Allergic fungal rhino sinusitis (AFS) is classically described as allergic manifestation to the f... more Allergic fungal rhino sinusitis (AFS) is classically described as allergic manifestation to the fungal antigen present in sinuses with no evidence of invasion. Granulomas in histopathology, suspicious of invasion, are occasionally observed in AFS and the disease in these patients behaves like invasive fungal sinusitis even without histologic evidence of invasion. We retrospectively studied AFS patients to analyze whether AFS should be continued to be designated as an allergic entity. AFS patients operated from January 2009 to July 2013 were retrospectively reviewed. Of the total 57 cases operated in last 4 years, nine showing presence of granuloma in histology were included in the AFS with granuloma Group (group 1) and the rest 48 were included in the AFS group (group 2). Both the groups were compared in terms of various parameters at presentation, treatment course and rate of recurrence. Group 1 had significantly high rates of orbital erosion (P = .000), with positive association o...
A descriptive epidemiological study of fungal rhinosinusitis (FRS) was conducted in rural north I... more A descriptive epidemiological study of fungal rhinosinusitis (FRS) was conducted in rural north India in the form of house-to-house survey of villages of two districts each of Punjab and Haryana provinces using a clinical case definition of chronic rhinosinusitis (CRS). The suspected cases were investigated further in the laboratory to confirm FRS. Air and environment were sampled in different seasons to find Aspergillus spore count. The prevalence of chronic FRS cases was at 0.11% of the population and Aspergillus flavus was the predominant (97.6%) agent of all types of chronic FRS. The chronic FRS patients were classified as allergic FRS 41 (56.1%), chronic granulomatous FRS 13 (17.8%), eosinophilic FRS 11 (15.0%), fungal ball 7 (9.5%) and chronic invasive FRS 1 (1.3%). Aspergillus spores were present in large numbers (~20%) in air with significantly higher counts of A. flavus during winter months in the wheat-thrashing areas of Punjab as compared to Haryana (P = 0.0079). The pres...
Objective: To assess the spectrum of lesions in the sinonasal region diagnosed on FNAC. Study Des... more Objective: To assess the spectrum of lesions in the sinonasal region diagnosed on FNAC. Study Design: This is a retrospective audit of sinonasal lesions diagnosed on FNAC over a period of 12 years (1998–2009). Results: Out of a total of 79,851 FNACs, 158 (0.2%) were from the sinonasal region. FNAC was non-diagnostic in 20 (12.6%) cases. Infective/inflammatory lesions comprised of 30 (19%) cases including non-specific inflammation (19), fungal infection (7), tuberculosis (2), actinomycosis (1) and filariasis (1). Benign cysts (24; 15.2%) included epidermal inclusion cysts, mucocele and aneurysmal bone cyst. Benign bone tumors (4) comprised of giant cell tumor, fibrous dysplasia, chondroma, and osteoblastoma. Other benign tumors included lipoma (6), hemangioma (5), schwannoma (2), meningioma (1), pleomorphic adenoma (1), sebaceous adenoma (1) and other skin adnexal tumors (3). Malignant epithelial tumors (24; 15.2%) included squamous cell carcinoma (10), basal cell carcinoma (5), poor...
JGH open : an open access journal of gastroenterology and hepatology, 2017
Deficiency of vitamin D may be related to the pathogenesis of nonalcoholic fatty liver disease (N... more Deficiency of vitamin D may be related to the pathogenesis of nonalcoholic fatty liver disease (NAFLD). The aim of the present study was to evaluate the effect of vitamin D supplementation in patients with NAFLD. A total of 81 patients with NAFLD with normal or raised ( = 47) serum alanine aminotransferase (ALT) having vitamin D deficiency were randomized prospectively. Group 1 ( = 51) received lifestyle modifications and a single injection of vitamin D (600 000 U) (standard medical treatment [SMT] + vitamin D) and group 2 ( = 30) received lifestyle modifications (SMT) for 6 months. The primary objective of this study was to assess the improvement in insulin resistance (IR) and serum ALT (in patients with raised ALT) and the secondary objective was to assess the change in cytokine profile in the SMT + vitamin D group. After 6 months, significant improvement in serum levels of ALT was observed in the SMT + vitamin D group when compared to the SMT group (ALT [87 ± 48 and 59 ± 32 IU/mL...
