Type Giant Cells Research Articles

S2212 A Rare Systemic Illness Presenting With Fever and Abdomen Pain

Introduction: Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytic disease. ECD can practically involve any organ system in the body with common organs involved being skeletal system, cardiovascular system and the central nervous system. Rarely, other organs like breast, liver, spleen, kidney, testis and thyroid glands were reported to be involved. Case Description/Methods: A 51-year-old female presented to our emergency with fever and left upper quadrant pain abdomen of 10 days. Historically, she was symptomatic for last 3 years with complaints of intermittent fever, knee joints pain, polyuria, nocturia and polydipsia. Contrast enhanced computer tomography (CECT) chest and abdomen showed bilateral pleural and pericardial effusion, thrombosis in splenic vein and right portal vein, splenic infarct, bilateral urothelial thickening with perinephric fat stranding, soft tissue thickening around the aorta and asymmetrical bulky adrenals. PET-CT revealed Flouro-deoxyglucose (FDG) avid ill-defined lesion in the pericardium which was extending into the inter-atrial and atrioventricular septum and FDG avid asymmetrical mural thickening of aorta extending from ascending thoracic aorta up to the infrarenal abdominal aorta. There was presence of bulky tail of pancreas, bulky left adrenal, lytic lesions involving left femoral head, right sacrum and mandible, FDG avid lesions involving meninges, sella and cranial venous sinuses. Tc-99m bone scan showed increased tracer uptake in maxilla, mandible, bilateral forearm bones, bilateral femurs and bilateral tibia. PET guided biopsy from the lytic bone lesion in the right sacrum showed presence of cluster of atypical histiocytes with occasional multinucleated Touton type giant cells. The cells also showed granular cytoplasmic positivity for BRAFV600E, confirming the diagnosis of Erdheim Chester disease (ECD). She was initiated on oral vemurafenib, BRAF inhibitor, at a dose of 240mg twice a day. Discussion: ECD presenting with splenic infarct has not been described previously. A thorough evaluation and targeted biopsy confirmed the diagnosis. BRAFV600E is the most common mutation noted in these patients, seen in nearly 60% of the patients and the patients with BRAF mutations respond well to vemurafenib, a kinase domain inhibitor of mutant BRAF. Here in, we report a patient of ECD who presented with multisite venous thrombosis and splenic infarct, a rare manifestation of ECD, who was treated successfully with vemurafenib.

Multinucleated Giant Cells: Current Insights in Phenotype, Biological Activities, and Mechanism of Formation.

Monocytes and macrophages are innate immune cells with diverse functions ranging from phagocytosis of microorganisms to forming a bridge with the adaptive immune system. A lesser-known attribute of macrophages is their ability to fuse with each other to form multinucleated giant cells. Based on their morphology and functional characteristics, there are in general three types of multinucleated giant cells including osteoclasts, foreign body giant cells and Langhans giant cells. Osteoclasts are bone resorbing cells and under physiological conditions they participate in bone remodeling. However, under pathological conditions such as rheumatoid arthritis and osteoporosis, osteoclasts are responsible for bone destruction and bone loss. Foreign body giant cells and Langhans giant cells appear only under pathological conditions. While foreign body giant cells are found in immune reactions against foreign material, including implants, Langhans giant cells are associated with granulomas in infectious and non-infectious diseases. The functionality and fusion mechanism of osteoclasts are being elucidated, however, our knowledge on the functions of foreign body giant cells and Langhans giant cells is limited. In this review, we describe and compare the phenotypic aspects, biological and functional activities of the three types of multinucleated giant cells. Furthermore, we provide an overview of the multinucleation process and highlight key molecules in the different phases of macrophage fusion.

Renal Neoformation: A Diagnosis to Consider

Renal granulomas related to suture material are rare and usually accidental findings in imagiological studies. A 12-year-old boy, followed-up after Anderson-Hynes pyeloplasty 7 years before, was submitted to an ultrasonography that described a solid nodular lesion, possibly in the dependence of the left kidney. Subsequently, magnetic resonance imaging was performed, which reported a lesion with non-specific features, suggesting neoformation with predominant fibrous peripheric component and myxomatous center. Percutaneous biopsy was morphologically compatible with chronic xanthogranulomatous inflammatory process. Anatomopathological examination of the surgical excised lesion described histiocytic cells with frequent participation of foreign body type giant cells and granulomatous reaction in relation to exogenous suture-like material. He remains asymptomatic since then. Foreign body granulomatous pseudotumors are difficult to diagnose regarding the absence of specific imagiological features distinctive from neoplasms, requiring histological examination to confirm the diagnosis.

