Granular Positivity Research Articles

P-2175. Prospective study on the clinico-epidemiological characteristics, diagnostic approaches and correlation with autopsy findings of rabies encephalitis

Abstract Background Rabies is the deadliest infectious disease, with a nearly 100% fatality. Due its fear, it is often overlooked, resulting in scarcity of comprehensive knowledge, most of which is derived from retrospective studies. This prospective study is aimed to narrow this knowledge gap.Table 1:Clinical features Table 1: Table summarizing the frequency of clinical features in both forms of rabies at the time of presentation Methods This prospective observational study included 36 participants. Detailed clinical history and clinical examination was done, Milwaukee protocol was used for patient management. For diagnostics, CEMRI Brain was performed, and samples of CSF, saliva, serum, skin and brain biopsies were collected for various diagnostic tests. Autopsy was done for 8 patients. Table 2 and Figure 1 & 2: Incubation period Table 2: Table representing various incubation periods, in median (IQR), and the respective p-values between 2 groups Figure 1: Figure demonstrating statistically significant trend of shorter incubation period with proximity of site of bite to CNS. P-values are calculated using Dunn test with post-hoc Sidac correction Figure 2: Box plot representing the difference between incubation period based on no application of red-chilli vs application of red-chilli, p-value (ranksum test) = 0.0478 Results The study unearthed numerous intriguing aspects of the disease. Despite presence of adequate infrastructure, only 48% initiated PEP, and a mere 26% received Rabies Immunoglobulin. Adherence to the vaccination schedule was subpar, with only 13.3% completing full course. The median incubation period was 29 days, with variations based upon the type of rabies, bite site, and irritant application. Autonomic dysfunction emerged as prominent manifestation, with variations in heart rate (90%), BP (90%), and temperature (81%); hypersalivation (61%), hyperhidrosis, spontaneous ejaculations (29%), and neurogenic pulmonary edema (19%) being the common features. MRI revealed dorsal brainstem (90%), peri-aqueductal grey (72.7%), basal ganglia (63.6%), and cervical spinal cord (72.2%) as most affected areas. Antemortem diagnosis showed the following positivity rates: nape of neck skin biopsy IHC (40%), saliva-PCR (23.8%), skin biopsy PCR (20%), and CSF-PCR (4.3%). Postmortem brain biopsy PCR demonstrated a 100% positivity. Autopsy findings revealed the following – negri bodies, perivascular lymphocytic infiltrate, neuronophagia and microglial formation or nodule formation in almost all areas of the brain with maximum in hippocampus, cortex, and brainstem. Table 3 and 4: Diagnostic tests and MRI features Table 3: Diagnostic performance of various tests Table 4: Table summarizing the MRI findings in rabies patients Conclusion This is the first of its kind prospective study, which studies in-depth the clinico-epidemilogic, neuroimaging and autopsy features and the performance of various diagnostic tests in rabies. The unique features of the study include – its prospective nature, prominent clinical features of dysautonomia, neuroimaging characteristics and their corelation with autopsy. Figure 3, 4, 5 & 6: Histopathology and immunohistochemistry findings in autopsy Figure 3: Perivascular lymphocytic cuffing Figure 4: Negri bodies in the cortical neurons and purkinje cells of cerebellum Figure 5: Microglial nodule and diffuse microglial proliferation Figure 6: Immunohistochemistry demonstrating rabies virus antigen within the neurons seen as diffuse granular cytoplasmic positivity within the neurons, its axons and dendrites Disclosures All Authors: No reported disclosures

De novo proliferative glomerulonephritis with monoclonal IgG deposits in an adolescent kidney transplant recipient.

Proliferative Glomerulonephritis with Monoclonal IgG Deposits (PGNMID) is a glomerular disease characterized by membranoproliferative and mesangioproliferative lesions, with granular capillary wall monoclonal IgG positivity and immunoglobulin light chain restriction. Most commonly a disease of older adults, we present the case of an 18-year-old patient who developed de novo PGNMID in a kidney allograft three years after kidney transplantation. There was minimal proteinuria and no serum paraproteinemia was detected, so the patient was managed conservatively. To our knowledge, this is the youngest reported case of de novo PGNMID occurring in a kidney allograft and highlights the importance of considering PGNMID as a possible etiology of de novo glomerular disease in adolescent and young adult patients.

Diagnostic Utility of Direct Immunofluorescence on Paraffin-Embedded Skin Biopsy Samples for the Diagnosis of Autoimmune Vesiculobullous Lesions.

