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   Table of Contents - Current issue
Coverpage
October-December 2020
Volume 17 | Issue 4
Page Nos. 239-299

Online since Monday, December 28, 2020

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EDITORIAL  

Editorial p. 239
Rajendra N Srivastava
DOI:10.4103/am.am_131_20  
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ORIGINAL ARTICLES Top

Cytological evaluation of p16Ink4a in precancerous lesions of the cervix: Conventional papanicolaou smears p. 240
Seema Singhal, Vinod Kumar Arora
DOI:10.4103/am.am_17_20  
Background: Cancer of the uterine cervix is the second most common cancer among women worldwide. More than three fourths of these patients are diagnosed at advanced stages, leading to poor prospects of long term survival and cure. Introduction of Papanicolaou (Pap test) cytological screening for cervical precancerous lesions has significantly reduced the incidence and mortality of cervical cancer. Human papillomavirus (HPV) DNA testing has been recently demonstrated to be efficient to be integrated into screening programs, so it can be used to triage women with equivocal cytological abnormalities and also identifies women at risk of residual or recurrent disease after treatment of cervical intraepithelial neoplasia. However, it fails into triage low grade lesions. HPV DNA test confirms infection by the virus, present in 99% of cases. However, it does not discriminate between transient and persistent infection as it is crucial because it is the persistent infection which progresses to neoplasia. Histological assessment of cervical biopsy that is considered as “gold standard” can be hampered by intra and inter observer variability. A more specific triage marker is required to identify women who would need colposcopy. Hence, p16INK4a has emerged as a new diagnostic and prognostic biomarker. Aims and objectives: This study was conducted to evaluate the utility of staining of p16INK4a on conventional Pap smears and its comparison with corresponding biopsies. Material and Methods: 50 cases of conventional Papanicolaou stained cervical smears cases were randomly selected from the archive of cytopathology laboratory. The cervical smears were re-evaluated for adequacy, preservation of cells, cytomorphology and various lesions were categorized according to The Bethesda system 2001 (TBS) classification. Consecutive such cases were selected for which both cytological and histological material were available. Immunostaining of cervical cytological specimens for p16 was performed using monoclonal murine antibody, clone 16P04, JC2. Ready to use antibody was used for immunostaining as per manufacturer's protocol. Results: Out of the 50 smears of preneoplastic and invasive lesions, ASCUS was seen in 5 cases, LSIL in 10 cases, HSIL in 20 cases, SCC in 20 cases and AGUS in 5 cases. Of the 5 cases of ASCUS, histopathology showed 3 chronic cervicitis and 1 each in CIN-1 and CIN-2. Histopathological diagnosis of 10 cases of LSIL showed 6 CIN-1 and 2 each in CIN-2 and chronic cervicitis. Similarly, for 10 cases of HSIL, 3 were CIN-2, 5 CIN-3 and 2 SCC. All 20 cases of carcinoma showed SCC while 5 cases of AGUS showed 4 chronic cervicitis and one adenocarcinoma. Immunohistochemical staining of p16INK4A showed weak positivity in 3 cases of chronic cervicitis and 4 cases of CIN-1. In CIN-2 cases, 66.67% showed strong positivity, CIN-3 showed 80% while both carcinoma and adenocarcinoma showed 100% strong positivity. The sensitivity of immunohistochemical staining of p16INK4A was 77.5%, specificity was 100%, PPV 100% and NPV 52.6%. The relation between histological and cytological immunostaining of p16INK4A. Conclusion: p16INK4A is a reliable marker for dysplastic squamous and glandular cervical cells both in tissue sections and in cervical smears. p16 immunostaining can be easily performed on CPS, and there is high concordance of positivity on smears and tissue sections.
