Strongyloides papillosus causes sudden death in weaned calves on New York dairies

CASE DESCRIPTION Outbreaks of sudden death in apparently healthy weaned dairy calves due to Strongyloides papillosus parasitism were diagnosed on 2 separate and independent New York (NY) dairies. CLINICAL FINDINGS Most calves were found dead; however, 1 calf observed while dying showed signs of tachycardia, tachypnea, vocalization, and convulsions shortly before death. In 6 affected heifers that underwent post-mortem examination, precocious bilaterally symmetric mammary gland enlargement was seen. A portion of their parasitized living cohorts also demonstrated similar mammary gland enlargement. A diagnosis of S papillosus hyperinfection was made based upon the presence of high numbers of S papillosus ova in feces, and confirmation by S papillosus–specific PCR assays. Consistent histopathological findings in affected calves included generalized mammary gland vascular congestion, interstitial edema and hemorrhage with ductal hyperplasia. Mild multifocal cardiomyocyte degeneration was found in 5 of 14 calves examined. Factors believed to contribute to the parasite’s environmental amplification and host hyperinfection included group housing on wood shavings and high environmental temperatures and humidity. TREATMENT AND OUTCOME Treatment of calves with doramectin pour-on stopped mortality and resolved the udder enlargement. CLINICAL RELEVANCE Similar outbreaks have previously been described in Japan and South Bohemia (Czech Republic), where researchers hypothesized that sudden death may be due to fatal arrhythmia caused by a parasite-associated cardiotoxin. This report highlights the importance of including S papillosus among the differential diagnoses for sudden death alone or together with precocious udder enlargement in calves kept in confinement housing.

Clinical, Radiological and Histopathological Features of Patients With Lacrimal Gland Enlargement

Background: The purpose of this study was to describe the radiologic and histopathologic features of lacrimal gland in patients presenting with lacrimal gland enlargement. Methods: We retrospectively retrieved the data of patients with lacrimal gland enlargement in Farabi Eye Hospital between 2012 and 2017. These data included demographics, the patients’ facial photographs, orbital CT-scans, and histopathological findings of lacrimal gland biopsies. Results: Forty-seven patients (15 men and 32 women) were enrolled in this study with a median age of 37.9 years (range, 15–79 years). Histopathologic diagnoses were chronic dacryoadenitis in 26 cases (55.32%), IgG4-related disease in 6 patients (12.77%), two cases of acute dacryoadenitis, two cases of non-necrotizing granulomatous inflammation, two cases of Non-Hodgkin’s B-cell lymphoma, two cases of adenoid cystic carcinoma and two cases of mixed tumor (4.26% each), as well as one case of conjunctival epithelial cyst, and one case of benign lymphoid tissue and fibrofatty tissue (2.13%). In two samples (4.26%), biopsy revealed normal lacrimal glands. Interestingly, in two cases with relapsing lacrimal gland enlargement, different histopathologic diagnoses were found in biopsies taken from each lacrimal gland at different times. The average size of enlarged lacrimal glands was 19.67 mm × 7.06 mm on axial CT scan and 19.44 mm × 6.20 mm on coronal CT scan. Conclusion: Tissue biopsy is needed for diagnosis of lacrimal gland enlargement because it is difficult to distinguish the type of the lacrimal gland pathology based solely on clinical or radiological presentation.

