Volume 54 (2016): Issue 1 (March 2016)

Mycosis fungoides is the most common primary T-cell lymphoma of skin. The disease has a protean clinical and histological presentation in its early patch and plaque stages, when distinction from mimicking inflammatory dermatoses is difficult. Since no single criterion is specific enough, a reliable diagnosis in early stages requires integration of clinical, histopathological and molecular findings. In skin biopsies, the most helpful histologic features are the detection of atypical lymphocytes in the epidermis with minimal epidermal changes, basal alignment of lymphocytes along dermal-epidermal junction and formation of Pautrier microabscesses. An aberrant immunophenotype of T cells and molecular detection of a clonal T-cell population are factors that could allow a more specific diagnosis. This work recapitulates and discusses these features from a practical perspective.

Background. Crohn’s disease and ulcerative colitis are inflammatory bowel diseases (IBD) associated with colorectal cancer risk in long-standing diseases. In order to assess the colonic mucosa and to discover dysplastic or neoplastic lesions, advanced endoscopic techniques are needed. Such techniques are detailed in this review: chromoendoscopy, autofluorescence imaging (AFI), narrow band imaging (NBI), i-SCAN, Fujinon Intelligent Color Enhancement (FICE) and confocal laser endomicroscopy (CLE).

Aim. The aim of the review is to describe and establish the clinical impact of advanced endoscopic techniques, that could be used in IBD patients’examination in order to assess mucosal healing, microscopic inflammation, dysplasia or neoplasia.

Materials and Methods. A literature research about new endoscopic approaches of patients with IBD was made.

Results. A lot of studies have been performed to reveal which imaging technique might be used for IBD surveillance. Regarding dysplasia or neoplasia detection and mucosal healing or inflammation assessment, CE proved to be superior to white light endoscopy (WLE), while NBI and AFI did not show an encouraging result. I-SCAN did not improve the colonoscopy quality while FICE has been used in a few studies. CLE could be used to characterize a lesion, providing the same results as conventional histology.

Conclusion. At the moment, CE is the only technique which has been included in guidelines for IBD surveillance. CLE can be used to assess any lesion detected with WLE during surveillance, while the other imaging techniques require more studies to determine their efficacy or inefficacy.

Solid masses of the pancreas represent a variety of benign and malignant neoplasms of the exocrine and endocrine tissues of the pancreas. A tissue diagnosis is often required to direct therapy in the face of uncertain diagnosis or if the patient is not a surgical candidate either due to advanced disease or comorbidities. Endoscopic ultrasound (EUS) is a relatively new technology that employs endoscopy and high-frequency ultrasound (US). EUS involves imaging of the pancreatic head and the uncinate from the duodenum and imaging of the body and tail from the stomach. It has been shown to be a highly sensitive method for the detection of pancreatic masses. It is superior to extracorporeal US and computed tomographic (CT) scans, especially when the pancreatic tumor is smaller than 2-3 cm. Although EUS is highly sensitive in detecting pancreatic solid masses, its ability to differentiate between inflammatory masses and malignant disease is limited. Endoscopic retrograde cholangiopancreatography (ERCP) brushing, CT-guided biopsies, and transabdominal ultrasound (US) have been the standard nonsurgical methods for obtaining a tissue diagnosis of pancreatic lesions, but a substantial false-negative rate has been reported. Transabdominal US-guided fine-needle aspiration biopsy (US-FNAB) has been used for tissue diagnosis in patients with suspected pancreatic carcinoma. It has been shown to be highly specific, with no false-positive diagnoses. With the advent of curvilinear echoendoscopes, transgastric and transduodenal EUS-FNAB of the pancreas have become a reality EUS with FNAB has revolutionized the ability to diagnose and stage cancers of the gastrointestinal tract and assess the pancreas. Gastrointestinal cancers can be looked at with EUS and their depth of penetration into the intestinal wall can be determined. Any suspicious appearing lymph nodes can be biopsied using EUS/FNAB. The pancreas is another organ that is well visualized with EUS. Abnormalities such as tumors and cysts of the pancreas can be carefully evaluated using EUS and then biopsied with FNAB. There are many new applications of EUS using FNAB. Researchers are looking to deliver chemotherapeutics into small pancreatic cancers and cysts. Nerve blocks using EUS/FNAB to inject numbing medicines into the celiac ganglia, a major nerve cluster, are now routinely performed in patients with pain due to pancreatic cancer. The aim of this study is to perform a review of the literature regarding the usefulness of EUS/FNAB in the diagnosis of pancreatic adenocarcinoma.