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Intraoperative ultrasound in neurosurgical procedures p. 246
V A Kiran Kumar, N A Sai Kiran, B Girija Kumari, Ranabir Pal, V Umamaheswar Reddy, Amit Agrawal
DOI:10.4103/am.am_49_20  
Introduction: The objective of the present study was to study the utility and the effectiveness of intraoperative ultrasound in neurosurgical procedures and to assess the outcome. Material and Methods: In this prospective study, operative procedures by a single surgeon under intraoperative ultrasound localization for basal ganglia/thalamic haematoma or traumatic brain contusions or brain tumours were included. Ultrasound scanning of the brain was performed before and after the excision of the lesion and during the procedure to verify the extent of removal of the lesion. Results: 74 patients underwent surgery for brain tumor/basal ganglia bleed/head injury with hemorrhagic contusion with the help of intraoperative ultrasound. Gross tumor resection was noted in 25 out of 36 cases of brain tumors (69.44%), complete evacuation of hematoma was noted in 14 out of 34 cases(41.2%) of basal ganglia bleed and in 2 out of 4 cases (50%) of intracerebral contusion. As per Modified Rankin scale (MRS)score, among the brain tumor cases, all patients had fared well in recovery and had better MRS scores except in one patient who expired during postoperative period. Conclusions: IoUS is a widely accessible, cheap, portable and less space occupying and reliable imaging tool to follow and modify the surgical plan in real time, and is more accurate and helpful in complete tumor resection, evacuation of intracerebral bleeds and contusions, and biopsy of deep seated lesions. It is easy and safe to handle with no risk of radiation.
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Prevalence of Side Effects of Propofol Anesthesia among Adult and Pediatric Patients Undergoing Surgery p. 252
Khaled D Alsaeiti, Fathi M Elbraky, Salem A Ibkhatra, Khawla A Al-Zoubi, Ghada A Alagoury, Fatima F Al-Farajani, Hawa Al-Kharaz, Fatima A Al-Megrahi
DOI:10.4103/am.am_95_20  
Introduction: Propofol is a short-acting medication that lowers awareness and causes a transient memory loss. It is given intravenously. The aim of this study was to assess the prevalence of various side effects of the use of propofol as an anesthetic in various surgical procedures and to compare their prevalence among adults and children. Materials and Methods: One hundred patients were included in the study, fifty adults and fifty of children, who underwent various types of surgery and received propofol anesthesia, at Pediatrics Hospital, Benghazi Medical Center (BMC) and Al-Hawari hospital, from September to November 2019. Results: The mean age was 6.37 ± 4.18 years in the pediatric group (ranging from 1 to 15 years) and 40.0 ± 17.03 years in the adult group (range from 16 to 97 years). The indication of surgery among the adult group was cholecystectomy (14 patients, 28%), followed by ENT operations (12 patients, 24%), while the indication of surgery among the pediatric group was tonsillectomy (20 patients, 40%), followed by hernia repair (15 patients, 30%). Thirty-five adults (70%) and 40 children (80%) suffered different types of complications during the study. Pain at the site of propofol injection was the most common complication. It was observed in 21 adult patients (42%) and 23 children (46%). Bronchospasm developed among 11 children who underwent tonsillectomy. Low blood pressure was more prevalent among adult patients (14 patients, 28%). An arrhythmia was developed in nine patients (six adults and three children). Two adults and five children experienced delayed recovery from anesthesia. The recovery time was 14.67 ± 8.37 min (5–45 min), Conclusion: Burning at site of propofol injection is the most common side effect of propofol anesthesia; other complications need further evaluation by more detailed studies.
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REVIEW ARTICLES Top

