Acquired nasolacrimal duct obstruction: clinical and histological findings of 275 cases

Background Acquired nasolacrimal duct obstruction is a blockage of the lacrimal outflow system usually caused by local nonspecific inflammation of the lacrimal sac and the nasolacrimal duct. However, cases exist where the primary nasolacrimal system obstruction is caused by malignancies. Our aim was to investigate lacrimal sac pathologies in patients with acquired nasolacrimal duct obstruction and compare their clinical manifestations. Methods This retrospective clinical study included 275 patients with acquired nasolacrimal duct obstruction who underwent external dacryocystorhinostomy and lacrimal sac biopsy. Cases were classified into tumor or nonspecific pathology groups and subdivided according to the level of inflammation. Histological and clinical data were analyzed. Results Three tumors (1.1%) (an adenoid cystic carcinoma, an eccrine spiradenoma and small B cell lymphoma) were diagnosed. Chronic nongranulomatous inflammation was the most common histological finding, corresponding to 194 cases (70.5%). The other 81 (29.5%) were subacute, acute forms of nongranulomatous inflammation, tumors and fibrosis cases. Epiphora with continuous purulent discharge was the most common clinical sign reported by 144 (52.4%) patients, and two (0.7%) patients had a palpable mass near the medial canthal tendon, which was identified as an eccrine spiradenoma and small B cell lymphoma. There was no significant difference in the clinical symptoms, duration or case history between the nonspecific pathology and tumor groups (p = 0.292). Conclusions Chronic nongranulomatous inflammation of the lacrimal sac was the most common finding among acquired nasolacrimal duct obstruction cases. There were no associations between the histological findings and clinical presentation. The authors recommend a lacrimal sac biopsy only in cases when a tumor is clinically suspected.

Penile porokeratosis mimicking annular lichen planus

Sir, Porokeratosis is a group of cutaneous diseases presented by epidermal keratinization [1]. Herein, we report the case of a patient with porokeratosis who responded well to carbon dioxide (CO2) laser therapy. A 22-year-old Vietnamese male visited our department with an asymptomatic plaque on the penis present for three months. He denied a family history of similar lesions. A cutaneous examination of the penis revealed an annular, well-circumscribed plaque with slightly raised borders with scales (Fig. 1a). Other mucocutaneous lesions were absent. Fungal microscopy, a rapid plasma reagin (RPR) test, and a Treponema pallidum hemagglutination (TPHA) test were negative. Histological findings revealed a hyperkeratotic lesion with a discrete parakeratotic column. There was the presence of a cornoid lamella, which was a parakeratotic column overlying a small vertical zone of dyskeratotic and vacuolated cells within the epidermis (Fig. 2a). There was also a focal loss of the granular layer. A mild lymphocytic infiltrate could be seen around an increased number of capillaries in the underlying dermis (Fig. 2b). CO2 laser removal was performed. There was no recurrence after a twelve-month follow-up (Fig. 1b). However, a hypopigmented scar was seen. Porokeratosis is an uncommon disorder of keratinization with clinical variants, such as classical porokeratosis of Mibelli, disseminated superficial actinic porokeratosis, linear porokeratosis, and porokeratosis palmaris et plantaris disseminata [2]. Porokeratosis involving the genital areas and other adjacent sites is rare [2]. Genital porokeratosis was first described by Helfman in 1985 [3]. More than 69 cases have been reported in the literature [1]. The pathophysiology of genital porokeratosis remains unknown. It has been supposed that porokeratosis is linked to repeated minor frictional trauma. A benign lesion may transform into squamous cell carcinoma or basal cell carcinoma [4]. However, no malignant transformation of genital porokeratosis has been noted in the literature. Genital porokeratosis manifests itself clinically as classic or plaque-type porokeratosis of Mibelli [2]. Histological findings revealed a cornoid lamella with the absence of a granular layer and dyskeratotic cells in the upper spinous zone [2]. Our case may mimic some annular lesions, such as secondary syphilis, fungal infection, and annular lichen planus. Because a fungal examination and syphilis serology were negative, we could exclude fungal infection and annular secondary syphilis. The distinctive histology of porokeratosis such as a cornoid lamella with a decreased granular layer may help to differentiate between porokeratosis and annular lichen planus [4]. Numerous therapeutic methods of treatment exist, including surgical excision, CO2 laser, cryotherapy, topical retinoids, 5% 5-fluorouracil, vitamin D3 analogs, imiquimod cream, and 3% diclofenac gel [2,5].

