Retrospective Case Series Analysis Research Articles

Retrospective Analysis of Opportunistic Brain Abscesses in Patients With Hematologic Malignancies

Background Patients with hematologic malignancies have a high rate of opportunistic infections (OIs) with pathogens that could lead to the formation of brain abscesses. Nocardia, toxoplasmosis, Aspergillus, zygomycetes and Fusarium are a few of these organisms, which may be increasing in prevalence. Several immunologic defects such as severe neutropenia (absolute neutrophil count < 500), impaired B-cell immunity, hypogammaglobulinemia, and defective T-cell immunity are related with increased risk of OIs. Recipients of hematopoietic stem cell transplantation (HSCT) are similarly at an increased risk of these OIs due to prolonged neutropenia and defective T-cell–mediated immunity. Design and Methods A retrospective case series analysis at Moffitt Cancer Center, a tertiary cancer hospital, screened for patients with hematologic malignancies and microbiological proven diagnosis of opportunistic brain abscess (OBA) from January 1998 to January 2010. The OBAs were diagnosed via positive cultures from cerebrospinal fluid, brain tissue, or bronchoalveolar lavage for one of the following microorganisms: Nocardia species, Toxoplasmosa species, Aspergillus species, zygomycetes, or Fusarium species; 5 of the 13 cases involved recipients after allogeneic HSCT. A literature review of the most common pathogens related to OBAs in hematologic patients from PubMed between 1998 and 2011 is also included. Results The OBAs documented by culture included Nocardia (5/13, 38%), zygomycetes (3/13, 23%), toxoplasmosis (2/13, 15%), Aspergillus (2/13, 15%), and a single case of disseminated Fusarium (1/13, 8%). The underlying hematologic malignancies were as follows: lymphoma (4/13, 2 cases involved Hodgkin lymphoma and 2 cases involved non-Hodgkin lymphoma), chronic myeloid leukemia (3/13), acute lymphoblastic leukemia (ALL) (3/13), acute myelogenous leukemia (AML) (1/13), multiple myeloma (1/13), and myelodysplastic syndrome (1/13). The age range at diagnosis was 26 to 76 years, with a median age of 51 years at the time of diagnosis with OBA. The male-to-female ratio was 3.3:1 (10 males, 3 females). The most common predisposing factors were severe neutropenia for 7 to 15 days within the month before the diagnosis (6/13, 46%), chronic graft-versus-host disease (GVHD) after allogeneic HSCT (5/13, 38%), lymphoma (4/13, 30%), chronic lymphocytic leukemia, and ALL (3/13, 23%). Of the 13 patients, 7 (54%) had severe neutropenia (absolute neutrophil count < 500 cell/µL) within the month before OBA diagnosis, but only 1 had a prolonged neutropenia for more than 6 months. None of the patients with Nocardia brain abscesses were neutropenic during the year before the diagnosis. The most common presenting symptoms were focal neurologic deficits (7/13, 54%), headaches (5/13, 38%), and altered mental status (5/13, 38%). Conclusions An OBA should be highly suspected in patients with lymphoma, chronic lymphocytic leukemia, ALL, or chronic GVHD presenting with headache and focal neurologic deficits. The most important risk factor for OBA in allogeneic transplant after engraftment is the development of chronic GVHD and effects of its subsequent immunosuppressive treatment. Chronic GVHD is associated with persistently depressed T-cell and humoral immunity. Perhaps Trimethoprim- and sulfamethoxazole-based prophylaxis should be considered for the prevention of OBA infections in HSCT with chronic GVHD complications. Early OBA diagnosis, surgical intervention if indicated, and culture-directed treatment is vital for decreased morbidity and mortality.

Efficacy and safety of low-dose doxepin in depressed patients suffering from insomnia: a retrospective, naturalistic case series analysis.

