Download Nigerian National Diagnostic Histopathology EQA

Nigerian National Diagnostic Histopathology EQA circulation 007 (For the Nov
2014 TSL workshops). Clinical information
Please submit your answers online via the EQA page of www.tslworkshopsng.com. The
submission of responses is crucial to the overall quality of the program
Part 1: Autopsy Pathology
There are 3 cases in this section (PM1, PM2 and PM3). Key slides have
been provided for each case and there is a summary of the PM report for
each case (attached as an appendix) at the end of this document.
For each case
A) identify the organ on the slides and state the histologic abnormalities
B) Putting the findings in A together with the information in the PM report,
propose a primary disease and cause of death.
Part 2: Lymph node/lymphoma pathology (emphasis on the use of
immunohistochemistry)
1) 3 year old boy with bilateral neck swelling and recurrent cough x 8 months.
There was also night sweats and progressive weight loss. Neck lymph node
excision biopsy
IMMUNOHISTOCHEMISTRY: The lesional cells express S100 but are
negative with CD1a, melan A and broad-spectrum cytokeratins (AE1/3).
2) 67 year old man with generalised lymphadenopathy.
IMMUNOHISTOCHEMISTRY: The lesional cells express CD20, CD5 and
CD23 with a Ki-67 index that ranges from 5% to 30% in different areas
3) 27 year old female with generalised lymphadenopathy ? cause. Excision
biopsy of neck lymphnode
IMMUNOHISTOCHEMISTRY: Lesional cells negative with CD45 and EBVLMP1, positive with CD15 and CD30.
4) 87 year old male with left haemorrhagic pleural excision and bilateral
axillary lymph nodes. Lymph node biopsy
IMMUNOHISTOCHEMISTRY: Lesional cells strongly express CD20 and
CD23 but are negative with CD5. Ki-67 index is focally up to 10% in areas.
5) Supraclavicular lymph node 28 yr old female who is very ill with multiple
enlarged lymph nodes, distended neck veins and collapsed/consolidated right
lung.
IMMUNOHISTOCHEMISTRY: Lesional cells express CD30 but not CD15.
They are also negative for CD45, EBV-LMP1, CD3, ALK-1, CD20 and EMA.
6) Male 13 years, biopsy site not stated. Clinically ? Rhabdomyosarcoma
IMMUNOHISTOCHEMISTRY: lesional cells strongly and uniformly express
CD30, CD45, CD4 and EMA with weak focal expression of CD8. They are
negative with CD15, AE1/3, CD3, CD5, PAX5, CD20, EBV-LMP1, S100,
Desmin and Sarcomeric actin.
7) Male 21 yrs.Multiple generalised masses (lymphadenopathy) - cervical,
axillary, preauricular, occipital, inguinal and chest wall for 3 months. Hilar
lymphoma reported on chest x-ray. Patient says masses suddenly began to
shrink after growing to a large size. Diagnosis - non-Hodgkin's lymphoma
probably lymphoblastic lymphoma
IMMUNOHISTOCHEMISTRY: There is some difficulty with
immunohistochemistry due to poor original preservation, but there is definite
strong positive staining with TdT and CD10. Bcl-2 also appears positive as
does CD5. CD20 marks a small apparently residual population of nodal B
lymphocytes. There is no expression of cyclin D1 or CD23. The Ki-67 index of
the tumour cells is up to 40%.
8) 44 yr old female with axillary lumps.
IMMUNOHISTOCHEMISTRY: Lesional cells express CD20, CD10 and Bcl-2
but not CD5
9) Left neck lymph node enlargment of 3 months duration in a 30 yr old
female
IMMUNOHISTOCHEMISTRY: No fungal or mycobacterial organism identified
with special stains and EBV-LMP1 negative.
10) 52 year old woman with swelling on the forehead
IMMUNOHISTOCHEMISTRY: Not yet done
11) 74 year old man with long history of chronic granulomatous dermatitis.
Enlarged left supratrochlear lymph node biopsied
IMMUNOHISTOCHEMISTRY: Not yet done
SEE APPENDIX FROM NEXT PAGE
EXTRACTS FROM POST MORTEM REPORTS
PM1
CLINICAL HISTORY
The index illness started with vomiting after during a meal with the husband.
The vomiting continued intermittently and was later compounded by
breathlessness. There was no diarrhoea.
