Parathyroid carcinoma: a difficult histological diagnosis

INTRODUCTION

Parathyroid carcinomas are rare and usually difficult to diagnose, both clinically and histologically.

CASE REPORT

A 60-year-old man was hospitalised for hypotension. Investigations revealed renal failure associated with hypercalcaemia and elevated serum parathormone. (99m)Tc-sestamibi scintigraphy of the parathyroid glands (PT) revealed a mass in the right PT that was treated by parathyroidectomy and recurrent laryngeal lymph node dissection. Histological examination demonstrated a tumour with numerous cytonuclear atypias and immuno-histochemistry demonstrated PTH expression by tumour cells without loss of parafibromin expression. The diagnosis of PTC was based on criteria of invasion and local aggressiveness, despite the absence of lymph node metastasis. The patient developed four recurrences, treated surgically and by adjuvant radiotherapy.

DISCUSSION

The diagnosis of PTC is usually difficult to establish on a simple histological examination in the absence of specific cytological, architectural or immuno-histochemical markers. This diagnosis must therefore be based on a combination of clinical, radiological and histological signs in a context of atypical presentation of parathyroid tumour.

Case of sparganosis: a diagnostic dilemma

Sparganosis, also known as larval diphyllobothriasis, is a rare disease of humans as man is not a natural host in the life cycle of Spirometra spp. Diagnosis of the latter is difficult as it mimics other conditions that commonly cause subcutaneous or visceral fluid collection. Clinical diagnosis of this particular case was also erroneously labelled as tuberculosis but later labelled as a case of sparganosis. To the best of our knowledge, this is the first case from India where a sparganum-like parasite was isolated in drain fluid from the perinephric area.

Female genital TB and HIV co-infection

HIV-induced immunosuppression paves the way for several infections, tuberculosis being very common in our country. Female genital tuberculosis (FGTB), presenting as menstrual irregularities, is a diagnostic challenge in an adolescent female when these may be considered normal. The present case is of a young female who presented with menstrual irregularities, diagnosed subsequently as a case of genital tuberculosis. Microbiological relapse after anti-tubercular treatment of six months caused suspicion of a co-existing immunodeficiency and investigations revealed HIV co-infection; thus emphasizing the need of HIV testing in all patients of tuberculosis for timely diagnosis and treatment support thereafter.

Wolf Hirshhorn syndrome in a case of ring chromosome 4: phenotype and molecular cytogenetic findings

Ring chromosome 4 associates concomitant loss of the telomeric 4p and 4q regions and leads to variable clinical manifestations depending on the size of the deleted chromosomal material. We report on a patient with ring chromosome 4, showing the Wolf-Hirshhorn Syndrome (WHS) phenotype and minor symptoms of distal 4q deletion syndrome; the severity of the signs of WHS masks the symptomatology of the 4q deletion syndrome. The absence of seizures despite the absence of the specific 4p16.3 region with haploinsufficiency of the LETM1 gene is striking. The double telomeric deletion due to the ring chromosome formation confirmed by FISH has been rarely described in WHS.

Mediastinitis and cardiac surgery--an updated risk factor analysis in 10,373 consecutive adult patients

BACKGROUND

Deep sternal wound infection (DSWI) remains a serious complication after cardiac surgery. New evolving techniques including the utilization of internal mammary arteries (IMA), beating heart procedures, and minimal invasive surgery (MIC) require an updated risk factor analysis to identify high risk patients in order to improve perioperative treatment.

METHODS

10,373 consecutive patients receiving cardiac surgery between May 1996 and August 1999 were evaluated: 9,303 underwent full sternotomy whereas a minimally invasive (MIC) approach using partial sternotomy or lateral thoracotomy was used in 1,070 patients. DSWI was defined as the evidence of mediastinitis seen at reoperation along with one or more of the following: positive culture of mediastinal fluid, positive blood culture or temperature higher than 38 degrees C and/or leukocytosis.

RESULTS

The overall incidence of DSWI in the "full sternotomy" group was 1.44 % (134 of 9,303). Univariate risk factor analysis showed a significant influence of IMA use, ICU / IC treatment > 5 days, postoperative ventilator time > or = 72 h, need for reexploration, diabetes, surgery time > or = 180 min, assist device implantation (including use of IABP), peripheral vascular disease and increased body mass index. Multivariate analysis identified double IMA, ICU treatment > 5 days, single IMA, diabetes, reexploration and increased body mass as significant risk factors. No mediastinitis was observed in the MIC group.

