bluuebunny/crossref_metadata_2025_split huggingface dataset:
Eosinophilic Myocarditis as a Cause of Death: A Case Diagnosed at Autopsy
Authors: Khokhar H , Beversdorf W , Fox S 
Published: October 2020

Abstract

Introduction/Objective
Eosinophilic (Loffler) myocarditis is a rare disease defined by the influx of eosinophils into the endocardium and myocardium. Etiologies are numerous and include drug or hypersensitivity reactions, hypereosinophilic syndrome, hematologic malignancies, and parasitic infections. It is a diagnostically challenging entity. Presenting symptoms recorded in the literature are indefinite and nonspecific; heart failure, demonstrable arrhythmia, and elevated cardiac biomarkers. This is especially the case among younger, otherwise healthy patients without classical risk factors for atherosclerotic coronary artery disease.

Methods
Herein we present several cases of sudden cardiac death in young adults, including a case of unknown eosinophilic myocarditis, which highlights the potential trials in the diagnosis of this disease.

Results
Autopsies were performed on several adults (age range, 30-40 years) thought to have died of cardiac causes. This included a 30-year-old African American female with no significant known medical history who presented with a chief complaint of palpitations. The initial clinical impression at an outside institution was of cardiac amyloidosis. But the Technetium99 scan was inconclusive. Despite clinical management, she developed ventricular arrhythmias and could not be resuscitated. There was a vague history of taking nutritional supplements from a local grocery store. Gross findings at autopsy included circumferential subepicardial erythema, thymic enlargement (60g), and congested lungs. The heart was thoroughly sampled. Microscopic examination revealed diffuse infiltration of eosinophils, mast cells, lymphocytes and macrophages with mild myocyte necrosis and interstitial edema in all sections. There were no giant cells, no interstitial deposition of amorphous acellular material and no focus of infarcted myocardium. Thymic sections were histologically normal. Acetylcholine receptor antibody panel was negative.

Conclusion
We conclude that eosinophilic myocarditis though rare (0.5% unsuspected and 0.1% suspected cases), is a distinctive cause of death with a specific microscopic presentation. Our case also included thymic enlargement at autopsy – a finding not previously noted.
The Crushing Effects Of Opiate Abuse: Two Cases Illustrating The Morphologic Features Of Acute And Chronic Intravenous Administration Of Crushed Oral Opiates
Authors: Clarke-Brodber A , Lee J , Victor T , Kaur A 
Published: October 2020

Abstract

Introduction/Objective
Drug overdose related deaths in the US have shown a four-fold increase over the past two decades, increasing from 6.1 to 21.7 per 100,000, the increasing majority of which involve synthetic opioid use. With this continuing increase, it is important for pathologists to become aware of unusual gross and microscopic changes related to unconventional modes of drug abuse. A less recognized unconventional method for opiate abusers to ingest these substances exemplified by our two cases is by crushing oral tablets and inhaling or injecting the drug intravenously, subcutaneously or intramuscularly.

Methods
The two cases being presented show morphological features of acute and chronic opiate abuse by autopsy study. Case 1 was a 38-year old female, who underwent spinal fusion surgery 1 month prior, and was found unresponsive at home. Case 2 was a 37-year-old female with a history of Antiphospholipid Antibody Syndrome (APA) and upper limb DVTs who was found unresponsive one day after elective utero-vaginal prolapse surgery.

Results
At autopsy, Case 1 showed extensive embolization of polarizable foreign body material (possible “pill filler”) and fibrin in small and medium sized vessels without inflammatory reaction in the lungs bilaterally. The foreign material was also present in the small vessels of the heart associated with multifocal acute inflammation, hemorrhage, foreign body giant cell reaction and multiple myocardial infarcts (elevated troponin levels clinically). Blood and vitreous fluid were positive for oxycodone. At autopsy, Case 2 showed an extensive angiocentric miliary pattern of granulomatous reaction to polarizable foreign material, consistent with pill filler in the lungs bilaterally. This foreign material was also present within the lumens and walls of pulmonary vessels and in the skin of the legs. Chronic changes of hypertrophic cardiomyopathy, hepatic cirrhosis and congestive splenomegaly were evident. The blood oxycodone levels were ten times the normal limit.