She was given IV infusions and some drugs including hydralazine and
aminophylline during an admission in hospital on the same day. The systolic
blood pressure was initially 200mmHg but later dropped to 120mmHg after
medications. The patient’s condition worsened and she was transferred to
another hospital a few days later where she was diagnosed with shock. She
died within 24 hours of admission in the second hospital.
EXTERNAL EXAMINATION
Middle aged female with dark maculo-papular skin rashes on the entire body.
The body was moderately dehydrated. There was neither palor nor jaundice.
There was also no sign of trauma on the body. There were sutured incisions
above the medial area of both ankles (which were said to be areas of venous
access [cut-down]).
INTERNAL EXAMINATION
The visceral organs were in their normal anatomical positions. There was no
excess fluid or blood in the cavities. There was no sign of trauma.
Brain: 1230g. NAD
Trachea and Bronchial Tree: NAD
Right Lung: (640g) The right lung was heavy and sub-crepitant with patchy
variable sized haemorrhagic sub-pleural bullae. No sign of aspiration was
seen. Cut sections revealed very congested and oedematous surfaces,
oozing blood and frothy fluid. Cut pieces from all lung lobes floated in water.
Left Lung: (604g). The left lung was heavy and sub-crepitant with patchy
variable sized haemorrhagic sub-pleural bullae. No sign of aspiration was
seen. Cut sections revealed very congested and oedematous surfaces,
oozing blood and frothy fluid. Cut pieces from all lung lobes floated in water.
Heart and Great Vessels: NAD. Heart 250g
Tricuspid valve circumference 13.0cm, Pulmonary valve circumference 7.4cm
Mitral valve circumference 9.5cm
Aortic valve circumference 7.0cm
Oesophagus: NAD
Stomach: There was obvious flattening of the rugal folds and also patchy
haemorrhagic lesions on the mucosal surface.
Small Intestine: NAD
Large Intestine: The large bowel contained some dark fecal matter.
Liver and Gall Bladder: The liver (1340g) capsule was normal. However, the
sub-capsular surfaces show patchy light yellowish discoloration. Cut sections
show moderate fatty changes and congestion. The gall bladder contained bile
and the duct was patent.
Spleen: The splenic capsule was wrinkled. Cut section of the spleen was
fairly normal.
Pancreas: NAD
Right Kidney and Adrenal: The right kidney weighed 100g. The capsule
stripped with ease. Cut surface showed global palor with hyperamia in the
cortico-medullary border. The right adrenal was anatomically normal.
Left Kidney and Adrenal: The left kidney weighed 100g. The capsule
stripped with ease. Cut surface show global palor with hyperamia in the
cortico-medullary border. The left adrenal was anatomically normal.
Urinary Bladder and Ureters: NAD
Uterus and adnexia: NAD
PM 2
DOD- 19/2/14
DOP- 20/2/14
O.F., 57 year old Brine discharge operator, known RVD patient (on ?HAART)
referred from the Navy Reference Hospital on account of fever of 2 days’
duration, and vomiting of blood and loss of consciousness of 5 hours’
duration. Fever has been occurring on and off for some time (the exact
duration was not stated) and he has been receiving treatment at the Navy
Reference Hospital. Fever was said to be high grade and associated with
chills. The pattern of the fever is not documented. Five hours prior to
presentation, the patient started vomiting blood. After 2 episodes of vomiting
frank blood, he lost consciousness. He has a positive history of associated
reversal of sleep pattern. No history of patient being irritable or acting
aggressive. He had hepatitis 7 years ago. There is positive history of
significant alcohol ingestion. There is positive history of progressive
abdominal and leg swelling. There is no orthopnea, paroxysmal nocturnal
dyspnoea. He was not a known hypertensive or diabetic.
On clinical examination, he was found to be a middle aged man, unconscious
(GCS- 3/15), afebrile (T-34.82oC), severely pale, severely icteric, and bilateral
pitting pedal oedema up to the distal third of the leg. He had no pubic or
axillary hair.
The abdomen was uniformly distendedby fluid. Ascites was demonstrable by
fluid thrill. The liver was shrunken (Liver span- ?5cm), the spleen and the
kidneys were not palpably enlarged.
Digital rectal examination showed anal tags on the verge, and gloved finger
was stained with dark stools
The pulse rate-105beats/ min, BP- 83/40mmHg, heart sounds 1 and 2 only,
RR- 30 cycles/ min, vesicular breath sounds.
