Superficial Biopsy Research Articles

Simultaneous Occurrence of Eosinophilic Esophagitis and Esophageal Granular Cell Tumor: Two Case Reports

Case 1: A 29-year-old female with history of asthma presented with dysphagia and globus sensation for one year. Patient was treated with omeprazole 20 mg daily with only partial symptomatic relief. Esophagogastroduodenoscopy (EGD) revealed a 20 mm-wide, submucosal nodule with normal appearing overlying mucosa located in upper esophagus at 22 cm from incisors, and focal mild rings and transient transverse folds (felinization) of esophageal mucosa. Pathologic analysis of mucosal biopsies from middle third of the esophagus was histologically consistent with EoE (>15 eosinophils/hpf). Pathologic analysis of endoscopic biopsies of esophageal nodule was consistent with GCT. Endoscopic ultrasound revealed esophageal nodule originated from deep mucosal (second esophageal wall) layer, an endosonographic characteristic consistent with GCT. The tumor was extracted using endoscopic mucosal resection (EMR) without complications. Histologic analysis of the resected specimen confirmed granular cell tumor. Patient underwent treatment with standard six food elimination diet for EoE resulting in symptomatic improvement. Case 2: A 15-year-old male with history of asthma presented with intermittent dysphagia, without heartburn or dyspepsia and with several episodes of esophageal food impaction during the prior 5 years. EGD revealed one 10-mm-wide, submucosal nodule with normal appearing overlying mucosa in upper esophagus at 25 cm from incisors without other endoscopic abnormalities. Pathologic analysis of superficial endoscopic biopsies of esophageal nodule were nondiagnostic. Histologic analysis of biopsies of middle esophageal mucosa was consistent with EoE (>20 eosinophils/hpf). Endoscopic ultrasound revealed esophageal nodule originated from deep mucosal (second esophageal wall) layer, an endosonographic feature consistent with GCT. The nodule was endoscopically extracted using EMR technique without complications. Histologic analysis of the resected specimen demonstrated GCT. Patient was recommended to undergo trial of daily omeprazole 20 mg therapy and follow-up with allergist for eventual six food elimination diet. This report adds 2 cases to the single previously published case of EoE with GCT. Although these two entities appear to have different pathophysiology and their concurrence may be coincidental, future large endoscopic studies are warranted to further investigate this potential association and determine its potential pathophysiology. Both entities should be considered in the differential diagnosis of dysphagia, particularly in young patients.

Spectrum of pathologic lesions in superficial lymph node biopsies –a one and half year study

Aim/Objective: The aim of this study is to analyse pathological spectrum of various neoplastic and non-neoplastic diseases affecting superficial lymph nodes in the neck, axilla and inguinal region and correlation with clinical findings.Materials and Methods: The retrospective study conducted from January 2013 to June 2014 in Yenepoya Medical College, Mangalore. The study included 45 cases of superficial lymph node biopsies received in the pathology department.Results: Out of 45 superficial lymph node biopsies received 28 were from cervical region followed by, axillary lymph nodes in 14 cases (31.2%) and 3 were from Inguinal region with male predominance affecting all age groups. Most common condition involving the lymph node was found to be tuberculosis followed by reactive hyperplasia. Suppurative lymphadenitis and lymphoma had equal incidence. BCG adenitis, metastasis and Kimuras disease were seen in the descending order of frequency.Conclusion: Lymph node involvement by non-neoplastic diseases is much more common than the neoplastic processes with tuberculosis being the predominant disease.

Audit of Superficial Temporal Artery Biopsies (TAB) for Suspected Giant Cell Arteritis (GCA)

between VTE and postoperative complications, length of stay, mortality and costs in Head and Neck Cancer (HNCA) surgery. The medical records of 50 patients that underwent major HNCA surgery over a 12 months period were reviewed and the data collected on patient demographics, risk of VTE at pre-assessment, risk of bleeding, type of VTE prophylaxis, timing of VTE prophylaxis, and complications. Seventy two percent of patients were assessed for VTE at pre-assessment and 58% within 24 hrs of admission. Ninety three percent were given Thrombo-embolic deterrant stockings and 58% were prescribed pharmacological VTE prophylaxis 6-12 hrs after surgery. Ten percent of patients developed complications.We also present on the type and timing of chemical VTE prophylaxis and the cost incurred and financial loss due to lack of compliance to VTE assessment. We propose recommendations to improve VTE assessment and prophylaxis in HNCA patients.

