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Primary tuberculosis of thyroid: a rare case report
ABSTRACTS
PRIMARY MALIGNANT MELANOMA OF THE OESOPHAGUS: A CASE STUDY AND LITERATURE REVIEW Melisa Vazquez, Khashayar Asadi, Julie Lokan Department of Anatomical Pathology, Austin Pathology, Vic, Australia Primary malignant melanoma of the oesophagus is a very rare, aggressive tumour with high metastatic potential and a poor prognosis. Patients typically present with dysphagia and a soft, pedunculated and often pigmented, exophytic lesion on endoscopy. However, there is a spectrum of presenting features which often present a diagnostic challenge, for both clinician and pathologist. A lack of specific staging criteria and no well-defined management guidelines add to the challenges. In this case study, we describe a single case from our institution, including clinical presentation and histopathological findings. We also explore the literature with regard to typical diagnostic features, molecular biology, treatment modalities and patient outcomes. PRIMARY TUBERCULOSIS OF THYROID: A RARE CASE REPORT Seema Veerappa, Deepak Kumar, Srinivasa V. Murthy Department of Pathology, ESIC MC PGIMSR, Bangalore, India Case report: The thyroid gland is rarely affected by tuberculosis. Incidence of tuberculosis of the thyroid is 0.1–0.4%. We present a case of a 43-year-old male with painless swelling over the front of neck with history of loss of weight. On local examination swelling was soft to firm, measuring 2×2 cm and moved with deglutition. Clinical diagnosis of colloid goitre was made. The patient’s complete blood picture, thyroid function test, and chest X-ray were normal. USG showed a hypoechoic lesion in the left lobe of the thyroid. On FNAC, 1 mL pus-like material yielded, which on microscopy showed caseous necrosis, with epithelioid cells, lymphocytes, histiocytes, plasma cells and occasional thyroid follicular cells. ZN stain for acid fast bacilli was positive. A diagnosis of granulomatous thyroiditis of Koch’s aetiology was made. Primary tuberculosis of thyroid was first diagnosed by Bruns in 1893, in a middle-aged woman with enlarged gland with no evidence of primary pulmonary tuberculosis. The reasons for reactive immunity of the thyroid for tuberculosis may be explained as bactericidal attribute of colloid in gland, extensive vascularity, high iodine content, and intact capsule of thyroid. Thyroid tuberculosis should always be considered as a differential diagnosis during assessment of a midline cervical mass, as preoperative diagnosis can avoid unnecessary surgery. References Mondal A, Patra DK. Efficacy of fine needle aspiration cytology in the diagnosis of tuberculosis of the thyroid gland: a study of 18 cases. J Laryngol Otol 1995; 109; 36–8. Sharma B, Kumar LD, Sharma HD, et al. Primary tuberculosis of thyroid gland – a rarity. JIACM 2006; 7: 363–4. Balasarkar D, Joshi MA, Dhareswar J, et al. Primary thyroid tuberculosis. Bombay Hospital J 1999; 41: 2.