Clinical diagnosis:
1. Coma secondary to decompensated chronic liver disease precipitated
by sepsis
2. Upper GI bleeding possibly due to ruptured oesophageal varices
His condition continued to deteriorate and he died about 2 hours after he was
admitted.
POSTMORTEM FINDINGS
We received the body of a cachectic middle-aged man who is severely pale,
deeply icteric with bilateral pitting pedal oedema.
Serous cavities
The peritoneal cavity contains 1.5L of serous fluid, the pleural cavity about
200mls of serous fluid. The pericardial cavity is free of excess fluid.
Trachea, bronchi, lungs and pleura
Both lungs are heavy, the right and the left lungs weigh 600 grams and 500
grams respectively. All lung lobes feel subcrepitant to touch. Cut sections
through all lobes show free flowing frothy fluid. Floatation test is negative.
The pulmonary vasculature is free of thrombi.
Heart, pericardium and great vessels
The heart is not enlarged, it weighs 350 grams. The heart measurements are
as follows: All the valvular circumferences are within normal limits. The left
ventricular free wall measures 1.6cm in thickness while the right ventricular
free wall measures 0.5cm in thickness. The papillary muscles appear bulbous.
The coronary vessels are patent. No thromboemboli in the pulmonary trunk.
Oesophagus, stomach and intestines
An ulcer is seen on the mucosa of the distal oesophagus. 200mls of fresh
blood is found in the stomach.
Liver and Gallbladder
The liver is not enlarged, it weighs 1250 grams. Cut sections show multiple
macro and micronodules diffusely distributed throughout the parenchyma.
The spleen is enlarged and weighs 500 grams. Cut sections show prominent
fibrous trabeculae.
Kidneys
Both weigh 100grams. Cut sections show increased corticomedullary
differentiation.
Other organs appear unremarkable.
PROVISIONAL ANATOMIC SUMMARY
Retroviral disease (status clinical) with
Severe anaemia and shocked kidneys
Upper Gastrointestinal bleeding
Ruptured oesophageal varices
Dilated oesophageal veins due to Portal hypertension
Liver cirrhosis
Chronic liver disease with severe jaundice
PM 3
B. A., 42 year old female, known patient with depression who is being
managed at the Neuropsychiatric Hospital, and who was referred on account
of abdominal pain and vomiting of 4 days, and constipation of 2 days’
duration. The abdominal pain was of acute onset, colicky, and associated with
abdominal cramps. The pain progressively became generalized. Vomiting
was non-projectile, she had up to 10 episodes/ day and vomitus consisted of
recently ingested foods.
She developed absolute constipation 2 days later. She had Caesarean
section 5 years before the present illness.
No chronic illnesses or other significant information in her past medical
history.
On examination, she was found to be drowsy (GCS-not stated), febrile
(Temperature-not stated), moderate pallor, no jaundice, no cyanosis, no
peripheral lymphadenopathy, no pedal oedema. Pulse rate, blood pressure
and RR are normal. Examination of the abdomen revealed a distended
abdomen (Abdominal girth-not stated), with multiple scarification marks,
healed Pfannenstiel scar, moderate tenderness, nil rebound tenderness, nil
rigidity, reduced bowel sounds.
Digital rectal examination showed an anal tag at the 11 o’clock position,
normal sphincteric tone, rectum filled with loose faeces.
Clinical diagnosis: Small intestinal obstruction, likely secondary to adhesions
following the prior caesarean section.
The following investigations were ordered: Abdominal X-rays, Abdominal
ultrasound, Full blood count and Electrolytes and Urea/ Creatinine. She was
placed on intravenous fluids and antibiotics. Abdominal Ultrasound showed
dilated bowel loops. Abdominal X-rays showed distended bowel loops with
air-fluid levels. Electrolytes and urea/ creatinine showed elevated Calcium
(Ca++= 3.4mmol/L), elevated Sodium, Chloride, Urea and Creatinine levels.
She was reviewed by the Medical team and a diagnosis of renal insufficiency
was made (GFR- not stated).
The plan was for an exploratory laparatomy once the electrolyte
derangements have been corrected.
On the 5th day of admission, while awaiting surgery, the patient was noticed to
have suddenly stopped breathing. She was certified dead shortly after.
PROVISIONAL ANATOMIC SUMMARY
Fibrous adhesions between the ileum and the sigmoid colon.
Shocked kidneys