Tuberculosis of Uterus: A Case Report

Female Genital Tract Tuberculosis is caused by Mycobacterium tuberculosis, being usually secondary to tuberculosis of the lungs. In Female Genital Tract Tuberculosis, fallopian tubes are affected in 90 percent woman, whereas uterine endometrium is affected in 70 percent and ovaries in about 20 percent. HIV induced immunosuppresion paves the way for several infections, tuberculosis being very common. This is a case of genital tuberculosis which was diagnosed after hysterectomy by histopathological examination in HIV patient. To describe an uncommon case of female genital tract tuberculosis diagnosed by histopathology. Total abdominal hysterectomy specimen was received. Brief clinical history was taken and clinical examination was done. Histopathological examination of hematoxylin & eosin stained sections was done. AFB staining was done to look for bacilli. Sections studied from endometrium and cervix revealed granulomas comprised of epithelioid cells, langhan’s type of giant cells. Testing for Tuberculosis & HIV should be undertaken because these are the infections which can affect any organ in the body. In patients with extra pulmonary tuberculosis, early institution of therapy & close clinical monitoring are keys to timely diagnosis and treatment of such co-infections. Keywords: Tuberculosis, HIV, Female genital tract

English

This is a rare case report of a thirty-eight-year-old male who presented with multiple asymptomatic hyper-pigmented papulonodular lesions on the face for the past two years without the association of pain or pruritus and with restriction of elbow movements. The diagnosis of multicentric reticulohistiocytosis was made on histopathological findings of Touton type of giant cells and sheets of foamy histiocytes along with immunohistochemistry (IHC) studies. Workup was done for other associated diseases. Multicentric reticulohistiocytosis (MRH) is also known as lipoid dermatitis,1 a rare disease which is characterised by the presence of extensive papulonodular cutaneous eruptions and severe, sometimes destructive arthropathy, followed by eruption of the skin and mucous membrane lesion.2,3 It’s a rare idiopathic nonLangerhans cell histiocytosis.4 This disorder is characterised by predominant cutaneous manifestation and joint involvements. The lesions may show regression and recurrence, many case studies show an association of this lesion with internal malignancies, autoimmune diseases, hyperlipidaemias, and tuberculosis.5,6 Few cases have shown musculoskeletal involvement with features such as myositis. The disease was described initially as reticulocytosis granuloma in 1952 by Caro and Senear, later the term was coined by Goltz and Laymon as multicentric reticulohistiocytosis in 1954.4 It is also known by different names such as giant cell histiocytosis, lipoid dermato-arthritis, lipoid-rheumatism and reticulohistiocytosis granuloma. The disease incidence is very low worldwide, less than 200 cases have been reported in literature5 and reports from India are limited.

Hepatic echinococcus granulosus: a clinicopathological analysis of thirteen cases

Objective: To investigate the clinicopathologic characteristics of hepatic echinococcus granulosus (HEG). Methods: Thirteen cases of HEG were collected from Linzhi People's Hospital between January 2017 to October 2020, and their clinicopathologic features, ultrasound classification, immunophenotype and histochemical data were analyzed, retrospectively and the relevant literature was reviewed. Results: Thirteen patients (5 male patients, 8 female patients) were included in this cohort, and the mean age was 40 years. The most common clinical presentation was mild abdominal distention and pain (9/13). Based on WHO-IWGE ultrasound standardized classification, these cases were classified into 5 types, including type CL (1 case), type CE1 (2 cases), type CE2 (4 cases), type CE3 (3 cases) and type CE4 (3 cases). Gross examination revealed a solitary cyst localized in the liver, varying from 2.7 to 13.5 cm in diameter, and most of them(10/13)were more than 10 cm. Histopathologically, these cysts possessed a thin inner germinal layer and outer adventitial layer, and a central cavity filled with a clear"hydatid"fluid. The germinal layer was continuous and generated brood capsules and protoscoleces. The laminated membranes were clearly demonstrated by elastic fiber and Gomori's stains. Inside the"mother"cyst, there were a varying number of"daughter"vesicles of variable sizes. The inflammatory reaction around the cyst consisted of eosinophils, mononuclear cells immediately next to the cyst layer and sometimes formed granuloma and giant cells resembling the Langhan's type giant cells. The lymphoid cells were positive for CD20 and CD3. The CD68 immunohistochemistry clearly demonstrated epithelioid cells of granuloma in two cases. Moreover, immunohistochemistry revealed plasma cells were locally positive for CD38, IgG and IgG4, but not meeting the criteria for IgG4 related lesion. Conclusions: Hepatic echinococcus granulosus is a zoonotic parasitic disease prevalent in pastoral areas such as Tibet. It is important to understand its clinical features, ultrasound characteristics and histological morphology.