Fibroblast sources: Where can we get them?

Fibroblasts are cells widely used in cell culture, both for transient primary cell culture or permanent as transformed cell lines. Lately, fibroblasts become cell sources for use in disease modeling after cell reprogramming because it is easily accessible in the body. Fibroblasts in patients will maintain all genetic background during reprogramming into induced pluripotent stem cells. In spite of their large use, fibroblasts are obtained after an invasive procedure, a superficial punch skin biopsy, collected under patient's local anesthesia. Taking into consideration the minimum patient's discomfort during and after the biopsy procedure, as well as the aesthetics aspect, it is essential to reflect on the best site of the body for the biopsy procedure combined with the success of getting robust fibroblast cultures in the lab. For this purpose, we compared the efficiency of four biopsy sites of the body (skin from eyelid, back of the ear, abdominal cesarean scar and groin). Cell proliferation assays and viability after cryopreservation were measured. Our results revealed that scar tissue provided fibroblasts with higher proliferative rates. Also, fibroblasts from scar tissues presented a higher viability after the thawing process.

Graft Vasculopathy May Affect the Skin of Vascularized Composite Allografts Undergoing Rejection.

Acute rejection (AR) episodes often occur in the early post-graft period in Vascularized Composite Allografts (VCA) and manifest mainly with perivascular lymphocytic infiltration and epidermal changes but no severe vascular damage. More recently changes of graft vasculopathy (GV) similar to the ones developing in chronic rejection in kidney and heart were observed in three cases of VCA (2 hands, one knee) undergoing rejection. These affected deep arteries of the graft and manifested with myo-intimal proliferation and fibrosis of medium and large-sized blood vessels resulting in luminal narrowing/occlusion. We recently observed typical changes of GV in the skin of a hand allograft undergoing rejection following weaning of the immunosuppresive treatment. The patient received an allograft of the right hand in 2000. The induction immunosuppression included basiliximab, MMF, tacrolimus and steroids; the maintenance regimen included tacrolimus, MMF and steroids. The patient developed several episodes of AR (on days 76, 2653, 4400, 4500 and 4600). He was intermittently adhering to the treatment, developed rejection manifesting linically with diffuse erythemato-violaceous cutaneous macules, and was eventually amputated on day 4680 post-graft. Pathological examination of the radial artery showed GV, characterized by myo-intimal proliferation, fibrosis, lumen narrowing/obstruction, lymphocytic infiltration, calcification and fibrinoid necrosis of vessel wall. Remarkably, changes of GV, consisting namely of myo-intimal hyperplasia resulting in luminal occlusion, were observed in the skin in medium and small-sized vessels of the mid- and deep dermis and the dermal-hypodermal junction. Several medium-sized vessels were extensively infiltrated with CD4+ lymphocytes, and dermal capillaries were thickened. C4d deposits were seen in vascular endothelial cells but their presence was unrelated to the severity of pathological changes. This is the first observation of GV occurring in the skin of a VCA, and shows that even superficial (punch) skin biopsies are adequate to reveal GV. This specific alteration remains an exceptional finding in VCA, and apparently reflects chronic rejection, as it is not seen in the commonly-observed episodes of AR.

MRI displays involvement of the temporalis muscle and the deep temporal artery in patients with giant cell arteritis.

