Case 1 - Click here for Text and References
Submitted by: Bobbi S. Pritt
Clinical Summary:
A 48 yo Somalian woman presented to ED after a fall complaining of severe right pelvic pain. She noted 4 months of pelvic/leg pain preceding the fall. Four years prior, she had an episode of back pain which was treated by having a family member walk on her back (a common practice in her culture). When the person put pressure on her right buttock, the patient noted a cracking noise. Plain pelvis radiographs showed a non-displaced fracture through the right inferior and superior pubic rami as well as a small fracture through the right iliac wing. A follow- up pelvis CT showed a 4.8 x 2.8 x 3.0 cm right iliac expansile lytic lesion associated with a pathologic fracture adjacent to the sacral iliac joint. The lesion extended into the iliacus musculature and the gluteus medius and gluteus minimus muscles anteriorly and posteriorly respectively. The radiologic differential diagnosis was “chondromyxoid fibroma, chondrosarcoma, or fibrous dysplasia with cartilaginous element,” while the clinical differential diagnosis was lymphoma, myeloma, primary bone malignancy, metastasis, or infection. An Infectious Disease consult was obtained; their differential diagnosis was polymicrobial abscess, anaerobic infection (e.g. actinomycosis), or tuberculosis. The patient had moved to the United States from Somalia 7 years prior to presentation and had not returned for a visit since. While in Somalia, she drank unpasteurized milk and dairy products. Upon arrival to the U.S., she was found to be PPD positive and underwent 9 months of INH treatment for latent TB. While in the U.S., she spent 8 months in California, 5 years in Ohio, and then moved to Minnesota.
Pertinent Laboratory Data:
CBC with differential was within normal limits, but her Sedimentation rate was elevated (70). Gram, AFB, and Fungal stains on material sent to the microbiology lab were negative.
Findings at open biopsy. Note that a well- delineated fracture of the right iliac crest is apparent. Inside of the bone cavity is gelatinous material.
Findings at open biopsy. Note that a well- delineated fracture of the right iliac crest is apparent. Inside of the bone cavity is gelatinous material.
CT Findings: large destructive mass involving the right ilium adjacent to the sacral iliac joint, extending into both the iliacus musculature and the gluteus medius and gluteus minimus muscles anteriorly and posteriorly respectively
H&E, 40 times original magnification, showing laminated layers around a single small cyst (center). This cyst is lined with a germinal layer that gives rise to the parasite forms. Within is a single pear-shaped/piriform protoscolex (immature tapeform).
H&E, 100 times original magnification, showing a close-up of the cyst.
High magnification (1000x) of the protoscoles showing the refractile internal hooklets. Narrowing the condenser emphasizes the hooklets.
High magnification (1000x) of the protoscoles showing the refractile internal hooklets. Narrowing the condenser emphasizes the hooklets.
H&#, 1000x: Free floating hooklets.
Case 2 - Click here for Text and References
Submitted by: Dhanpat Jain
Clinical Summary:
Patient is a 64-year-Jamaican old male who underwent screening colonoscopy. Colonoscopy showed colonic mucosa, which was diffusely mildly edematous with decreased vascular markings. There were a few small cecal erosions. Few small polyps (0.5-1cm) were also identified (Fig1). The polyps were removed and multiple random biopsies were taken from the terminal ileum and colon (Fig2-4). He had no symptoms pertaining to gastrointestinal system. He is diabetic for which he takes Insulin. He had traumatic fracture of his ribs many months ago for which he has been taking variety of pain killers including Acteoaminophen and Oxycodone.
Pertinent Laboratory Data:
His blood work reveal a total white cell count of 4900/µL with a differential of 30% neutrophils, 45% lymphocytes, 9% monocytes and 16% eosinophils; hemoglobin of 13.1g/dl and PCV of 41.6%.
Case 2 - Slide 1
Colonoscopy showed a few polyps with diffuse mucosal edema, few erosion and decreased vascularity.
Low magnification photograph showing a tubular adenoma. Note that the lamina propria is packed with inflammatory cells.
Higher magnification to show that the inflammation in the lamina propria consists primarily of eosinophils.
Higher magnification to show few cross sections of filariform larvae of Stongyloides surrounded by dense aggregates of eosinophils in the lamina propria.
Case 3 - Click here for Text and References
Submitted by: S. David Hudnall
Clinical Summary:
10 year old male child with a 2cm painless right superior cervical lymph node that has persisted for several months.
Pertinent Laboratory Data:
CBC: hemoglobin 12.7, WBC 6.8, platelets 237 (normal)
Sed rate 14 (normal)
LDH 275 (normal for age)
Case 3 - Slide 1
Case 4 - Click here for Text and References
Submitted by: Wun-Ju Shieh
Clinical Summary:
A 31 years-old female from Kenya arrived in Denver in October 2009 and became ill shortly after her arrival. She was originally from Sudan and went to Kenya as a refugee before coming to the United States. She was admitted to a local hospital in Denver and was diagnosed to have acute leukemia. She underwent chemotherapy treatment and received bone marrow transplant in November 2009. During chemotherapy treatment she became quite hypotensive with cardiac decompensation. On January 24, 2010, approximately 2 months after bone marrow transplant, she was admitted to hospital for hyperglycemia, dehydration, blood in stool, and coagulopathy. After several days of admission, she developed severe intractable cardiac decompensation and died. Autopsy was performed but limited to lung, heart and brain. Gross findings included slightly enlarged heart with pericardial effusion (100-200 cc clear, straw-colored). There was no known animal exposure.
10X - Cystic structures in vessels, perivascular areas, and myocytes, accompanied by foci of hemorrhage, edema, inflammatory infiltrate, and necrosis of myocytes.
20X - Cystic structures in vessels, perivascular areas, and myocytes, accompanied by foci of hemorrhage, edema, inflammatory infiltrate, and necrosis of myocytes.
40X - Foci of inflammation with prominent eosinophils.
63X - High-power views of cystic structure showing small round protozoal organisms (2-3 um) with no kinetoplast.
100X - High-power views of cystic structure showing small round protozoal organisms (2-3 um) with no kinetoplast.
Thin-sectioned EM showing protozoa with a nucleus, conoid with microtubules, micronemes, rough endoplasmic reticulum, mitochondria, and lipid droplet.
Case 5 - Click here for Text and References
Submitted by: Dan A. Milner
Clinical Summary:
A 23 year old female presents with initial headache which progresses to somnolence. Computed tomography of her head demonstrates multiple lesions. A brain biopsy is performed. Her elicited travel history is consistent with the histological diagnosis.
HnE
HnE