Histology and Immunohistochemistry Localization of ESAT6 Expression on Caseous and Non-caseous Granuloma of Extrapulmonary Tuberculosis

Background: TB diagnosis by histopathological examination is based on the presence of epithelioid granuloma with caseous necrosis. The absence of caseous necrosis will make it difficult to distinguish between TB and non-TB granulomas. The use of ESAT-6 as a confirmative examination of TB immunohistochemically has not been fully used nor are there sufficient data showing the features of ESAT-6 immunolocalization in a granuloma. The purpose of the study was to identify differences in ESAT-6 expression in caseous and noncaseous EPTB granulomas.Methods: A cross sectional study using 66 samples of formalin fixed paraffin embedded tissues from several anatomical lesions.The samples previously diagnosed as tuberculous granuloma were evaluated histologically and immunohistochemically. Mann Whitney tests were used for statistical analysis. Result: There were no significant differences in histological findings and immunohistochemical staining of ESAT-6 on macrophages of caseous and non-caseous granuloma of EPTB. ESAT-6 protein was expressed on cytoplasm of epithelioid macrophages, foamy macrophages, Langhans type giant cells and some necrosis areas in the granulomas.Conclusions: This study showed that macrophages of caseous and non-caseous granuloma of EPTB expressed ESAT-6 protein in the same way. This finding supports the use of the anti ESAT-6 antibody as a complementary diagnostic test in diagnosing granuloma of EPTB.

Clinicopathological Study on TB Lymphadenopathy Case

Background: Tuberculosis in the form of pulmonary and extrapulmonary TB is common in developing countries like Bangladesh. Among extrapulmonary TB, lymphnode TB is still common in our setting. So, the objectives of the present study were to evaluate theclinicopathological findings among the lymphnode TB cases in our context.
 Materials and methods: This observational study was done from January 2017 to December 2019 among 300 lymphnode TB cases in a tertiary care hospital during a three-year study period. Patients were selected after obtaining informed written consent and clinical evaluation. Then enlarged lymphnodes were evaluated by FNAC or histopathology. If lymphnode TB features were found then the patients were included in our study.Other findings like metastasis, lymphoma or pyogenic lymphadenitis were excluded from this study. After collection, data was recorded and analyzed by Microsoft Excel.
 Results: Among 300 cases of TB lymphadenitis subjects were commonly within the age groups 11-20 years (Male 63 and female 51) and 21-30 years(male 45 and female 42) with amale: female ratioof 1.22:1. Regarding different clinical signs and symptoms,low grade fever was found in 21(7%) cases, local lymphnode pain and tenderness was found in 67 (22%) and 63(21%) of subjects. Discharging sinuses was present in 33(11%) patients, 35(12%) had history of weight loss, 39 (13%) had anorexia and 42(14%) had history of night sweats. Regarding locationof different lymph node areas, 125(41.67%) patients had deep cervical nodes, 65(21.67%) had supraclavicular lymph nodes, 60(20%) had lymph nodes in the posterior triangle 33 (11%) in jugulo-omohyoid and 17 (5.66%) in submandibular area. Among all cases, 83% cases showed bilateral and 17% showed unilateral involvement.Regarding nature of lymph nodes, firm, matted multiple lymphnodes were found in 130(43%) cases, single discrete nodes were found in 70(23.33%) cases, others were found as suppurative noded with single and multiple sinuses. Cytopathological and histopathological findings revealed caseating granuloma with epithelioid cell with Langerhans type giant cell was found in 220(73%) cases, caseating granuloma with epithelioid cell was found in 47(16%) epithelioid cell was found in 20(7%) cases and epitheliod cells with smear positive AFB was found in 13(4%) cases.
 Conclusion: TB lymphadenitis is still a common form of extrapulmonary tuberculosis and it has variable clinical and pathological presentations.
 Chatt Maa Shi Hosp Med Coll J; Vol.20 (1); January 2021; Page 77-80