Conclusion
These cases illustrate the importance of recognizing the clinical and morphological features of unorthodox acute and chronic opiate abuse. Lack of familiarity with their differing features can lead to a delay in diagnosis and institution of appropriate timely management and treatment.
Lymphamatosis Cerebri With Rare Marginal Zone Lymphoma Phenotype: An Autopsy Case Report In A Patient With History Of Peripheral Diffuse Large B Cell Lymphoma And Chronic Lymphocytic Leukemia
Authors: Kaur A , Clarke-Brodber A , Eldibany M , Alikhan M , Lee J 
Published: October 2020

Abstract

Introduction/Objective
Lymphomatosis cerebri (LC) is a term used to describe primary central nervous system lymphomas which may present as diffuse, non-enhancing, infiltrative lesions. Although most of these are diffuse large B-cell lymphomas, there are other cases in the literature of low-grade B-cell lymphoma, Burkitt lymphoma and T-cell lymphoma.

Methods
We present a 76-year-old male with a past medical history of chronic lymphocytic leukemia (2014), diffuse large B cell lymphoma of right jaw (2019) s/p chemotherapy, prostate cancer s/p prostatectomy and radiation. The patient presented 3 weeks prior to admission due to generalized weakness with rapidly declining mental status, anorexia and deconditioning. MRI brain revealed scattered T2/FLAIR signal abnormalities in the cerebrum and cerebellum. An assessment of encephalitis was rendered. The patient continued to worsen and passed away.

Results
On autopsy of the brain, there was extensive involvement of the basal ganglia, cerebellum and all cerebral lobes by a lymphoid process. It had a predominant perivascular, parenchymal and leptomeningeal distribution.
Microscopically, there was a diffuse proliferation of small to intermediate sized lymphocytes with mature chromatin. These lymphocytes were neoplastic B cells which stained for CD20, CD43 and negative for CD5, CD3 and CD23. It also showed low Ki67 index. This immunophenotype is most consistent with a marginal zone lymphoma.

Conclusion
It is quite rare that our patient’s infiltrative process was a small mature B-cell lymphoma most compatible with marginal zone B-cell lymphoma. Our case illustrates the importance of recognizing this entity, particularly in context with different morphology since our patient had three different types of lymphoma. The dilemma in diagnosing such lesions can lead to delay in diagnosis and institution of appropriate management. Thus, knowledge about its imaging and morphological features is very critical for correct categorization and to avoid potential misdiagnosis.
Tackling The Challenge Of Opioid Use And Abuse And Treatment Of Chronic Pain Management
Authors: Arora K , Umar B , Hogan K , Winston-McPherson G N , Copeland J R , Varney R , Shah V , Totten A 
Published: October 2020

Abstract

Introduction/Objective
Deaths from opioid overdose increased 12% from 2016 to 2017. This major economic burden cost roughly $78.5 billion in the US. This steep increase in drug overdose deaths can be attributed to increased synthetic opioid abuse. To better understand and reduce opioid abuse amongst patients at Henry Ford Health System, Detroit MI, we sought to collaborate with physicians to manage prescribing, interpret test results, improve patient care, and deliver more value.
Primary Aim: To create a directed pain panel for ordering and interpreting pain management drugs to help providers to better manage patients and to assess compliance from test ordering history to serve patients safely and effectively.
Secondary Aim: To streamline the process of prescribing pain medications and to create a patient centered approach to treat chronic non-cancer patients who actually need opioids, to minimize the risk of abuse, diversion and addiction among patients.

Methods
Plan Do Check Act (PDCA) cycles of process improvement were used to achieve our two aims. In the first cycle, a drug screen-ordering guide was developed to facilitate screening (qualitative) and confirmation (quantitative) ordering practices. As part of this, providers prescribing for chronic pain patients were advised to use drugs of abuse panel rather than our emergency drug screen. In the second cycle, a directed pain panel (DPP) was introduced with reflex to confirmation testing. The DPP led to discovery of unexpected fentanyl positives, which were further investigated.

Results
A survey was conducted to investigate provider-ordering practices, which showed that use of the new drugs of abuse panel rose from 57% to 77%. The DPP was accepted by ~60% of physicians and was frequently reordered in follow-up. Analysis of unexpected fentanyl positivity revealed 30% true positivity, thus identifying unknown patient use. A future PDCA cycle is focused on developing, implementing, and measuring the customer value of a laboratory generated interpretive opioid results report at 5 similar organizations with a goal to assist with test selection and simplify provider interpretation of results.