Introduction. Reticulocyte hemoglobin equivalent (RET-He) is a new parameter for evaluating iron status. This study aims to assess diagnostic value and investigate RET-He as early predictor of response to intravenous iron supplementation.

Methods. Seventy-two regular hemodialysis patients at Adam Malik Hospital were studied from April to May 2011. RET-He was compared with conventional iron parameters for identification of iron deficiency. Fifteen patients with iron deficiency anemia were selected to receive 100 mg iron sucrose intravenous during every dialysis session (2x/weeks) for 4 weeks.

Results. Receiver operating characteristic (ROC) curve for RET-He revealed the value of area under the curve was 0.818 (p < 0.0001). Using cutoff level 31.65 pg, RET-He showed 81.5% sensitivity and 61.6% specificity. Serum ferritin (r = 0.499, p < 0.0001) and transferrin saturation/ TSAT (r = 0.592, p<0.0001) were correlated to RET-He. Significant improvement in hemoglobin, hematocrit and RET-He were found after intervention (p = 0.023, p = 0.049 and p = 0.019, respectively).

Conclusion. RET-He is a useful marker of iron deficiency and early predictor of response to intravenous iron supplementation in regular hemodialysis patients.

Background and Aims. Two-dimensional (2D) and Doppler echocardiography are the main methods for the non-invasive evaluation of ventricular function in children. Our study monitored the evaluation of systolic and diastolic function in pediatric patients, using classical echocardiographic parameters and pulsed tissue Doppler parameters, as well as the correlation between these.

Methods. The study included 18 healthy children and 9 children diagnosed with congestive heart failure secondary to congenital heart malformations. The parameters of systolic and diastolic function were measured by 2D echocardiography, 2D guided M mode, color and pulsed Doppler, as well as by pulsed tissue Doppler at the level of the mitral and tricuspid annulus.

Results. A relaxation alteration pattern or a pseudonormal pattern of E diastolic velocity compared to the A wave was found (E = A; E > A) in the group of subjects with heart failure. E wave deceleration time had significantly increased values in the case of patients with CHF, being correlated with diastolic dysfunction. Left ventricular flow propagation velocity Vp was decreased in patients with heart failure, the E/Vp ratio being maintained relatively constant in subjects with congestive heart failure and healthy subjects, most probably on account of the concomitant change in the E wave. Associations between the severity of systolic dysfunction and the diastolic dysfunction were found in pediatric patients diagnosed with congestive heart failure (Student test, p < 0.05).

Conclusions. Tissue Doppler measurements proved to be useful for the evaluation of pediatric patients with altered ventricular geometry secondary to congenital heart disease, systolic-diastolic dysfunction and heart failure.

Introduction. Hydatidosis is a parasitic disease with tumour-like development of a cystic mass. This has specific endemic areas, Romania being amongst them. Our hospital has national addressability and the collaboration between the Departments of Parasitology, General Surgery and Pathology ensures optimal multidisciplinary approach to cases of therapeutic and diagnostic standpoint. The study aims to test the hypothesis that the gallbladder is a hydatid reservoir, to identify signs of biliary fistulas in the pericyst and liver parenchyma; to identify inflammation elements in the pericyst and the gallbladder.

Material and methods. The study is a retrospective observational one, carried out between 2011-2014, on a total of 35 patients operated for hepatic hydatidosis in the General Surgery Department of “Colentina” Clinical Hospital. All the selected patients had sent to the Pathology Department: gallbladder, cyst and pericyst. Statistical analysis of the data was performed using SPSS package Statistics 19.

Results. The main results of the study revealed no evidence to confirm the hypothesis that the gallbladder is a hydatid reservoir. Out of the 35 cases, in 16 we observed the tendency to include hepatic biliary ducts in the pericyst or the formation of new canals which lead to the formation of biliary fistulas. Using immunohistochemical techniques with mark of CK19 (cytokeratin 19), have been observed the pattern of fistulization and modification of local architecture through the formation of the pericyst, in 16/35 (45.7%) of cases.

Conclusion. Although it is a benign pathology, the evolution of hepatic hydatidosis can lead to severe complications and a low quality of life for the patient, both before and after surgery. Better knowledge of the pathology behind the local evolution of the disease can influence the therapeutic approach.

Introduction. Diabetes Mellitus causes ultrastructural changes triggered by partially clarified cellular mechanisms. Since cell death is an important mechanism in the appearance and progression of diabetic nephropathy, we studied alteration of several markers of apoptotic pathways signaling in renal tissue of diabetic or prediabetic patients.