Background Autoimmune vesiculobullous diseases (AIBDs) are a group of diseases characterized by blisters of the skin/mucosa due to the presence of circulating autoantibodies against antigens in the epidermis or the dermo-epidermal junction. Direct immunofluorescence (DIF) for immunoglobulin (Ig)G, IgC3, and IgA on fresh-frozen tissue is the gold standard diagnostic test for AIBDs. However, DIF in the absence of frozen tissue is challenging for the diagnosis of AIBDs. This study aimed to analyze the practical utility of DIF using paraffin-embedded skin biopsy rather than fresh frozen tissue for the diagnosis of AIBDs. Methodology This cross-sectional comparative study included 30 cases of AIBDs. DIF for IgG and IgA was performed on paraffin-embedded tissue (PE-DIF) after proteinase digestion on histopathologically confirmed 15 pemphigus vulgaris (PV), three pemphigus foliaceous (PF), four bullous pemphigoid (BP), three dermatitis herpetiformis (DH), three subcorneal pustular dermatosis (SCPD), and one case each of linear IgA disease and pemphigoid gestationis (PG). PE-DIF staining pattern was compared with the DIF on fresh frozen tissue (FF-DIF). Results All cases of PV and PF showed an intercellular IgG chicken wire staining pattern similar to FF-DIF. However, background staining was more intense in PV cases while less intense in PF cases. Three BP cases showed linear IgG staining in PE-DIF. DH, SCPD, linear IgA disease, and PG cases did not show IgG positivity. Out of three DH cases, two cases showed granular IgA positivity while linear IgA positivity along the basement membrane was seen in a single case of linear IgA disease. Negative IgG staining was observed in SCPD. Immunofluorescence in PE-DIF was rapidly deteriorating than in FF-DIF. Conclusions DIF done on paraffin-embedded tissue can be used as a supplement and salvage technique with histopathology for the diagnosis of AIBDs,particularly when a cryostat facility for frozen tissue is not available and the patient is unable to undergo a second biopsy procedure.

A Rare Case of Granular Cell Tumour of Tongue in a 13-year-old Girl

Granular Cell Tumour (GCT) is a rare benign tumour that usually affects adults in the third to sixth decades, with females being more commonly affected. Here, a rare case of GCT occurring in a 13-year-old child is presented. A young girl presented with a painless swelling on the right-side of her tongue. Her past medical history was unremarkable. Upon examination, a firm, well-defined, non pulsatile, non tender lesion measuring 1×0.8 cm was noted, involving the right lateral border of the tongue. The lesion was excised and sent for histopathological examination. Gross examination revealed a 1×0.8×0.6 cm mass with a grey-white cut surface. Microscopy showed hyperplastic stratified squamous epithelium overlaying a submucosal tumour composed of polygonal cells arranged in sheets. The tumour cells had central small round nuclei with abundant granular eosinophilic cytoplasm and intervening skeletal muscle fibres. No necrosis, atypia, or increased mitosis were observed. Immunohistochemistry showed strong nuclear positivity and bright granular cytoplasmic positivity for S-100, confirming the diagnosis of GCT. The patient was followed-up for 14 months after surgery and reported no recurrences. GCTs typically manifest in older individuals, with the highest prevalence in the fifth and sixth decades of life. However, this case deviates from the norm, being noted in a 13-year-old child. This exceptionally unusual presentation should prompt the inclusion of GCT in the differential diagnosis of tongue neoplasms in paediatric patients as well. Periodic follow-up of these patients is recommended to detect malignant transformations and late recurrences at early stages.

Chasing the Zebra: a case of membranous-like Glomerulopathy with SSA/RO52 deposits and no overt connective tissue disease

BackgroundThe nature of the deposits in immune-mediated glomerulonephritis with a membranous pattern and masked IgG-Kappa deposits (MGMID) remains still to be elucidated.Case presentationWe present a case of 33-year-old woman developing a continuous asymptomatic proteinuria (0.8–1 g/24 h) with no overt connective tissue diseases. She tested positive at high titers for SSA antibodies (Ro52 838 UI/mL, Ro60 2716 UI/mL) and at the kidney biopsy histological findings were compatible with an immune-mediated glomerulonephritis with a membranous pattern and masked IgG-Kappa deposits. Also, we demonstrated a positive immunohistochemistry staining for anti-Ro52-SSA antibodies, with a granular positivity in mesangium and along rare glomerular capillaries. To date, only one case of a patient with overt diagnosis of Sjögren’s syndrome with MGMID has been described but a pathogenic role for SSA and SSB antibodies has never been proven.ConclusionsIn this case, we described for the first time by immunohistochemistry a Ro52+ granular positivity in the mesangium and glomerular capillaries, potentially paving the way for a better understanding of MGMID.

