Zeihl Neelson Research Articles

Coexisting parathyroid adenoma, thyroid carcinoma, and tuberculosis of thyroid: a case report

BackgroundCoexisting parathyroid adenoma, thyroid carcinoma, and tuberculosis of thyroid is a very rare phenomenon. Primary thyroid tuberculosis is itself very rare despite high global prevalence of tuberculosis in developing countries. Majority of thyroid tuberculosis identified in postoperative histopathology or cytopathology. The coexistence of thyroid cancer with tuberculosis or parathyroid adenoma has been reported in the literature but not a single case of the three pathologies coexisting together has been found in the literature published. We are presenting a rare case of a constellation of synchronous parathyroid adenoma, thyroid carcinoma, and thyroid tuberculosis. This case report will provoke researchers to work on understanding the association of hypercalcemia or chronic inflammation leading to development of malignancy or parathyroid adenoma in the presence of hypothyroidism will give future perspective in managing such patients.Case presentationA Islam lady aged 45 years old, diagnosed with hypothyroidism, was evaluated for pregnancy loss and rapid weight gain from 13 years back and started on tablets of levothyroxine 25 µg once daily. She was doing well until the past 2 years; there after she noticed insidious onset of a swelling over anterior aspect of right side of the neck and bone pain in back and lower limbs. Patient underwent routine investigations and was found to have raised serum calcium (11.4 mg/dl) and parathyroid hormone (253 pg/ml). Anti-thyroid peroxidase (TPO) and anti-thyroglobulin (Tg) level were normal. Ultrasounds showed multiple nodules in both lobe of thyroid and left inferior parathyroid adenoma. The patient underwent total thyroidectomy with left inferior parathyroidectomy, and final histopathology showed features of subacute granulomatous thyroiditis along with hurthle cell change in right lobe of thyroid. The left lobe additionally showed necrotizing epitheloid cell granulomas, which on Zeihl–Neelson staining revealed presence of acid-fast bacilli. Sections from the isthmus show a focus of papillary thyroid microcarcinoma. The left inferior parathyroid gland sent as a frozen sample was found to be parathyroid adenoma. On 6-month follow-up, the patient was feeling much relief in bone pain and tolerating antitubercular drugs uneventfully.ConclusionCoexistence of parathyroid adenoma, nonmedullary thyroid carcinoma, and thyroid tuberculosis is extremely rare. Surgery is curative for hyper parathyroidism and thyroid carcinoma. Thyroid tuberculosis responds well to current antitubercular drugs. Its etiology needs to be explored more; the probable hypothesis is chronic inflammation due to latent tuberculosis might leads to development of thyroid carcinoma and parathyroid adenoma. Further studies need to be done for better understanding of underlying mechanism and better management options for such patients. To the best of our knowledge, similar cases have not been reported.

P383 ‘It's not Fungus, its Nocardia’—an elementary diagnostic challenge for draining sinus on abdominal wall (rare): a case report

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PMIntroductionA rare finding of abdominal wall clinical presentation of persistent progressive tumefaction with draining sinus with no granules caused by Nocardia brasiliensis.MethodsHistory: A 22-year-old presented to the Dermatology OPD with complaints of swelling and tenderness and discharging sinuses with no granules around the periumbilical region in the lower abdominal area for three years. His initial fine needle aspiration cytology specimen report was inconclusive. He received anti-Kochs treatment based on a positive Montoux test and family history from outside the hospital.Initially punch biopsy samples were sent for fungal processing to our laboratory which was inconclusive. Repeat pus aspirate and punch biopsy samples were subjected to conventional techniques. The sample was inoculated on Sabouraud's Dextrose agar, Brain heart Infusion agar, and Lowenstein-Jensen media. Direct Smear was subjected to Gram stain and Modified Zeihl Neelson stain with 1% Sulfuric acid as decoloriser.ResultsOn Gram stain, Gram-positive filamentous bacilli against a background of pus cells in pus aspirate only (not in punch biopsy specimens).Modified Zeihl Neelson stain with 1% Sulfuric acid decoloriser was performed on all three samples. Beaded acid-fast filamentous bacilli with plenty of pus cells in the background were seen in pus aspirate only (not in punch biopsy specimens).No fungal elements were observed on the 20% KOH mount.Clinicians were notified immediately with the provisional report of possible Actinomycetoma due to Nocardia sp.Growth was observed within 9 days on SDA as well as LJ. It was a chalky white, dry colony to begin with that turned orangish-yellow in another week's time. Smear from the colony showed Gram-positive filamentous bacilli which on Modified ZN Smear were acid-fast filamentous beaded bacilli. The isolate was identified as Nocardia species. This was further confirmed as Nocardia brasiliensis by MALDI-TOF.On admission, the patient was initially started on Inj. Amikacin and then changed to Modified Raman regime of double dose Cotrimoxazole and Gentamicin. His lesions started showing improvement over 2 weeks of in-patient treatment. He was discharged on oral treatment thereafter.ConclusionAbdominal wall clinical presentation of persistent progressive tumefaction with draining sinus with no granules caused by N. brasiliensis is a rare clinical entity as Mycetoma. The differential diagnosis would lead to either bacterial or fungal etiology or neoplasia.Delay in correct diagnosis led to the chronicity of the clinical presentation with inappropriate therapy.For a chronic destructive debilitating infective mycetoma presentation, appropriate microbiological diagnostics become essential to have early correct detection with proper sampling technique to guide the appropriate therapy as per the causative pathogen.