A review of chronic relapsing inflammatory optic neuropathy p. 256
Pushpendra Nath Renjen, Dinesh Mohan Chaudhari, Kamal Ahmad, Shivangi Garg, Anjali Mishra
DOI:10.4103/am.am_38_20  
Chronic relapsing inflammatory optic neuropathy (CRION), initially described in 2003, is a form of recurrent optic neuritis (ON) that has relatively good response/dependency to steroid treatment. In demyelinating ON, patients present with periorbital ache and pain elicited by eye movement, which usually begins insidiously and worsens, in synchrony with or preceding a reduction in vision, which deteriorates over days. The etiology of CRION is unknown. However, the excellent response to corticosteroids and the need for immunosuppressive therapy to prevent relapse suggests an immunomediated origin.
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Recurrent respiratory papillomatosis: A challenging clinical entity p. 259
Santosh Kumar Swain, Sidharth Mohanty, Bulu Nahak, Mahesh Chandra Sahu
DOI:10.4103/am.am_45_18  
Recurrent respiratory papillomatosis (RRP) is a benign lesion seen in the respiratory airway caused by human papillomatosis virus (HPV).RRP can affects children to young adults. Most of the childhood RRP occur at birth which contaminated from birth canals of the mother. In adult ages, the infections transmitted via sexual route. The lesions are often seen as exophytic nodules, mostly in the larynx and occasionally at the nasopharynx, tracheobronchial trees and lung parenchyma. This disease is often unpredictable and varies from spontaneous remission to aggressive persistent or recurrence in nature.RRP has chance for malignant transformation to squamous cell carcinoma although it is a rare happening. The diagnosis is confirmed by histopathological study. Presently there is no definite treatment for RRP available. Surgery is the treatment of choice along with several adjuvant therapies available. The aim of this review article is to describe the detail etiology, epidemiology, clinical presentations, investigations and treatment of RRP.
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A Reflection on the Use of Additive Manufacturing in Nephrology for Education and Surgical Planning p. 264
Azhar Equbal, Shahid Akhtar, Md. Asif Equbal
DOI:10.4103/am.am_101_20  
Additive manufacturing (AM) or three-dimensional printing (3DP) is a new technology known for rapid fabrication of customized or finely detailed parts with decreased cost. The technology uses the principle of layer by layer-based manufacturing of parts following the bottom-up approach. In recent years, AM technologies have seen a rapid development in various fields of engineering, medical, and aeronautics. Development in technology and biomaterials has made AM more novel and approachable techniques for complex medical treatments. In the current work, a reflection on the use of AM technology in the field nephrology has been presented. At present, AM technologies are used in conceptualizing and fabricating urological instruments, planning surgeries, and educating the apprentices and patients. The review primarily aimed to present the use of AM for education and surgical planning in nephrology. The study will also discuss the limitation and future scope of AM in the field of nephrology.
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Diabetes Mellitus and Periodontitis: Relevance of the Diabolic Duo in India p. 267
Sumidha Bansal, Sangeeta Dhir, Subhash Kumar Wangnoo
DOI:10.4103/am.am_118_20  
Diabetes and periodontitis are highly prevalent diseases. Chronic nature, along with shared risk factors, magnifies the complexity of both the diseases. Periodontal treatment results in clinically relevant reductions in HbA1c, and the presence of diabetes worsens the periodontal health and vice-versa. This paper presents an overview on the pathogenic mechanisms, impact of intervention, and significance of interprofessional collaborations for holistic management in diabetes and periodontitis.
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CASE REPORTS Top