To assess deep temporal artery and temporalis muscle involvement in patients with giant cell arteritis (GCA). Ninety-nine patients who received magnetic resonance imaging (MRI) and superficial temporal artery biopsy (TAB) were included in this study. Patients with positive TAB (n = 61) were defined as GCA patients, those with negative TAB (n = 38) as the GCA-negative reference group. Contrast-enhanced T1w-images were acquired utilizing 1.5 T and 3 T MRI. Two radiologists assessed the images. Mural contrast-hyperenhancement and wall thickening of the deep temporal artery and hyperenhancement of the muscle were defined as inflammation. MRI results were correlated with jaw claudication in 70 patients. The two observers found temporalis muscle involvement in 19.7 % (n = 12) and 21.3 % (n = 13) of GCA patients. It occurred bilaterally in 100 %. Specificities were 92/97 % and sensitivities were 20/21 %. Deep temporal artery involvement was found in 34.4 % (n = 21) and 49.2 % (n = 30) and occurred bilaterally in 80/90.5 %. Specificities were 84/95 % and sensitivities were 34/49 %. Both structures were affected simultaneously in 18/21.3 %. Jaw claudication correlated moderately with inflammation of the temporalis muscle (r = 0.31; p < 0.05) and the deep temporal artery (r = 0.38; p = 0.01). MRI visualizes changes in the temporalis muscle and the deep temporal artery in GCA. Moderate correlation of clinical symptoms with MRI results was observed. • Approximately 20 % of GCA patients presented with temporalis muscle inflammation. • A total of 34-49 % of GCA patients presented with vasculitis of the deep temporal artery. • In approximately 20 % of GCA patients, both structures were simultaneously involved. • Involvement of both structures correlated moderately with presence of jaw claudication. • MRI is a suitable tool for the assessment of vasculitis and muscle inflammation.

CD99 Expression in Dermatofibrosarcoma Protuberans and Dermatofibroma

Differentiating between dermatofibrosarcoma protuberans (DFSP) and hypercellular dermatofibroma (DF) can sometimes be challenging, and a panel of immunostains is often employed. Expression of conventional markers oftentimes overlaps. We evaluated CD99 expression in DFSP and DF and its utility in distinction between these 2 entities. CD99 immunostaining was performed on 34 DFSPs and 24 hypercellular DFs. The intensity of staining was graded as "weak," "moderate," or "strong," and the proportion of positive cells was graded as follows: "scattered" when individual cells comprised <5% of the total cellularity of the lesion; "focal" with >5% but <25% of the cells; or "diffusely distributed" with staining of >25% of lesional spindle cells. Overall, DFSPs showed positive CD99 staining in 21 (61.76%) cases. Moderate and weak patterns of staining were the most frequent, seen in 13 (38.2%) and 7 (20.6%) cases, respectively. CD99 staining in DFSPs was predominantly scattered or patchy (4 and 11 lesions respectively) with less than 25% of cells expressing CD99. In comparison, all 24 DF cases showed strong CD99 positivity in >25% of the spindle cell component (P = 0.0003). The most striking difference related to the distribution of staining. In DFSP, tumor cells in the superficial dermis, when present, were always CD99 negative. In contrast, DF cells in the superficial dermis always demonstrated strong CD99 positivity. DF strongly expresses CD99 in a diffuse pattern that may serve as evidence in distinction from DFSP. As the differences in staining were most pronounced in the superficial portions of the tumor, CD99 staining may be well suited to superficial biopsy specimens, where distinction in hematoxylin and eosin sections may be most problematic.

Distinct polymicrobial populations in a chronic foot ulcer with implications for diagnostics and anti-infective therapy

BackgroundPolymicrobial infections caused by combinations of different bacteria are being detected with an increasing frequency. The evidence of such complex infections is being revealed through the use of novel molecular and culture-independent methods. Considerable progress has been made in the last decade regarding the diagnostic application of such molecular techniques. In particular, 16S rDNA-based sequencing and even metagenomic analyses have been successfully used to study the microbial diversity in ecosystems and human microbiota. Here, we utilized denaturing high-performance liquid chromatography (DHPLC) as a diagnostic tool for identifying different bacterial species in complex clinical samples of a patient with a chronic foot ulcer.Case presentationA 45-year-old female suffered from a chronic 5x5cm large plantar ulcer located in the posterior calcaneal area with subcutaneous tissue infection and osteomyelitis. The chronic ulcer developed over a period of 8 years. Culture and DHPLC revealed a distinct and location-dependent polymicrobial infection of the ulcer. The analysis of a superficial biopsy revealed a mixture of Staphylococcus aureus, Proteus vulgaris, and Fusobacterium nucleatum, whereas the tissue-deep biopsy harbored a mixture of four different bacterial species, namely Gemella morbillorum, Porphyromonas asaccharolytica, Bacteroides fragilis, and Arcanobacterium haemolyticum.ConclusionsThis clinical case highlights the difficulties in assessing polymicrobial infections where a mixture of fastidious, rapid and slow growing bacteria as well as anaerobes exists as structured communities within the tissue architecture of chronic wound infections. The diagnosis of this multilayered polymicrobial infection led to a microbe-adapted antibiotic therapy, targeting the polymicrobial nature of this infection in addition to a standard local wound treatment. However, a complete wound closure could not be achieved due to the long-lasting extensive destruction of tissue.