Low-dose doxepin has produced favorable results in healthy adults and elderly persons with chronic or transient insomnia, while exhibiting an amenable adverse event profile. The aim of this article is to investigate the efficacy and safety of low-dose doxepin for insomnia in depressed patients. In this retrospective case series analysis, the files of 17 inpatients diagnosed with major depressive disorder (MDD) and comorbid insomnia between January 1, 2011, and October 1, 2012 who had received a course of off-label doxepin (< 25 mg/d) were analyzed with regard to dose, efficacy, and safety for up to 4 weeks of treatment. Hamilton Depression Rating Scale (HDRS) sleep item scores were used to estimate efficacy. Our results showed no improvement in sleep onset and sleep maintenance insomnia in patients with MDD during the 4 weeks of treatment. We found a significant improvement in insomnia between baseline and week 3 when considering all 3 HDRS sleep items (P = .058). Contrasting previous results in healthy subjects, low-dose doxepin does not seem to improve sleep onset or maintenance in patients with MDD. Further research, preferably placebo-controlled, double-blind sleep laboratory trials, is necessary to determine whether low-dose doxepin may be beneficial in this important patient subgroup.

Laparoscopic surgical management of localized recurrent ovarian cancer: a single-institution experience

Optimally, secondary cytoreduction is acknowledged as a valid option in terms of oncologic outcome for patients with platinum-sensitive recurrent ovarian cancer. In cases of localized relapse, a laparoscopic approach has been attempted at various institutions, but studies on its role for this subset of patients still are limited. This report describes the authors' experience using laparoscopic secondary cytoreduction for patients with localized recurrent ovarian cancer. The results from a retrospective analysis of a prospective case series are reported. Between October 2011 and May 2013, 29 patients with localized recurrent ovarian cancer were selected for a laparoscopic cytoreduction. Two conversions to laparotomy occurred. The analyzed outcome variables included stage and site of disease, type of surgical procedure, operative time, blood loss, length of hospital stay, complications, and oncologic outcome. The median operating time was 188 min. The median estimated blood loss was 150 mL, and the median hospital stay was 4 days. Complete debulking was achieved for 96.2% of the patients. No intraoperative complications occurred, and postoperative complications were noted in only one patient. The median disease-free survival time was 14 months. For selected patients, laparoscopy is a feasible and safe approach to optimal cytoreduction for patients with localized recurrent ovarian cancer.

Early Additional Immune-Modulators for Mycoplasma pneumoniae Pneumonia in Children: An Observation Study.

BackgroundMycoplasma pneumoniae (MP) pneumonia is a self-limiting disease, but some patients complain of progressive pneumonia, despite of appropriate antibiotic treatment. We aimed to introduce the role of immune-modulators (corticosteroid and/or intravenous immunoglobulin, IVIG) treatment for childhood MP pneumonia based on previous our experiences.Materials and MethodsA retrospective case series analysis for 183 children with MP pneumonia was performed. MP pneumonia patients were diagnosed by two Immunoglobulin M (IgM) tests: the micro-particle agglutination method (≥1:40) and the cold agglutination test (≥1:4), and were examined twice at the initial admission and at discharge. Among 183 MP pneumonia patients, 90 patients with persistent fever for over 48 hours after admission or those with severe respiratory symptoms and signs received additional prednisolone (82 patients, 1 mg/kg/day) or intravenous methylprednisolone (8 patients, 5-10 mg/kg/day) with antibiotics. Four patients with aggravated clinical symptoms and chest radiographic findings after corticosteroid treatment received IVIG (1 g/kg/day, 1-2 doses).ResultsMean age of 183 patients was 5.5 ± 3.2 years (6 months-15 years), and the male: female ratio was 1.1:1 (96:87). Fifty-seven patients (31%) were seroconverters and 126 seropositive patients showed increased diagnostic IgM antibody titres during admission (over 4 folds). The majority of the patients who received corticosteroids (86/90 cases) showed rapid defervescence within 48 hours with improved clinical symptoms, regardless of the used antibiotics. Also, 4 patients who received additional IVIG improved both clinically and radiographically within 2 days without adverse reaction.ConclusionsIn the era of macrolide-resistant MP strains, early additional immune-modulator therapy with antibiotics might prevent from the disease progression and reduce the disease morbidity without adverse reaction.