Outcome of tuberculosis and diabetes mellitus coinfection: A study in a tertiary care centre in semiurban India

Tuberculosis has for a very long time been one of the major causes of morbidity and mortality globally. Diabetes mellitus is another disease which is growing into another major global challenge. Presence of diabetes increases the risk of tuberculosis by 2 to 3 times.2 sputum samples were collected from all the 202 patients for Zeihl Neelson’s staining to screen the Mycobacterium tuberculosis bacillus. Venous blood was taken for blood glycated hemoglobin and other biochemical and hematological tests.Out of these 41.6% had diabetes and 58.4% were non diabetic. The chest X-rays were severe in 51.2% patients among the TB and DM comorbid patients and 33.9% among the non diabetic patients. Poor outcome was seen in 54.8% of the cases among the DM and TB patients which in only TB patients with no diabetes, the number of cured patients was far more.There was a high incidence of diabetes among the patients with TB, which increases the morbidity and mortality among these patients. Smoking and alcoholism are preventable risk factors. So proper counselling and health education is necessary so that the patients would be able to monitor their blood sugar levels.

Comparative study of fine needle Aspiration Cytology, Acid Fast Bacilli staining and Cartridge Based Nucleic Acid Amplification test in the diagnosis of extrapulmonary tuberculosis

Introduction: Tuberculosis (TB) is an important health problem in the developing countries. Extrapulmonary sites of TB commonly include lymph nodes, pleura, gastrointestinal system, genitourinary system, central nervous system, bones. Most of the EPTB cases present with lymphadenopathy and effusion. The conventional methods to diagnose EPTB includes fine needle aspiration cytology (FNAC) and demonstration of acid fast bacilli (AFB) using Zeihl- Neelson (ZN) staining. Objectives: 1). To assess the efficacy of FNAC positivity in comparison to CB-NAAT in the diagnosis of EPTB. 2). To assess the efficacy of AFB positivity in comparison to CB-NAAT in the diagnosis of EPTB. Materials and Methods: The present retrospective record based study was conducted at the Department of Pathology and CB-NAAT Centre, Mandya Institute of Medical Sciences (MIMS), Mandya, Karnataka. The study was started after obtaining approval from the Institutional Ethics Committee. The records of suspected 100 EPTB patients who had under gone FNAC, ZN stain and CB-NAAT test for EPTB diagnosis during the study period of four months from March to June 2018 were analysed. Results: A total of 100 subjects were included in the final analysis. In our study, youngest patient was 8 months and oldest was 75 years. Of the 100 cases, lymph node involvement accounted for 96 cases and soft tissue swellings accounted for 4 cases. The diagnosis of FNAC of 100 cases were reactive lymphoid hyperplasia, suppurative lesion, epithelioid granuloma without necrosis, epithelioid granuloma with necrosis, caseous necrosis without epithelioid cells and lymphoma and their proportion were 30%, 21%, 22%, 13%, 12% and 2% respectively. Out of 47 cases with FNAC findings favouring EPTB, 30 were CB-NAAT positive and 17 were CB-NAAT negative. Out of 53 cases with negative FNA findings, CB-NAAT was positive in 5 cases (14.2%). Only 13 cases were positive for AFB when compared to 30 CB-NAAT positive cases. Among the 35 CB-NAAT positive

Prevalence of mycobacterium tuberculosis and their possible risk factors in suspected tuberculosis patients of district mardan khyber pakhtunkhwa, Pakistan