S1697 Biliary Schwannoma in a Post-Liver Transplant Patient Presenting as Biliary Obstruction

Introduction: Schwannomas are benign, mesenchymal-derived neoplasms which present as solid, slow growing tumors. They can rarely be observed in the gastrointestinal (GI) tract, with very limited reports of them occurring in the biliary system. In this case, we describe a bile duct schwannoma in a post-liver transplant patient. Case Description/Methods: A 77-year-old man with a history of alcohol-related cirrhosis with hepatocellular carcinoma treated with orthotopic liver transplantation 16 years prior, and end stage renal disease on hemodialysis presented with jaundice. Labs demonstrated new elevations in his liver enzymes: AST 181 U/L, ALT 189 U/L, alkaline phosphatase 625 U/L, total bilirubin (TB) 7.9 mg/dL, and direct bilirubin 5.0 mg/dL. A magnetic resonance cholangiopancreatography was performed and demonstrated a 16 x 15 x 11 mm enhancing mass causing abrupt narrowing of the mid common bile duct (CBD) with upstream duct dilation to 10 mm ( Figure A) without other discrete mass identified. A follow-up endoscopic ultrasound confirmed a hypoechoic mass in the mid CBD and fine needle biopsy was obtained. An endoscopic retrograde cholangiopancreatography was subsequently performed, which demonstrated a severe biliary stricture at the level of the prior biliary anastomosis which was treated with balloon dilation and placement of a covered metal stent. The procedure was complicated by post-sphincterotomy bleed and mild post-ERCP pancreatitis. His liver enzymes failed to improve, and his TB progressively worsened to 23.3 mg/dL. Pathology returned showing a low-grade spindle cell tumor (Figure B), with staining positive for S100 (Figure C) and negative for CD117 and desmin, consistent with a diagnosis of schwannoma. Surgical intervention was not pursued, in line with his goals of care, and he was ultimately transitioned to comfort-oriented care and passed 5 days after admission. Discussion: Schwannomas are rare neoplasms which can arise from the nonepithelial wall of the GI tract containing nerve fibers. They are composed of highly cellular spindle cells which stain positive for vimentin (marker of mesenchymal origin) and S100 protein (marker of nerve sheath origin), and negative for CD117 (marker of GI stromal tumors) and desmin (muscle cell marker). Neoplasms can often be suspected in late presentations of post-transplant biliary obstruction. To our knowledge, this is the first case report of a biliary schwannoma occurring at the site of a biliary anastomosis in a liver transplant patient.Figure 1.: A) MRCP T1-weighted coronal image demonstrating a 16 x 15 x 11 mm enhancing mass with diffusion restriction (yellow arrow) at the mid common bile duct causing an abrupt biliary stricture with upstream dilation, B) 10x magnification H&E showing spindled, wavy nuclei in a fibroblastic stroma consistent with a spindle cell neoplasm in a background of unremarkable columnar biliary epithelium, C) 10x magnification S100 immunohistochemical stain showing diffuse nuclear and granular cytoplasmic positivity consistent with nerve sheath origin.

Netrin G1 Is a Novel Target Antigen in Primary Membranous Nephropathy.

Primary membranous nephropathy (MN) is caused by circulating autoantibodies binding to antigens on the podocyte surface. PLA2R1 is the main target antigen in 70%-80% of cases, but the pathogenesis is unresolved in 10%-15% of patients. We used native western blotting to identify IgG4 autoantibodies, which bind an antigen endogenously expressed on podocyte membranes, in the serum of the index patient with MN. These IgG4 autoantibodies were used to immunoprecipitate the target antigen, and mass spectrometry was used to identify Netrin G1 (NTNG1). Using native western blot and ELISA, NTNG1 autoantibodies were analyzed in cohorts of 888 patients with MN or other glomerular diseases. NTNG1 was identified as a novel target antigen in MN. It is a membrane protein expressed in healthy podocytes. Immunohistochemistry confirmed granular NTNG1 positivity in subepithelial glomerular immune deposits. In prospective and retrospective MN cohorts, we identified three patients with NTNG1-associated MN who showed IgG4-dominant circulating NTNG1 autoantibodies, enhanced NTNG1 expression in the kidney, and glomerular IgG4 deposits. No NTNG1 autoantibodies were identified in 561 PLA2R1 autoantibodies-positive patients, 27 THSD7A autoantibodies-positive patients, and 77 patients with other glomerular diseases. In two patients with available follow-up of 2 and 4 years, both NTNG1 autoantibodies and proteinuria persisted. NTNG1 expands the repertoire of target antigens in patients with MN. The clinical role of NTNG1 autoantibodies remains to be defined.