Branchial Fistulas—A Rare Entity in Pediatric Otorhinolaryngology: Current Management Protocols and Review of Literature

ABSTRACTBackground/objectivesSurgical managements which form the mainstay of these branchial apparatus anomalies are based on accurate understanding of the embryology and surgical anatomy. The conspicuous scarring in the young which becomes conspicuous as the age advances are reduced by newer approaches, the facelift approach, retroauricular approach and endoscope-assisted neck approach.Case reportA retrospective case series analysis of eight patients with complete fistula managed by the combined trans cervical approach. The recurrence was nil, with good surgical access and minimal scar at the incision site.ConclusionCombined transcervical approach is the conventional procedure of choice for branchial fistulas. While retroauricular hairline incision (RAHI) approach and endo-scopic approaches need expertise and more instrumentation, meticulous cosmetic surgery techniques helps reduces scars of the transcervical approach.How to cite this articleBhat RS, Naik SM, Goutham MK, Bhat S, Appaji M, Chidananda KV, Devi NP, Joseph S, Nayak P. Branchial Fistulas—A Rare Entity in Pediatric Otorhinolaryngology: Current Management Protocols and Review of Literature. Int J Head Neck Surg 2014;5(3):108-111.

Acute Formic Acid Poisoning: A Case Series Analysis with Current Management Protocols and Review of Literature

ABSTRACT Background Formic acid (FA) being pungent, odorless, easily available and consumed for suicidal purposes and the dilute form being colorless and odorless is consumed accidentally. Accidental ingestion is rare and deliberate self-harm is very painful and violent which has been a rare modality of committing suicide but for these areas where it is easily available. Materials and methods This a retrospective case series analysis study 14 patients with acute formic acid poisoning. There were 14 patients, with 3 females and 11 males. The average age was 35.5 years, with the average in males being 34.9 and 37.6 in females. Thirty milliliter were considered as cutoff range as diluted/undiluted FA below 30 ml were managed in our institution and 30 ml+ were referred to higher toxicology speciality care. Results Act of deliberate self-harm was seen in 11 cases (78.5%) and accidental ingestion in three cases (21.5%). All had orofacial burns, 4 had mild hematemesis and 3 severe hematemesis with impending renal complications. All the stabilized and referred cases were no further evaluated for follow-up. Facial burns and contracture needing cosmetic correction was seen in three cases, while corneal and lid scarring seen in two cases while a case of esophageal stricture with lower GIT and renal complications were seen in one case. Conclusion Formic acid poisoning is uncommon, and limited literature review is available with fewer protocols laid. So, immediate management of this corrosive poisoning with supportive measures reduces the mortality drastically. Serial upper gastrointestinal imaging diagnose stricture earlier and cosmetic reconstruction helps in facial scarring and contractures. How to cite this article Bhat RS, Naik SM, Goutham MK, Bhat CR, Appaji M, Chidananda KV, Devi NP, Joseph S, Nayak P. Acute Formic Acid Poisoning: A Case Series Analysis with Current management Protocols and Review of Literature. Int J head Neck Surg 2014;5(3):104-107.

Clinical Outcomes in Descemet Stripping Automated Endothelial Keratoplasty With Internationally Shipped Precut Donor Corneas