Tuberculosis (TB) is one of the chronic contagious diseases caused by Mycobacterium Tuberculosis that affect humans and animals. It is stated that TB is one of the major leading cause of morbidity and mortality throughout the globe. According to the WHO, approximately one-third people of the world are infected and about 3 million people die annually due to this disease. The present study reported the incidence rate of pulmonary TB and their possible risk factors in suspected TB patients according to age, gender, and location-wise prevalence of the disease in District Mardan, Khyber Pakhtunkhwa, Pakistan. A total of 380 sputum samples were collected from infected Tuberculosis patients and initially screened for acid-fast bacilli through Zeihl Neelson (ZN) microscopy and positive samples were further assayed by Real-time Polymerase Chain Reaction (GeneXpert). Out of these sputum samples 40% were positive for ZN staining and 31.57% were positive by GeneXpert. The prevalence rate was reported high in the age group of above sixty while a lower prevalence rate was found in the age group of 5-20 years. Male to female ratio was recorded at 37.83% and 41.37% respectively. Geographically, rural populations were highly infected by M. Tuberculosis which showed 45.19% as compared to the urban population showed 26.16% prevalence rate. All the relative risk factors are statistically significant having p-value (<0.05). It was concluded from our finding that TB was considerably increased in the general population of District Mardan, and proper supervision, diagnosis, treatment, and awareness of rapid prophylactic measures are needed to eradicate the risk.

Parasitic contamination of vegetables marketed in Arba Minch town, southern Ethiopia

BackgroundConsumption of unwashed, raw or unhygienically prepared fruits and vegetables act as potential source for the spread of various parasitic diseases. Moreover, the level of contamination and species of contaminant parasites vary from place to place because of variations in environmental and human factors. Therefore local determination of the level of contamination and associated factors is important for efficient intervention of infections acquired via those food items.MethodsA Cross-sectional study was conducted among purchased vegetables in selected markets of Arba Minch town from January to March, 2018. A structured questionnaire was used to capture data about factors associated with parasitic contamination of vegetables in the marketing phase. Selected vegetables were purchased and processed for examination of parasitic contamination using direct wet mount, iodine wet mount and modified zeihl Neelson staining following standard protocols. All data were analyzed using SPSS version 20.0.ResultsAmong 347 vegetable samples examined, 87(25.1%) were contaminated with at least one parasite species. Tomato (35.0%) was the most commonly contaminated vegetable while green pepper (10.6%) was the least contaminated one. Entameoba histolytica/dispar (29, 8.4%) was the commonest parasitic contaminant detected followed by Giardia lamblia (24, 6.9%) and oocyst of Cryptosporidium species (5.8%). Vegetable type (X2 = 13.5; p = 0.009) and source of vegetables (X2 = 24.1; p < 0.001) were significantly associated with parasitic contamination of vegetables.ConclusionParasitic contamination rate among marketed vegetables in the present study is significantly considerable. Entameoba histolytica /dispar was the most frequently detected parasite. We recommend to the local public health sector to establish a system for continuous monitoring of contamination of vegetables sold at local markets.

Prevalence of enteric pathogens in HIV patients with chronic diarrhoea and their relationship with CD4 count

Background: HIV presently accounts for the highest number of deaths attributable to any single infective agent. Opportunistic infections (OIs) and associated complications account for a considerable proportion of such mortality. Diarrhoea is among the most common symptom of HIV infection. During the natural course of HIV infection, there is a progressive loss of CD4 T cells. Autors’ aim is to study the prevalence of enteric pathogens in HIV patients with chronic diarrhea and their relationship with CD4 count.Methods: We analysed 186 HIV positive patients out of which 126 had chronic diarrhea and 60 patients presenting without diarrhea as controls. The faecal samples were subjected to microscopic examination. Zeihl Neelson’s Stain for mycobacterium, Kinyoun’s acid fast stain for microsporodia, stool culture for salmonella and shigella. All patients had barium meal contrast studies, USG of abdomen and pelvis. FNAC of peripheral lymph nodes and finally CD4+ Tcell count using BD FACS.Results: Total of 68,10,01 patients of HIV diarrhoea with identifiable cause had CD4 &lt;200, 200-250 and &gt;350 respectively. Among HIV diarrhoea without any identifiable cause 22, 17, 08 patients had CD 4 &lt;200, 200-250 and &gt;350 respectively. All diarrhoeal stool samples with Isopora had CD 4 &lt;200, M. tuberculosis 26 patients CD4 &lt;200, 12 had 200-350 and 03 had &gt;350. Microsporodium 03 patients had CD4 &gt;350. Finally, among stool samples with Cyclospora, E. histolytica, Giardia and Strongyloides all patients had CD 4&lt;200.Conclusions: The present study highlights the importance of testing intestinal pathogens in HIV. Chronic diarrhoea was more common in patients with low CD4 counts.