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.

S2691 A Rare Presentation of Gastric Plastocytomas in a Patient With Multiple Myeloma

Introduction: Multiple myeloma is an uncommon hematological neoplasm. This malignancy involves unchecked plasma cell growth in the bone marrow, but in a subset of often more advanced cases, these cells may migrate to soft tissues causing extramedullary plasmacytoma. This is unusual, and, in the literature, few cases of extramedullary plasmacytomas involve the gastrointestinal tract. Within this system, the more common locations are the stomach, the liver, the large bowel, and more rarely, the small bowel. Case Description/Methods: A 59-year-old male with a medical history of chronic hepatitis C, and Stage III multiple myeloma status post four cycles of chemotherapy presented with altered mental status. Upon evaluation, he had significant electrolyte abnormalities, remarkable anemia, severe renal and liver dysfunction, and a positive hemoccult test. Our patient received intravenous fluid, and multiple blood products. He was then admitted to the intensive care unit for a high level of care. On the second day of admission, he developed new onset hematemesis, and the gastroenterology team was consulted. The patient was started on a pantoprazole drip. Urgent esophagogastroduodenoscopy showed several polypoid appearing masses with overlying ulceration in the gastric fundus (Figure a &b), and tissue biopsies were obtained. Biopsy result of the polypoid fundal mass showed a large cell neoplasm with plasmocytic differentiation. Gastric tissue sections showed an ulcerated lesion with submucosal, tightly packed atypical large cells with multinucleation, prominent nucleoli and relatively identifiable mitoses (Figurec). A panel of immunohistochemical stains with plasma cell markers were positive for kappa, Multiple Myloma-1 nuclear protein, and CD138 (Figure d-f). The overall findings were compatible with gastric involvement by a plasma cell neoplasm. Discussion: This case highlights a complicated, yet a uniquely rare presentation of extramedullary plasmacytoma in a patient diagnosed with multiple myeloma. Although the gastrointestinal tract is rarely involved in patients with multiple myeloma, it should be considered as the differential diagnosis in patients with gastrointestinal bleeding especially with a known concurrent systemic hematological malignancy. The presence of gastrointestinal involvement and the malignant phase of multiple myeloma are associated with a poor prognosis despite aggressive therapy, and it is therefore paramount to establish an accurate diagnosis early to avoid any delays in treatment.Figure 1.: (a,b) EGD shows polypoid EMP in the gastric fundus. (c) Infiltration of plasmablasts with highly atypical nuclei and prominent nucleoli (hematoxylin-eosin 20x). (d) Granular positivity for kappa immunoglobulin light chain. (e) Positive immunostaining for MUM-1. (f) Positive CD138 immunostaining highlights the plasma cells in the lamina propria of the gastric fundus EMP.

When the Donor Surprises You: A Case Report

The possibility of transplanting a graft from a cadaveric donor with unknown membranous nephropathy (MN) has been described in the literature. We present the case of 2 patients who received their first kidney transplant (KT) from a 27-year-old male donor with no relevant medical history. The first recipient was a 50-year-old man with stage 5 chronic kidney disease secondary to diabetic kidney disease. Two biopsies were performed; the first was performed on day +9 because of impaired renal function coinciding with high levels of tacrolimus, and vacuolization of the arteriolar walls was observed with no other findings; the second was performed on day +13 because of creatinine stagnation, and methenamine silver staining showed multiple cavities and isolated spikes. Immunofluorescence revealed contiguous granular positivity in capillary walls for IgG and C4d, and immunohistochemistry showed contiguous parietal positivity for IgG4, compatible with donor membranous glomerulopathy. Anti-phospholipase-2 receptor (PLA2R) antibodies were negative. The second-year biopsy showed persistence of stage 1 MN, without proteinuria. The second recipient was a 38-year-old man with hypertension and unknown stage 5 chronic kidney disease who experienced immediate kidney function post-KT. In the protocol kidney biopsy 3 months post-KT, data consistent with stage 1 membranous glomerulopathy were also observed. Anti-PLA2R antibodies were negative, and proteinuria did not increase. The second-year protocol biopsy showed no MN data.