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BREATHING COLOURS OF THE RAINBOW – YELLOW CRYSTALS IN PLEURAL FLUID Danielle Vignati, Madeline Lising, Irene Low Histopathology Department, Middlemore Hospital, Auckland, New Zealand Unilateral pleural effusions are frequently associated with malignancies, and pleural aspirate cytology is an invaluable tool in identifying malignant cells in this setting. In cases where malignancy has been excluded, careful examination of the cytologic preparations can sometimes yield important clues to the underlying cause of recurrent effusions. This case study reports the presence of distinctive yellow extracellular crystals in a unilateral pleural aspirate from a 40-year-old male, with recurrent abdominal pain but no other concerning symptoms of malignancy. Subsequent to the cytology findings, the patient underwent further imaging investigations, which identified a large pancreatic pseudocyst that has formed a pancreatico-pleural fistula. A variety of intracellular and extracellular pigment has been reported on pleural fluid cytology, including anthracotic pigment, hemosiderin, melanin, and iodine. To the best of our knowledge, this is the first reported case of extracellular bilirubin crystals being identified in a pleural fluid sample, even though pleural effusions are a known, albeit rare, complication of pancreatic pseudocysts. In this case, the unusual cytology finding was able to direct clinical investigations, which led to appropriate surgical management for this patient. CONCURRENT DIAGNOSIS OF PLASMABLASTIC LYMPHOMA AND SMALL LYMPHOCYTIC LYMPHOMA: RICHTER TRANSFORMATION OR COMPOSITE LYMPHOMA? Lisa Wilkinson1,2, Simone Birch1 1 Pathology Queensland, Princess Alexandra Hospital, and 2 School of Medicine, University of Queensland, Qld, Australia Richter syndrome is the transformation of chronic lymphoid leukaemia (CLL)/small lymphocytic lymphoma (SLL) to an aggressive lymphoma. This most commonly involves a diffuse large B cell lymphoma and less commonly classical Hodgkin lymphoma. Other rare entities have been reported including prolymphocytic lymphoma, dendritic cell sarcoma and plasmablastic lymphoma. We describe a case of plasmablastic lymphoma and small lymphocytic lymphoma in the same lymph node in a 69-year-old patient who had no known previous diagnosis of CLL/SLL. The patient presented with weight loss and dyspnoea associated with bilateral pleural effusions. Radiology revealed widespread lymphadenopathy, extensive thoracic and abdominal disease, and skeletal involvement. Pleural fluid cytology showed a malignant lymphoid effusion. A left supraclavicular lymph node excision was performed. Flow cytometry showed a lambda light chain restricted population of B cells positive for CD20 (weak), CD19, CD5 (weak) and CD23. Histology of the lymph node revealed plasmablastic lymphoma with a rim of residual CLL/ SLL. We report a rare presentation of Richter transformation to plasmablastic lymphoma diagnosed concurrently with SLL/CLL and discuss the histology.
PRIMARY MALIGNANT MELANOMA OF THE OESOPHAGUS: A CASE STUDY AND LITERATURE REVIEW Melisa Vazquez, Khashayar Asadi, Julie Lokan Department of Anatomical Pathology, Austin Pathology, Vic, Australia Primary malignant melanoma of the oesophagus is a very rare, aggressive tumour with high metastatic potential and a poor prognosis. Patients typically present with dysphagia and a soft, pedunculated and often pigmented, exophytic lesion on endoscopy. However, there is a spectrum of presenting features which often present a diagnostic challenge, for both clinician and pathologist. A lack of specific staging criteria and no well-defined management guidelines add to the challenges. In this case study, we describe a single case from our institution, including clinical presentation and histopathological findings. We also explore the literature with regard to typical diagnostic features, molecular biology, treatment modalities and patient outcomes. PRIMARY TUBERCULOSIS OF THYROID: A RARE CASE REPORT Seema Veerappa, Deepak Kumar, Srinivasa V. Murthy Department of Pathology, ESIC MC PGIMSR, Bangalore, India Case report: The thyroid gland is rarely affected by tuberculosis. Incidence of tuberculosis of the thyroid is 0.1–0.4%. We present a case of a 43-year-old male with painless swelling over the front of neck with history of loss of weight. On local examination swelling was soft to firm, measuring 2×2 cm and moved with deglutition. Clinical diagnosis of colloid goitre was made. The patient’s complete blood picture, thyroid function test, and chest X-ray were normal. USG showed a hypoechoic lesion in the left lobe of the thyroid. On FNAC, 1 mL pus-like material yielded, which on microscopy showed caseous necrosis, with epithelioid cells, lymphocytes, histiocytes, plasma cells and occasional thyroid follicular cells. ZN stain for acid fast bacilli was positive. A diagnosis of granulomatous thyroiditis of Koch’s aetiology was made. Primary tuberculosis of thyroid was first diagnosed by Bruns in 1893, in a middle-aged woman with enlarged gland with no evidence of primary pulmonary tuberculosis. The reasons for reactive immunity of the thyroid for tuberculosis may be explained as bactericidal attribute of colloid in gland, extensive vascularity, high iodine content, and intact capsule of thyroid. Thyroid tuberculosis should always be considered as a differential diagnosis during assessment of a midline cervical mass, as preoperative diagnosis can avoid unnecessary surgery. References Mondal A, Patra DK. Efficacy of fine needle aspiration cytology in the diagnosis of tuberculosis of the thyroid gland: a study of 18 cases. J Laryngol Otol 1995; 109; 36–8. Sharma B, Kumar LD, Sharma HD, et al. Primary tuberculosis of thyroid gland – a rarity. JIACM 2006; 7: 363–4. Balasarkar D, Joshi MA, Dhareswar J, et al. Primary thyroid tuberculosis. Bombay Hospital J 1999; 41: 2.