GFNN: Gaussian-Fuzzy-Neural network for diagnosis of tuberculosis using sputum smear microscopic images

Tuberculosis (TB) is one of the infectious diseases spread by the infectious agent, Mycobacterium tuberculosis. Sputum smear microscopy is a primary tool used for the diagnosis of pulmonary TB, but it has limitations, like low sensitivity, large observation time, and so on. Hence, an automated technique is preferred for the diagnosis of TB. This work proposes the Gaussian-Fuzzy-Neural network (GFNN) by combining the Gaussian mixture model (GMM) along with the fuzzy and the neural network for the TB detection. Initially, the input sputum smear microscopic image is subjected to a color space (CS) transformation, for which the thresholding is applied to obtain the segmented result. Then, the texture feature and other features are extracted for GFNN-based classification which classifies the segments into few-bacilli, non-bacilli and overlapping bacilli. Again, the overlapping bacilli are applied to the classifier to find the number of bacilli in the overlapping bacilli. The experimentation of the proposed GFNN classifier utilizes the Zeihl-Neelson (ZN) database containing the sputum smear images. From the experimental results, it is clear that the proposed GFNN model achieved better performance with the values of 0.91379, 0.04596, and 1.55714 for the performance metrics segmentation accuracy (SA), mean squared error (MSE), and missing count (MC), respectively.

Tuberculosis: Diagnosed and Undiagnosed as a Cause of Death

Aims and Objectives: This study has been conducted to find out the frequency of tuberculosis, histopathological pattern analysis of tuberculosis along with associated non-neoplastic changes and there role in the cause of death.&#x0D; Methodology: A retrospective cross-sectional study is done based on a Histomorphological evaluation of 23 cases diagnosed at Department of Pathology, tertiary care hospital of south Gujarat from January 2017 to December 2017. We received the gross specimen of the lungs, heart, liver, kidney, spleen, and brain for post-mortem examination in all autopsy cases. We did gross pathological and histopathological analysis of all the autopsy cases sent for histopathology over a period of one year.&#x0D; Results: In the present study out of 656 autopsy cases, 23 cases (3.5 %) were of granulomatous inflammation. Mean age of diagnosis was found to be 38 years. Males (65.2%) were more affected than females. Tuberculosis was diagnosed in only 21.7 % of total 23 cases before death. Findings were found in the lung in all cases while spread to the liver, spleen, kidney, and brain was also observed. Zeihl Neelson stain showing the presence of Acid Fast Bacilli confirms the diagnosis of tuberculous inflammation in 91% of cases.&#x0D; Conclusion: Tuberculosis is not an uncommon finding at autopsy. The lack of diagnosis pre mortem might be attributable to either the presence of social stigma in some parts of the world that dissuades people from seeking timely medical assistance, or non-typical presentations of tuberculosis cases. Indeed, even autopsies potentially have a role in helping improve community health services.

Isolated Tubercular Liver Abscess: an entity rarely thought, diagnosed on cytology

INTRODUCTION: Tuberculosis is a rare cause of liver abscess in the Indian subcontinent even though the disease itself has high prevalance rates here. Isolated tubercular liver abscess presenting without any other foci of infection is a rare presentation with a documented prevalence of 0.34%. In an adult immune competent patient diagnosis can be challenging as it is likely to be confused with pyogenic and amoebic liver abscess or hepatoma. CASE HISTORY: A 30 year old female patient presented with complaints of low grade fever, vague abdominal pain of 4 months duration, breathlessness and loss of appetite for 1 month. Past or family history was non-contributory. Ultrasonography abdomen revealed a small hypoechoic lesion in sub-hepatic region of size 49x20mm suggestive of a liver abscess. Computerized Tomographic scan images confirmed loculated irregular collections in and around left lobe of liver and Reidel’s lobe. Fine needle aspiration cytology from the lesion revealed ill formed granulomas on a necrotic background. Zeihl Neelson staining was positive for acid fast bacilli CONCLUSION: Isolated tubercular liver abscess is a rare entity, particularly in immunocompetent individuals.Symptomatology and radiologic findings may not be contributory. Diagnosis of this entity rests on the demonstration of acid fast bacilli in material obtained. FNAC is a simple minimally invasive, cost effective procedure which helps attain the same. DOI: 10.21276/APALM.1382