METASTATIC MEDULLOBLASTOMA TO THE MANDIBLE: A CASE REPORT

<h3>Introduction</h3> Medulloblastoma is the most common tumor of the brain of neuroendocrine origin in children and typically demonstrates an aggressive, relentless clinical behavior and high recurrence rate. Extraneuraxial metastasis of medulloblastoma to the jaw is extremely rare, with fewer than 10 cases reported in the literature. <h3>Case Report</h3> A 10-year-old male patient presented with a swelling in the right side of the face for 15 days. The patient had a past history of medulloblastoma diagnosed a few years earlier. Clinical examination revealed a diffuse painless mass in the right mandible. Multiplanar reconstruction demonstrated a 1.5 × 1.5 cm well-defined round lesion with extensive necrosis involving mostly the ramus of right mandible with resultant bone erosion on the lingual aspect. The lesion involved the regional structures including maxillary sinus, pterygoid process, and carotid sheath. Microscopic examination of the biopsy specimen exhibited sheets of poorly differentiated malignant small round blue cells with extensive necrosis. The tumor cells revealed molding of nuclei with speckled chromatin and inconspicuous cytoplasm. Evidence of vascular and perineural invasion was noted. Immunohistochemical studies demonstrated weak granular positivity for synaptophysin, but staining for AE1/3, desmin, CD99, and LCA was negative in the lesion tissue. A diagnosis of round blue cell malignancy of neuroendocrine origin compatible with medulloblastoma metastatic to the jaw was rendered. Our case represents only the 10th such as case in the English-language literature. Owing to the rarity of this entity, a more accurate understanding of the prognosis and treatment of metastatic medulloblastoma is not well known.

Cyclooxygenase 2 (Cox 2) Expression in Newly Diagnosed Plasma Cell Myeloma: A Clinicopathological and Immunohistochemical Study on 73 Cases from a Single Tertiary Care Center.

To study the cyclooxygenase 2 (Cox 2) expression in newly diagnosed plasma cell myeloma cases by immunohistochemistry (IHC) and correlate with clinicohematological characteristics. Immunohistochemical expression of Cox 2 on bone marrow trephine biopsy was studied in seventy-three newly diagnosed myeloma cases [56 males, 17 females, median age; 58years (36-75)] and fifteen controls using SP21 clone antibody. A median immuno-score (proportion x intensity) stratified the entire cohort into low and high expressors. Cox 2 immunoexpression was compared and correlated with clinicolaboratory characteristics and marrow histomorphology and survival. Twenty one of 73 (38.7%) cases had a plasmablastic morphology whereas remainder fifty-two (61.3%) had a differentiated morphology. The Cox 2 expression was noted in 71/73 (97.2%) cases (median score = 127.3) and 15/15 (100%) controls. Low expressors was associated with higher circulating plasma cells, increased marrow tumor burden, blastic morphology, and lower proliferation index (p < 0.05) with a peculiar 'dot-block' cytoplasmic positivity (p < 0.001); whereas high expressors had thinned out bony trabeculae with granular cytoplasmic positivity with or without membrane accentuation (p < 0.001). Cox 2 expression had a weak negative correlation with tumor burden (r; -0.32, p = 0.01) and positive correlation with proliferation index (r; 0.29, p = 0.03). There was no statistically significant difference in the survival between low (n = 20) and high (n = 23) expressors (log rank p = 0.11). A high proportion of myeloma cells in our cohort expressed Cox 2 using SP21 clone; and this may have a role in futuristic research and therapy.

Detection of ALK Gene Rearrangements in Non-Small Cell Lung Cancer by Immunocytochemistry and Fluorescence in Situ Hybridization on Cytologic Samples.

Determination of the molecular status is mandatory for personalized treatment of patients with non-small cell lung carcinoma. The present study was performed to detect anaplastic lymphoma kinase (ALK) rearrangements in pulmonary adenocarcinoma on cytology samples, using immunocytochemistry (ICC) and fluorescence in situ hybridization (FISH) on cell-blocks to assess the diagnostic reliability of these two techniques. A total of 50 confirmed lung adenocarcinoma cases were included. In all the 50 cases, ICC was performed for ALK protein expression by using the D5F3 clone on Ventana platform. On the basis of ALK protein expression on ICC, the cases were categorized as ALK positive (2+ or 3+ strong cytoplasmic granular positivity) or negative (negative or 1+ cytoplasmic granular positivity). FISH for detection of ALK gene rearrangement was performed in 7 ALK ICC positive cases and 7 ALK ICC negative cases using the Vysis ALK break apart FISH probe kit. Based on ICC, 7(14%) cases were ALK positive and 43(86%) were ALK negative. ALK gene rearrangements in lung adenocarcinoma were more commonly seen in non-smokers (31.25%) as compared to smokers (6.25%). Among the ALK-ICC positive cases, FISH demonstrated break apart signal in 5 cases (ALK- ICC positive); however, no break-apart signals were seen in 2 ALK-ICC positive and all the seven ALK-ICC negative cases. Immunocytochemistry on cell- blocks using DF53 clone is a highly sensitive and specific method for the detection of ALK gene rearrangements in lung adenocarcinoma with a greater number of ALK positive cases being detected on ICC as compared to the ALK-FISH.