A 42-year-old woman presented with a 2-year history of pain in lower back and both shoulder joint... more A 42-year-old woman presented with a 2-year history of pain in lower back and both shoulder joints. She was undergoing radiotherapy for suspected chordoma since 3 months. On examination, multiple translucent papules coalescing to form plaques were present on the eyelids (figure 1A), axilla and sacral area (figure 1B). There were no purpuras, telangiectasias, bleeding on application of pressure and macroglossia. Histopathological examination demonstrated deposition of pale amorphous eosinophilic material in the upper dermis with positive …
Journal of clinical and experimental hepatology, 2018
Histopathological distinction of various nodular lesions in liver with sufficient sensitivity and... more Histopathological distinction of various nodular lesions in liver with sufficient sensitivity and specificity is a challenge even in an expert set up. The panel of immunohistochemical markers composed of glutamine synthetase (GS), Glypican3 (GPC3) and heat shock protein 70 (HSP70) was recommended by the International Consensus Group for Hepatocellular Neoplasia group for the differentiation of high grade dysplastic nodule and early hepatocellular carcinoma (HCC). The panel has been extensively validated in the western population. This study aims to test this panel on Indian population on resected, explanted and autopsy cirrhotic and non-cirrhotic liver specimens of HCC. This study was conducted on 39 such liver specimens (12 cirrhotic, 12 pre-cirrhotic and 11 non-cirrhotic, non-fibrotic livers), including 35 cases of HCC over a period of 12 years. Immunohistochemistry was performed with antibodies against GS, GPC3 and HSP70 on the sections containing both malignant and dysplastic no...
Journal of clinical and experimental hepatology, 2018
Primary hepatic leiomyosarcoma is a rare primary mesenchymal tumor of the liver requiring exclusi... more Primary hepatic leiomyosarcoma is a rare primary mesenchymal tumor of the liver requiring exclusion of any other primary site of origin and histological and immunohistochemical exclusion of other hepatic/extrahepatic tumors with spindle cell morphology. Only about 70 cases are reported in the English literature and many of these tumors have predisposing conditions in the form of immunosuppression or associated malignancies. The occurrence of this tumor in the immunocompetent individual is also known. Histomorphology of this tumor shows a spindle cell lesion which needs to be distinguished from other spindle cell lesions of this region. The main diagnostic challenge of this tumor lies in its rarity, lack of awareness and morphological mimickers in the given site. A complete range of immunohistochemical markers is required to distinguish the lesion from its close morphological mimickers. Here, we discuss a case of primary hepatic leiomyosarcoma in an adult female patient with detailed...
Mucormycosis due to Mucorales is reported at large numbers in uncontrolled diabetics across India... more Mucormycosis due to Mucorales is reported at large numbers in uncontrolled diabetics across India, but systematic multicenter epidemiological study has not been published yet. The present prospective study was conducted at four major tertiary care centers of India (two in north and two in south India) during 2013-2015 to compare the epidemiology, treatment strategies and outcome of mucormycosis between the two regions. Molecular techniques were employed to confirm the identity of the isolates or to identify the agent in biopsy samples. A total of 388 proven/probable mucormycosis cases were reported during the study period with overall mortality at 46.7%. Uncontrolled diabetes (n = 172, 56.8%) and trauma (n = 31, 10.2%) were the common risk factors. Overall, Rhizopus arrhizus (n = 124, 51.9%) was the predominant agent identified, followed by Rhizopus microsporus (n = 30, 12.6%), Apophysomyces variabilis (n = 22, 9.2%) and Rhizopus homothallicus (n = 6, 2.5%). On multivariate analysis...
Chronic liver injury due to various etiological factors including environmental carcinogens resul... more Chronic liver injury due to various etiological factors including environmental carcinogens results in development of liver fibrosis. Numerous studies showed role of miRNAs in liver fibrosis. In the present study, we determined the rno-miR-183-96-182 cluster expression during hepatic fibrosis induced by diethylnitrosamine (DEN) treated Wistar rats and its association with plasma levels of circulating rno-miR-96, rno-miR-182, rno-miR-183, liver function test and lipid profile, aiming to identify their potential for histological stratification and early diagnosis of liver fibrosis. We found significant upregulation in the hepatic expression of rno-miR-183-96-182 cluster upon development of fibrosis in a DEN treated rats. Interestingly, the hepatic expression of this miRNA cluster correlates positively with the progression of fibrosis. Univariate analysis showed that hepatic expression of rno-miR-182-5p and rno-miR-183-5p and plasma activity of ALT are significant predictors of fibrosi...