Clinical Neuropathology practice guide 3-2014: Combined nerve and muscle biopsy in the diagnostic workup of neuropathy – the Bordeaux experience

Simultaneous combined superficial peroneal nerve and peroneous brevis muscle biopsy, via the same cutaneous incision, allows examination of several tissue specimens and significantly improves the diagnosis of systemic diseases with peripheral nerve involvement. Vasculitides are certainly the most frequently diagnosed on neuro-muscular biopsies, but this procedure is also well advised to asses a diagnosis of sarcoidosis or amyloidosis. More occasionally, combined nerve and muscle biopsy may reveal an unpredicted diagnosis of cholesterol embolism, intra-vascular lymphoma, or enables complementary diagnosis investigations on mitochondrial cytopathy or storage disease.

A Clinical and Neuropathological Study of Chinese Patients with Diabetic Peripheral Neuropathy

ObjectiveTo examine whether the neuropathological and metabolic changes of peripheral nerves are correlated to clinical features in diabetes mellitus type 2 patients with peripheral neuropathy.Methods147 type 2 diabetic patients with signs/symptoms of diabetic peripheralneuropathy (DPN) aged 53.4±12.3 years and 134 healthy volunteers aged 55.5±11.7 years were investigated for fasting plasma glucose (FPG), hemoglobin A1C (HbA1c), and red blood cell sorbitol (RBC sorbitol) in addition to nerve conduction velocity (NCV). Among the 147 diabetic patients, 10 patients underwent superficial peroneal nerve biopsy for light and electron microscopy.ResultsIn the experimental group, the levels of HbA1c and RBC sorbitol showed significant increase compared with the controlled group, whereas motor nerve conduction velocity (MNCV) and sensory nerve conduction velocity (SNCV) both showed decline and SNCV decreased at a greater extent. Morphologically, there were various degrees of nerve fiber loss, associated with axon degeneration and capillary luminal narrowing in 10 patients undergone nerve biopsy.ConclusionThe metabolic change of sorbitol, the consequently observed changes in NCV and histopathology of peripheral nerves are positively correlated with the duration of diabetes and overall level of blood glucose.

Yield and complications of frame-based and frameless stereotactic brain biopsy – The value of intra-operative histological analysis

Objectives. Image-guided brain biopsy is an established method to obtain histopathological diagnosis and guide management for cerebral lesions. The study aimed to establish negative biopsy and symptomatic haemorrhage rates at a single centre, and to assess the influence of factors such as lesion location, final pathology and the use of intra-operative smears. Methods. A retrospective analysis of all frame-based and frameless stereotactic biopsies carried out over 57 months from July 2006 to March 2011. Results. A total of 351 biopsies were undertaken, 256 frame-based (73%) and 95 frameless (27%). Mean age was 57 years (range 18–87). Negative biopsy rate was 5.1%. There was a significantly greater negative biopsy rate in deep brain biopsies (p = 0.011) and in the cerebellum (p < 0.001). Intra-operative smear significantly reduced negative biopsy rates from 11.1% to 3.7% (p = 0.011). If repeat smear was requested, yet not provided, then the negative biopsy rate was 57.1% (p = 0.0085). The overall symptomatic haemorrhage rate was 3.7%. There was a significant increase in haemorrhage rate in deep versus superficial biopsies (p = 0.023) and a significantly greater haemorrhage rate in lymphoma biopsies (p = 0.015). There was no significant increase in haemorrhage rate in high-grade- compared with low-grade tumour biopsies. Mortality rates at 7 and 30 days post-operatively were 0.6% and 1.7%, respectively, with mortality after 7 days unrelated to biopsy. Conclusion. We advocate intra-operative histopathological analysis to decrease negative biopsy rates and advise increased caution when undertaking biopsies of deep lesions or suspected lymphoma cases due to the potentially increased risk of haemorrhage.

