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Professor, Consultant Pathologist, American Board Certified Pathologist, Fellow College of American Pathologists. Areas of interest Fine Needle Aspiration Cytology, Cytology, Cancer, Ethics, Islam, Humanity

Editorial: Paperless Examinations

Anwar Ul Haque

Department of Pathology, AJK Medical College, Muzaffarabad, Azad Kashmir, Pakistan

Editorial

Examinations constitute fundamental integrated element of education and training programs. They not only measure the competency of the candidates but also serve as potent stimulant for better training and learning. If they are defective they may produce catastrophic results. Traditional paper examinations have several serious problems that had led to their replacement with paperless examinations in many developed countries. US examinations for example Step 1, 2 (Ex ECFMG paper exams) are in vogue for some years. Thousands of medical graduates take these examinations across the world to qualify to enter in accredited residency programs in USA. Time has proven their validity.

OA The Toxic Effects of Cyclosporine on Splenic Tissue of Rat and it’s Amelioration with Nigella Sativa

Nadia Younus, Kishwar Sultana and Asma Basharat Ali
Department of Anatomy; Baqai Medical University, Karachi, Pakistan
ABSTRACT

Background: Cyclosporine is an immunosuppressive drug. Its mechanism of action is inhibition of T cells activation. Cyclosporine has toxic effects on many organs including spleen. Nigella sativa is an immunomodulatory agent. It increases lymphocyte population and also has promising anti-oxidative effects. Objective: Observe the toxicity of cyclosporine and evaluate the ameliorative effects of Nigella Sativa in spleen

Material and Methods: This study was conducted in Baqai Medical University from November 2016 to December 2016. Sprague Dawley rats were randomly divided into three groups. Group A was control, group B was given oral cyclosporine only and group C was given cyclosporine with Nigella sativa. At the end of study period animals were sacrificed and spleen was harvested.

Results: Body weight of cyclosporine group B was decreased significantly (P<0.001) in comparison to control A and increased in Nigella sativa and cyclosporine group C. Absolute and relative spleen weights were also decreased in cyclosporine group B and increased in Nigella sativa and cyclosporine group C. Morphometric examination of splenic tissue showed thickened capsule, congested red pulp, reduced white pulp and hyalinosis and vacuolization in central artery in cyclosporine group B while these features were reduced in Nigella sativa and cyclosporine group C.

Conclusion: Cyclosporine caused toxicity in spleen while Nigella sativa was helpful in ameliorated these effects.

Keywords: Cyclosporine, Nigella Sativa, Spleen, morphometric Study, arterial vacuolization, Arterial hyalinosis

OA Intracranial Tuberculomas Presenting Symptoms and Outcome with Anti Tuberculous Drugs

Ehtisham Ahmed Khan Afridi*, Shabana Naz**, Baynazir Khan*, Shagufta Naeem**, Raisa Naz, Sajid Nazir Bhatti*, Saad Sultan and Sajid Hussain

Departments of *Neurosurgery and **Pathology Ayub Teaching Hospital Abbottabad

 

ABSTRACT

Background: Tuberculosis is still common in developing countries, and sometimes involves central nervous system, proper diagnosis and early treatment effectively reduces the mortality and morbidity associated with this disease

Objective: Observe presenting symptoms and outcome on anti-tuberculosis drug treatment

Material and Methods: This prospective study was conducted in the Department of Neurosurgery in collaboration with Department of Pathology, Ayub Teaching Hospital Abbottabad from March 2010 to December 2016. 22 patients; 8 females and 14 males were studied for their signs & symptoms and outcome after anti- tuberculosis drug treatment.

Results: The most common location of tuberculous lesions was supratentorium (81%) particularly in parietal lobe (50%) followed by frontal lobe (22.7%) and occipital lobe (18.2%). 45% patients had prior history of tuberculosis. Headache was the predominant complaint (72.7%) followed by altered sensorium (31%), seizures (27.3%) and cranial nerve palsies (22.7%). After 12 months of anti-tuberculosis treatment ATT, about 87% of patients had either resolved or regressed tuberculoma.

Conclusion: Brain tuberculomas are benign lesions with” malignant” behavior. Early diagnosis and anti- tuberculosis drug treatment can effectively treat this lesion forever. So in developing countries like Pakistan, when there is cystic, nodular or multiple lesions, there should be suspicion for brain tuberculoma and work up should be done because of very good prognosis associated with anti-tuberculosis drug treatment.