Conclusion
A future PDCA cycle is focused on developing, implementing, and measuring the customer value of a laboratory generated interpretive opioid results report at 5 similar organizations with a goal to assist with test selection and simplify provider interpretation of results.
Cutaneous Plasmacytosis: A Pitfall For B and Plasma Cell Neoplasms
Authors: Giraldo C N , Myers D , Holmes A , Dodd J , Wendi W 
Published: October 2020

Abstract

Introduction/Objective
Cutaneous plasmacytosis (CP) is an uncommon condition typically affecting Asian males in the 3rd to 5th decades. It is thought to be a reactive process that classically presents with asymptomatic, red-brown, plaques and nodules on the face and neck. It has been associated with polyclonal hypergammaglobulinemia and systemic involvement. Histologically it is characterized by dense superficial and deep dermal infiltrates of mature plasma cells with polyclonal differentiation on in-situ hybridization (ISH). The differential diagnosis includes neoplastic plasma cell processes, characteristically with monoclonal plasma cell infiltrate, and mature B cell neoplasms with polyclonal plasma cell differentiation.

Methods
We report a case of a 69 year old Caucasian male who presented with asymptomatic, enlarging red-brown nodules on bilateral nasal ala. Histologic examination revealed dense, superficial plasma cell infiltrate, concerning for a plasma cell neoplasm. CD138 and Kappa/Lambda ISH demonstrated plasma cell polyclonality. Further workup ruled out infectious or systemic involvement and a plasma cell dyscrasia was ruled out by Hematology/Oncology.

Results
These findings supported the diagnosis of CP. Treatment with intralesional steroids showed initial improvement with regrowth of the nodules. To date, treatment with topical steroids and CO2 laser ablation are being considered.

Conclusion
CP is reported as type of pseudolymphoma, which is described as a reactive lymphoproliferation that histopathologically and/or clinically imitates cutaneous lymphoma. The pathogenesis is unknown, however, there are studies suggesting an association with increased interleukin-6, which is involved in the differentiation of B cells to mature plasma cells. The majority of patients with CP have a favorable prognosis. There has been variable success with both topical and intralesional treatment to include, cyclophosphamide, topical tacrolimus, prednisone, intralesional steroid therapy, topical psoralens combined with ultraviolet A exposure, and other chemotherapies. Familiarity with this rare entity is imperative to prevent misdiagnosis and overtreatment.
Excellence Available Everywhere: The Virtual Pathology Grand Rounds Experience
Authors: Wobker S E , Mirza K M , Jiang X , Gonzalez R 
Published: October 2020

Abstract

Introduction/Objective
Grand Rounds seminars are a cornerstone of scholarship in all academic departments. They provide education, stimulate discussion, and build faculty reputation. The COVID-19 pandemic led to cancellations in teaching conferences and lost opportunities for all of the above starting in March 2020. The social medial hashtag #VirtualPathGR and @VirtualPathGR Twitter (San Francisco, CA) accounts (VPGR) were created to address a need for continued engagement in academic pathology, during and after periods of physical distancing.

Methods
#VirtualPathGR was first used on March 21, 2020 to assess interest in a VPGR format. Six pathologists organized a social-media based platform, utilizing video conferencing. Zoom (San Jose, CA) was selected because it is free and easy to use. A committee developed criteria for inviting hosts and speakers, developed a logo and template for announcements and promoted VPGR. Potential speakers were selected initially via self-nomination and subsequently by selections from the VPGR board. Free pre-registration was required to minimize risk of disruption by malicious actors. Academic institutions served as “hosts” similar to traditional GR, and the speaker was introduced by one of the VPGR board members. Evaluations were sent to participants via the chat function in Zoom. Lectures were recorded and archived via YouTube (San Bruno, CA).

Results
As of May 1, #VirtualPathGR has 2.6 million impressions and the Twitter account has 808 followers. From April 2 to May 1, five VPGR were held with 1,720 registrations (average 344 per event) and 829 Zoom attendees overall (average 165 per event). 4 separate academic host institutions were involved and speakers included Assistant to Full Professors. Participants from 16 different countries attended the live sessions. The archived talks have been viewed 954 times via YouTube. VPGR received support from the American Society for Clinical Pathology (Chicago, IL), leading to a partnership to provide CME credit.

