Category Archives: 4(2) July-Dec 2006

Discoid Lupus Erythematosis affecting the Eyelid with Dramatic Response to Chloroquine and Intralesional Triamcinolone

Khalid Mahmood
Consultant Dermatologist, PAF Hospital Islamabad, Pakistan.
Summary: The discoid lupus erythematosus (DLE) may present with a wide range of cutaneous lesions. However, the eyelid involvement has been only rarely reported. The involvement of eyelids may lead to potentially serious complications secondary to the scarring like ectropion, entropion, symblephron and loss of eyelashes. It is therefore important to diagnose and appropriately treat the eyelid lesions of DLE at an early stage. A case of DLE involving the eyelid which responded dramatically well to chloroquine and intralesional triamcinolone, is being reported.
Key Words: Eyelid, Discoid lupus erythematosus, chloroquine, triamcinolone.

George Nicholas Papanicolaou

Anwar Ul Haque
Department of Pathology, Pakistan Institute of Medical Sciences, Islamabad.
PAP smears are not pap talks! They are taken
seriously not only by pathologists and gynecologists
but also by lay public particularly women. Thanks to
George Nicholas Papanicolaou who created awareness
among medical and lay community about the
importance of simple smear cytological examination in
prediction and prevention of cancer. Although
Papanicolaou’s work had been largely confined to the
female genital tract smears examination, his work no
doubt sparked the interest in other areas of the body.
Exfoliative cytology of other organs, touch cytology
and even Fine Needle Aspiration Cytology owe its
popularity and its service to the humanity to some
extent on Papanicolaou who significantly contributed
to make cytology a popular discipline. Papanicolaou
comes from the land of earlier sciences i.e. Greece.
However he was quite different from earlier Greek
scientists who were mostly philosophers who did little
hard work in laboratory sciences. It were Muslims
who actually founded the laboratory sciences through
their zeal for understanding and hard work sparked
by constant encouragement of Quran–e-Majeed and
the teachings of the Prophet Muhammad (PBUH) on
learning from birth to grave.

Hospital Waste & It’s Management

Anwar Ul Haque
Department of Pathology, Pakistan Institute of Medical Sciences, Islamabad.
What is Waste? It is Relative Term!
There is nothing as waste in the universe!
If it is waste for someone, it is treasure for another!
Animal waste is a good nutrition for the plants which
in turn provide food for the animals. This is the system
of All Mighty Allah Ta’lah which is based on utmost
wisdom and there is no partner to Him. If there wasn’t
a world of microbes, we would have seen the dead
bodies of birds and animals all over and all around,
and the oceans would have been full of corpses of fish
and other sea animals. There would have been such a
foul smell that living would have become extremely
uncomfortable and painful. We would have been
deprived of enormous amounts of oxygen which are
produced by microbe world and that is so vital for
our survival! Allah Ta’lah has bestowed upon man
intellect and wisdom and it is only natural to use these
virtues. Not using these faculties is not natural but
rather farthest away from nature and quite unnatural!
We may thus define waste as something which is
temporarily useless and may pose dangers if not
properly disposed off to let it complete its natural
cycle and circle.

Medical Curriculum & Teaching Strategies: Need for Constant Evaluation and Improvement

Anwar Ul Haque
Department of Pathology, Pakistan Institute of Medical Sciences, Islamabad.
A critical look at the medical curriculum in
different countries reveals gross inadequacies which
are directly and amply reflected in their products i.e.
doctors! The deficiencies are multidimensional and
include character, capabilities, zeal, care, commitment
and performance. Jungle of useless details masks
the essentials and kills the creativity! The poorly
trained and defectively formed doctors spoil systems.
All these contribute towards overall failed and
incompetent health systems. The proverb “You are
what you eat” is quite applicable to the medical
curriculum. What you feed them, what you will get! A
poorly trained but encyclopedic doctor is often poor in
ethical and moral virtues! He/she does not have good
communication skills and poorly understands the
impact of costly and useless investigations. Self
motivation for learning and research is often lacking.
Certainly material greed is not the best form of
motivation. Materialism without ethical values is a
recipe for sub-animal materialism which snatches
away peace and tranquility in all spheres!

