate clinical settings. Here we present a known case of renal cell carcinoma with liver lesions that showed parasitic infestation on histology. Patient case A 70-year-old male with a history of right partial nephrectomy for clear cell renal cell carcinoma having an uneventful postoperative follow-up for 2 years underwent a surveillance CT scan. Multiple hepatic cystic lesions were identified, which on subsequent MRI and PET scan were suspicious for metastasis. Partial hepatectomy was performed for histological evaluation. Results Multiple discrete cystic hepatic lesions were noted on macroscopy. Histological examination revealed multiple necrotic hyalinized nodules with granulomatous inflammation within the liver and dense neutrophil infiltration with microabscess formation. Within the central necrotic area, there were non-viable parasite eggs and parts of worm, in keeping with parasitic infestation. On further expert opinion, this was diagnosed as Enterobius infestation of liver. Conclusions Hepatobiliary parasitic infestations may be encountered as clinically and biochemically asymptomatic lesions, especially in immunocompromised patients. Strong clinical history of travel and parasite serology screen is always helpful to clinch the diagnosis but may not be always available during histological examination. This case highlights the importance of thorough histological and microbiological examination as all nodular lesions in liver are not malignant and could be infective.

Who are the Better Candidates for Epilepsy Surgery?

The resective epilepsy surgery can be the effective procedure to get seizure-free outcome in these drug resistant epilepsy (DRE) patients. Class I evidence firmly establishes the superiority of epilepsy surgery over medical treatments in both seizure control and quality of life for DRE patients. For the effective identification of optimal surgical candidates, it's essential to understand the prognostic factors of epilepsy surgery based on the surgical methods employed. Established positive prognostic indicators for temporal resection include the presence of hippocampal sclerosis on magnetic resonance imaging (MRI), focal lesions on MRI, unilateral temporal spikes, concordant ictal electroencephalography (EEG), and a history of prolonged febrile convulsion. Potential negative predictors encompass preoperative secondary generalized tonic-clonic seizures, a normal MRI, postoperative EEG spikes, and age at the time of surgery. For neocortical epilepsy, the prognostic factors identified through multivariate analysis were the presence of a discrete lesion, localized hypometabolism on Fluorodeoxyglucose positron emission tomography (FDG-PET), and localized ictal EEG. A significant correlation was found between achieving a seizure-free outcome in no visible lesion on MRI (MR-negative) epilepsy patients and having concordance in two or more presurgical evaluations, specifically in interictal EEG, ictal EEG, FDG-PET, and ictal single-photon emission computed tomography. There was a marked improvement in the seizure-free outcome in MR-negative temporal lobe epilepsy (TLE) by the application of this strategy. The better surgical candidates for epilepsy surgery are the followings: patients displaying a discrete lesion on MRI with concordant video-EEG monitoring (VEM) results, patients diagnosed with unilateral hippocampal sclerosis who have concordant VEM results, patients with unilateral hippocampal sclerosis but discordant VEM results, patients with focal cortical dysplasia and concordant VEM results, and patients diagnosed with MR-negative TLE who exhibit two or more consistent results from presurgical evaluations.