To report the endothelial cell loss and clinical outcomes in Descemet stripping automated endothelial keratoplasty (DSAEK) with internationally shipped, precut donor corneas. Retrospective analysis of a noncomparative case series. The setting was a single hospital. The clinical results of 134 eyes of 128 patients who underwent DSAEK in Kyoto, Japan, with internationally shipped precut donor corneas from Portland, Oregon, or Seattle, Washington, were evaluated. In addition, 40 precut donor corneas from Seattle were evaluated in respect to the postprecut international shipment-related loss of corneal endothelial cell density (ECD). Observation procedures were noncontact specular microscopy. The main outcome measures were the evaluation of international shipment-related ECD loss, postoperative ECD, visual recovery, and complications. The mean postprecut ECD loss in 40 donor corneas during international shipment was 2.3%. The mean elapsed time from cut to surgery was 63.2 ± 31.1 hours. At 6, 12, 24, and 36 months postoperatively, the mean ECD of the internationally shipped donor corneas was 2038, 1933, 1670, and 1431 cells/mm(2), respectively. The mean ECD loss at 6, 12, 24, 36 months after DSAEK was 30%, 34%, 44%, and 51%, respectively. Preoperative logarithm of the minimum angle of resolution (logMAR) best spectacle-corrected visual acuity was 1.40 ± 0.55, and at 12 months after DSAEK was 0.22 ± 0.19. Complications included graft dislocation in 12 eyes (8.9%) and graft rejection in 3 eyes (2.2%). The present study shows that the outcomes of DSAEK with internationally shipped precut donor corneas were acceptable and that the additional endothelial cell loss associated with international shipment was minimal and did not affect the clinical results.

Ocular Adnexal Lymphoma

Outcome evaluation in ocular adnexal lymphoma (OAL) is based on clinical assessment and conventional volumetric changes in tumor size. The purpose of this retrospective study was to compare if changes in apparent diffusion coefficient (ADC) tumor values obtained by diffusion-weighted MRI corresponded to changes in enhancing tumor volume in the evaluation of early treatment response or failure in patients with OAL. A retrospective case series analysis of conventional contrast-enhanced orbital MRI and diffusion-weighted sequences was performed on 8 pathologically confirmed OAL tumors before and after therapy. Mean ADC values and normalized ADC ratios were obtained using a region-of-interest analysis method on enhancing OAL lesions; tumor volumes were calculated using a manual segmentation method. Changes in tumor volume, mean ADC tumor values, and normalized ADC ratios were compared before and after therapy using a Wilcoxon rank-sum test. Overall, a significant difference was found in mean ADC values and normalized ADC ratios within OAL tumors before and after therapy (p < 0.05), irrespective of the type of therapy administered. There was a trend toward decreased mean enhancing tumor volume after therapy (p = 0.161). An increase in ADC values and a decrease in enhancing tumor volume after therapy correlated with a positive treatment response in 7 of 8 tumors; a decrease in ADC values and an increase in enhancing tumor volume after therapy correlated with a negative treatment response in 1 of 8 tumors. Tracking changes in tumor ADC values after various treatment regimens for OAL may be useful in predicting early treatment response or failure and can provide complementary information that corresponds to conventional volume changes in tumor size. Further validation of these preliminary results in larger prospective randomized trials is needed.

Comparable outcome of stem cell transplant versus bortezomib-based consolidation in myeloma patients after major response to induction

High-dose therapy with autologous stem cell transplant (ASCT) has been established as standard treatment for eligible patients with myeloma. However, whether this approach is still beneficial with new therapy is yet to be determined. Consolidation of effective therapy may be an alternative to ASCT following major response to initial induction. This retrospective case-series analysis included a total of 48 patients with newly diagnosed myeloma. All these patients achieved complete response or very good partial response to bortezomib-based induction and were eligible for ASCT; 24 of these patients proceeded with ASCT, and other 24 patients opted out of ASCT and received two additional cycles of bortezomib therapy as consolidation. With a median follow-up of 28.5 months in ASCT group and 29 months in non-ASCT group, no significant difference was seen in progression-free survival, 39 versus 32 months, P = 0.82. Median overall survival had not been reached, and the estimated 3-year overall survival rates were 87.5 and 67.5% in ASCT and non-ASCT, respectively, P = 0.97. This study provides an initial assessment of survival outcome of ASCT in comparison with non-ASCT consolidation. The additional study is required to establish the efficacy of non-ASCT consolidation.

