bluuebunny/crossref_metadata_2025_split huggingface dataset:
Atypical Plasmablastic Lymphoma Presenting as a Perianal Mass in a 19-Year-Old Male
Authors: Ding Daniel , Wang Jun 
Published: September 2019

Abstract

Objectives
To describe a case of plasmablastic lymphoma with an atypical immunophenotype in an unusual location.

Methods
We received this specimen for routine processing after the patient underwent an incision and drainage surgery. The specimen was sent to hematopathology for workup of lymphoma. We then ordered several special stains and molecular tests to confirm our diagnosis of plasmablastic lymphoma.

Results
Histologic examination of the tissue reveals sheets of large plasmablastic cells with eccentrically located round nuclei, prominent nucleoli, and cartwheel chromatin. Frequent apoptotic bodies and mitotic figures are present. Immunohistochemistry shows strong, diffuse positivity for leukocyte common antigen CD45, CD10, plasmacytic markers (MUM1, CD79a) and negativity for B-cell markers (CD20, PAX5) and CD138. The Ki-67 proliferation index is very high (>90%) and Epstein-Barr virus encoded small RNA (EBER) in situ hybridization is diffusely positive. Molecular FISH testing for aggressive B-cell lymphoma genetic abnormalities is positive for MYC gene rearrangement in 68% of nuclei and the loss of one copy of the BCL2 gene on chromosome 18 in 64% of nuclei.

Conclusion
This case of plasmablastic lymphoma is unique due to its atypical presentation as a perianal mass in a young patient with undiagnosed HIV. Usually, this lymphoma presents as an oral lesion in an older patient with HIV. In addition, immunohistochemistry showed an unusual immunophenotype (CD138–, MUM1+, CD45+, CD10+). Most plasmablastic lymphomas are CD138+, MUM1+, and CD45– but this specimen is CD138–, MUM1+, and CD45+. Further testing shows EBER positivity, a positive HIV test, and MYC gene rearrangement, which confirms our diagnosis of a plasmablastic lymphoma. Of note, genetic analysis also reveals a loss of one copy of the BCL2 gene on chromosome 18 in 64% of nuclei.
Comparing Efficacy of Low Dose Cytoreduction and Manual Exchange Blood Transfusion in Managing Hyperleukocytosis: A Case Report
Authors: Otokiti Oluwakemi , Ogbenna Ann , Bolarinwa Abiola , Olatinwo Adejoke 
Published: September 2019

Abstract

Objectives
Hyperleukocytosis is defined as white cell count greater than 100,000 cells/mm3. Symptomatic hyperleukocytosis (leukostasis) is a medical emergency and can complicate hematological malignancies. It is commoner in myeloid leukemia but can occur in extremely high-count lymphoid leukemia causing tumor lysis syndrome and death. Immediate management is hydration, cytoreduction, and leukapheresis. In a developing country without leukapheresis, how effective is manual exchange blood transfusion compared to low-dose cytoreduction? We present a case of chronic lymphocytic leukemia with severe hyperleukocytosis, comparing response to different treatment modalities in the absence of leukapheresis.

Case Summary
A 57-year-old woman with complaints of a vaginal protrusion and an incidental finding of a splenomegaly with moderate anemia. Hemogram showed a white cell count of 301,000 cells/mm3, and blood film revealed a chronic lymphocytic leukemia. She had two cycles of cyclophosphamide, vincristine, and prednisolone and presented 8 months later with worsening leukocytosis of 697,000 cells/mm3, severe anemia, dizziness, headaches, fatigue, and hyperkalemia. Two manual exchange blood transfusions insignificantly decreased count by 40,000 cells/mm3 with slight reduction of hyperkalemia. She had low-dose cytoreduction with weekly vincristine and prednisolone. White cell count reduced from 653,000 cells/mm3 to 467,000 cells/mm3 with normal electrolytes. She was then commenced on cyclophosphamide, mini-hydroxorubicin, vincristine, and prednisolone. There was a steady decline in counts with improvement in hematological parameters and overall well-being.