P27 Lymphoma-mimicker of IgG4-related dacryoadenitis and sialadenitis

Case report - Introduction Major salivary gland (sialadenitis) and lacrimal gland (dacryoadenitis) involvement can be a common feature of IgG4-related disease. There can be involvement of lacrimal and parotid gland which was previously called as Mikulicz disease and/or submandibular gland enlargement which was previously called Küttner tumour. These were previously mistakenly considered to be subcategories of Sjogren’s syndrome, but are now classified as IgG4-related disease. Here we discuss a case report of a patient who presented with bilateral dacryoadenitis and unilateral submandibular gland enlargement which initially was thought to be IgG4-related disease but turned out to be low-grade lymphoma. Case report - Case description A 15-year-old boy presented with 6-month history of bilateral eyelid swelling. The swelling was more on the lateral side of the eyelids and was painless. It had come on suddenly over a couple of days. No history of weight loss, dry eyes, dry mouth, joint issues or skin rashes or any other symptoms. Physical examination revealed bilateral ptosis, no visual impairment and systemic examination revealed an enlarged right submandibular gland. He had initially been to a local hospital where he had investigations which included autoimmune screen including ANA, ENA, ANCA, dsDNA, serum ace and complement levels which were all negative. C1 esterase inhibitor was normal. Routine bloods including complete blood count, urea and electrolytes, thyroid stimulating hormone and erythrocyte sedimentation rate were within normal limits. Urine albumin to creatinine ratio was not raised. Hepatitis serology including Hepatitis B & C and HIV was negative. Ultrasound abdomen was unremarkable. CT scan of orbits showed bilateral enlarged lacrimal glands with patchy post contrast enhancement and the glands extending up to insertion of lateral rectus muscle. CT chest some enlarged axillary lymph nodes and nodes in lung query infective etiology. CT abdomen and pelvis was unremarkable. Ultrasound neck showed right submandibular node enlargement with colour doppler showing increased vascularity. Fine needle aspirate of the submandibular gland showed reactive lymphoid hyperplasia. He was given two short courses of steroids and each time the swelling rapidly responded to the steroids but recurred on cessation of the steroids. IgG subset analyses revealed elevated IgG4 levels of 1152mg/dl. The differential here was IgG4-related disease but as there was no clear tissue diagnosis a core biopsy of the right submandibular gland was done. This revealed tissue suspicious of low grade (extranodal marginal zone and mucosa-associated lymphoid tissue [MALT]) lymphoma and excision biopsy was performed for definitive diagnosis. Case report - Discussion IgG4-related disease is an immune mediated fibroinflammatory condition which can affect a variety of organs and can present as tumour-like enlargement and/or organ dysfunction. The pathological findings in IgG4-related disease are lymphoplasmocytic infiltrates of IgG4-positive cells along with increased levels of serum IgG4 levels. Salivary and lacrimal glands can be commonly affected and present as enlargement, which is usually painless and bilateral. The combination of lacrimal gland enlargement with both parotid and submandibular gland enlargement is called IgG4-related Mikulicz disease. Apart from salivary glands, another commonly affected organ is the pancreas which can present as a pancreatic mass and painless jaundice, sclerosing cholangitis, retroperitoneal fibrosis, aortitis and periaortitis. Less commonly it can affect thyroid, kidney and lungs. Early recognition, diagnoses and treatment is important due to the fibroinflammatory nature of the disease. Malignancy is always in the differential and should be excluded. Steroids are the mainstay of treatment. If patients experience flare, rituximab can be added. Diagnosis should be confirmed with biopsy but histopathological findings are never alone diagnostic of IgG4-related disease and should be interpreted with clinical, serological and radiological findings. Case report - Key learning points Although this patient had typical presentation of IgG4-related disease with painless enlargement of salivary and lacrimal glands and elevated IgG4 serum levels, biopsy was imperative to get to the diagnoses of low-grade lymphoma and fine needle aspirate was not adequate. As mentioned above, biopsy in IgG4-related disease will confirm the diagnosis provided there are other supporting features (radiological and serological). However, it is imperative for excluding other important diseases like lymphoproliferative disorders.

Bilateral parotid gland enlargement as a presenting manifestation of relapsed pediatric acute myeloid leukemia

Parotid gland involvement is a rare presentation of Acute Myeloid Leukemia (AML). We report a 10-year-old girl of acute myelomonocytic leukemia with normal cytogenetics and positivity for inversion 16, who after completion of first consolidation of the BFM 2004 AML protocol, presented with bilateral parotid gland enlargement. Bone marrow examination was suggestive of a relapse. Fine needle aspiration of the parotid gland showed presence of myeloblasts. Patient was given FLAG-IDA chemotherapy, with which the parotid swellings rapidly regressed and she achieved a remission and was planned for allogenic bone marrow transplantation. Acute myelomonocytic and monoblastic leukemias are known to be associated with tissue infiltration. However, exocrine gland involvement such as parotid enlargement is rare and is associated with a poor prognosis as was seen in our patient who despite having inversion 16 positivity had poor disease outcome. Keywords: acute myeloid leukemia; parotid gland enlargement; granulocytic sarcoma.