Esophageal Stenosis Caused by a Rare Entity

Question: A 45-year-old man presented in our surgical department with progressive dysphagia for solids and liquids and weight loss over the last 6 month, he had a long history of tobacco abuse (25 pack-years), but no history of trauma or alcohol use. Physical examination showed his cachexia, but was otherwise unremarkable without palpable lymphadenopathy. He had been treated with long-term bouginage over 4 years for a long segment esophageal stenosis starting 30 cm distal to the dental arch. Repeatedly performed biopsies over that time course had been nondiagnostic, with only chronic inflammation and hyperkeratosis. He presented in our institution owing to shorter bouginage intervals and weight loss. Upper endoscopy showed a thickened, white, contact-vulnerable, exophytic, and lumen-constricting polypoid mass in the esophagus over a distance of 15 cm (Figure A; star = esophageal lumen). Multiple deep biopsies were taken; they revealed keratosis and chronic inflammation but no evidence of malignancy. The subsequent computed tomography with contrast enhancement revealed a long-segment thickening of the thoracic esophagus (Figure B, arrows) without any lymphadenopathy or metastases. What is the most likely diagnosis? Look on page 871 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The verrucous carcinoma (VC) of the esophagus is a rare, well-differentiated, squamous cell carcinoma with about 20 cases described worldwide. It is associated with long-term local inflammation; tobacco abuse1Alkan A. Bulut E. Gunhan O. et al.Oral verrucous carcinoma: a study of 12 cases.Eur J Dentistry. 2010; 4: 202-207Crossref PubMed Google Scholar and recent studies suggest a potential role for human papillomavirus in carcinogenesis.2Viera C.L. Lopes J.C. Velosa J. A case of esophageal squamous cell carcinoma with positive HPV 11.Gastroenterol Hepatol. 2013; 36: 311-315Crossref PubMed Scopus (12) Google Scholar Despite its high degree of differentiation and slow growth, the outcome of patients with VC is unsatisfactory owing to late diagnosis and perioperative complications.3Osborn N.K. Keate R.F. Trastek V.F. et al.Verrucous carcinoma of the esophagus: clinicopathophysiologic features of a rare entity.Dig Dis Sci. 2003; 48: 465-474Crossref PubMed Scopus (42) Google Scholar Local invasion and its spread within the submucosa and paraesophageal layer leave it invisible for superficial biopsies, which usually show nonspecific acanthosis and hyperkeratosis associated with acute or chronic inflammation. The tumor invades the surrounding tissue, grows locally destructive, and has a very low potential for metastasis. Typical endoscopic appearances—mostly the only “proof” for this malignancy—include wart-like polypous, exophytic, spiked, or cauliflower like masses.3Osborn N.K. Keate R.F. Trastek V.F. et al.Verrucous carcinoma of the esophagus: clinicopathophysiologic features of a rare entity.Dig Dis Sci. 2003; 48: 465-474Crossref PubMed Scopus (42) Google Scholar Surgery is adequate therapy for early stages that are locally resectable; patients with esophageal VC do not benefit from chemotherapy. Our patient underwent thoracoabdominal esophagectomy. Intraoperatively, we found a thin, dilated, proximal esophagus with a thick wall in the stenotic area and inflamed adhesion to the mediastinum. The macroscopic pathological specimen showed the strong hyperkeratotic, exophytic growth of the tumor (Figure C, arrows); final histology revealed the VC of the esophagus pT2, pN0, L0, V0, Pn0, R0, G1. The microscopic image displays the invasive component of the squamous cell carcinoma (Figure D, arrow). The patient was dismissed after an uneventful postoperative course on postoperative day 15. VC of the esophagus is not only a rare entity, its preoperative diagnosis also is extraordinary challenging and relies on clinical suspicion induced by typical endoscopic appearance. An esophageal resection should be performed in case of severe, progressive dysphagia in combination with typical endoscopic appearance even without histologic proof, because definitive diagnosis can mostly first be seen in the resected specimen.

A case report of primary cutaneous histoplasmosis requiring deep tissue sampling for diagnosis

This is a case of primary cutaneous histoplasmosis, without any systemic involvement, that occurred without a history of trauma. Due to its rarity and varied clinical presentation, there is much difficulty in diagnosis of this disease entitiy, especially in differentiating it from pyoderma gangreosum. This patient required deep tissue sampling and a DNA probe for Histoplasma to establish a time-sensitive diagnosis as multiple superficial biopsies are nondiagnositic.