Oxalosis in the Bone and Bone Marrow

Khalid Hassan, Javaid Hussain Qaisrani, Humaira Qazi, Lubna Naseem,
Hasan Abbas Zaheer and Tahira Zafar
Department of Pathology, Pakistan Institute of Medical Sciences, Islamabad.
Hyperoxaluria is characterized by supersaturation of calcium oxalate in the urine, and is strongly associated with nephrolithiasis
and nephrocalcinosis. Oxalate is the salt form of oxalic acid and is a natural end product of
glyoxylate metabolism. Oxalate does not appear to be needed for any human body process and
normally more than 90% is excreted by the kidneys, with a small amount of excretion into the lower gut.
Hyperoxaluria can result form excessive dietary intake of oxalates, overproduction of oxalates from the
intestinal tract associated with intestinal diseases (enteric hyperoxaluria) and abnormalities in oxalate
metabolism (primary hyperoxaluria)1. Long-standing and unattended hyperoxaluria can progressively impair renal functions, and ultimately lead to renal failure. This devastating phenomenon is characterized by oxalosis, a condition in which calcium oxalate crystals are deposited in the extrarenal organs. The common sites
of oxalate deposition are the bones, bone marrow, blood vessels, central nervous system, peripheral
nerves, retina, skin, and thyroid, etc2.

Paediatric Renal Cell Carcinoma – A Case Report

Nusrat Bokhari and Anwar-Ul-Haque
Department of Pathology, Pakistan Institute of Medical Sciences, Islamabad.
We report a case of a four-year-old child with a partly cystic mass arising from right kidney with no lymphadenopathy and treated by simple nephrectomy. The histology showed renal cell carcinoma with a predominantly solid growth pattern, clear to eosinophilic cells, focal papillary features and no extension beyond renal capsule or into renal vein. Renal cell carcinoma of childhood is a rare neoplasm constituting 2.6% of renal neoplasms in children and adolescents younger than 15 years.
Paediatric RCC has a variety of morphological patterns: papillary to alveolar to solid and is associated with numerous gene translocations, most resulting in TFE3 gene fusion, which is expressed immunohistochemically by positive nuclear staining for this protein. Certain morphological features have been debatably associated with specific gene translocations. Although immunohistochemistry and cytogenetic analysis could not be done in our case, certain morphological features were observed such as a more solid growth pattern, hyaline bodies and large vegetable-like cells, that have caused us to guardedly hypothesize upon the possibility of ASPL-TFE3 gene fusion in this tumor.

Reye’s Syndrome: Diagnosed on a Postmortem Needle Liver Biopsy in an Unexplained Death

Ambreen Moatasim, Anwar Ul Haque and Humeira Rizwan
Department of Pathology, Pakistan Institute of Medical Sciences, Islamabad.
We report here a case of a 14 year old child whose disease remained undiagnosed till death, when the diagnosis of Reye’s
syndrome was established via a core needle biopsy of liver done for academic purposes. Although Reye’s syndrome is a
diagnosis of exclusion, a high index of suspicion is critical for its diagnosis.
Key words: Reye’s syndrome, Fatty change, Micro vesicular steatosis, Needle biopsy, Autopsy.

Role of Vascular Endothelial Growth Factor Expression in Sub-typing of Breast Carcinoma

*Ahmad M. Ragab Shalaby
*Oncologic Pathology Department-Damanhour National Medical Institute
The detection of subtypes of breast cancer based on their molecular features has brought new scope in breast cancer work.
Some key regulators of angiogenesis and tumor infiltration were evaluated in breast carcinomas of basal phenotype
(cytokeratin [CK] 5+). Immunohistochemical analysis with 14 primary antibodies was performed in 200 formalin-fixed,
paraffin-embedded samples of invasive ductal carcinomas. CK5 correlated with indicators of poor outcome, including
precocious age, high histological grade, lymph node positivity, advanced pathologic stage, negativity for hormonal receptors, and a high proliferative rate (Ki-67 labeling index). CK5 also correlated with vascular endothelial growth factor (VEGF) expression. Considering that VEGF-over-expressing neoplastic mammary cells display increased proliferative activity in vitro regardless of the angiogenic effect of VEGF, the differential expression of VEGF might contribute to the more aggressive behavior of these neoplasms. CK5 correlated with tissue inhibitor of metalloproteinase (TIMP)-1, but not matrix metalloproteinase (MMP)-1, MMP-2, extracellular matrix metalloproteinase inducer, TIMP-2, or plasminogen activator inhibitor, indicating that antiproteolytic stimuli might be preponderant in these neoplasms.
** Key words: Breast Cancer, Immuno-histochemistry.