CONCLUSION

As DSWI is related to sternotomy, a MIC approach should be considered for patients at high risk for DSWI. IMA takedown as a pedicled graft should be especially avoided in patients with diabetes since the risk for postoperative mediastinitis is unacceptably high in this patient group.

Lesser evaluated determinants of fistula formation in children with hypospadias

Determinants of fistula formation, some of them not previously evaluated, were studied in 30 consecutive children admitted for hypospadias repair to our centre. All children were screened for any urinary or local infections. Vicryl and catgut were used alternately for reconstruction of the neo-urethra. Per urethral drainage was employed in all patients. The presence of unfavourable local anatomical factors, the surgeon's satisfaction at the end of the procedure and duration of surgery were noted. The patients were followed up for any urethrocutaneous fistula. Unsatisfactory surgery (chi-square = 6.53, p = 0.01), unfavourable anatomical factors (chi-square = 10.80, p = 0.001) and local infection (chi-square = 5.66, p = 0.017) had a strong association with fistula formation, whereas urine leakage and a history of previous surgery had only a marginal association. On application of stepwise binary logistic regression, unfavourable local anatomical factors (OR [95% CI]: 13.19 [1.20-143.50]) and urine leakage (OR [95% CI]: 14.35 [1.20-171.45]) emerge as strong risk factors for urethrocutaneous fistula, and local infection (OR [95% CI]: 8.70 (0.93-81.01]) as a moderate risk factor.

Colorimetric detection of the tuberculosis complex using cycling probe technology and hybridization in microplates

Cycling probe technology (CPT) is a simple signal amplification method for the detection of specific target DNA sequences. CPT uses a chimeric DNA-RNA-DNA probe that is cut by RNase H when bound to its complementary target sequence. In this study, a hybridization assay was developed to detect biotinylated CPT products that result from the amplification of a Mycobacterium tuberculosis complex sequence. The chimeric probe was specifically designed to avoid the formation of secondary structures. The chosen capture probe was perfectly complementary to and was the same size as OL2, one of the two CPT products. The assay was based on the observation that a long sequence, such as the initial probe, was destabilized when bound to a small capture probe as a result of steric hindrance. The capture probe preferentially bound OL2 rather than the long initial probe. We added a prehybridization step with a helper DNA to enhance this discrimination between the two sequences. Colorimetric detection was performed using a peroxidase-streptavidin conjugate. After optimization, the non-isotopic hybridization assay allowed the detection of around 10 amol of target DNA. Besides being faster and easier to perform, this detection method was compared to electrophoresis separation and gave similar results.

Bacterial infections in burns patients: a three years study at RML Hospital, Delhi

A study was undertaken at RML Hospital, Delhi to examine the bacterial infections of burn cases and determine the antibiograms of the isolates to commonly used antimicrobial agents. A total of 489 pus samples from as many patients received, over a period of three years (January 1992 to December, 1994) yielded 793 isolates. Pseudomonas sp. was the commonest (53.9%) followed by Klebsiella sp. (35.1%) Staphylococcus aureus (30.6%) Proteus sp. (23.5%). Esch. coli (14.1%) and others (4.9%). The most resistant isolate to commonly used antimicrobial was Klebsiella sp. (16.4%), followed by Esch. coli (15.4%) Pseudomonas sp. (15.2%) Proteus sp. (7.8%) and Staphylococcus aureus (4.6%). The infection of burn wounds with multiple organisms, with superadded problem of drug resistance, indicate the institution of a drug policy by the hospitals for burns patients.

Aluminium levels in the blood plasma of persons working in the aluminium industry

Due to the exposure to alumina in the air, workers in the primary aluminium industry are expected to exhibit a higher aluminium exposure than the general population. The additional daily intake will be less than 20 mg. The determination of aluminium in blood plasma of electrolysis-workers by flameless atomic absorption spectrometry revealed levels before shift in the range of 20-30 μg/L compared to levels of less than 3 μg/L in a non-occupationally exposed group. These levels refer to work in old plants with unhooded pots. The plasma levels can rise up to 60 μg/L during the shift. A similar rapid change of the levels during work is seen in the urine values. Due to the delay in excretion the maximal values in the range of 5 μg/h are found four hours after cessation of work. It seems therefore that only preshift samples give a reliable measure of the body burden. Compared to the much higher levels in dialysis patients the observed values in aluminium workers are not considered to be of relevance to health.