Keywords: Intracranial Tuberculoma, Anti-tuberculosis Drug Treatment, Brain space occupying lesion

OA Epidemiological Profile of Dengue Fever Cases in Azad Jammu & Kashmir, Pakistan 2016

Syed Nadeem-ur-Rehman1, Uzma Hafeez2, Tamkeen Ghafoor3 and Jawad Asghar Rana4 1Directorate General Health, Muzaffarabad, Azad Jammu & Kashmir, 2Assistant Professor, Department of Community Medicine, AJK Medical College, Muzaffarabad, Azad Jammu & Kashmir, 3Faculty FELTP-Pakistan, National Institute of

Health, Islamabad, 4Resident Advisor CDC, FELTP-Pakistan

ABSTRACT

Background: The first outbreak of Dengue fever was reported in State of Azad Jammu & Kashmir (AJ&K) in 2016.

Objective: This study was carried out to assess the magnitude of dengue fever and its description with respect to socio demographic and clinical characteristics during 2016 in AJ& K.

Methodology: This descriptive study was carried out on secondary data received at the Directorate of Communicable Diseases Control (CDC) Muzaffarabad. A case was defined as “any resident of state of AJ&K, presenting with fever and having any two of the symptoms; Headache, retro-orbital pain, myalgia, arthralgia, nausea, vomiting, abdominal pain and bleeding, and found positive on screening with Immune chromatographic IgM/IgG rapid test or NS1Ag from 1st January 2016 to 31st December, 2016”. Data was analyzed by person place and time and frequencies proportions and rates were calculated.

Results: A total of 388 cases were recorded in which 61.85% (n=240) were males. Majority of the cases (98.7%) were reported from district Muzaffarabad. The median age of cases was 30 years (range 4-72 yrs). Majority of cases (78%) were below 40 years. The attack rate was heigiest in age group 20-29 years(25/100,000 population) The Epi-curve showed that index case was reported on 21st August 2016.Multiple peaks were noted thereafter & epidemic subsided in November 2016. Fever was associated with headache (90%), myalgia (86%), retro-orbital pain (60%), nausea (51%) vomiting (45%) abdominal pain (38%) arthralgia (35%) and rash (20%) of the cases. Diagnosis was made on NS1 in 30% & IgM serology in 70% of the cases. Mortality rate was zero and recovery rate was 100%.

Conclusions: Majority of cases were males below 40 years. Headache, retro-orbital pain and myalgia were commonly associated symptom with fever in dengue patients and all cases recovered fully with treatment. Dengue surveillance and community awareness regarding its prevention are keys to keep it under control in AJ&K.

Keywords: Vector Borne, Dengue Profile, AJ&K

OA Cyclin-D1 Utility in Classification of Endometrial Stromal Sarcomas and Segregation from other Uterine Sarcomas

Kanwal Zahra, Ahmareen Khalid, Shaista Khurshid ,Ghazal Zafar and Ashok Kumar Tanwani

Department of Pathology, Pakistan Institute of Medical Sciences, Islamabad

 

ABSTRACT

Context: Endometrial stromal sarcomas (ESSs) are rare mesenchymal tumors of uterus which accounts for less than 10% of all uterine sarcomas. Gene rearrangement studies unveil their genetic heterogeneity with the discovery of specific YWHAE-FAM22 gene fusion. According to recent WHO classification of endometrial stromal tumors all Endometrial stromal sarcomas with this fusion are labeled as high grade-Endometrial Stromal Sarcomas (HG-ESS). Immunohistochemically HG-ESSs with YWHAE- FAM22 translocation express nuclear Cyclin D1 positivity which can be used as a surrogate immunohistochemical marker for this translocation.

Objective: Determine diagnostic utility of Cyclin D1 as a marker to segregate high grade- Endometrial Stromal Sarcomas (HG-ESS) from low grade-Endometrial Stromal Sarcomas (LG-ESS) and undifferentiated uterine sarcoma (UUS) and from other uterine sarcomas including leiomyosarcomas and carcinosrcomas.

Materials and Methods: Cases of Endometrial stromal sarcomas, leiomyosarcomas and carcinosarcomas received from Jan 2010- Jan 2015 were reviewed and immunostained with Cyclin D1, CD-10, ER, PR and Desmin. Nuclear positive or negative staining for Cyclin D1 was noted.

