Search

Background: Hepatitis B is a major global health problem. Chronic hepatitis B is characterized by hepatic inflammation, necrosis and persistence of HbsAg for at least 6 months. Chronic liver disease is more predictably associated with impaired metabolism of drugs than acute liver dysfunction. Prescribing drugs in patients with chronic hepatitis B is challenging because of concerns that the drug may exacerbate the liver disease. There is also the fear that the altered liver state may change metabolism and excretion of the drug. Methods: A cross-sectional prospective study was conducted involving patients diagnosed with chronic hepatitis B at the liver clinic outpatient department (OPD) of AIIMS Bhopal. A total of 102 patients with chronic hepatitis B who met the inclusion criteria were recruited in the study. Results: Out of 102 prescriptions, 492 drugs were prescribed for the 102 patients. Out of 102 patients, 81 patients (81.66%) were on entecavir monotherapy and rest 21 patients (18.34%) were on tenofovir disoproxil fumarate (TDF) monotherapy. Of the 102-prescription issued, 92.15% (94/102) were compliant and 7.85% (8/102) were noncompliant. Conclusions: Entecavir was the most common antiviral drug prescribed, followed by tenofovir in patients of chronic hepatitis B. Spironolactone plus torasemide combination was the most common fixed dose combination used among study participants. Liver cirrhosis followed by portal hypertension was the most common complication. Majority of prescriptions were compliant with recommendations for pharmacotherapy and safety guidelines in patients of chronic hepatitis B.

Chronic lymphoedema can rarely be complicated by an angiosarcoma. This combination called Stewart-Treves syndrome usually observed in upper limb in patients of post-mastectomy with axillary lymph node resection. Here, we report a male patient who had a 10-year history of right leg elephantiasis. Later on, he developed two large ulceronodular masses in the same leg with few satellite nodules in the surrounding skin. With the clinical suspicion of malignancy, a wedge biopsy was performed which revealed histological features of angiosarcoma with sickled red cells. The above knee amputation specimen received further confirmed the histological diagnosis. The investigation for haemoglobinopathy also suggested the presence of sickle cell trait. This report describes a multifocal tumour as a rare manifestation of Stewart-Treves syndrome in a post-filariasis case with sickle cell trait, which is an extremely uncommon combination.

Fine needle aspiration cytology is an important diagnostic tool in cytopathology. There are many challenges and pitfalls encountered in intraoral salivary gland cytopathology as tumours of these glands show morphological diversity and overlapping features. There are often variable solid-cystic components, metaplastic or necrotic changes, fibrosis, hyalinisation and haemorrhage accounting for heterogeneity of these tumours. The tumour profile of intraoral salivary gland is quite different from the major salivary glands and needs special attention. A low-grade malignant tumour may sometimes mimic a benign neoplasm or a non-neoplastic lesion resulting in a false negative diagnosis. Moreover, misinterpretation and failure to recognize subtle morphological and architectural patterns of cells also pose diagnostic challenges. In this chapter, we intend to highlight the key cytopathological features of intraoral salivary gland tumours and tumour-like lesions with emphasis to overcome diagnostic challenges and pitfalls to avoid misdiagnosis which will aid in planning further management and treatment.

Hydatid cyst in the breast is rare. We report a case of hydatid cyst in the breast in a 30-year-old Indian rural woman who presented with a lump in her left breast. MRI findings showed a cystic lesion in the breast. Histopathological examination showed features consistent with hydatid cyst with surrounding adherent pericystic breast tissue showing fibrocollagenisation and inflammatory response. ELISA for echinococcal antigen was also found to be positive. This case emphasises that preoperative diagnosis of hydatid cyst in the breast is difficult and often missed as the breast is a rare site of echinococcal infection and clinical and imaging findings are wide and non-specific. Cytological diagnosis by fine-needle aspiration may not always be possible. Therefore, hydatid cyst in the breast should always be considered in the differential diagnosis of a breast lump and histopathological confirmation is necessary for early and appropriate treatment.

A 7-year-old Indian girl presented with symptoms of excessive development of breasts, early menarche, growth of pubic hairs, accelerated growth and abdominal distension. On clinical examination, a large right abdominopelvic mass was palpable. MRI revealed a large, heterogeneous, solid and cystic tumour in the right adnexal region, suggestive of an ovarian neoplasm. The hormonal profile showed markedly elevated oestradiol and low follicle-stimulating hormone levels. Clinical diagnosis of precocious puberty with right ovarian mass was concluded. Right-sided salpingo-oophorectomy was performed. Histopathology showed features consistent with sclerosing stromal tumour of the ovary. Postoperatively, signs and symptoms of precocity gradually regressed and her serum oestradiol level came down to normal. This is the first reported case from India.