Gastrointestinal: Franseen-tip transmural fine-needle biopsy for localized gastric linitis plastica.

A 59-year-old male patient presented with refractory nausea and vomiting. Esophagogastroduodenoscopy revealed a concentric, malignant-appearing stricture in the distal antrum (Fig. 1a). Of note, despite the clinical picture of functional outlet obstruction, endoscopic passage into the duodenum was maintained. However, two extensive rounds of conventional mucosal biopsies (each > 12) did not yield a malignant histology. While a thoracoabdominal computed tomography scan excluded distant metastases, endoscopic ultrasound (EUS) revealed marked, diffusely hypoechogenic wall thickening up to 30 mm with irregular margins and fusion of layers, highly suggestive of gastric linitis plastica (GLP) (Fig. 1b, linear probe: Pentax, EG38J10UT). Final locoregional staging was determined uT3N0, and transmural EUS fine-needle biopsy (FNB) using a novel FNB-dedicated 22G Franseen-tip needle was performed (Acquire, Boston Scientific) (Fig. 1c). Relative to more established EUS-FNB needle, such as the Procore needle, the specific design of the needle with its stabilizing three-point tip allows for improved tissue capture and reduced fragmentation. EUS-FNB was performed in the slow pull technique with extensive fanning through the lesion, resulting in a macroscopically excellent yield (Fig. 1d). Pathology assessment indicated atypical epithelial cells with a prominent desmoplastic stroma within the muscularis propria (Fig. 1e, top). There was faint granular positivity in the periodic acid-Schiff staining, albeit a clear-cut signet ring morphology was absent. Ancillary immunohistochemistries were positive for CK-20 (Fig. 1e, lower left), CDX-2 (Fig. 1e, lower right), and (not shown) carcinoembryonic antigen, while p53 remained negative. In conjunction with clinical characteristics, a final diagnosis of poorly differentiated adenocarcinoma underlying linitis plastica was entertained. After an unremarkable ileocolonoscopy, the patient underwent diagnostic laparoscopy, excluding peritoneal carcinomatosis and providing an enteral nutrition access, and perioperative chemotherapy using FLOT4 (fluorouracil plus leucovorin, oxaliplatin, and docetaxel) was recommended prior to surgical gastrectomy. EUS-based tissue acquisition of either the gastric wall and/or suspicious lymph nodes is instrumental in confirming the malignant nature of gastric wall thickening, albeit the distinct benefit of newer FNB-dedicated needles, such as with a Franseen-tip design, considered to translate into improved maintenance of tissue architecture, is yet to be better determined in systematic, GLP-exclusive analyses.

Positive/retained SDHB immunostaining in renal cell carcinomas associated to germline SDHB-deficiency: case report

BackgroundAccording to WHO, succinate dehydrogenase (SDH)–deficient renal cell carcinoma is characterized by negative immunostaining for SDHB, which remains positive in non-tumor tissue despite germline mutations in the SDHB gene. We now report a patient with a SDHB mutation, c.166_170del (p.Pro56Tyrfs*5) who developed renal cell carcinomas with characteristic morphological features of SDH-deficient renal cell carcinoma but had positive SDHB immunostaining.Case presentationWithin a 6-year period, the patient developed two different renal cell carcinomas, which had characteristic morphological features of SDH-deficient renal cell carcinoma (uniform cells characteristically displaying eosinophilic granular material intermixed with fewer cells exhibiting clear intracytoplasmic inclusions and bland centered nuclei) but displayed immunohistochemistry for SDHB with a cytoplasmic granular positivity (mitochondrial pattern) in tumor cells. For the second case, this was initially interpreted as positive by IHC, but on review some subtle differences were identified.ConclusionsSDHB immunostaining may be positive in renal cell carcinoma associated to germline SDHB deficiency which have other typical morphological features. Immunohistochemistry interpretation may be complex.

Urotensin II receptor expression in prostate cancer patients: A new possible marker.