Conclusion
Due to nonavailability of leukapheresis, we attempted a manual exchange without a significant decrease in white cell count. However, with low-dose cytoreduction, there was a considerable decrease in white blood cell count and improvement of electrolyte with no tumor lysis syndrome, and it was more affordable. Therefore, in a resource-poor setting, using low-dose cytoreduction might be cheaper, safer, and more effective than exchange blood transfusion in managing hyperleukocytosis.
Synoptic Versus Narrative Reporting of Prostate Biopsies at a Tertiary Healthcare Institution: Challenges, Successes, and Expectations
Authors: Orah Nnamdi , Charles Anunobi 
Published: September 2019

Abstract

Objectives
Cancer pathology reports are expected to contain all information required for patient management and disease surveillance. Moreover, reports for patients with prostate cancer have become increasingly complex with the addition of more pathological details. This study aimed to compare narrative and synoptic prostate cancer reports for core needle biopsies received at a tertiary hospital in Nigeria in order to determine which form was most complete according to international standards.

Methods
This study was conducted from January 2010 to December 2015 at the Lagos University Teaching Hospital, Lagos, Nigeria. All malignant prostate cancer histopathology reports received during this period were analyzed for the presence of important clinicopathological parameters, including the numbers of cores taken and those involved by the tumor, percentage of tumor involvement, Gleason score, and the presence of high-grade prostatic intraepithelial neoplasms (HGPINs) and perineural and lymphovascular invasion.

Results
A total of 83 reports were reviewed, of which 27 were in narrative and 56 in synoptic format. The documentation of clinicopathological characteristics in narrative reports was significantly incomplete compared to synoptic reports in recording the number of cores (33.3% versus 96.4%), number of cores involved by the tumor (11.1% versus 94.6%), percentage of cores involved by the tumor (3.7% versus 100.0%), and the presence of HGPINs (7.4% versus 100.0%) and perineural (59.3% versus 98.2%) and lymphovascular (48.1% versus 100.0%) invasion (P < .001 each).

Conclusion
Synoptic reports of malignant prostate cancer biopsies received at the Lagos University Teaching Hospital were found to contain more complete information than narrative reports.
Implementation of Whole-Slide Imaging as a Pathology Teaching Tool and for Institutional Tumor Boards: A Resident’s Experience
Authors: Mishra Ashish , Tuthill J Mark 
Published: September 2019

Abstract

Objectives
This presentation will describe our experience implementing and utilizing whole-slide imaging (WSI) as a teaching tool for the pathology residents in Henry Ford Hospital, Detroit, as well as our initial efforts to use WSI at institutional tumor boards.

Methods
Glass slides were scanned for practice over several weeks to determine basic operation, system performance, and workflow processes. Experience quickly showed that the scanner could be used to improvement quality and efficiency of weekly unknown slide conference. Informatics lecture and luncheon meeting topics as well as a grand-rounds presentation on novel ways to use WSI were shared with residents and other members of the department. This resulted in marked increased interest. Soon interest grew from attending physicians to use WSI for a subset of tumor boards. The same processes and procedures used for scanning slides for unknown conference were applied.

Results
In October 2016, an unknown slide conference was presented using WSI. The reaction to the quality of the histopathology system usage was excellent: nuclear contours and nucleoli were clear; navigation was easy; response time was excellent, with no screen lag. Residents and attending loved the new format. Since then, the unknown conference has been presented monthly using WSI. In November 2016, we started presenting cases on WSI in the GYN tumor board. Some had no idea that this was even technically possible. All GYN weekly tumor boards are now presented using WSI.

Conclusion
Whole-slide imaging is a useful tool for teaching and presentation purposes. It can be easily implemented and integrated into our day-to-day pathology practice and resident training. The reluctance to use WSI is initially high among pathologists, but enthusiasm increases once implemented into regular practice. WSI provides for efficiencies and ease of collaboration in both educational and clinical case review settings such as institutional tumor boards.
The Value of Monitoring Requisition Forms in the Laboratory
Authors: Ebare Kingsley , Lanceta Joel , Restivo JeanneAnn , Opitz Lynne 
Published: September 2019

Abstract

Objectives
Insufficient or extraneous information on requisition forms may delay turnaround time and become a source of error in diagnosis. Monitoring the completeness and accuracy of clinical information in the requisition forms provided to pathologists is a potential target in laboratory quality improvement, but its effectiveness is currently not known. Here, we describe a pilot study at our institution’s anatomic pathology laboratory to determine the effect of monitoring the completeness of information filled in the requisition forms by clinicians.

Methods
We randomly selected and reviewed records in each quarter from August 2017 to January 2019. All records were obtained from one hospital site and included requisition forms for specimens from inpatient and outpatient surgical operating rooms. The percentage of incomplete or improperly filled forms was tracked each quarter and feedback is provided to clinicians with insufficient information in the forms.