SURGICAL PROCEDURES IN PINNIPED AND CETACEAN SPECIES

Significant advances in veterinary diagnostic and surgical techniques have been made over the past several decades. Many of these advances, however, have not reached the field of marine mammal medicine. A number of limitations exist: risks of anesthesia, anatomical challenges, difficulties with wound closure, environmental constraints, equipment limitations, and perceived risks. Despite these limitations, surgical treatments have been successfully utilized in marine mammals. While surgery is performed in pinnipeds more frequently than in cetaceans, studies conducted in the 1960s and 1970s on dolphin sleep and hearing demonstrated that general anesthesia can be successfully induced in cetaceans. Since this pioneering work, a small number of successful surgeries have been performed in dolphins under both general anesthesia and heavy sedation. While these surgical procedures in pinnipeds and cetaceans have typically been limited to wound management, dentistry, ophthalmic procedures, fracture repair, and superficial biopsy, a number of abdominal surgeries have also been performed. Recently there have been pioneering successes in the application of minimally invasive surgery in marine mammals. Many of the anatomical challenges that almost prohibit traditional laparotomies in cetacean species and present challenges in pinnipeds can be overcome through the use of laparoscopic techniques. Due to the limited number of pinnipeds and cetaceans in captivity and, thus, the limited case load for veterinarians serving marine mammal species, it is vital for knowledge of surgical procedures to be shared among those in the field. This paper reviews case reports of surgical procedures, both traditional and laparoscopic, in pinnipeds and cetaceans. Limitations to performing surgical procedures in marine mammals are discussed and surgical case reports analyzed in an effort to determine challenges that must be overcome in order to make surgery a more feasible diagnostic and treatment option in the field of marine mammal medicine.

Superficial biopsy of the cervix: new technique

Cytological examination of the cervix in all patients is considered a necessity. A new technique of superficial biopsy is described and advantages en­numerated.

Culturing of Human Nasal Epithelial Cells at the Air Liquid Interface

In vitro models using human primary epithelial cells are essential in understanding key functions of the respiratory epithelium in the context of microbial infections or inhaled agents. Direct comparisons of cells obtained from diseased populations allow us to characterize different phenotypes and dissect the underlying mechanisms mediating changes in epithelial cell function. Culturing epithelial cells from the human tracheobronchial region has been well documented, but is limited by the availability of human lung tissue or invasiveness associated with obtaining the bronchial brushes biopsies. Nasal epithelial cells are obtained through much less invasive superficial nasal scrape biopsies and subjects can be biopsied multiple times with no significant side effects. Additionally, the nose is the entry point to the respiratory system and therefore one of the first sites to be exposed to any kind of air-borne stressor, such as microbial agents, pollutants, or allergens. Briefly, nasal epithelial cells obtained from human volunteers are expanded on coated tissue culture plates, and then transferred onto cell culture inserts. Upon reaching confluency, cells continue to be cultured at the air-liquid interface (ALI), for several weeks, which creates more physiologically relevant conditions. The ALI culture condition uses defined media leading to a differentiated epithelium that exhibits morphological and functional characteristics similar to the human nasal epithelium, with both ciliated and mucus producing cells. Tissue culture inserts with differentiated nasal epithelial cells can be manipulated in a variety of ways depending on the research questions (treatment with pharmacological agents, transduction with lentiviral vectors, exposure to gases, or infection with microbial agents) and analyzed for numerous different endpoints ranging from cellular and molecular pathways, functional changes, morphology, etc. In vitro models of differentiated human nasal epithelial cells will enable investigators to address novel and important research questions by using organotypic experimental models that largely mimic the nasal epithelium in vivo.

A man with small vessel vasculitis presenting with brachial diplegia, multiple cranial mononeuropathies and severe orthostatic hypotension in diabetes mellitus: a case report