Choleteryl ester storage disease: A rare cause of adrenal calcifications in children p. 272
Fatiha Benmiloud, Maria Rkain, A El Aouali, A Babakhouya, Noufissa Benajiba
DOI:10.4103/am.am_19_20  
Cholesteryl ester storage disease (CESD) in children is a rare anatomo-clinical entity, characterized by a secondary lysosomal accumulation and an autosomal recessive mutation in the LIPA gene, which results from a lysosomal acid lipase (LAL) deficiency. The work of this paper is based on our observation of a 25-month-old infant, who had an abdominal distension with a hepatomegaly of 13 cm. The abdomen X-ray has shown some bilateral adrenal calcifications. The results of the biological assessment : the hepatic check showed a slight cytolysis, triglycerides increased to 5.4 g.l with a reduced rate of high density lipoproteins. The blood smear has shown the presence of intracytoplasmic lipid vacuoles in the lymphocytes, with a positive MGG staining and a negative PAS staining. The activity of the LAL enzyme has decreased to 3.6%. This observation joins the rare pediatric cases of the CESD and highlights the interest in a simply available radiological examination to make a guidance diagnosis of a complex metabolic disorder.
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Xanthogranulomatous osteomyelitis p. 275
Seema Singhal, Chander Shekher
DOI:10.4103/am.am_72_19  
Xanthogranulomatous osteomyelitis (XO) is a type of chronic osteomyelitis characterized by collection of foamy macrophages admixed with mononuclear cells. Xanthogranulomatous inflammation is characterized by the presence of histiocytes, foamy macrophages, activated plasma cells, and presence of suppurative foci and hemorrhage. It has been encountered in various tissues such as gallbladder, kidney, urinary bladder, fallopian tube, ovary, vagina, prostate, testis, epididymis, colon, and appendix. Very rarely, it can affect lungs, brain, or bone. Only three cases of XO have been described previously in the literature till date.
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A rare case of pancreatic neuroendocrine tumor p. 277
Raja Rao Nudurupati, Ravi Kamal Kumar Akunuri, Tarun Kumar Suvvari, Lakshmi Venkata Simhachalam Kutikuppala
DOI:10.4103/am.am_98_20  
Pancreatic neuroendocrine tumors (PNETs) are a group of endocrine neoplasms that exhibit neuroendocrine phenotypes. These include the production of neuropeptides, large dense-core secretory vesicles, and a lack of neural structures. They arise in the pancreas and are among the most common neuroendocrine tumors. A case of 38 years old female presented with a painless progressive swelling in the right upper abdomen since one month which is insidious in onset, gradually increasing in size with a history of significant weight loss and patient is not a known diabetic. On Examination, a swelling of size 5x7cm noted involving epigastric and right hypochondrium, which is not moving with respiration and dull on percussion. Plane of swelling is Intra-abdominal& retroperitoneal. Computed tomography abdomen (CECT) showed well defined rounded iso dense lesion showing heterogeneous enhancement in arterial and venous phase. Magnetic resonance cholangiopancreatography (MRCP) showed well defined lobulated heterogeneous solid lesion with central areas of necrosis seen in the pancreaticoduodenal groove (PDG) involving main pancreatic duct (MPD) and loss of fat planes with surrounding structures most likely malignant etiology. The patient underwent pancreaticoduodenectomy surgery (Whipple procedure) and had an uneventful recovery. Post-operative biopsy report confirmed pancreatic neuroendocrine tumor grade II (well-differentiated type), stage II a – pT3 N0 Mx.
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Tubercular arthritis of knee: Navigating the diagnostic dilemma p. 280
Nitin P Ghonge, Raju Vaishya
DOI:10.4103/am.am_96_20  
The illustrated case of 48 years male highlights the challenges in clinical diagnosis of tubercular arthritis. Multi-modality imaging of knee joint and confirmation with synovial fluid aspiration and biopsy allowed prompt and accurate diagnosis.
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Multiple insufficiency fractures related to Vitamin D deficiency in a young lady p. 283
Abhishek Vaish, Raju Vaishya
DOI:10.4103/am.am_103_20  
A young girl presented with increasing bilateral groin pain for the past 3 months (visual analog scale score 8/10) and inability to weight bear for the last 1 month. Plain X-rays showed bilateral fractures of the femoral neck, extending in the intertrochanteric and subtrochanteric regions on both sides. Laboratory investigations revealed severe Vitamin D deficiency with secondary hyperparathyroidism. The insufficiency fractures are subtypes of stress fractures with decreased mineralization and weakened zone calcification of the bone. Clinical awareness about the insufficiency fractures and a high index of suspicion is required to make an early diagnosis. The majority of insufficiency fractures due to Vitamin D deficiency can be managed conservatively with timely diagnosis, adequate supplementation of Vitamin D, and calcium.