Atypical hemograms of the commercial duck

A description of standard and atypical heterophils, lymphocytes, and 2 types of giant cells found in the circulation of 17 wk commercial ducks (N = 24) in apparent good health is the subject. Heterophils were sorted as either “classic” (HC) having red rod-shaped cytoplasmic granules, “typical” (HT) having weakly stained granules providing a reticular cytoplasmic appearance, or rarely as “variant” types (HV) having orange spherical granules. Atypical HT's and HC's were in 14 of 24 (58%) of the ducks.Small lymphocytes (Ls), reactive lymphocytes and plasmacytes (Lm) were routinely found. Giant cells, also present, were placed with Lm or monocytes (Mn) depending on cytology. Two counts of 200 leukocytes gave the total white count (TWBC) and 2 heterophil/lymphocyte ratios. H/L 1 = (HT + HC +HV) / Ls; and H/L 2 = (HT + HC + HV) / (Ls + Lm). The results showed that TWBC were normal (~ 23,000 /μL) but both H/L ratios were highly variable. HT were differentiated from HC on nuclear and cytoplasmic criteria. Many HT and HC exhibited signs of deterioration.Some giant cells likely represented developmental stages. Multiple nucleoli were evident in others suggesting polyploidy. The more common lymphoid giants were usually round whereas monocyte types were irregular. Mn types were actively phagocytic often consuming thrombocytes or rarely erythrocytes (RBC). Giant cells of either type were in 13 of 24 (54%) of the duck hemograms.Conidiospores were detected in the blood smears of 4 ducks and bacteria in 2 with 1 duck having both.As all ducks were in apparent good health the blood born microorganisms likely represented low grade infections. Presumably the atypical cells were a response to the presence of toxins of bacterial and fungal origin.The presence of atypical heterophils and lymphocytes complicates interpretation of H/L ratios traditionally used to establish stress. As atypical cells can be found in the context of normal TWBC or nonstress H/L values cytological observations attain additional importance. Moreover, giant cells may be useful indicators of infection even without direct microscopic observation or isolation of the offending organisms.

Anti-IL17 antibody Secukinumab therapy is associated with ossification in giant cell tumor of bone: a case report of pathologic similarities and therapeutic potential similar to Denosumab

BackgroundGiant cell tumor of bone is a benign, locally aggressive neoplasm. Surgical resection is the preferred treatment method. However, for cases in which resection poses an increased risk to the patient, denosumab (anti-RANKL monoclonal antibody) is considered. Secukinumab is an anti-IL-17 antibody that is used in psoriatic arthritis to reduce bone resorption and articular damage.Case presentationOne case of giant cell tumor of bone (GCTB) in a patient treated with secukinumab for psoriatic arthritis demonstrated findings significant for intra-lesional calcifications. Histologic examination showed ossification, new bone formation, and remodeling. A paucity of osteoclast type giant cells was noted. Real-time quantitative polymerase-chain-reaction (qRT-PCR) analysis revealed decreased osteoclast function compared to treatment-naive GCTB.ConclusionsSecukinumab may play a role in bone remodeling for GCTB. Radiologists, surgeons, and pathologists should be aware of this interaction, which can cause lesional ossification. Further research is required to define the therapeutic potential of this drug for GCTB and osteolytic disease.

Giant cell lesions of the oral cavity

Giant cells are formed by the union of several monocytes or macrophages which undergo a defined set of intercellular interactions that ultimately results in a multinucleated cell with a single cytoplasmic compartment. Giant cells are not only pathologic, there are even physiologic giant cells such as osteoclast, megakaryocytes, and trophoblast that helps in maintaining normal repair and remodeling process in the body. There are various classifications and theories for the formation of giant cells. Some of these giant cells act as a characteristic histopathologic feature in oral lesions and aid in diagnosis. In the field of challenging diagnosis, these characteristic features can provide a clue for diagnosing some oral lesions. On this background, the article was attempted to review various types of giant cells, their formation, and giant cell lesions of the oral cavity with basic information about their clinical, radiologic, histopathological features, and treatment planning.