The Effect of Oriental Medicine Music Therapy on the Improvement of Elementary School Children’s Concentration: Retrospective Analysis of Case Series

The Effect of Oriental Medicine Music Therapy on the Improvement of Elementary School Children’s Concentration: Retrospective Analysis of Case Series

Forty-five years of keratoprosthesis study and application at the Filatov Institute: a retrospective analysis of 1 060 cases.

To present results of the keratoprosthesis method used at The Filatov Institute of Eye Diseases and Tissue Therapy. A retrospective case series analysis was used to describe the development of new types of keratoprostheses and methods of implantation as well as different ways of leukoma strengthening. Keratoprosthesis was performed in 1 060 eyes of 1 040 patients with leukomas of different etiology: burns, 725 eyes (68.4%); trauma, 120 eyes (11.3%); keratitis and ocular pemphigoid, 108 eyes (10.2%); and bullous keratopathy, 107 eyes (10.1%). Visual acuity before keratoprosthesis consisted of light perception in 962 eyes (92%), and 98 eyes (8%) had minimal visual acuity (1/200-1/50). Both eyes were blind (visual acuity less than 1/200) in 955 patients (91.8%). The period of blindness varied from 1 to 52 years. As a result of keratoprosthesis, visual acuity of ≥1/200 was restored in 1 023 of 1 060 eyes (96.5%). Visual acuity of 20/200-20/20 was achieved in 716 eyes (67.5%). At the last follow-up visit visual acuity of ≥1/200 was preserved in 806 eyes (76%), visual acuity of 20/200-20/20 was measured in 583 of 1 060 eyes (55%) and good keratoprosthesis fixation in the cornea was achieved in 986 of 1 060 eyes (93%). The minimal follow-up was 12 months (range, 12 months to 37 years, median 5 years). Our techniques of keratoprosthesis effectively restore vision in patients with leukomas that cannot be treated by optical corneal grafting.

G34 Is There a Link Between Attention Deficit Hyperactivity Disorder (ADHD) and Delayed Puberty?

IntroductionRecently, our department has seen 4 boys with ADHD present with delayed puberty. Only one was on treatment for ADHD with no effect on growth. We conducted a literature search...

G62(P) Retrospective Analysis of PICU Readmissions Over a One Year Period

AimsReadmission may suggest premature discharge and may be detrimental to the patient’s care. Our aim was to determine our PICU readmission rate and review the patterns of readmission.MethodsA retrospective case...

Retrospective case series analysis of patients treated with liver cirrhosis at our specialist care centre between 2006 - 2011

Introduction:Our 36-bed gastroenterology unit has been running with a focus on hepato-pancreatology system disorders since 2006. In addition to providing secondary care for the 430,000 local residents in our county, we are also a country-wide tertiary referral centre for liver diseases including chronic viral hepatitis and preparation for liver transplantation. At our specialist care centre, we are able to provide the complete spectrum of diagnostic tests for hepato-pancreatology system diseases and offer access to the full range of therapeutic procedures. In this presentation, we carry out a structured analysis of the case series of patients treated with liver cirrhosis at our specialist care centre between 2006 – 2011.

Leprosy in a rheumatology setting: a challenging mimic to expose

Leprosy can manifest arthritis both as a complication and a comorbid disorder and can be a challenging differential diagnosis in rheumatology practice due to several common features. Uncommonly, it may present as acute severe polyarthritis with skin lesions and neurological deficit or a digital vasculitis and gangrene. We demonstrate this profile in a retrospective case series analysis of 33 patients (13 females, median age 55 years) in a community-based clinic setting over the period 1998–2012; an electronic search of case records of 41,000 patients was carried out. Rheumatoid arthritis (RA) coexisted in seven patients (three lepromatous, two tuberculoid, and two polyneuritic). Serological rheumatoid factor and antinuclear antibody were often false positive. Several patients of RA were on long-term supervised methotrexate. Rheumatologists should be aware of this clinical mimic to avoid errors in diagnosis and management.