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Castleman's disease in an adolescent p. 286
Ujjwala Singh, Manish S Nayak, Shreya Singh, K Rajgopal Shenoy
DOI:10.4103/am.am_47_20  
Castleman’s disease is a clinic-pathological entity of unknown etiology with non–neoplastic lymph node hyperplasia. It is extremely rare and can be found in patients of all age groups. It can present as localized with local signs and symptoms or disseminated disease which includes a wide range of systemic problems. Our patient is a 15-year-old adolescent female with nonspecific features of abdominal pain, vomiting. Blood and Imaging studies were inconclusive and the diagnosis of Castleman’s diseases was confirmed by histopathology. Here, we discuss the importance of considering Castleman’s diseases as a differential diagnosis for a case of acute abdomen.
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Laparoscopic management of congenital splenic cyst with intracystic bleed p. 289
Shaik Mohammed Waseem, Jayanth Bannur Nagaraja, Nairuthya Shivathirthan
DOI:10.4103/am.am_53_20  
Splenic cysts can be congenital, vascular, neoplastic, inflammatory, and posttraumatic contributing to 30%–40% of the total splenic lesions.Congenital splenic cysts are usually asymptomatic and are rarely seen in routine surgical practice. Due to lack of typical clinical presentation, they are discovered incidentally. Splenic congenital cysts constitute approximately 10% of total cysts. Primary (true) cysts make up approximately 20% of all types of cysts which occur in spleen. Epidermoid cysts are the rarest, which comprise only 10% of benign, nonparasitic cysts which occur in the spleen. Here, we present a case of 28-year-old female who presented to the hospital with vague upper abdominal pain and on clinical and radiological investigations was diagnosed as a case of congenital epidermoid cyst of the spleen with evidence of intracystic bleed which was managed laparoscopically.
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Long term complication of feeding jejunostomy – small bowel volvulus p. 292
GK Adithya, Varun Madaan, Rigved Gupta, Satya Prakash Jindal, Deepak Govil
DOI:10.4103/am.am_32_19  
Introduction: Feeding jejunostomy (FJ) is a lifesaving procedure on many occasions in patients requiring long term nutritional assistance. It is associated with many short and long term complications. Small bowel perforations, small bowel volvuli with infarction, intraperitoneal leaks and intussusception are well reported complications of FJ. Here we present a case report of FJ giving rise to small bowel volvulus. Case report: An elderly male patient of 71 years with underlying systemic hypertension, diabetes mellitus, and thoracic aortic aneurysm with aortoesophageal fistula underwent feeding jejunostomy for long term feeding purpose. Feeding went on well for almost a year. He had a second intravascular procedure for type 1 endoleak. Four months following this he developed an episode of severe colicky abdominal pain associated with vomiting. He was evaluated with CECT abdomen which showed the possibility of mesenteric volvulus with small bowel obstruction at distal ileal level. Patient underwent emergency exploratory laparotomy and untwisting of mesentery with redoing of FJ distal to the previous site of FJ. There was no bowel compromise. He developed severe hypokalemia post operatively which required intra venous potassium infusion and ventilator support. With all supportive management patient continued to deteriorate and succumbed.
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LETTER TO EDITOR Top

Phenytoin psychosis p. 295
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
DOI:10.4103/am.am_62_19  
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SHORT COMMUNICATION Top

Ameliorating the consequences of climate change in small islands p. 297
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/am.am_69_19  
In general, small islands are very small in physical dimensions, situated far away from the major lands, possess minimal natural resources, with an unstable economy and limited infrastructure, financial and human resources. It has been observed that these small islands are exposed to extreme weather changes, which essentially casts a negative impact on health. There is an immense need to formulate and implement a wide range of strategies and policies targeting the burden of climate-sensitive diseases or other hazardous events. In conclusion, owing to the multi-dimensional impact of climate change in small islands on the residents, it is very important for the policy makers to prioritize the issue and manage the available resources. However, it is important to involve all the concerned sectors to have a better and a more effective response.
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CLINICAL IMAGES Top

Concurrent gingival hyperplasia, hirsutism, and megaloblastic anemia due to phenytoin use p. 299
Saurabh Gaba, Samiksha Gupta, Monica Gupta, Gautam Jesrani
DOI:10.4103/am.am_117_20  
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