Diagnostic dilemma of kimura disease of eyelids

Kimura disease (KD) is a rare benign chronic inflammatory disease that presents as a nodule mostly involving deep subcutaneous tissue of the head and neck region with frequent regional lymphadenopathy and peripheral blood eosinophilia. KD shares some clinical and histopathological similarity with angiolymphoid hyperplasia with eosinophilia (ALHE). Consequently, KD and ALHE were once considered variants of the same disease spectrum. We present here rare cases of Kimura disease and ALHE involving the eyelid and lacrimal gland and discuss their differential features.

Absence of Plasmodium inui and Plasmodium cynomolgi, but detection of Plasmodium knowlesi and Plasmodium vivax infections in asymptomatic humans in the Betong division of Sarawak, Malaysian Borneo

Background

Plasmodium knowlesi, a simian malaria parasite, has become the main cause of malaria in Sarawak, Malaysian Borneo. Epidemiological data on malaria for Sarawak has been derived solely from hospitalized patients, and more accurate epidemiological data on malaria is necessary. Therefore, a longitudinal study of communities affected by knowlesi malaria was undertaken.

Methods

A total of 3002 blood samples on filter paper were collected from 555 inhabitants of 8 longhouses with recently reported knowlesi malaria cases in the Betong Division of Sarawak, Malaysian Borneo. Each longhouse was visited bimonthly for a total of 10 times during a 21-month study period (Jan 2014–Oct 2015). DNA extracted from blood spots were examined by a nested PCR assay for Plasmodium and positive samples were then examined by nested PCR assays for Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, Plasmodium ovale, Plasmodium knowlesi, Plasmodium cynomolgi and Plasmodium inui. Blood films of samples positive by PCR were also examined by microscopy.

Results

Genus-specific PCR assay detected Plasmodium DNA in 9 out of 3002 samples. Species-specific PCR identified 7 P. knowlesi and one P. vivax. Malaria parasites were observed in 5 thick blood films of the PCR positive samples. No parasites were observed in blood films from one knowlesi-, one vivax- and the genus-positive samples. Only one of 7 P. knowlesi-infected individual was febrile and had sought medical treatment at Betong Hospital the day after sampling. The 6 knowlesi-, one vivax- and one Plasmodium-infected individuals were afebrile and did not seek any medical treatment.

Conclusions

Asymptomatic human P. knowlesi and P. vivax malaria infections, but not P. cynomolgi and P. inui infections, are occurring within communities affected with malaria.

Tuberculosis of the skull mimicking multiple myeloma

There is a resurgence of tuberculosis globally but lesions affecting the skull are rare. Cases reported are of single, focal lesions as seen on plain x-rays. We report a 34 yearold patient with tuberculosis of the skull where multiple punched out lesions are seen, mimicking that of multiple myeloma.

Cutaneous nodules in Irrawaddy dolphins: an emerging disease in vulnerable populations

The presence of cutaneous nodules is reported in vulnerable populations of Irrawaddy dolphins Orcaella brevirostris from Malaysia (Kuching, Bintulu-Similajau, Kinabatangan-Segama and Penang Island), India (Chilika Lagoon) and Bangladesh (Sundarbans). Approximately 5700 images taken for photo-identification studies in 2004 to 2013 were examined for skin disorders. Nodules were detected in 6 populations. They appeared as circumscribed elevations of the skin and varied in size from 2 to >30 mm, were sparse or numerous and occurred on all visible body areas. In 8 photo-identified (PI) dolphins from India and Malaysia, the lesions remained stable (N = 2) or progressed (N = 6) over months but did not regress. The 2 most severely affected individuals were seen in Kuching and the Chilika Lagoon. Their fate is unknown. Cutaneous nodules were sampled in a female that died in a gillnet in Kuching in 2012. Histologically, the lesions consisted of thick collagen bundles covered by a moderately hyperplasic epithelium and were diagnosed as fibropapillomas. Whether the nodules observed in the other O. brevirostris were also fibropapillomas remains to be investigated. Disease prevalence ranged from 2.2% (N = 46; Bintulu-Similajau) to 13.9% (N = 72; Chilika) in 4 populations from Malaysia and India. It was not significantly different in 3 study areas in eastern Malaysia. In Chilika, prevalence was significantly higher (p = 0.00078) in 2009 to 2011 (13.9%) than in 2004 to 2006 (2.8%) in 72 PI dolphins. The emergence of a novel disease in vulnerable O. brevirostris populations is of concern.

Limb salvage in osteosarcoma using autoclaved tumor-bearing bone

BACKGROUND

Tumor prostheses currently give the best short- and medium-term results for limb-salvage reconstruction procedures in the treatment of bone tumors. However, in developing countries, the cost of a tumor prosthesis is beyond the reach of much of the population. We report the use of autoclaved tumor-bearing bone in 10 patients, as an affordable alternative to the use of prostheses.

METHODS

This is a case series of 10 patients (mean age 19 years) with osteosarcoma who were treated at our hospital from 1998 to 2008, and followed up for a mean of 35 months (range 14 to 8). The femur was involved in six cases, the humerus in three cases, and the ulna in one case. The mean length of the autoclaved bone was 150 mm (range 60-210).