A young Indian female presented with a recurring tumor in the right breast masquerading as phyllodes tumor. Patient had history of five times excision and recurrences of the tumor, diagnosed as fibrous phyllodes of the breast. Presently, a well-circumscribed tumor of about 10 cm size, comprising of benign fibrous-angiomatous tissue with evidence of foci of pyogenic vasculitis was observed. Immuno-histochemical markers for the myo-epithelial and epithelial elements excluded the possibility of fibrous phyllodes, inflammatory myofibroblastic tumor, desmoid fibromatosis, and metaplastic carcinoma. The present findings were diagnostic of an inflammatory angio-fibroma of the right breast, not reported in the earlier literature. The observations indicated that the female breast may be susceptible to spontaneous productive and common-antibiotic-resistant focal septic vascular inflammation giving rise to angio-fibromatous proliferation producing a well-defined tumor mass in the breast, distinguishable from the other breast lesions by the connective tissue stains and immuno-histochemical markers.

Calcifying fibrous tumor is a rare, benign mesenchymal tumor of children and young adults, usually occurring within the subcutaneous and deep soft tissues of the extremities, trunk, neck, inguinal and scrotal region. Its occurrence in peritoneum is rare. Here, we report a case of calcifying fibrous tumor, which incidentally presented as peritoneal mass at the right hepatic flexure of colon in a 30-year-old female who underwent laparotomy for ulcerative colitis and was operated for the same. The histopathological and immunohistochemical findings of the peritoneal mass were consistent with calcifying fibrous tumor, comprising of spindled fibroblasts, abundant hyalinized collagen, several foci of dystrophic and psammomatous calcifications with focal lympho-plasmacytic inflammation and positive vimentin and factor XIIIa immunoexpression.

A 45-year-old Indian woman presented in neurosurgery outpatient with seizures, headache and vomiting for the past 1 month. MRI of the brain was suggestive of a malignant central nervous system (CNS) tumour. Histological and immunohistochemical examinations of stereotactic biopsy of the tumour were diagnostic of a low-grade diffuse small lymphocytic lymphoma of the CNS. No evidence of any occult systemic lymphoma was observed, confirming its 'primary' origin in the CNS. The diagnosis of a low-grade primary CNS lymphoma (PCNSL) is difficult as clinical and neuroradiological features are wide and variable. The clinical course is more indolent than a high-grade PCNSL and thus, a less aggressive and localised targeted treatment could be sufficient rather than the high dose, neurotoxic methotrexate-based chemotherapeutic treatment, recommended for high-grade PCNSL. Histological and immunohistological confirmation is therefore mandatory for early, appropriate treatment and prognostic implications.

Reticular/microcystic schwannoma is a recently described rare distinctive variant of schwannoma with a predilection for gastrointestinal tract. Its occurrence in soft tissue is extremely rare. We report a case of reticular/microcystic variant of schwannoma in a 55-year-old Indian woman who presented with a painless slow-growing swelling in the right forearm for the past 6 months. MRI findings suggested myxoid sarcoma. However, histological and immunohistochemical findings in the excised specimen were consistent with reticular/microcystic variant of schwannoma. This case report emphasises that the diagnosis of reticular/microcystic schwannoma should always be considered in cases where myxoid sarcomas are suspected as it can mimic malignant myxoid sarcomas, clinically and radiologically, thereby avoiding aggressive intervention and overtreatment.

A 5-month-old male infant presented with a 15 day history of distension of abdomen. On clinical examination, a soft lump was palpable in the left lumbar region. Radiological findings suggested an enlarged non-functional left kidney with ureteropelvic adhesive obstruction. The left renal mass was excised and submitted for histopathological examination. The excised renal mass was cystic with its wall partly white and partly blue. Gross and histopathological findings were diagnostic of a white-blue pyelocalyceal cyst with hydrotic glomerulonephritis. This entity needs to be differentiated from a large number of other cystic diseases of the kidney. Intrauterine screening and diagnosis may be significant for a possible early intrauterine uro-laparoscopic recanalisation of the pyeloureteral obstruction to save the affected kidney.

A 32-year-old Indian woman presented with swelling in the anterior part of the neck for the last 3 years. Clinical and radiological examination and fine needle aspiration cytology suggested the diagnosis of multinodular goitre. A subtotal thyroidectomy was performed by the surgeon and the specimen was submitted for the final diagnosis. Histological examination of the specimen revealed multiple caseating tubercular granulomas coexistent with multinodular goitre and adenomatous hyperplasia. The sections demonstrated acid-fast tubercle bacteria, confirming the diagnosis of tubercular thyroiditis. This case emphasises that tubercular thyroiditis should always be considered in patients with thyroid swelling or nodule, in countries where the prevalence of tuberculosis is high.