Results: Total 36 cases of uterine sarcomas including 10 cases of ESS, 20 cases of leiomyosrcoma and 6 cases of carcinosarcoma were retrieved from surgical database. Out of ten cases of endometrial stromal sarcomas, five were low grade, two were high grade and three were undifferentiated sarcomas. Cyclin D1 was expressed in three cases previously diagnosed as low grade, high grade and undifferentiated sarcomas respectively. Cyclin D1 positive undifferentiated uterine sarcoma (UUS) also revealed diffuse CD-10 positivity. Other two cases with a positive Cyclin D1 expression revealed a patchy CD-10 positivity. Negative expression of Cyclin D1 was noted in all cases of leiomyosrcoma and carcinosarcoma.

Conclusions: Endometrial stromal sarcomas are relatively uncommon tumors and can pose diagnostic problems for pathologists. Smooth muscle tumors (leiomysrcomas) and carcinosarcomas are among the top differentials. Final diagnosis usually requires immunohistochemistochemical analysis with a panel of immunomarkers. Cyclin D1 expression along with patchy CD-10 positivity favors HG-ESS over LG-ESS and UUS. Cyclin D1 positivity along with diffuse CD-10 expression favors Undifferentiated Uterine Sarcoma. Negative expression in other uterine sarcomas makes it a specific marker for ESSs. It is suggested that Cyclin D1 along with CD-10, ER, PR and Desmin should be added in immunohistochemical panel of high grade uterine sarcomas especially if patchy expression of CD-10 is noted. It is to make a provisional diagnosis of YWHAE-FAM22 associated HG-ESS when fluorescence in situ hybridization (FISH) and reverse transcriptase polymerase chain reaction (RT-PCR) are not available to make a final diagnosis.

Keywords: Endometrial Stromal Sarcoma (ESS), Low grade-Endometrial Stromal Sarcoma (LG-ESS), High grade- Endometrial Stromal Sarcoma (HG-ESS), Undifferentiated Uterine Sarcoma (UUS).

OA Comparison of Vaginal Culture and Pap Smear in The Diagnosis of Bacterial Vaginosis

Mehreen Iqbal1, Nuzhat Sultana2, Saadia Haroon Durrani3, Muhammad Zubair4 and Shazia Tariq4 1Obs&Gynea, Combined Military Hospital Peshawar, Pakistan, 2Department of Pathology, Khyber Medical College, Peshawar, Pakistan, 3Heamatology, Department of Pathology, Gajju Khan Medical College Swabi

Peshawar, Pakistan, 4Pathology Department Rehman Medical College Peshawar, Pakistan

 

ABSTRACT

Background: Amongst the myriad of physiological and pathological conditions presenting as vaginal discharge, bacterial vaginosis is the most frequently encountered complaint in women of child bearing age, all over the world. It involves the replacement of normally predominant hydrogen-peroxide producing lactobacilli, by an overgrowth of anaerobic bacteria. We want to examine the diagnostic efficacy of Pap-Smear and vaginal culture in the diagnosis of bacterial vaginosis, while Amsel’s clinical criteria is used as the gold standard

Methods: It was a descriptive study expanding over a period of 5 months, from January 2013 to May 2013, enrolling 150 patients, from the outpatient’s department of lady reading hospital and Hayatabad medical complex, Peshawar. All patients who complained of vaginal discharge were eligible for study. Patients using antibiotics, vaginal suppositories as well as those who were pregnant were excluded from the study. All patients were subjected to simultaneous testing for Amsel’s criteria, vaginal culture, and Pap-staining. Sensitivity, specificity, positive predictive value and negative predictive values were calculated for vaginal culture and Pap smear, with amsel’s criteria being the gold standard.

Results: Sensitivity, specificity, positive and negative predictive values for culture was determined as 75%, 92.1%, 64.3% and 95.1%. Pap smear was found to be 62.5% sensitive, 93.7% specific, positive and negative predictive values being 65.2% and 92.9% respectively.

Conclusion: Out of these two tests, vaginal culture was labeled as the more sensitive test for the diagnosis of bacterial vaginosis.

Keywords: Bacterial Vaginosis (BV), Papanicolou Smear (Pap smear), Culture, Amsel’s Criteria

OA Quality of Life in Spinal Cord Injury Experience at a Military Tertiary Care Hospital-1

Omer Jamshed Khan1, WafaMunir Ansari2 and Nadeem Ahmed3

1 Combined Military Hospital, Muzaffarabad, 2 Azad Jammu & Kashmir Medical College, Muzaffarabad.3 Armed Forces Institute of Rehabilitation Medicine, Rawalpindi.