APMIS : acta pathologica, microbiologica, et immunologica Scandinavica, 2018
Villous adenoma and urothelial carcinoma with villoglandular differentiation (UCVGD) are rare uro... more Villous adenoma and urothelial carcinoma with villoglandular differentiation (UCVGD) are rare urothelial tumours showing villous morphology, the former being a preneoplastic entity and the latter being a malignant one. The detailed immunohistochemistry of these entities is previously not described in the literature. Moreover, a limited biopsy sample of UCVGD or a villous adenoma with or without adenocarcinoma may be difficult to distinguish on the basis of the histomorphology alone. An immunohistochemical panel comprising of GATA3, p63, β-catenin, CK7 and CK20 was performed on five cases of UCVGD and three cases of villous adenoma with the aim of studying the expression of the proteins thereby aiding in the diagnosis of these entities in a limited surgical pathology specimen. The mean age of UCVGD was 66.8 years and all the patients were male. All the cases of UCVGD were associated with high grade papillary urothelial carcinoma with lamina propria invasion. The immunohistochemical p...
Idiosyncratic drug-induced liver injury (DILI) is ranked among the top most common etiologies of ... more Idiosyncratic drug-induced liver injury (DILI) is ranked among the top most common etiologies of acute liver failure (ALF). It carries poor transplant-free survival. Pirfenidone is an anti-inflammatory and antifibrotic drug that is commonly used for the treatment of idiopathic pulmonary fibrosis (IPF). Hepatotoxicity due to pirfenidone is rare and generally manifests as a mild rise in serum aminotransferases. In this mini-review, we report an unusual case of idiosyncratic DILI due to pirfenidone presenting as ALF, with emphasis on the definition, classification, diagnostic criteria, histopathology, molecular markers, and treatment options for DILI and related ALF. A 77-year-old man with known Parkinson's disease and IPF presented with jaundice for 7 days and altered mental status for 4 days. His long-term medications included a levodopa/carbidopa combination with a recent addition of pirfenidone over the previous 1 month; there was no monitoring of liver function tests. The eval...
Allergic fungal rhino sinusitis (AFS) is classically described as allergic manifestation to the f... more Allergic fungal rhino sinusitis (AFS) is classically described as allergic manifestation to the fungal antigen present in sinuses with no evidence of invasion. Granulomas in histopathology, suspicious of invasion, are occasionally observed in AFS and the disease in these patients behaves like invasive fungal sinusitis even without histologic evidence of invasion. We retrospectively studied AFS patients to analyze whether AFS should be continued to be designated as an allergic entity. AFS patients operated from January 2009 to July 2013 were retrospectively reviewed. Of the total 57 cases operated in last 4 years, nine showing presence of granuloma in histology were included in the AFS with granuloma Group (group 1) and the rest 48 were included in the AFS group (group 2). Both the groups were compared in terms of various parameters at presentation, treatment course and rate of recurrence. Group 1 had significantly high rates of orbital erosion (P = .000), with positive association o...
A descriptive epidemiological study of fungal rhinosinusitis (FRS) was conducted in rural north I... more A descriptive epidemiological study of fungal rhinosinusitis (FRS) was conducted in rural north India in the form of house-to-house survey of villages of two districts each of Punjab and Haryana provinces using a clinical case definition of chronic rhinosinusitis (CRS). The suspected cases were investigated further in the laboratory to confirm FRS. Air and environment were sampled in different seasons to find Aspergillus spore count. The prevalence of chronic FRS cases was at 0.11% of the population and Aspergillus flavus was the predominant (97.6%) agent of all types of chronic FRS. The chronic FRS patients were classified as allergic FRS 41 (56.1%), chronic granulomatous FRS 13 (17.8%), eosinophilic FRS 11 (15.0%), fungal ball 7 (9.5%) and chronic invasive FRS 1 (1.3%). Aspergillus spores were present in large numbers (~20%) in air with significantly higher counts of A. flavus during winter months in the wheat-thrashing areas of Punjab as compared to Haryana (P = 0.0079). The pres...