Pathology of Tuberculosis in Camels ( &lt;i&gt;Camelus dromedaries&lt;/i&gt;) in the Sudan

The study was aimed to investigate the pathological changes of condemned lungs of dromedary camels in the Sudan abattoirs using conventional H & E and Zeihl Neelson (ZN) staining procedures. Proliferative granulomatous reaction was demonstrated in one H & E stained lung section which was characterized by focal fibrosis and infiltration of mononuclear cells resembled to tuberculous lesions. While ZN stained sections demonstrated acid fast rod in one pulmonary associated lymph node. These lesions were evidenced presence of tuberculous mycobacteria in camel tissues and recommended further deep investigation of tuberculosis among camels in the Sudan.

Tuberculous mastitis–A great mimicker

ObjectiveTo focus on the increasing incidence of breast tuberculosis, its mistaken identity with carcinoma or pyogenic abscess and its effective diagnosis on cytology. MethodsThis retrospective study was carried over short period of two months. Six patients were included. air dried and wet fixed smears prepared and stained with May-Grunwwald-Giemsa and Papanicolaou respectively. Zeihl Neelson staining was also applied. ResultsAge groups varied from 16 to 70 years. Six cases presented within 2 months. Most common presentation was painless lump breast. One patient presented with discharging sinus. Lumps mostly favored right breast with predominance of upper outer quadrant. All except one were found to be positive for AFB. ConclusionsIncidences of tuberculous mastitis are increasing, can mimic carcinoma or abscess and should always be kept in differential diagnosis of lump breast. FNAC is helpful and ZN staining is gold standard in diagnosing acid fast bacilli.

Comparative evaluation of IS6110 PCR via conventional methods in rapid diagnosis of new and previously treated cases of extrapulmonary tuberculosis

In developing countries the diagnosis of extrapulmonary tuberculosis (EPTB) is a major burning challenge. EPTB encounters many problems like pauci-bacillary nature, inadequate specimen volume. All the limitations reflect in the poor contribution of conventional bacteriological technique in the establishment of diagnosis of EPTB. Nucleic acid amplification methods are rapid and sensitive has modified strategies for the detection of mycobacterial DNA. A fragment of DNA of 123 bp belonging to insertion sequence IS6110 based on specific gene of Mycobacterium tuberculosis complex was amplified by polymerase chain reaction (PCR) for the rapid diagnosis of EPTB. The present study was to comparative evaluation of IS6110 PCR via conventional methods in the rapid diagnosis of new and Previously treated cases of extra pulmonary tuberculosis. Four hundred fifty specimens were collected from suspected cases of EPTB were processed for Mycobacteria by Zeihl Neelson (ZN) staining and BACTEC culture for M. tuberculosis. All the specimens were also processed for IS6110 based PCR amplification with primers targeting 123 bp fragment of insertion element IS6110 of M. tuberculosis complex. We found significant difference was seen in sensitivities of different tests. Of these 450 specimens, 60 (13.4%) were positive for AFB by ZN staining, 202 (45%) for BACTEC culture and IS6110 PCR were positive for M. tuberculosis complex in 283 (63%) specimens (p< 0.05). However, there was no significant difference (p< 0.05) as far as specificity of different tests. We found that IS6110 PCR has higher sensitivity than smear microscopy and BACTEC culture in both cases of new cases as well as in previously treated cases. IS6110 PCR can be highly useful in diagnosis of new and treated cases of EPTB. It may facilitate therapeutic decisions for those with suspected of EPTB.

FNAC of Bacillus- Calmette- Guerin lymphadenitis masquerading as Langerhans cell histiocytosis

Bacillus Calmette Guerin (BCG) lymphadenitis is a well known entity. Disseminated BCG infection usually presents as generalized lymphadenopathy, skin rash and hepatosplenomegaly and at times, can pose a diagnostic challenge to clinicians. There are only a few published studies on the cytological findings of BCG lymphadenitis. In this letter we report the fine needle aspiration cytology (FNAC) of BCG lymphadenitis clinically masquerading as Langerhans cell histiocytosis (LCH). FNA smears showed sheets of foamy macrophages and many polymorphs in a dirty necrotic background with many macrophages as well as polymorphs showing negatively stained rod like structures within their cytoplasm. Zeihl Neelson stain revealed that these cells were heavily loaded with acid fast bacilli (AFB). In the index case, AFB were also seen within the cytoplasm of polymorphs, which has not been documented earlier in the literature.