Granulomatous Mastitis: A Clinical and Diagnostic Dilemma.

Granulomatous mastitis (GM) is a challenging inflammatory disorder of the breast. In this study we aimed to present the detailed clinical and morphological features of GM cases, diagnostic clues for specific and idiopathic etiologies, the difficulties in evaluating trucut biopsies, and the results of different therapeutic approaches. We retrospectively analysed the clinical, radiological and morphological features of 114 GM cases diagnosed with fine needle aspiration, and trucut, incisional, and excisional biopsy. The mean age was 35.8. Only eight cases were older than 45 years. Bilateral involvement was observed in 4 (3.5%) cases. The most common clinical symptoms were breast mass/abscesses, tenderness, and skin changes. Microbiological culture was positive in 4 cases for gram-positive bacteria. Only 3 cases showed a positive tuberculin/PCR test for tuberculosis. The major USG finding was a hypoechoic well-defined or ill-defined mass/abscess; MRI finding was heterogeneous non-mass contrast enhancement. Cases diagnosed with cytology (35 cases) did not have breast malignancy either in their history or clinical follow up period. Fine needle aspiration cytology materials revealed epitheloid granulomas mixed with neutrophils, lymphocytes accompanied by giant cells, and suppurative necrosis. Histopathological reevaluation of 65 trucut/incisional/ excisional biopsies revealed granuloma formation in 65 (100%), Langhans type giant cells in 59 (90.7%), microabscess formation in 41 (63%), caseous necrosis in 1 (1.5%), neutrophilic cysts in 30 (46.1%), eosinophilic infiltration in 48 (73.8%), interlobular inflammation in 14 (21.5%), fat necrosis in 5 (7.6%), ductal ectasia in 6 (9.2%), and lactational changes in 4 (6.1%) cases. Granulomas were lobulocentric in 58 cases, foreign body type/fat necrosis-related in 6 case, and periductular in 1 case. Cystic neutrophilic granulomatous mastitis was observed in one case. We also evaluated the histochemical stains of these 65 biopsies. Only one sample was positive for acido-resistant bacilli (ARB) by the EZN method and one sample was positive for gram-positive bacilli by gram stain. Small, superficial trucut biopsies may cause difficulties in determining the etiology and differential diagnosis of granulomatous mastitis. For optimal management and timing the appropriate therapy, the ideal biopsy procedure, special stains, and a multidisciplinary team consisting of the surgeon, pathologist, and radiologist are the most important issues.

Long-term effects of uterine artery embolization caused by the embolic material

Background and objectives. Uterine artery embolization (UAE), or uterine fibroid embolization (EFM), a technique introduced in the conservative treatment of uterine fibroids in the 1990s, has been increasingly used in the last decades. The data accumulated in time revealed also, besides the expected benefits, some undesirable complications, initially unanticipated. The study aims at analyzing the histological changes of myometrium occurred after uterine artery embolization for fibroids. Materials and method. Presentation of a series of three cases that have undergone gynecologic surgery in the Bucur Maternity of the “Sf. Ioan” Emergency Clinical Hospital, Bucharest, after the embolization of the uterine arteries performed (in the past) for fibroids. Results. In two of the three cases presented, it was practiced hysterectomy with bilateral anexectomy and in one case myometrectomy. At the histopathological examination, what was proven to be specific for the long-term effects of UAE was the thickening of vascular structures containing intraluminal amorphous material, with vascular and perivascular infiltration with giant multinucleated histiocytes around the foreign body. This histological aspect corresponds to a nonspecific granulomatous inflammation with giant cells. Conclusions. Embolization of the uterine arteries may cause a giant-cell type inflammation at the level of the myometrium and fibrosis, and this type of changes could be the cause of a poor prognosis for women who want a future pregnancy.

Feline giant-cell pleomorphic sarcoma: cytologic, histologic and immunohistochemical characterization.