Objective: To assess the spectrum of lesions in the sinonasal region diagnosed on FNAC. Study Des... more Objective: To assess the spectrum of lesions in the sinonasal region diagnosed on FNAC. Study Design: This is a retrospective audit of sinonasal lesions diagnosed on FNAC over a period of 12 years (1998–2009). Results: Out of a total of 79,851 FNACs, 158 (0.2%) were from the sinonasal region. FNAC was non-diagnostic in 20 (12.6%) cases. Infective/inflammatory lesions comprised of 30 (19%) cases including non-specific inflammation (19), fungal infection (7), tuberculosis (2), actinomycosis (1) and filariasis (1). Benign cysts (24; 15.2%) included epidermal inclusion cysts, mucocele and aneurysmal bone cyst. Benign bone tumors (4) comprised of giant cell tumor, fibrous dysplasia, chondroma, and osteoblastoma. Other benign tumors included lipoma (6), hemangioma (5), schwannoma (2), meningioma (1), pleomorphic adenoma (1), sebaceous adenoma (1) and other skin adnexal tumors (3). Malignant epithelial tumors (24; 15.2%) included squamous cell carcinoma (10), basal cell carcinoma (5), poor...
JGH open : an open access journal of gastroenterology and hepatology, 2017
Deficiency of vitamin D may be related to the pathogenesis of nonalcoholic fatty liver disease (N... more Deficiency of vitamin D may be related to the pathogenesis of nonalcoholic fatty liver disease (NAFLD). The aim of the present study was to evaluate the effect of vitamin D supplementation in patients with NAFLD. A total of 81 patients with NAFLD with normal or raised ( = 47) serum alanine aminotransferase (ALT) having vitamin D deficiency were randomized prospectively. Group 1 ( = 51) received lifestyle modifications and a single injection of vitamin D (600 000 U) (standard medical treatment [SMT] + vitamin D) and group 2 ( = 30) received lifestyle modifications (SMT) for 6 months. The primary objective of this study was to assess the improvement in insulin resistance (IR) and serum ALT (in patients with raised ALT) and the secondary objective was to assess the change in cytokine profile in the SMT + vitamin D group. After 6 months, significant improvement in serum levels of ALT was observed in the SMT + vitamin D group when compared to the SMT group (ALT [87 ± 48 and 59 ± 32 IU/mL...
A 42-year-old woman presented with a 2-year history of pain in lower back and both shoulder joint... more A 42-year-old woman presented with a 2-year history of pain in lower back and both shoulder joints. She was undergoing radiotherapy for suspected chordoma since 3 months. On examination, multiple translucent papules coalescing to form plaques were present on the eyelids (figure 1A), axilla and sacral area (figure 1B). There were no purpuras, telangiectasias, bleeding on application of pressure and macroglossia. Histopathological examination demonstrated deposition of pale amorphous eosinophilic material in the upper dermis with positive …
Journal of clinical and experimental hepatology, 2018
Histopathological distinction of various nodular lesions in liver with sufficient sensitivity and... more Histopathological distinction of various nodular lesions in liver with sufficient sensitivity and specificity is a challenge even in an expert set up. The panel of immunohistochemical markers composed of glutamine synthetase (GS), Glypican3 (GPC3) and heat shock protein 70 (HSP70) was recommended by the International Consensus Group for Hepatocellular Neoplasia group for the differentiation of high grade dysplastic nodule and early hepatocellular carcinoma (HCC). The panel has been extensively validated in the western population. This study aims to test this panel on Indian population on resected, explanted and autopsy cirrhotic and non-cirrhotic liver specimens of HCC. This study was conducted on 39 such liver specimens (12 cirrhotic, 12 pre-cirrhotic and 11 non-cirrhotic, non-fibrotic livers), including 35 cases of HCC over a period of 12 years. Immunohistochemistry was performed with antibodies against GS, GPC3 and HSP70 on the sections containing both malignant and dysplastic no...
Journal of clinical and experimental hepatology, 2018
Primary hepatic leiomyosarcoma is a rare primary mesenchymal tumor of the liver requiring exclusi... more Primary hepatic leiomyosarcoma is a rare primary mesenchymal tumor of the liver requiring exclusion of any other primary site of origin and histological and immunohistochemical exclusion of other hepatic/extrahepatic tumors with spindle cell morphology. Only about 70 cases are reported in the English literature and many of these tumors have predisposing conditions in the form of immunosuppression or associated malignancies. The occurrence of this tumor in the immunocompetent individual is also known. Histomorphology of this tumor shows a spindle cell lesion which needs to be distinguished from other spindle cell lesions of this region. The main diagnostic challenge of this tumor lies in its rarity, lack of awareness and morphological mimickers in the given site. A complete range of immunohistochemical markers is required to distinguish the lesion from its close morphological mimickers. Here, we discuss a case of primary hepatic leiomyosarcoma in an adult female patient with detailed...