Results
A total of 70 requisition forms from 7 quarters were reviewed. Five different physicians were responsible for all the requisition forms without complete information. One physician was responsible for 33.3% of all requisition forms with incomplete information. Commonly recurring missing information in requisition forms were preoperative diagnosis (40%), postoperative diagnosis (35%), type of procedure (15%), and indications for procedure (10%). There was a remarkable improvement on completion of requisition forms from 60% at the beginning of the review period to 100% at the end of the review period (P < .0001).

Conclusion
Long-term review of requisition forms submitted to the laboratory and provisional feedback to clinicians are associated with sustainable improvement on information provided to pathologists to ensure specimen identification, integrity, and accurate interpretation.
Choosing Wisely: Persistent Amylase Concurrent With Lipase Testing at Multiple Academic Health Systems
Authors: Ritter Jacob , Ghirimoldi Federico , Manuel Laura , Moffett Eric , Shireman Paula , Brimhall Bradley 
Published: September 2019

Abstract

Objectives
Choosing Wisely is a multidisciplinary effort to reduce unnecessary tests and procedures. Evidence-based guidelines advocate using serum lipase to diagnose acute pancreatitis; concurrent amylase and lipase tests provide minimal benefit compared to either alone. Serial measurements after the first elevated test are ineffective for tracking disease course. Our study determined the number of concurrent amylase/lipase tests and unnecessary serial tests to examine adherence to Choosing Wisely recommendations at four academic health systems. We also identified provider-ordering patterns and quantified the variable and total costs of unnecessary tests.

Methods
We analyzed deidentified laboratory data from four academic health systems in the Greater Plains Collaborative for all serum amylase and lipase tests from 2017, including results, timing, and patient-encounter location. We defined concurrent tests occurring within a 24-hour period and unnecessary serial inpatient measurements occurring after the first elevated result.

Conclusion
While the majority of providers adhered to Choosing Wisely recommendations obtaining 58,693 lipase-only tests, 85.8% of amylase tests were obtained in parallel with lipase (20,771 concurrent tests; amylase only, 3,447; total amylase tests, 24,218). Encounter location revealed concurrent rates of 43%, 32%, and 5% for ambulatory, inpatient, and emergency department settings, respectively. Ambulatory clinics from multiple services obtained concurrent tests, with Family Medicine obtaining 48%. Services with order sets containing both amylase and lipase were associated with higher rates of concurrent testing. Inpatient unnecessary serial testing resulted in 413 amylase and 1,266 lipase tests occurring in 33% and 31% of inpatient encounters for amylase and lipase, respectively. Unnecessary amylase and lipase tests resulted in $31,195 variable costs and in $86,297 total costs. Targeted education to clinicians/services ordering unnecessary amylase/lipase tests and revising order sets could decrease costs and improve quality of care by decreasing the volume and frequency of blood draws. Funded by UL1TR002645 and the Greater Plains Collaborative.
Comparison of Acid-Fast Stain and Auramine Rhodamine Fluorescent Smear on Bronchoalveolar Lavage Specimens Submitted for Cytologic Examination
Authors: Samra Hasan , Ledeboer Nathan , Buchan Blake 
Published: September 2019

Abstract

Objectives
Testing of bronchoalveolar lavage specimens with acid-fast bacilli (AFB) stain is not routinely performed in many institutions. In 2017, we began performing AFB stain on all BAL specimens submitted for cytologic examination. Herein, we evaluate the diagnostic value of this test in comparison to the auramine rhodamine fluorescent stain performed in parallel by the microbiology laboratory for specimens also submitted for AFB culture.

Methods
We retrospectively reviewed all BAL specimens that were reported as culture positive for Mycobacteria spp. (n = 109) by our microbiology laboratory between 7/20/2017 and 12/30/2018. Of these, 84 (77.0%) specimens were concurrently submitted for cytologic examination and reviewed by a board-certified cytopathologist.

Results
Of the 84 culture-positive BAL specimens submitted for cytologic exam, only 2 cases were positive for acid-fast bacilli on cytologic examination with AFB stain, yielding a sensitivity of 2.38%. In comparison, 11 of those specimens were identified on auramine rhodamine fluorescent stain, yielding a sensitivity of 13.1%. Both cases identified by the AFB stain on cytology were also identified by auramine rhodamine stain in microbiology. These data indicate that AFB stain conducted in cytology is 81.2% less sensitive for detection of AFB when compared to auramine rhodamine stain. All cases identified on smear and AFB stain (n = 11) belonged to the Mycobacterium avium-intracellulare complex.