IntroductionWe report a rare case of fulminant vasculitic mononeuropathy resulting in brachial diplegia, with suspected brainstem and autonomic nervous system involvement in a patient with diabetes mellitus.Case presentationA 58-year-old Hispanic Caucasian man with diabetes mellitus presented with a 1-year history of progressive bilateral upper extremity weakness, orthostatic intolerance and progressive memory decline. Diagnostic evaluation including laboratory tests for progressive encephalopathies, systemic inflammatory and non-inflammatory neuropathies, cerebrospinal fluid analyses, electrodiagnostic studies, and nerve biopsy were performed. Clinical examination revealed moderate cognitive deficits on the Montreal Cognitive Assessment scale, bilateral facial weakness and weakness of bilateral shoulder girdle and intrinsic hand muscles. Cerebrospinal fluid analyses revealed elevated protein and an elevated immunoglobulin G synthesis rate, suggesting an immune-mediated process. Further laboratory work up was non-diagnostic. Electrodiagnostic studies demonstrated chronic asymmetric axonal mononeuropathies with ongoing denervation. A superficial radial nerve biopsy showed a chronic vasculitic neuropathy. Glucocorticosteroid treatment, symptomatic pharmacologic and supportive non-pharmacologic therapies resulted in improved clinical outcomes despite challenges with glycemic control.ConclusionsThis case report emphasizes the importance of a thorough evaluation of atypical or uncommon neuromuscular presentations in diabetic patients without etiological presumptions. This is necessary in order to promptly establish a diagnosis, initiate appropriate therapies and prevent irreversible nerve injury.

Giant Cell Arteritis Presenting as Critical Lower Limb Ischemia

A 62-year-old woman presented with ischemic pain of her lower limb on 2 occasions, without upper limb or cranial vessel involvement. She was treated with open bypass of her left lower limb when she presented with critical limb ischemia during her second admission. Although bilateral temporal artery biopsies were negative, superficial femoral artery biopsy at the time of surgery confirmed the diagnosis of giant cell arteritis. Corticosteroid therapy was promptly commenced.

Colonic Endometriosis Presenting as a Sigmoid Stricture Requiring Laparoscopic Colonic Surgery for Diagnosis and Treatment

Colonic endometriosis may be difficult to diagnose because it is relatively uncommon [1, 2], may present without stereotypic findings of symptoms related to menstruation [3], and may not be diagnosable by colonoscopy with superficial colonoscopic biopsies when endometrial implants are deep within the colonic wall [4]. An unusual case is reported in which a patient developed progressively more severe constipation leading to obstipation from partial colonic obstruction that went undiagnosed for more than 1 year despite extensive abdominal tests, including abdomino-pelvic CT, colonoscopy, and an initial laparoscopy; the etiology was definitively diagnosed as partial mechanical obstruction from colonic endometriosis after repeat laparoscopy with resection of a sigmoid stricture. This case report with literature review illustrates the potential difficulty in establishing this diagnosis, especially by colonoscopy, when endometrial lesions are deep within the colonic wall; the potential for a missed diagnosis at an initial laparoscopy; and the potential requirement for a second laparoscopy for diagnosis and treatment.

Oncofetal protein IMP3: a new diagnostic biomarker for laryngeal carcinoma

An accurate diagnosis of laryngeal squamous cell carcinoma (LSCC) is essential for patient management. The diagnosis of LSCC, especially in superficial biopsies, can present a diagnostic challenge for pathologists. The ability to diagnose LSCC would be greatly improved by the detection of a tumor-associated antigen. IMP3 is an oncofetal protein associated with aggressive and advanced tumors and is specifically expressed in malignant tumors but not found in benign tissues. The aim of this study was to determine the expression and diagnostic value of IMP3 in LSCC to determine whether it can serve as a diagnostic biomarker. A total of 238 cases (laryngectomy, n = 121; biopsy, n = 117) consisting of 11 laryngeal carcinoma in situ/severe dysplasia and 227 invasive LSCC were examined by immunohistochemistry for IMP3 expression. IMP3 showed strong cytoplasmic staining in 217 (92%) of 238 LSCCs regardless of histologic grade. In addition, 58 (89%) of 65 small biopsies (≤5 mm in greatest dimension) containing a minute amount of carcinoma were positive for IMP3. In contrast to malignant tumors, IMP3 expression was not found in any of the adjacent benign squamous epithelium (0/118 cases; 0%), mild or moderate dysplasia (0/139 cases; 0%), or pseudoepitheliomatous hyperplasia (0/99 cases; 0%). In summary, we are the first to describe that IMP3 is a highly sensitive and specific biomarker for LSCC. The expression of IMP3 in LSCC can be used as a positive biomarker to increase the level of confidence in establishing a definitive diagnosis of a malignancy in laryngeal biopsy.