Mucormycosis due to Mucorales is reported at large numbers in uncontrolled diabetics across India... more Mucormycosis due to Mucorales is reported at large numbers in uncontrolled diabetics across India, but systematic multicenter epidemiological study has not been published yet. The present prospective study was conducted at four major tertiary care centers of India (two in north and two in south India) during 2013-2015 to compare the epidemiology, treatment strategies and outcome of mucormycosis between the two regions. Molecular techniques were employed to confirm the identity of the isolates or to identify the agent in biopsy samples. A total of 388 proven/probable mucormycosis cases were reported during the study period with overall mortality at 46.7%. Uncontrolled diabetes (n = 172, 56.8%) and trauma (n = 31, 10.2%) were the common risk factors. Overall, Rhizopus arrhizus (n = 124, 51.9%) was the predominant agent identified, followed by Rhizopus microsporus (n = 30, 12.6%), Apophysomyces variabilis (n = 22, 9.2%) and Rhizopus homothallicus (n = 6, 2.5%). On multivariate analysis...
Chronic liver injury due to various etiological factors including environmental carcinogens resul... more Chronic liver injury due to various etiological factors including environmental carcinogens results in development of liver fibrosis. Numerous studies showed role of miRNAs in liver fibrosis. In the present study, we determined the rno-miR-183-96-182 cluster expression during hepatic fibrosis induced by diethylnitrosamine (DEN) treated Wistar rats and its association with plasma levels of circulating rno-miR-96, rno-miR-182, rno-miR-183, liver function test and lipid profile, aiming to identify their potential for histological stratification and early diagnosis of liver fibrosis. We found significant upregulation in the hepatic expression of rno-miR-183-96-182 cluster upon development of fibrosis in a DEN treated rats. Interestingly, the hepatic expression of this miRNA cluster correlates positively with the progression of fibrosis. Univariate analysis showed that hepatic expression of rno-miR-182-5p and rno-miR-183-5p and plasma activity of ALT are significant predictors of fibrosi...
APMIS : acta pathologica, microbiologica, et immunologica Scandinavica, 2018
Villous adenoma and urothelial carcinoma with villoglandular differentiation (UCVGD) are rare uro... more Villous adenoma and urothelial carcinoma with villoglandular differentiation (UCVGD) are rare urothelial tumours showing villous morphology, the former being a preneoplastic entity and the latter being a malignant one. The detailed immunohistochemistry of these entities is previously not described in the literature. Moreover, a limited biopsy sample of UCVGD or a villous adenoma with or without adenocarcinoma may be difficult to distinguish on the basis of the histomorphology alone. An immunohistochemical panel comprising of GATA3, p63, β-catenin, CK7 and CK20 was performed on five cases of UCVGD and three cases of villous adenoma with the aim of studying the expression of the proteins thereby aiding in the diagnosis of these entities in a limited surgical pathology specimen. The mean age of UCVGD was 66.8 years and all the patients were male. All the cases of UCVGD were associated with high grade papillary urothelial carcinoma with lamina propria invasion. The immunohistochemical p...
Idiosyncratic drug-induced liver injury (DILI) is ranked among the top most common etiologies of ... more Idiosyncratic drug-induced liver injury (DILI) is ranked among the top most common etiologies of acute liver failure (ALF). It carries poor transplant-free survival. Pirfenidone is an anti-inflammatory and antifibrotic drug that is commonly used for the treatment of idiopathic pulmonary fibrosis (IPF). Hepatotoxicity due to pirfenidone is rare and generally manifests as a mild rise in serum aminotransferases. In this mini-review, we report an unusual case of idiosyncratic DILI due to pirfenidone presenting as ALF, with emphasis on the definition, classification, diagnostic criteria, histopathology, molecular markers, and treatment options for DILI and related ALF. A 77-year-old man with known Parkinson's disease and IPF presented with jaundice for 7 days and altered mental status for 4 days. His long-term medications included a levodopa/carbidopa combination with a recent addition of pirfenidone over the previous 1 month; there was no monitoring of liver function tests. The eval...
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