Response to chemotherapy of solitary fibrous tumour: A retrospective study

BackgroundTo report on anthracycline-based chemotherapy in a retrospective case-series analysis of solitary fibrous tumour (SFT) patients treated within the Italian Rare Cancer Network. Patients and methodsWe reviewed a set of SFT treated with chemotherapy since 2002, focusing on anthracycline, administered alone or in combination with ifosfamide. Responses to ifosfamide as a single agent were also evaluated. Pathologic diagnosis was centrally reviewed, distinguishing typical, malignant (MSFT) and dedifferentiated (DSFT) subtypes. ResultsAmong 42 SFT patients treated with chemotherapy, we selected 31 cases (mean age: 62years; locally advanced/metastatic: 13/18; front-line/further line: 25/6; typical/MSFT/DSFT/not assessable: 1/17/12/1) who received anthracycline-based chemotherapy (anthracycline monotherapy: eight; anthracycline+ifosfamide: 23). 30 patients are evaluable for response. Best response by Response Evaluation Criteria in Solid Tumours (RECIST) was: partial response (PR): 6 (20%), stable disease (SD): eight (27%), progressive disease (PD): 16 (53%) cases. Responses were confirmed after 3months. Median progression-free survival (PFS) was 4 (range 2–15) months, with 20% of patients being progression-free at 6months. PR was found in 2/18 (11%) MSFT and 4/12 (30%) DSFT, with a median PFS of 3.5 and 5months in MSFT and DSFT, respectively. 19 patients received high-dose prolonged-infusion ifosfamide (front-line/further line: 11/8; typical/MSFT/DSFT: 0/15/4) with two (10%) PR, five (26%) SD, 12 (63%) PD. ConclusionsThis retrospective series suggests that in SFT anthracyclines have a degree of antitumour activity in the range of soft tissue sarcoma chemotherapy. Ifosfamide monotherapy seemed to have lower activity. A higher response rate was observed in DSFT in comparison to MSFT. Studies on targeted therapies are ongoing.

Diuretic-induced hyponatremia and osteoporotic fractures in patients admitted to the emergency department

ObjectiveHyponatremia is a complication of diuretic treatment and has been recently identified as a novel factor associated with osteoporosis and fractures. The impact of diuretic-associated electrolyte disorders on osteoporotic fractures (OF) has rarely been studied systematically. Design and settingWe conducted a study in patients presenting to the emergency department at the University Hospital Bern. In this retrospective case series analysis of prospectively gathered data, over a 2-year period we identified 10,823 adult (≥50 years) outpatients with a measured baseline serum sodium, at admission to the hospital. OF patients were compared to a control group without fractures using standard statistical methods. ResultsFour hundred and eighty (5%) patients had 547 OF. The OF group had a higher mean age (73 vs. 68 years, p<0.0001), smaller proportion of men (37% vs. 58%, p<0.0001), higher hospitalisation rate (83% vs. 62%, p<0.0001) and longer hospital stay (8 vs. 6 days, p<0.0001). Any diuretic agent (p<0.0001), loop diurietics (p=0.02), spironolactone (p=0.02) and amiloride (p<0.01) were used significantly more in OF patients, but not thiazides (p=0.68). The prevalence of hyponatremia increased significantly (p<0.0001) with the number of diuretics taken. Advanced age (odds ratio [OR] 1.04, p<0.0001), hyponatremia (OR 1.46, p=0.011) higher serum creatinine (OR 1.53, p=0.0001), furosemide use alone (OR 1.40, p=0.01) and co-treatment with amiloride (OR 2.22, p=0.02) were associated with a higher risk for OF. ConclusionsThis study highlights the clinical association of hyponatremia during the use of certain diuretics (i.e. furosemide or in combination, i.e. amiloride) with an increased risk of osteoporosis associated fractures. Although evidence-based data is currently lacking a pragmatic approach concerning hyponatremia monitoring and correction appears reasonable in selected groups of patients.