RESULTS

Bone union occurred in seven patients over an mean duration of 12 months (range 8-17). Three patients had non-union. Two of these had associated implant failure, with one of them also developing chronic infection, and the third is still being followed up. Two other patients had local recurrence.

CONCLUSION

The use of autoclaved tumor grafts provides an inexpensive limb-salvage option without sacrificing appropriate oncologic principles. A painless and stable limb is achievable, and the use of this technique can be further refined.

Endolymphatic sac tumour

We present a case of a papillary tumour at the cerebellopontine angle in a 41-year-old man. He presented with left-sided facial and ear pain associated with dizziness, nystagmus and hearing loss. CT scan of the temporal bone showed a destructive tumour at the left cerebellopontine angle. Surgical excision was performed and the diagnosis of the endolymphatic sac tumour was made. Endolymphatic tumour is a low grade adenocarcinoma that originates from the endolymphatic sac. The definitive diagnosis requires a combination of clinical features, radiological finding and pathological correlation.

Intraosseous synovial sarcoma of the proximal femur: Case report

ABSTRACT

Synovial sarcoma is primarily a soft tissue malignancy that most often affects adolescents and young adults. It very rarely presents as a primary bone tumour and has only been reported in nine other cases to date. We report a case of primary synovial sarcoma arising from the proximal femur in a 57-year-old man.

KEY WORDS

Synovial sarcoma, primary bone tumour.

Acral melanoma of the extremities: a study of 33 cases Sarawakian patients

BACKGROUND

Acral melanoma involve the non-pigmented palmoplantar and subungual areas and are commonly seen among Asians. Patients commonly display advanced stage of disease at presentation. It may appear unnoticed and mimic benign lesions.

METHODS

Data for this retrospective study was retrieved from Histopathology Unit, Sarawak General Hospital, Malaysia archive from 2003 to 2009.

RESULT

62.3% cases of malignant melanoma were acral melanoma. The mean age of diagnosis was 64.3 +/- 12.1. The involved sites were the heel (39.4%), middle and frontal plantar area (24.2%), toe (24.2%) and web spaces (9.1%). The clinical presentations were; an enlarging mass (60.6%), non-healing ulcer (24.2%) and abnormal pigmented lesion (15.2%). Most cases exhibited Breslow thickness >4.00 mm (87.9%) and Clark's levels V (50%). The majority showed moderate (non brisk) tumour infiltrating lymphocytes (57.6%). Ulceration (84.8%) and lymphovascular involvement were seen (24.2%).

CONCLUSION

Acral melanoma is the commonest malignant melanoma in this Sarawakian cohort. Most of the cases presented with advanced stage disease.

Severe malaria - a case of fatal Plasmodium knowlesi infection with post-mortem findings: a case report

BACKGROUND

Zoonotic malaria caused by Plasmodium knowlesi is an important, but newly recognized, human pathogen. For the first time, post-mortem findings from a fatal case of knowlesi malaria are reported here.

CASE PRESENTATION

A formerly healthy 40 year-old male became symptomatic 10 days after spending time in the jungle of North Borneo. Four days later, he presented to hospital in a state of collapse and died within two hours. He was hyponatraemic and had elevated blood urea, potassium, lactate dehydrogenase and amino transferase values; he was also thrombocytopenic and eosinophilic. Dengue haemorrhagic shock was suspected and a post-mortem examination performed. Investigations for dengue virus were negative. Blood for malaria parasites indicated hyperparasitaemia and single species P. knowlesi infection was confirmed by nested-PCR. Macroscopic pathology of the brain and endocardium showed multiple petechial haemorrhages, the liver and spleen were enlarged and lungs had features consistent with ARDS. Microscopic pathology showed sequestration of pigmented parasitized red blood cells in the vessels of the cerebrum, cerebellum, heart and kidney without evidence of chronic inflammatory reaction in the brain or any other organ examined. Brain sections were negative for intracellular adhesion molecule-1. The spleen and liver had abundant pigment containing macrophages and parasitized red blood cells. The kidney had evidence of acute tubular necrosis and endothelial cells in heart sections were prominent.

CONCLUSIONS

The overall picture in this case was one of systemic malaria infection that fit the WHO classification for severe malaria. Post-mortem findings in this case were unexpectedly similar to those that define fatal falciparum malaria, including cerebral pathology. There were important differences including the absence of coma despite petechial haemorrhages and parasite sequestration in the brain. These results suggest that further study of knowlesi malaria will aid the interpretation of, often conflicting, information on malaria pathophysiology in humans.

An immunohistochemical study of CD1a and CD83-positive infiltrating dendritic cell density in cervical neoplasia

Cervical carcinoma is the second leading cancer in women in Malaysia, after breast cancer. Human papillomavirus (HPV) has been implicated in the development of dysplasia or cervical intraepithelial neoplasia and progression to squamous cell carcinoma. Because of the confinement of the human papillomavirus infection within the epithelial layer, the presence of dentritic cells or Langerhans cells in epithelial layer of the ectocervix is paramount in producing immune response. The mature dentritic cells express CD83 and high CD40/80/86, whereas the immature cells express CD1a and low CD40/80/86. By identifying CD1a and CD83, theoretically, both immature and mature dentritic cell populations can be studied. In view of the facts, we investigated the infiltrating cell density of mature and immature dentritic cells in cervical neoplasia.