Methods. We analyzed 48 human kidney tissue samples divided into two study groups: the research group (43 renal tissue samples from diabetic or prediabetic patients), and the control group (5 renal tissue samples from patients without diabetes). Immunohistochemistry revealed expression of Bcl-2, APAF-1, CD-95 and Caspase-9 in the renal cortical structures. Statistical analysis was also performed (significance level P<0.05).

Results. We found a variable expression of the antiapoptotic Bcl-2 with a decrease of Bcl-2 expression in diabetes. The control samples render evident intensely positive immunostaining for CD-95. In diabetes and diabetic nephropathy, there was positive immunostaining for APAF-1 at tubular cell level. Nuclear and cytoplasmic positivity for Caspase-9 was more frequently recorded as kidney damage progresses. APAF-1 and Caspase-9 positivity are arguments for an intrinsic apoptotic mechanism of cell death in diabetic nephropathy.

Conclusion. The mechanisms of apoptotic cell death identified in diabetic kidney samples prove that Bcl-2, CD-95, APAF-1 and Caspase-9 represent reliable markers of cell death in human renal tissue. Our results support the hypothesis that apoptosis is a pathogenic and initiator mechanism of renal remodeling in diabetic kidney disease.

A typical case of Fahr’s syndrome is described in a 76-year-old Brazilian female who underwent a total thyroidectomy three decades ago. Six years before the current admission, she started with generalized tonic-clonic seizures. Associated disorders involved extra-pyramidal, cognitive, nocturnal terror and mood changes. With suspicion of hypocalcemia due to secondary hypoparathyroidism, laboratory determinations confirmed the diagnoses. Furthermore, imaging studies of the central nervous system detected multiple calcifications, with characteristic distribution of Fahr’s syndrome. Clinical management was successful.

Acquired perforating disorders are a group of uncommon skin conditions characterized by transepidermal extrusion of altered dermal material, most often associated with diabetes mellitus and chronic kidney failure. Delusional parasitosis is a primary psychiatric disorder in which affected patients have fixed, false beliefs that their skin is infested by parasites, in the absence of any evidence supporting their statements.

A 69 year old malepatient addressed the Dermatology Department for a skin eruption consisting of multiple umbilicated keratotic papules with a generalized distribution. The patient believed that the lesions were produced by small parasites entering and exiting his skin. The histopathological examination confirmed the clinical diagnosis of Kyrle’s disease. The psychiatric examination established the diagnosis of delusions of parasitosis.

This is the first reported case of Kyrle’s disease associated with delusions of parasitosis. There is no evidence supporting the hypothesis that delusions of parasitosis might be a predisposing factor for Kyrle’s disease. However, we believe that the pruritic dermatosis might have triggered the delusions of parasitosis due to the associated pruritus. On the other hand the constant excoriations and traumatizing of a skin prone to develop idiopathic Kyrle’s disease in the attempt to remove the parasites prevented the complete resolution of the lesions.

A deep vein thrombosis was rarely associated with uterine myomas. Hereby, it is presented the case of a 40-year-old woman in which the clinical manifestation of the deep vein thrombosis revealed the further diagnosis of a large uterine myoma. The diagnosis, management and clinical outcome of the patient are emphasized and discussed. The management of a patient with a uterine myoma and deep vein thrombosis is challenging and implies a multidisciplinary team.

Cardiovascular manifestations of tertiary syphilis infections are uncommon, but represent an important cause of mortality and morbidity. Syphilitic aortitis is characterized by aortic regurgitation, dilatation of ascending aorta and ostial coronary artery lesions.

We report a case of 36 years old man admitted to our hospital for acute anterior ST segment elevation myocardial infarction complicated with cardiogenic shock (hypotension 75/50 mmHg). Transthoracic echocardiography revealed a dilated left ventricle with severe systolic dysfunction (ejection fraction = 25%), severe mitral regurgitation, moderate aortic regurgitation and mildly dilated ascending aorta. Coronary angiography showed a severe ostial lesion of left main coronary artery which was treated by urgent stent implantation and an intra-aortic contrapulsation balloon was implanted. Blood tests for syphilitic infection were positive. The patient was discharged with treatment including benzathine penicillin.

In our case, we present an acute manifestation of a syphilitic ostial left main stenosis treated by primary percutaneous coronary intervention in acute myocardial infarction. Long term follow-up of the patient is crucial as a result of potential rapid in-stent restenosis caused by continuous infection of the ascending aorta.

This case is particular because it shows that syphilitic aortitis can be diagnosed in acute settings, like ST segment elevation myocardial infarction.