Conclusion
VPGR serves as strong proof of concept of the ability and demand for high quality academic pathology talks to be given remotely. VPGR promotes academic engagement and provides career-building opportunities by partnering with host universities. While remote learning comes with challenges, VPGR shows that the pathology community can harness the power of remote technologies to enhance learning across the world, now and in the future.
An Unusual Case Of Disseminated Histiocytic Sarcoma Preceded By Myeloid Sarcoma With Concomitant Acute Myeloid Leukemia
Authors: Reddy A C , Reddy K S 
Published: October 2020

Abstract

Introduction/Objective
Histiocytic sarcoma (HS) is rare (&lt;1% of hematolymphoid neoplasms), and can present extranodally as disseminated disease. Immunophenotypically, the cells express CD163, CD68, lysozyme and CD45. HS often occurs as a secondary event following B-cell lymphomas, acute lymphoblastic leukemia or acute myeloid leukemia (AML) typically with monocytic differentiation retaining the same molecular/cytogenetic abnormalities as the primary tumor.

Results
Our patient, a 47 year old male was diagnosed with myeloid sarcoma (MS) following FNA of a new neck mass. A bone marrow biopsy revealed AML without monocytic differentiation. Flow cytometric findings of both marrow and neck mass were similar (positive for CD34, CD117, CD33, CD11b, CD13, CD15, CD64, CD7; negative for CD4, CD14, CD56). Karyotypic and FLT3 ITD mutation analysis were normal. CNS involvement was diagnosed 2 months later, while a marrow biopsy (status post therapy) confirmed resolution of AML. A hypermetabolic left perinephric mass noted by PET CT, when biopsied, showed large epithelioid polygonal cells with amphophilic cytoplasm and atypical vesicular nuclei (positive for CD68, PU.1; negative for LCA, CD163, CD34, CD4, pankeratin). A diagnosis of atypical epithelioid neoplasm suggestive of HS was rendered, although negativity for LCA and CD163 was unusual. No treatment was given for HS. A month later, the patient presented with a cheek mass diagnosed again as being suggestive of HS. His AML also relapsed. Next-generation sequencing (37 genes including BRAF) from both marrow and tissue samples detected the presence of a nonsense mutation in exon 7 of WT1 (p.Ser169).

Conclusion
Our case appears to be the first reported one of disseminated HS preceded by MS and concomitant AML, lacking monocytic differentiation. The findings overall support the hypothesis of origin as being from a common progenitor cell differentiating along both myeloid and histiocytic/other cell lineages at different time points.
Acute Myeloid Leukaemia with Vitreous Haemorrhage: Management Challenge in a Third World Country
Authors: Olatinwo A T , Ogbenna A A , Bolarinwa A 
Published: October 2020

Abstract

Casestudy
Leukaemic ophthalmopathy is commoner in acute myeloid leukaemias. Ophthalmic involvement in leukaemias is classified into: Primary or Secondary.

Methods
A 35-year-old man with history of working in an oil and gas company for 3years who presented 9months ago on account of one month history of recurrent fever, occasional bone pain and generalised body weakness.Had associated history of passage of dark coloured urine, mouth ulcers, mouth bleeds and dizziness. CBC at presentation showed WBC of 102,300/mcl with 79% blasts, hemoglobin of 5.4g/dL, platelet count of 12,000/mcl. Symptoms were consistent with leukostasis, and he had leukoreduction with exchange blood transfusion and hydroxyurea. Bone marrow aspirate confirmed the diagnosis of AML FAB M2. Bone marrow biopsy showed hypercellular marrow with increased myeloid series, other series depressed.
Three days after admission, he complained of painless blurred vision bilaterally and feeling of objects appearing reddish, a review by ophthalmologist with an assessment of bilateral retinal haemorrhage secondary to AML. B – Scan done showed whitish elevated hyperechoic mass (parapapillary) with moderate dot echoes in the vitreous bilaterally. They planned for dilated fundoscopy and advised haematologist to commence chemotherapy as planned.
He then had standard induction with cytarabine and daunorubicin.Post chemotherapy showed pancytopenia secondary to chemotherapy. Further review by Ophthalmologist showed bilateral vitreous haemorrhage secondary to bilateral choroidal mass and then planned for vitrectomy and also had bilateral intravitreal bevacizumab
Day 14 bone marrow exam showed hypocellularity with absence of blasts indicating remission. He subsequently underwent cycle 1 of consolidation with high-dose cytarabine with the goal to proceed with allogeneic hematopoietic stem cell transplant (HSCT). Post consolidation, patient has had surgeries of both eyes and subsequently regained full vision in both eyes. Though patient is yet to re-present for post consolidation chemotherapy despite adequate counsel due to financial constraints and yet to have allogeneic hematopoietic stem cell transplant (HSCT) and last showed up for follow up four months ago.