Malignancies in Immunoglobulin G4-Related Ophthalmic Disease

Purpose: Clinical phenotypes in Immunoglobulin G4-related disease (IgG4-RD) according to the affected organs affected have different risks of malignancies. We attempt to determine the association of malignances with IgG4-related ophthalmic disease (IgG4-ROD). Design: Retrospective cohort study. Methods: Review of medical records, orbital images and histopathology reports in a territory-wide cohort of patients fulfilling the “probable” or “definite” comprehensive diagnostic criteria of IgG4-RD from 2005-2019. Findings: Among 122 patients who had biopsies taken from adnexal lesions including lacrimal glands (n=108), orbital mass (n=30), infiltrated orbital fat (n=10), conjunctiva (n=2) or extraocular muscles (n=3), 16 (13%) developed malignancies over 73±48months’ follow-up. There were 9 cases of ocular adnexal lymphoma (OAL) and 7 extra-orbital malignancies. Compared with the general population, the incidence of OAL was significantly higher (standardized incidence ratios, SIRs=10.0, 95%CI=4.5-17.6) while that of extraorbital malignancy was similar. The SIR was highest within the first year (SIR=46.7, 95%CI=18.5-87.6) when 7 OAL were concomitantly diagnosed. Patients who developed OAL or extra-orbital malignancies were older than other patients when diagnosed of IgG4-ROD (64.9±7.1, 68.3±8.5 versus 55.2±15.0 years, p<0.05). Asymmetric lacrimal gland enlargement (78% versus 13%), lack of frontal (0% versus 12%) or infraorbital nerve enlargement (0% versus 36%)were associated with OAL (all p<0.05). Pre-treatment serum IgG4 level or pattern of extraorbital involvement was similar among patients with or without malignancies. Conclusion: In this biopsy-proven IgG4-ROD cohort, 7% developed OAL which was 10 times higher than the general population. Patients with asymmetric lacrimal gland enlargement or without trigeminal nerves involvement radiologically were associated with OAL.

Immunoglobulin G4 related disease: an overview

Immunoglobulin G4 related disease (IgG4-RD) is a recently perceived fibroinflammatory condition, identified as a systemic illness for the first time in the early 2000. It can involve virtually every organ of the body, commonly presenting as lymphadenopathy, retroperitoneal fibrosis, autoimmune pancreatitis, tubulointerstitial nephritis, parotid or lacrimal gland enlargement. The diagnosis is confirmed by histopathological analysis and is often, but not always accompanied by an increased level of serum IgG4 concentration. In fact, the name addressing this autoimmune fibroinflammatory condition may be considered a misnomer, as the role of the non-inflammatory immunoglobulin IgG4 in the immune mechanism of IgG4-RD remains to be elucidated. Ibrahim Med. Coll. J. 2021; 15(2): 44-51

Cytomorphological Profile of Thyroid Lesions on Fine Needle Aspiration Cytology

Background and Objectives: Fine needle aspiration cytology (FNAC) of thyroid offers an alternative, as an immediate, preliminary procedure associated with low cost, little trauma and complications. Being superficial and easily accessible it is an ideal organ for FNAC. It is useful in diagnosis of inflammatory, infectious and neoplastic conditions. The aim of this study was to evaluate the cytomorphological profile of thyroid lesions on FNAC with application of Bethesda system for reporting and perform cyto-histopathology correlation whenever possible with regards to age and sex distribution. Methodology: This two-year prospective study was conducted in the Cytology section of Pathology Department & included 243 cases of thyroid gland enlargement. The detailed history of the patient including age, sex, presenting symptoms and duration of thyroid gland enlargement along with any other significant findings was note. FNAC was performed as per the protocol using a 23-gauge needle and smears stained using Haematoxylin & Eosin (H&E) and Papanicolaou stain, while air-dried smears were stained with Giemsa stain. Results: The study period included a total of 243 FNACs of thyroid enlargement. The age of patients ranged from 10 to 80 years with male to female ratio of 1.4. The diagnosis on FNAC was as follows Colloid Goitre (54.7 %), Lymphocytic Thyroiditis (9.54%), Follicular Neoplasm (7.05%), Hashimoto Thyroiditis (5.80 %), Benign Thyroid Lesions (3.31%) and Multinodular Goitre (2.90%). Conclusion: Thyroid fine needle aspiration cytology has proven to be a first line tool to evaluate the thyroid lesions because of its cost effectiveness and high patient acceptance. Fine needle aspiration cytology is highly successful in triaging patients with thyroid nodules into operative and non-operative groups and enables surgeons to take an early decision regarding mode of treatment. The Bethesda system for reporting of thyroid lesions aims at standardization of reports. It makes the cytology report unambiguous and clinically relevant. Keywords: Fine needle aspiration cytology, thyroid lesions.