Conclusion
Our study results suggest that in a low-prevalence population, the use of AFB stain on BAL specimens sent for cytologic examination lacks sensitivity and is unnecessary if the same specimen is also sent for microbiologic culture and auramine rhodamine stain. The use of AFB stain on BAL specimens that were not sent for AFB culture is suboptimal but may identify AFB in specimens obtained from patients for whom mycobacterial infection is not in the differential and may be clinically insignificant.
Erysipelothrix rhusiopathiae Native Value Endocarditis: A Unique Case Presentation
Authors: Patel Krutika , Liu S Shawn , Dasaraju Sandhya , Carter J Elliot 
Published: September 2019

Abstract
ER is a facultative, non-spore-forming, non-acid-fast, gram-positive bacillus. It is a ubiquitous commensal in wild and domestic animals, birds, and fish and has an enormous economic impact on animal husbandry and marine industry, causing animal erysipelas. Human infections are extremely rare, occupationally acquired zoonosis. Human infections are acquired through wounds, contact with sick animals, and carriers and commonly includes localized or generalized self-limited cutaneous erysipelas. Seldom, systemic infection and septicemia occur. We present here, a case of a 50-year-old immunocompetent retired shipyard welder who enjoyed fishing in his spare time and presented to the emergency room with fever, chest pain, significant weight loss, and dry cough lasting 2 to 3 months. He did not report any bites or injuries, intravenous drug abuse, or travel history. An echocardiogram showed mobile vegetation on aortic valve with severe regurgitation. Blood and tissue cultures grew E rhusiopathiae, identified by MALDI-TOF method. He was treated with empiric vancomycin followed by penicillin and aortic valve replacement with a mechanical valve. Cases of E rhusiopathiae–induced native valve endocarditis and septicemia are extremely infrequent in immunocompetent individuals, especially when occupation-related exposure is not noted. Even after surgery, it may entail fatality rates as high as 40%, higher than endocarditis caused by other bacteria. While some current reports suggest incidences of human infections are declining due to technological advances in animal industry, infection still occurs in specific environments. Additionally, it may be underdiagnosed due to its resemblance to other infections and problems encountered in isolation and identification. The natural resistance of E rhusiopathiae to glycopeptides underlines the importance of a prompt microbiological diagnosis of such an uncommon human infection, especially when presented in an unusual clinical presentation. Clinicians and microbiologists working with exposed population should be aware of this microbe and its manifestations.
Mycobacterium chimaera Infection: A Case Report and Review of Literature
Authors: Salas Dongpo , Zhao Xing , Cavalieri Stephen 
Published: September 2019

Abstract
Mycobacterium chimaera (MCH) is a non-tuberculous mycobacterium commonly found in the environment. It is a member of the M. avium complex (MAC), and rarely causes infections in humans. However, invasive MCH infections have been reported associated with heater-cooler devices during cardiac surgery. Detection of MCH infections in this setting has been impeded by inadequate clinical awareness and laboratory tests. A 77-year-old man had aorta valve replacement 3 years ago. He recently presented with constitutional symptoms, including fatigue, night sweats, and 50 pounds of weight loss. PET CT showed ground-glass and nodular opacities in the lungs. Bone marrow biopsy demonstrated noncaseating granulomas. Transesophageal echocardiogram revealed severe stenosis and regurgitation of aortic valves. Despite antibiotics and heart surgery to relieve stenosis, the patient succumbed. Autopsy showed multiple small granulomas in the lung and multifocal chronic inflammation in the heart. Premortem mycobacterial cultures of aortic valves were performed, which grew MAC by DNA probe in 1 week. Subsequently, it was identified as MCH by sequencing of the ITS1/ITS2 region. The cause of death was heart failure due to MCH endocarditis. MCH infection is rare but potentially fatal if not promptly treated. Therefore, it is critical to identify patients at risk for infection. Since 2013, over 100 cases of MCH endocarditis have been reported worldwide, specifically associated with contaminated heater-cooler units during heart surgery. Characteristically, MCH infection has a long incubation period after exposure (median 17 months, range 3-72 months). Signs and symptoms are generally nonspecific and often include fatigue, fever, and weight loss. The risk of MCH infection in patients undergoing open heart surgery is low, but clinicians should be aware of the risks especially when heater-cooler units are utilized. A close follow-up over a long period may be necessary due to the long incubation period of this infection.
Paracoccus yeei, a Rare Cause of Ocular Infection
Authors: Masood Hassan Muhammad , Naab Tammey , Afsari Ali 
Published: September 2019