Results
Patient regained full vision in both eyes

Conclusion
This case illustrates that vitreous haemorrhage in Patients with AML can be effectively managed in a resource limited setting.
Pediatric-Type Follicular Lymphoma With A Prolonged Clinical Course And Unusual Mutational Profile
Authors: Muldoon J , Phelan A , Kitagawa Y , Czader M 
Published: October 2020

Abstract
Casestudy: Pediatric-type follicular lymphoma is crucial to differentiate from other subtypes of follicular lymphomas since it carries an excellent prognosis and generally does not require radio- or chemotherapy. We present a 22-year-old male with an 8-year history of a left submandibular mass. Interval imaging studies showed no change in the mass size over time and no other sites of involvement. The patient underwent excision of the mass. Histologic sections showed effacement of nodal architecture with expansile follicles composed of medium sized to large lymphoid cells with blastoid features. Follicles showed abundant tingible body macrophages. Polarization was not seen. Neoplastic follicles were positive for CD20, PAX5, BCL6, CD10, and FOXP1, and negative for BCL2. PD1 positive cells were localized peripherally in the follicles. Clonality was confirmed by flow cytometry (kappa restricted CD10 positive B-cells in a polyclonal background) and by IGH PCR analysis (clonal peaks in FR1 and FR2).
Molecular genetic testing showed the following mutations: TNFRSF14 W12* (VAF 14.8%), MAP2K1 F53V (5.7%), EZH2 Y646N (6.9%), ARID1A R1461* (7.1%). BCL2 rearrangement was not detected. MAP2K1 and TNFRSF1 are frequently reported in pediatric-type follicular lymphoma, however in the majority of cases they do not occur together. EZH2 mutation does not typically occur in pediatric-type follicular lymphoma, and is more common in classic adult- onset follicular lymphomas. Despite typical morphologic and clinical features, this patient showed a more complex genetic profile and EZH2 mutation, unusual findings in pediatric-type follicular lymphoma. It is conceivable that a higher genetic complexity has been acquired over time and is related to the long duration of the disease.
Evaluation of Renal Biopsy for Transplant: The Significance of Whole Slide Imaging (WSI) in Telepathology
Authors: Sonawane S , Borys E , Borys D , Picken M 
Published: October 2020

Abstract

Introduction/Objective
Percutaneous Renal biopsy remains a gold standard technique to provide diagnostic and prognostic information post kidney transplantation. Recently Whole slide imaging (WSI) telepathology systems have been widely used for clinical, education and research purposes. Our aim was to examine reliability and accuracy of WSI telepathology service in the pathology diagnosis of biopsy specimens from transplanted kidney.

Methods
At our institution we have two renal pathologists. They utilize WSI telepathology service with Aperio scanner for rapid initial assessment of the transplant renal biopsy specimens. We retrospectively reviewed reports of all transplant renal biopsies which were examined remotely utilizing WSI telepathology service and compared the results for initial versus final diagnoses.

Results
In period from Jan 2019 to April 2020 total 160 renal transplant biopsies were evaluated remotely utilizing the WSI scanner. The diagnosis was divided in 4 subcategories as reperfusion injury, rejection (Antibody mediated or T cell mediated), mixed inflammation-favor infection and Polyoma virus infection. There were 48 cases of reperfusion injury; 5 cases of polyoma virus infection, 37 cases of rejection and 28 cases with mixed inflammation and 42 cases with no significant histopathologic findings. There was no discrepancy between the preliminary and final diagnosis for all 160 cases. The ancillary studies including special stains and electron microscopy added to the final diagnosis or confirmed the preliminary diagnosis.

Conclusion
WSI telepathology is a reliable and simple method to rapidly review transplant kidney biopsies. The ability to transmit images from hospitals to pathologists with WSI scanner has the potential for not only an accurate assessment of the rejection but also for additional histopathological findings. Digital pathology enhances the clinical usefulness of immediate assessments of transplant biopsy samples and also provides a platform to share the scanned images with clinicians which also can be utilized for education of trainees.