S91
BREATHING COLOURS OF THE RAINBOW – YELLOW CRYSTALS IN PLEURAL FLUID Danielle Vignati, Madeline Lising, Irene Low Histopathology Department, Middlemore Hospital, Auckland, New Zealand Unilateral pleural effusions are frequently associated with malignancies, and pleural aspirate cytology is an invaluable tool in identifying malignant cells in this setting. In cases where malignancy has been excluded, careful examination of the cytologic preparations can sometimes yield important clues to the underlying cause of recurrent effusions. This case study reports the presence of distinctive yellow extracellular crystals in a unilateral pleural aspirate from a 40-year-old male, with recurrent abdominal pain but no other concerning symptoms of malignancy. Subsequent to the cytology findings, the patient underwent further imaging investigations, which identified a large pancreatic pseudocyst that has formed a pancreatico-pleural fistula. A variety of intracellular and extracellular pigment has been reported on pleural fluid cytology, including anthracotic pigment, hemosiderin, melanin, and iodine. To the best of our knowledge, this is the first reported case of extracellular bilirubin crystals being identified in a pleural fluid sample, even though pleural effusions are a known, albeit rare, complication of pancreatic pseudocysts. In this case, the unusual cytology finding was able to direct clinical investigations, which led to appropriate surgical management for this patient. CONCURRENT DIAGNOSIS OF PLASMABLASTIC LYMPHOMA AND SMALL LYMPHOCYTIC LYMPHOMA: RICHTER TRANSFORMATION OR COMPOSITE LYMPHOMA? Lisa Wilkinson1,2, Simone Birch1 1 Pathology Queensland, Princess Alexandra Hospital, and 2 School of Medicine, University of Queensland, Qld, Australia Richter syndrome is the transformation of chronic lymphoid leukaemia (CLL)/small lymphocytic lymphoma (SLL) to an aggressive lymphoma. This most commonly involves a diffuse large B cell lymphoma and less commonly classical Hodgkin lymphoma. Other rare entities have been reported including prolymphocytic lymphoma, dendritic cell sarcoma and plasmablastic lymphoma. We describe a case of plasmablastic lymphoma and small lymphocytic lymphoma in the same lymph node in a 69-year-old patient who had no known previous diagnosis of CLL/SLL. The patient presented with weight loss and dyspnoea associated with bilateral pleural effusions. Radiology revealed widespread lymphadenopathy, extensive thoracic and abdominal disease, and skeletal involvement. Pleural fluid cytology showed a malignant lymphoid effusion. A left supraclavicular lymph node excision was performed. Flow cytometry showed a lambda light chain restricted population of B cells positive for CD20 (weak), CD19, CD5 (weak) and CD23. Histology of the lymph node revealed plasmablastic lymphoma with a rim of residual CLL/ SLL. We report a rare presentation of Richter transformation to plasmablastic lymphoma diagnosed concurrently with SLL/CLL and discuss the histology.