This study aimed to characterize the cytologic, pathologic and immunohistochemical (IHC) aspects of feline giant-cell sarcoma. Biopsy and necropsy reports from the Department of Veterinary Pathology were retrieved, and 13 cases of pleomorphic sarcoma (PS) were selected according to the established epidemiologic, pathologic and IHC criteria. All samples were fixed in 10% formalin, routinely processed for histology, and stained with hematoxylin and eosin. Samples also underwent IHC testing for vimentin, ionized calcium-binding adaptor molecule 1 (Iba-1), desmin, actin and S-100. The mean age of the affected cats was 9.5 years, and females were over-represented. Most neoplasms were observed in the flank, lateral thorax, limbs and interscapular region, and were >2 cm in diameter. Cytology analysis revealed highly cellular preparations with three distinct populations (spindle cells, small round cells and multinucleated giant cells) in a dense eosinophilic stroma. Histologically, PS was composed of a combination of these three populations. IHC labeling for vimentin and Iba-1 was strongly positive for spindle cells and multinucleated giant cells, respectively. Desmin/actin showed variable labeling among the samples. S-100 was negative in all samples. PS is a neoplasm of mesenchymal origin, also known as malignant fibrous histiocytoma. The predominant subtype in this study that affected the cats was the giant-cell type, characterized by the presence of multinucleated giant cells among spindle-shaped cells. These findings are similar to those described in human patients; thus, a comparison between the neoplasms seen in these species might be useful, and the knowledge of biologic behavior and overall treatment approach for humans could be extrapolated to cats.

Anaplastic carcinoma (osteoclast-like giant cell type) in the remnant pancreas six years after resection of pancreatic carcinoma

Anaplastic carcinoma (osteoclast-like giant cell type) in the remnant pancreas six years after resection of pancreatic carcinoma

Exogenous Lipoid Pneumonia Presenting as an Enlarging Lung Nodule in a Patient with a Long-standing Usage of Petroleum Jelly

Abstract Introduction/Objective Lipoid pneumonia is an uncommon inflammatory lung lesion resulting from the aspiration of endogenous or exogenous oily substances. It has no age or sex preponderance, and its mode of presentation is non- specific. Radiologic imaging findings may mimic that of a malignant lung lesion. Methods We report a case of a 69-year-old female with a history of chronic obstructive pulmonary disease, rheumatoid arthritis and a 30-pack year smoking. She was being followed for an enlarging PET positive spiculated left upper lung nodule. She underwent a CT-guided core biopsy of the lung nodule. Results Biopsy showed histiocytes and multinucleated giant cells with lipid vacuoles and associated marked fibrosis. Review of a percutaneous lung biopsy performed two years prior showed a chronic inflammatory process with associated fibrosis in the presence of nonpolarizable vacuoles, many of which were intracytoplasmic within multinucleate foreign body type giant cells. A re-assessment of the patient with further history taking revealed a longstanding practice of nighttime application of petroleum jelly to nostrils and lips. Together, these findings are consistent with an exogenous lipoid pneumonia. Conclusion Lipoid pneumonia although an entity with limited literature description, should be considered in patients presenting with enlarging lung nodules. Early diagnosis of this lesion ensures appropriate treatment and prevents unnecessary invasive procedures.