Management of pubic symphysis diastasis with locking plates: A report of 11 cases

IntroductionThe optimal method of fixation of symphyseal disruptions in pelvic ring injuries and post-operative rehabilitation is still debated. Options include two-hole, multi-hole and multiplanar plates. Post-operative rehabilitation can range from non-weight bearing bilaterally to full weight-bearing with crutches. Locking symphyseal plates have recently been introduced. There is a paucity of literature evaluating their use in such injuries. We present the first clinical case series of symphyseal diastasis managed with locking plates. MethodsA retrospective analysis of a single centre case series between August 2008 and December 2011 was conducted. A total of 11 patients; 2 females and 9 males with a mean age of 42 years were included. The mean radiological follow up was 27 weeks. Radiological failure and need for revision were evaluated. Results4 patients sustained their injury as a result of a motorcycle accident, 3 patients following a car accident, 2 fell from a height and 2 had crush injuries. 9 patients had other concomitant injuries. The mechanism of injury was classified as anterior–posterior compression injury in 6 patients, vertical shear in 4 patients and combined mechanism in 1 patient. 6 patients required posterior pelvic fixation. Patients were mobilised fully or partially weight bearing. One patient had a significant radiological failure. All patients were asymptomatic at last follow-up and none required revision surgery. ConclusionOur series represents the first published clinical series of patients with symphyseal diastasis managed with locking plates. We have found the use of locking plates across the pubic symphysis to be safe with low complication rates despite early weight bearing.

Oral Syphilis: a retrospective analysis of 12 cases and a review of the literature

To present a retrospective analysis of multicentre case series of oral syphilis and a review of relevant literature. A PUBMED search was carried out from 1950 to 2011. Clinical records of patients with exclusive/prevalent oral manifestations of syphilis were collected and examined in three independent hospitals. Of 23 reports describing 34 patients were detected through the review (35% primary, 56% secondary, and 9% tertiary disease), describing unspecific ulcers (59%), mucosal patches (23%), keratosis (6%), pseudomembranes (3%), and gumma (9%). Multicentre case series revealed 12 patients with oral syphilis, of which 17%, 58%, and 25% with, respectively, primary, secondary, and tertiary lesions. Clinically, patients showed white patches (17%), blistering mucositis (8%), chronic unspecific ulcers with/without skin lesions (50%), gumma (17%), and necrosis of the dorsum of the tongue (8%). Oral bullae and tongue necrosis are never described in the current review. Diagnosis of syphilis remains a challenge because of the multiform and polymorphous clinical pattern at onset and its ability to imitate different diseases. It is mandatory to include syphilis in the differential diagnosis of unusual oral lesions. Diagnosis of oral lesions of syphilis is often difficult, and biopsy is required in controversial cases.

Primary Choroidal Melanoma with Divergent Neuroendocrine Differentiation

Primary Choroidal Melanoma with Divergent Neuroendocrine Differentiation Background: Despite well-defined histopathological characteristics, melanoma has been reported to have different histological and immunohistochemical variations that can lead to diagnostic controversy. Neuroendocrine divergent differentiation has been demonstrated previously in skin and metastatic melanoma, and also in metastatic tumors to the choroid, but not in primary choroidal melanoma. Aim: To report the clinical, histopathological, immunohistochemical and ultrastructural characteristics of four cases of primary choroidal melanoma with neuroendocrine differentiation. Methods and Results: A retrospective case series analysis was conducted for all patients with choroidal melanoma with confirmed histopathological features of neuroendocrine differentiation, evaluated at the Laboratory of Ophthalmic Research and Visual Sciences. Four cases were identified, two male and two female. Preoperative clinical diagnosis was choroidal melanoma for all cases. Atypical small-cell morphology distributed in a pattern forming an organoid, perivascular or nested architecture on light microscopy was found in all cases, which prompted further evaluation with neuroendocrine markers. Immunohistochemistry demonstrated positivity in at least three melanocytic and three neuroendocrine markers for each case. Hi-resolution optic microscopy showed granules corresponding to intracytoplasmic neurosecretory and melanin granules in the same cells, confirming the diagnosis. Conclusions: In this study we provide evidence suggestive of divergent neuroendocrine differentiation in primary choroidal melanoma.