Something new about prognostic factors for lupus nephritis? A systematic review

Background Lupus nephritis (LN) affects 30–45% of patients with systemic lupus erythematosus (SLE) and causes great morbidity and mortality. About 10–25% of patients will develop chronic kidney disease (CKD), and it has been described a mortality of 10–20% at 10 years. The contribution of clinical and biological markers to the prediction of outcome is unclear. Objective To describe the factors, with measures of association, that predict the main outcomes of LN. Material and Methods We have conducted a systematic review. Medline, Embase, and Cochrane Library were systematic searched from inception up to Oct 2019, with a strategy that included synonyms of all targeted outcomes of LN: (kidney failure, response to treatment, cardiovascular events, and mortality). Only studies with longitudinal prospective design or with warranties of unbiased recollection of the prognostic factors, where LN was confirmed by biopsy were included. Risk of bias was assessed with the New Castle Ottawa scale. Predictive factors and their effect measures were collected from each study. Results From 1221 studies identified, 25 studies were included, of which 15 were retrospective, nine prospective, and one was a trial extension study (range from 3 months to 11 years). The main predictive factors of renal response were serum creatinine (SCr) and glomerular filtration rate C3 levels, titer of anti-C1q, and anti-dsDNA antibodies. Renal histological findings such as class type (IV or V), tubulointerstitial or vascular lesions and chronicity index were risk factors for development of chronic kidney disease. The factors associated with persistence of activity were proteinuria, anti-dsDNA, anticardiolipin, anti C1q antibodies, and complement values. The factors associated to cardiovascular events and mortality were age, smoking, amount of proteinuria, and histological findings, such as vascular lesions. Meta-analysis was precluded given the heterogeneity of designs definitions and effect measures. Conclusions Nowadays, we do not have new biomarkers that establish the renal prognosis of patients with LN. Classical clinical, renal, and histological markers are used in most studies. It is worth noting the heterogeneity of studies in the definition of renal outcomes, which complicates risk stratification in these patients.

PILOMATRIXOMA OF FACE PRESENTING AS PAROTID SWELLING

Pilomatrixoma, also known as pilomatrixoma or calcifying epithelioma of Malherbe, is a benign tumor of skin appendages. Although it is an uncommon and benign neoplasm of the head and neck region, it may sometimes become malignant. It arises from the cells of the outer sheath of the hair follicle root. Owing to its rarity, pilomatrixoma can be missed during differential diagnosis, and it can be misdiagnosed as malignancy. Therefore, for definitive and confirmatory diagnosis, histopathological analysis is imperative. We report a case of a 26-year-old female who presented with hard swelling on the right side of her face near the angle of the mandible. We have discussed its clinical, radiological, and histological findings and reflected light on the treatment of choice for pilomatrixoma.

P-BN38 Patient Outcomes Following Laparoscopic Cholecystectomy after a Diagnosis of Gall Bladder (GB) Polyp over 10 Years

Background Gall Bladder (GB) polyps are elevations of the GB wall that project into the lumen. They are a rare incidental radiological finding with prevalence of 0.3% to 9.5%. Although the majority of these may be pseudopolyps correct follow up and management is essential as to ensure that true polyps, which may be malignant or have malignant potential, are not missed. We conducted a retrospective study assessing patient factors that may predispose to the finding of true polyps. Patient outcomes including histological findings as well as ongoing symptoms and further investigations or emergency attendances were also assessed. Methods Patients were identified for this retrospective ten year cohort study using International Statistical Classification of Diseases and Related Health Problems (ICD 10) code K 82.8, other specified diseases of gall bladder. Patients with other diagnoses such as gall bladder dysfunction were excluded after review of electronic patient record (EPR) (Sunrise, Allscripts). EPR allowed for review of emergency attendances, clinic letters, investigations and histological results for those diagnosed with a gall bladder polyp. Analysis was performed with Microsoft Excel. Results 35% patients had a laparoscopic cholecystectomy and the average wait time for surgery was 19 months but only 11% of patients were found to have true GB polyps on histology. Other histological findings included chronic cholecystitis (96%), cholesterolsis (33%) and stones 35%. Only 12% of those booked straight to laparoscopic cholecystectomy re-presented post operatively compared to 37% of those operated on after a period of surveillance. Patients booked straight for laparoscopic cholecystectomy, or diagnosed with polyps >10mm in size, were statistically more likely to have a true GB polyp (P < 0.05), however, gender, ethnicity, and whether an isolated polyp or multiple were diagnosed made no statistical difference to detection of a true polyp (P > 0.05). Conclusions From this series of patients true polyps are most likely to be identified if it is larger than 10mm at diagnosis and operated on straight away. 96% of all patients, however, displayed histological features of chronic cholecystitis. This suggests that proceeding to laparoscopic cholecystectomy straight from diagnosis of a GB polyp can be justified. Only 1patient in our cohort returned normal GB histology.. Following diagnosis of a GB polyp, the option of operation versus surveillance should be discussed wirth individual patients and decisions based on assessment of risks and benefits should be made. Further research will help identify those with a predisposition to high-risk true polyps.

Ectopic Pregnancy Diagnosed Post Caesarean Surgery in a Three Year Old Boerboel Bitch

A three year old nulliparous Boerboel bitch presented with complaints of fever and inappetence six weeks after an elective caesarean section was diagnosed with an extrauterine foetus. A per-cutaneous abdominal ultrasound revealed a foetal sac showing a well-developed skeletal structure and the absence of foetal movement or heartbeat. During laparotomy, a foetal sac containing a dead foetus was located between the spleen and the stomach. The foetal sac was excised following ligation of its mesenteric attachment to the spleen. The previously operated uterus was observed to have involuted but revealed a small bud observed on the middle portion of the left uterine horn. The histological findings of the foetal sac revealed fibro-adipose tissue with numerous congested vessels. It was concluded that the Boerboel bitch had a secondary abdominal ectopic pregnancy and recommended that owing to the difficulty of diagnosing the condition before or during routine elective caesarean surgery, post-operative abdominal ultrasound would have been instructive.