S1712 The Machiavellian Passenger

INTRODUCTION: Diarrheas affect a great number of individuals worldwide. Chronic diarrheas are defined as increased frequency of loose stools for more than 4 weeks. However, defining the etiology of chronic diarrheas is a challenging task, as ideal strategies for evaluation have yet to be established. Parasitic disease should always be considered as a possible cause in endemic regions. One important parasite to consider is Schistosoma. Clinical manifestations can range from asymptomatic to maculopapular rash, fever, headache, and diarrhea. This is the case of an unusual passenger found in a diagnostic colonoscopy. CASE DESCRIPTION/METHODS: A 77-year-old Puerto Rican male with past medical history of pulmonary sarcoidosis and Hepatitis B exposure presented with watery diarrhea for the last three years. The patient described about three episodes of loose stools daily aggravated by food intake and associated with abdominal pain and bloating. Physical exam was essentially unremarkable without stigmata of liver disease. Blood workup displayed thrombocytopenia and eosinophilia. Liver enzymes, coagulation parameters, and albumin were all within normal limits. Stool ova and parasites and urine and stool cultures were negative. ESR and CRP were not elevated. Abdominopelvic CT scan and abdominal sonogram were solely remarkable for fatty infiltrations with hepatocellular disease and splenomegaly. As a result, a diagnostic colonoscopy was performed. Random biopsies were obtained from the colon and sub centimeter tubular adenoma in the sigmoid colon. Biopsies from the rectum revealed a small non-necrotizing granuloma with a foreign body type giant cell at rectum suggestive of a parasitic infection. Schistosoma antigen was ordered and yielded a positive result. The patient was subsequently treated with praziquantel, which resulted in resolution of diarrhea and improvement in platelet count. DISCUSSION: Schistosomiasis is a serious infection endemic in the Caribbean and other places around the world. Therefore, this parasite should form part of the differential diagnosis when a patient presents with chronic diarrheas, eosinophilia and thrombocytopenia. Despite stool or urine microscopy being the gold standard for the diagnosis of schistosomiasis, our case illustrates how this is not infallible. The importance of combining social history, clinical presentation, histopathology and serum biomarkers should not be overlooked.

Immunoglobulin G4-Related Ophthalmic Disease: A Case Report

The authors reported a rare case with immunoglobulin (Ig) G4-related ophthalmic disease presented with chronic progressive bilateral complete ophthalmoplegia and blindness from orbital apex syndrome. MRI brain and orbit demonstrated ill-defined infiltrative lesions at bilateral orbital apexes, bilateral optic canals, and bilateral Meckel’s caves, causing optic nerve compression and possibly optic neuropathy with generalized leptomeningeal enhancement at dura, cavernous sinus, and parotid gland. Lumbar puncture revealed few small lymphocytes, rare monocytes, very rare neutrophils with degenerative cells in background, and negative for malignancy. Serology titers for IgG subclass 4 (IgG4) had resulted in 5.959 grams per deciliter (g/dL). A dural biopsy revealed aggregate histiocytes with chronic inflammation and focal foreign body type giant cells. Motility improvement was achieved in the patient after systemic corticosteroids treatment. IgG4 serology should be considered for workup when patients present with chronic idiopathic orbital inflammation. Keywords: IgG4-related ophthalmic disease, Ophthalmoplegia, Orbital apex syndrome

An interesting case of tonsillar tuberculosis in a 10-year-old boy

Tuberculosis of the tonsils is a rare type of extra pulmonary tuberculosis. The secondary form is more common than the primary, usually caused by the contact with the infected sputum or saliva from a sputum smear positive case of tuberculosis. We report a primary form of tonsillar tuberculosis in 10-year-old boy, with no remote history suggestive of documented pulmonary tuberculosis. Local examination revealed Grade IV tonsillar hypertrophy and congestion of posterior pharyngeal wall. Management included, Coblation assisted adenotonsillectomy under general anaesthesia. Histopathological examination revealed features suggestive of chronic adenotonsillitis, multiple epithelioid granulomas with caseous necrosis, langhans type of giant cells with scant inflammatory infiltrate in the background.

Pathology of cutaneous blastomycosis in a cat

Cats are common as pet animals in Indonesia and live in close vicinity of human neighborhood, which make them potential for transmitting diseases to human. Blastomycosis is infectious disease caused by Blastomyces spp yeast. Here we describe morphopathology of blastomycosis found in skin of a Persian Cat. Grossly, the lesion were characterized by ulcerated wounds and multiple subcutaneous small nodules (2-5 mm in diameter) in the base of tail. Skin biopsy was made and further processed for histopathology. Microscopically, the lesion consist of epidermal necrosis, dermatitis, with coalescing dermal granulomatous inflammation, characterized by epitheloid and foreign type giant cells infiltrates. Numerous spherical-shaped structures and pseudohyphae which are Periodic Acid Schiff (PAS)-positive consistent with yeast morphology were found within the granulomas; morphology is also consistent with Blastomyces spp yeasts. Conclusively, multiple granulomatous dermatitis with evidence of Blastomyces yeasts is a hallmark of cutaneous blastomycosis. Exposure to Blastomyces spp yeast may possess infection threat to pet owners.