Urotensin II receptor has been poorly studied in prostate cancer. To evaluate the expression of urotensin II receptor (UII-R) in patients undergoing radical prostatectomy. Overall, we identified 140 patients treated with retropubic radical prostatectomy (RP) in one center. UII-R was evaluated in prostate biopsies with immunohistochemical staining, resulting in a granular cytoplasmic positivity, through automated system using the kit Urotensin II Receptor Detection System provided by Pharmabullet srl. Immunostained slides were independently and blindly evaluated by ten uro-pathologists. To evaluate UTII-R expression three different parameters were considered: localization, granules dimensions and intensity of expression. A score from 0 to 3 was applied to each parameter to obtain a score from 0 to 9. Each parameter and the total score were evaluated as predictors of high grade disease on surgical pathology and of advanced stage disease. Accuracy of total score for the prediction of upgrading and upstaging was analyzed using receiver operator characteristics curve and decision curve analysis (DCA). On radical prostatectomy 92/140 (66%) presented high grade disease on surgical pathology. Patients with high grade disease presented an apical distribution of the receptor, larger granules and a more intense expression when compared to patients with low grade disease. A well they presented a higher total score. Subscores and total scores were found to be predictors of upgrading and upstaging. On ROC analysis total score presented an AUC of 0.72 and 0.70, respectively, for the prediction of upgrading and upstaging. On DCA total score showed a clinical benefit in the prediction of adverse pathological outcomes. Urotensin II receptor is a potential marker of adverse pathological outcomes. Further studies should confirm our data and evaluate its role as a prognostic marker.

Investigation of antinuclear antibodies in chronic hepatitis B patients

Antinuclear antibodies (ANA) facilitate the diagnosis and evaluation of patients in many systemic autoimmune conditions. Besides, ANA may also be detected in chronic infectious diseases. Although a number of investigations associated with autoantibody positivity in patients with chronic hepatitis C were reported, autoantibody positivity in patients with chronic hepatitis B remain rarely addressed in the literature. The aim of this study was to evaluate the antinuclear antibody (ANA), antimitocondrial antibody (AMA), anti-smooth muscle antibodies (ASMA) and anti-liver-kidney microsomal antigen (LKM) antibodies in chronic hepatitis B patients. Serum samples were obtained from adult patients with chronic hepatitis B diagnosis according to "European Association for the Study of the Liver (EASL)" criteria. Samples were taken from 47 patients (22 female, 25 male) with treatment-naive, histologically-proven chronic hepatitis B. Cases co-infected with HCV and/or HIV or that also had systemic autoimmune diseases were excluded. As a control group, 30 healthy blood donors were included in the study. Autoantibodies, including ANA, AMA, ASMA and LKM were detected with indirect immunofluorescence (IIF) method (Euroimmune, Lubeck, Germany) and evaluated by fluorescence microscope (Eurostar III plus, Germany). Positive results were graded into 4 levels ( "+", "++","+++" and "++++") from weak to strong Positive samples were studied with a immunoblotting method (ANA Profile 3, Euroimmun, AG) for the detection of extractable nuclear antigen (ENA). The positive results were detected in 8 (17%) of the HBV patients while all the samples were negative in the control group. The difference between the groups was significant (p< 0.05). Among the 47 serum samples tested, none of the patients were positive for AMA, ASMA, LKM. ANA was present in eight of the serum samples in which six were female and two were male patients. Among the IIF patterns of ANA positivity, one mixed pattern (homogeneous and nucleolar) and one cytoplasmic anti-golgi antibody pattern were detected. Positivity grade was ''++''. Other positive patterns were nucleolar (two patients), granular (two patients), ribozomal (one patient) and homogeneous (one patient) and positivity grade was ''+''. ENA was detected in three samples. Two of them was granular pattern positive samples. SS-A was borderline (±) in one and SS-B was borderline (±) in one of the samples. In the mixed pattern positive sample, histon was detected as ''+''. Autoantibody positivity between the patient and control groups were statistically significant (p< 0.05). The difference between autoantibody positivity and gender/age was not statistically significant. In conclusion, autoimmune manifestations may be detected in patients with chronic hepatitis B. Low level titer of antibodies such as ANA, AMA, ASMA or LKM may be present in such patients. An increased frequency of these autoantibodies may be associated with non-autoimmune conditions such as chronic viral infection even in treatment-naive patients.