Abstract

Objectives
Paracocci are nonfermenting obligate aerobes. The genus Paracoccus is classified in the family Rhodobacteraceae and contains 31 species. Gram stains reveal gram-negative cocci, diplococci, or coccobacilli/short rods, sometimes described as having an O shape due to peripheral stain. It may be confused with Neisseria sp. or Moraxella sp. due to oxidase positivity. Paracoccus yeei, a rare cause of infection in patients ranging from 6 weeks to 77 years, has been isolated from abdominal dialysate, wounds (ankle, toe), incision drainage, cerebrospinal fluid, bile, skin, blood, ear, and eye (uveitis, conjunctivitis, corneal transplant graft infection). It is a rare emerging pathogen with low pathogenic potential.

Methods
A 65-year-old heroin-dependent male with a nonfunctional left eye due to gasoline injury presented with a traumatic injury to the right eye. The ophthalmological exam revealed a central corneal ulcer, hazy pupil, right upper and lower lid swelling, periorbital edema with central vision loss, and conjunctival chemosis. B-scan showed no vitreous debris. Cultures of the ulcer were taken, and fortified tobramycin and fortified vancomycin drops were started.

Results
Nonhemolytic, whitish-gray, convex colonies, measuring 0.5 to 1 mm in diameter, grew on Columbia sheep blood and chocolate agar plates at 48 hours. Tiny pinpoint colonies were identified on MacConkey agar plate at 3 days. Gram stain revealed a small short gram-negative rod, which was oxidase and catalase positive. Microscan identified the isolate as P yeei. Antibiotic susceptibilities revealed low MICs for beta-lactam antibiotics and higher MICs for cephalosporins. The ulcer healed very well. The patient’s vision improved. The patient was subsequently discharged with instructions to follow up with clinic.

Conclusion
Our case reinforces the need to consider uncommon pathogens, including P yeei in eye infections and the role of microbiology in correctly identifying the organism where delay or incorrect treatment can lead to permanent damage.
Assessment of Anaerobic Culture Incubation Time: A Tertiary Care Center Experience
Authors: Gupta Akanksha , Easwar Arti , Maldonado Yanice , Hamilton Pam , Baumgartner Lori , Aslanzadeh Jaber 
Published: September 2019

Abstract

Background
Currently, there is no consensus on the ideal incubation time for anaerobic cultures. A recent survey of CliniMicroNet reported anaerobic culture incubation times from 2 to 7 days. The goal of this study is to determine the ideal anaerobic culture incubation time and to retrospectively determine if longer incubation time affected management.

Methods
In this prospective study at Hartford Hospital, an 869-bed level I trauma center, 838 consecutive anaerobic cultures were Gram stained and planted on anaerobic blood, colistin and nalidixic acid (CNA), and kanamycin and vancomycin (KV) agar plates (BD Diagnostic Sparks). Plates were incubated in jars at 35°C and Anoxomat system (Advanced Instruments) was used to create anaerobic conditions. Plates were checked for growth on days 2, 3, 5, and 7. Although not all patient records (EPIC) were available, the type and duration of antibiotics were recorded for more than 100 records.

Results
Out of 74 cultures from bronchoalveolar lavage (1), bone (2), fluid (21), tissue (14), and wound (36), 53 grew 1 isolate, 15 grew 2 isolates, 5 grew 3 isolates, and 1 grew 4 isolates, for a total of 102 isolates. Sixty percent of isolates were Gram negative and 40% were Gram positive. Of these, 43% were detected on day 2, 21% on day 3, 20% on day 5, and 17% on day 7. In a majority of cases, broad-spectrum antibiotics (vancomycin/cefepime) were administered until culture results were obtained.

Conclusion
Overall, 73% Gram-negative isolates and 50% Gram-positive isolates were detected on day 2 or 3. Days 5 and 7 yielded 20% and 17% of all isolates, respectively. We conclude and corroborate with CLSI recommendations that anaerobic cultures should be incubated for at least 5 to 7 days.