[Blood aluminum levels in workers in the aluminum industry]

Aluminium levels in the blood plasma were determined in a group of workers in an aluminium plant. The aluminium concentration in the plasma of potroom workers was 5 to 15 micrograms/l whereas workers in the cast-house showed values of approximately 5 micrograms/l. In a healthy non-occupationally exposed control population, normal values of less than 1 to 3 micrograms/l were obtained. Considerably higher values, in the range of 100 to 500 micrograms/l, were found in kidney patients, since they must ingest several grams of aluminium-hydroxides daily to bind phosphates in the intestinal system. The aluminium is, however, only partially removed by dialysis. Occasionally central nervous disturbances, possibly due to aluminium, occur in these patients. However, there is no evidence of any health effects due to the intake of aluminium compounds in workers in the aluminium industry.

Radioimmunoassay of serum-conjugated deoxycholic acid

A specific, sensitive, and reliable radioimmunoassay for serum-conjugated deoxycholic acid has been developed with antiserum obtained after immunization of rabbits with deoxycholic acid--bovine serum albumin conjugate. The displacement curve of glyco [3H] deoxycholic acid was linear on a logit-log plot from 7.5 to 320 pmol of unlabeled glycodeoxycholic acid. At 50% displacement of bound label, the cross-reactivity of taurodeoxycholic acid was 100%, deoxycholic acid 30%, taurocholic acid 3%, and glycocholic acid 2%. No cross-reactivity was observed with free cholic acid, conjugated or free chenodeoxycholic acids and conjugated or free lithocholic acids. Fasting serum-conjugated deoxycholic acid concentrations in 10 healthy volunteers ranged from 0.18 to 0.92 mumol/1. Over a period of 5 hours following 0.5 g oral cholate administration the serum-conjugated deoxycholic acid concentration did not change in 5 fasting healthy persons, whereas an initial increase of serum cholic acid was observed.

Impaired ganglioside synthesis in rat liver after D-galactosamine administration in vivo

D-Galactosamine reduces the hepatic content of uridine phosphates, UDP-galactose, and UDPglucose due to an accumulation of UDP-amino sugars; this deficiency can result in severe hepatocellular damage. Alterations of glycosphingolipid synthesis in the early phase of this pathogenic process were studied by measurements of the incorporation of labeled galactose into glycosphingolipids of rat liver. [1-14C]Galactose was injected 2 h after galactosamine administration and the specific radioactivities of the glycosphingolipid precursors, UCPgalactose and UDPglucose, were determined. The specific radioactivity of UDPgalactose, when integrated over the whole period of radioactive synthesis, was four times higher in the galactosamine-treated animals than in the controls; the corresponding ratio of UDPglucose was 0.85. The pattern of the glycosphingolipids isolated from the livers of normal and galactosamine-treated rats resembled that described by Siddiqui and Hakomori (1970, Cancer Res. 30, 2930-2936); GL1, GM3,GM1, GD1, and a small amount of GT could be characterized. The specific radioactivities of glucose and galactose obtained from individual glycosphingolipids were determined in normal and galactosamine-treated livers. The synthesis of the glycosphingolipids was calculated using the respective data of the UDPhexoses. The labeling of glucosylceramide (GL1) was not altered and only a small change of GM3 could be detected; the synthesis of gangliosides GM1 and GD1, however, was inhibited by 95% or more between 4 and 6 h after galactosamine administration.

Increased serum urate in galactosemia patients after a galactose load: a possible role of nucleotide deficiency in galactosemic liver injury

Five galactosemic and 5 normal children received an oral load of galactose under standardized conditions. The maximal blood galactose level after 1.5 hours was 12.6 +/- 2.0 (S.D.) mmol/l in individuals with a deficiency of uridylyl transferase (EC2.7.7.12) as compared to 5.8 +/- 1.2 (S.D.) mmol/l in the controls. The concentration of serum urate in galactosemics increased to 155% of the fasting level (P less than 0.005); no rise was detectable in the controls. The elimination of urate with the urine was augmented by the same amount in both groups. Our studies provide evidence for an increased catabolism of hepatic nucleotides. This may lead to a deficiency of nucleotides which is proposed as a cause of galactosemic liver injury.