Clinicopathological study of de novo membranous nephropathy of ‘stage 0’ after kidney transplantation

De novo membranous nephropathy (dnMN) contributes to graft failure, but the pathophysiology of the disease remains poorly understood. We defined cases exhibiting granular Immunoglobulin G (IgG) immunofluorescence staining but lacking dense deposits on electron microscopy as being of 'dnMN stage 0'; we studied the associated clinicopathological features. We studied 4653 allograft biopsy specimens (from 1747 cases treated in the Department of Urology, Tokyo Women's Medical University) and found 42 cases of allograft membranous nephropathy, of which 28 (1.6%) were diagnosed as dnMN. Of these, five cases (0.06%) fulfilled the criteria for dnMN stage 0. All five cases were diagnosed based on biopsies indicating increased serum levels of creatinine. Proteinuria status varied from negative to 2+. The median period from transplantation to allograft biopsy was 4068 days. Four of the five cases exhibited suspicious antibody-mediated rejection together with dnMN. The glomerular capillaries of all cases were C4d-positive, as were the peritubular capillaries of three of the four ABO-compatible transplants. In terms of IgG subclass, IgG1 and IgG3 predominated in all cases, and phospholipase A2 receptor status (evaluated via immunoreactivity) was negative in all cases. We examined two cases by immunoelectron microscopy using anti-IgG and anti-C4d antibodies. We found subendothelial and intramembranous deposits expressing both IgG and C4d, corresponding to positivity in immunofluorescence analysis. We confirmed the existence of dnMN stage 0 by focusing on granular IgG immunofluorescence positivity.

111 Primary Intracranial Ewing Sarcoma of the Mastoid Bone Mimicking an Inflammatory Process in a 5-Year-Old

Ewing sarcoma (ES) family of tumors (EFTs) of the head and neck are rare and account for only 1% to 4% of all EFTs. The head and neck is rarely involved as the primary site; an even rarer subset of EFTs is the ES involving the mastoid bone, for which there are only two reported cases based on our review of the world literature. A 5-year-old boy presented with fever and rapidly enlarging painful mass over the right mastoid region complicated by frontal headaches, right ear pain, and decreased hearing on the right side. The mass over the mastoid region measured 4.0 x 6.0 cm, and was hard, non-erythematous, and tender to palpation. MRI revealed lentiform epidural fluid collection with thick peripheral enhancement extending along the margins of mastoid into the right middle and posterior cranial fossa. Pathological evaluation showed small round blue cell proliferation embedded in fragments of trabecular bone. The tumor cells show patchy granular positivity for CD99. Periodic acid-Schiff (PAS) and PAS-D stains show glycogen granules in tumor cells. Tumor cells were negative for AE1/AE3, CD45, and desmin. Fluorescence in situ hybridization analysis confirmed that tumor cells are positive for EWSR1 gene rearrangement at chromosome 22q12. The EFT is a high-grade tumor, with local invasion and a strong tendency to metastasize. Identification of molecular characteristics of the ES/PNET family has contributed to clinical care by providing a greater degree of confidence for an often difficult diagnostic problem. Further understanding of the basic mechanisms of these tumor-specific molecules has the potential to lead to novel therapies. Given its rarity for affecting the skull, particularly the mastoid bone, our findings add to our global understanding of this uncommon subset of patients affected by ES.

Utility of Cytokeratin7 Immunocytochemistry in the Cytopathological Diagnosis of Fibrolamellar Hepatocellular Carcinoma.

Objective:To distinguish fibrolamellar hepatocellular carcinoma (FL-HCC) variant from the conventional hepatocellular carcinoma (HCC) by cytology, immunocytochemistry, and morphometry.Study Design:Retrospective detailed cytomorphological, immunocytochemical, and morphometric analysis was performed in 6 cases of FL-HCC reported on fine needle aspiration. Cell block immunocytochemistry (CB-ICC) for CK7 and CD68 was performed in four cases. Morphometry was carried out with Cell A software. Area of the cell, nucleus and nucleolus was measured in 50 nuclei per case in 6 cases each of FL-HCC and HCC.Results:The mean age of patients with FL-HCC was 19 years and all had normal serum alpha-fetoprotein levels. Fine needle aspiration smears showed large polygonal cells with abundant cytoplasm, vesicular nucleus and prominent nucleolus, associated with variably cellular fibrous stromal fragments. Intranuclear inclusions, cytoplasmic eosinophilic inclusions, and bile were also noted. FL-HCC showed strong membrano-cytoplasmic CK7 positivity and cytoplasmic granular and canalicular positivity for CD68. In contrast, HCC showed weak focal positivity for CK7 and only canalicular CD68 positivity. Morphometry revealed that FL-HCC cells were 2.19 times the size of HCC.Conclusion:CK7 immunocytochemistry on cell blocks is useful for confirming and distinguishing it from HCC.