Serum Copper Levels in Various Diseases: A Local Experience at Aga Khan University Hospital, Karachi

Imran Siddiqui, Joveria Q. Farooqi, Dilsha A Shariff, Aysha H. Khan and Farooq Ghani
Section of Chemical Pathology, Department Of Pathology,
Aga Khan University Hospital, Karachi.
Objective: To evaluate the possible alteration of serum copper levels in various clinical disorders using the method of Atomic Absorption.
Design: Descriptive analysis
Setting: The Aga Khan University Hospital (AKUH) Clinical Laboratories Karachi, Pakistan (January 2000 to July 2001).
Patients and Methods: 120 in-patients of AKUH were chosen through convenient sampling and their complete medical
records obtained from Health Information & Management System (HIMS). Their serum copper was then measured by Flame
Atomic Absorption method (Shimazdu AA 6500). Patients were categorised as having infectious (36), GI and hepatic (14), cardiovascular (20), renal (10), pulmonary (15), malignant (7) and haematological (18) disorders. Test results were sorted into high, low or normal serum copper levels for each clinical category, frequencies calculated for each group, and the overall percentage of normal, altered, high and low values determined.
Results: Statistically significant (p<0.05) associations were seen between altered copper levels and infectious, GI & hepatic, renal, malignant and haematological disorders. Cardiovascular and pulmonary diseases also showed a high frequency of abnormal results, but not significantly. Overall, 50% patients had serum copper levels greater than the normal mean + 2SD (115 μg/dl), while 27.5% had low serum Cu levels suggestive of Cu depletion whereas 22.5% showed normal values evenwith various clinical disorders. Conclusion: Alterations in Serum Copper, whether low or high, can give significant insight in disease process and should befurther studied as a reasonable marker of patient health. Key words: Serum Copper, Trace elements, Systemic disorders, Pakistan.

Spleen: An Organ Full of Mystery and its Mysterious Pathologies!

Anwar Ul Haque
Department of Pathology, Pakistan Institute of Medical Sciences, Islamabad.
The spleen is also known as Organ of Galen,
a great anatomist of Greek Era and the organ is
regarded as “Organ full of mystery” ! Although
recognized as one of the important sites of
extramedullary hemopoiesis in embryonic and fetal
life, it was treated almost as vestigial organ in adult
life! With slightest injury to it or its blood supply,
spleen was removed and thrown into dust bin! The
pathologists also did not examine spleen meticulously;
to them it appeared like a organ composed and
comprised of white and red pulps with blood filling
the sinusoids and that’s about it. When I was a
first year of resident of pathology in Des Moines,
Iowa, USA, two cases one after the other, gave me a
shock.1 First was an adult healthy man who had
stormy course after a trivial trauma and quickly died
despite all aggressive management. He had full blown
Waterhouse-Fredricksen syndrome i.e. Disseminated
Intravascular Coagulation (DIC) with pneumococcal
septicemia and bilateral adrenal hemorrhages. His
past history was significant that he had splenectomy
after motorbike accident 13 years prior to this episode.
Then a few months afterward I saw a woman
who presented with pneumococcal septicemia and
had lost all her twenty fingers and toes. Fortunately
she survived after these rather massive amputations.
Her past history was significant because she had
had splenectomy due to bicycle trauma 22 years
back. These two episodes sensitized me with the
importance of spleen and dire life long consequences
of missing it.2 We then carried out experiments on
Sprague-Dawley rats and found similar findings of
Waterhouse Fredricksen Syndrome!3