 

Background: Spinal Cord Injury can have devastating consequences on an individual’s physical and social capabilities. There is a scarcity of studies in Pakistan which identify the factors having a favorable and unfavorable effect on Quality of Life.

Objective: Determine the mean satisfaction score using Quality of life and Visual Analogue Scale scores in patients with Spinal Cord Injury.

Methods: The study was carried out for 6 months at the Armed Forces Institute of Rehabilitation Medicine (AFIRM), Rawalpindi. Total of 60 patients of SCI, both male and female were recruited by consecutive (non- probability) sampling. Quality of life and Visual Analogue Scale were measured using the Euro Quality o flife questionnaire. Data was analyzed using SPSS 17.

Results: The cross sectional descriptive study included 60 patients 49 (81.7%) males and 11 (18.3%) females. The average age in the study group was 32.37 ± 10 years. The mean duration of injury was 11.5 months ± 5.18. Employment status, level of education and duration of injury had moderately significant (p<0.05) effect while type of injury had a highly significant (p<0.01) effect on Quality of life and in Spinal cord injury patients. Age, marital status and gender did not have any significant influence on QoL in these patients. VAS score was significantly higher (p=0.002) in SCI patients with incomplete injury as compared to those with complete injury. Conclusion: Spinal cord injury rehabilitation greatly impacts outcome scores. Patient satisfaction can be improved by educating and guiding the patient . Standardized tools need to be used to measure rehab outcomes. Keywords: EQ- 5 D, Visual Analogue Scale, quality of life, spinal cord injury, Pakistan, Tertiary care

CR Multi-drug Resistant Salmonella Typhi Resistant to Ceftriaxone Isolated from Children Hospital, PIMS, Islamabad

Rubina Kamran, Hira Abdul Razaq, FauziaSabih and Muhammad Shafique

Department of Pathology, Pakistan Institute of Medical Sciences, Islamabad

 

Abstract:Enteric fever is a systemic infection caused by Salmonella typhi and Salmonella para-typhi A and B. It is a major cause of morbidity and mortality worldwide. Multi-drug resistant (MDR)S. typhihas been reported since 1997 rendering the primary anti-typhoidal drugs and the fluoroquinolones as no longer a choice for typhoid treatment, thus leaving Ceftriaxone as the mainstay for enteric fever treatment. There are reports of emerging resistance to Ceftriaxone from many Asian countries. We report the first case of Ceftriaxone ResistantS. typhi from Children hospital, PIMS.A four-and-a-half-year-old girl presented with fever, abdominal pain and loss of appetite for last one month. Systemic examination revealed abdominal tenderness and mild hepatomegaly. The Typhidot test was positive for IgM. Blood culture was initially done in BACTEC 9050,(Automated blood culture system by B.D.) and was positive after 24 hours’ incubation at 35oC. This sample was later sub culturedon Blood and MacConkey’sagarand showed S. typhi colonies which were further confirmed by api, (analytical profile index,byBiomeurex, Italy). Sensitivity was applied according to Kirby Bauer’s Disc diffusion method using CLSI 2016 guidelines,and the organism was found sensitive to only three drugs: Augmentin, Chloramphenicol and Imipenem. The patient was treated with Imipenem intravenously and recovered.MDRS. typhi is on the rise worldwide and effective surveillance methods need to be brought into action to curtail these resistance trends.

Keywords:Multi-drug resistant Salmonella Typhi, Enteric fever, Kirby Bauer’s Disc diffusion method

CR Dysplasia Epiphysealis Hemimelica A Case Report

Ruqqayya Ishaq, Ahmareen Khalid Sheikh, Ghazal Zaffar and Samina Akhter

ShaheedZulfiqar Ali Bhutto Medical University, Pakistan Institute of Medical Sciences, Islamabad, Pakistan

 

Abstract: Dysplasia epiphysealis hemimelica (DEH) is a developmental disorder with a very low incidence. It is characterized by overgrowth of bone and cartilage in one or more epiphyses. The usual presentation of disease is in a single limb and is hemimelic (involving either lateral or medial compartment). Lower extremities are more frequently affected. Here we present a case of a male patient at 2.5 years of age presenting with bilateral involvement of knee joints by DEH. The diagnosis was confirmed on both radiological and histopathological findings.