Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case report
Year : 2010 | Month : April | Volume : 4 | Issue : 2 | Page : 2311 - 2315 Full Version

A Unique Cytological Approach In Diagnosing A Case Of Invasive Aspergillosis Masquerading As Retro-Orbital Neoplasm


Published: April 1, 2010 | DOI: https://doi.org/10.7860/JCDR/2010/.703
KHANNA M*, MANNAN R, KHANNA A, MANNAN R, KAUR J.
Correspondence Address :
Dr Menka Khanna

Email: mona74_khanna@yahoo.co.in

Abstract

Aspergillus is a fungal mould that is commonly present and may colonize the paranasal sinuses and lungs by virtue of large number of Aspergillus spores present in the inhaled air. Rare cases
of invasive aspergillosis have been reported in immunocompetent individuals, although they are usually seen in immunocopromised individuals or diabetics.
The following is the description of a simple technique in the present case report of a young immunocompetent agricultural worker who presented with invasive aspergillosis as exophthalmos; where the diagnosis was made by isolating the pathogenic organism by employing the remnant material in the needle hub as the incubating material.
A 24 year old male presented to the ophthalmology OPD with the complaint of gradual and painless swelling of the right eye with accompanying loss of vision. A radiological opinion of orbital neoplasm was made, with differential diagnosis of benign fibrous histiocytoma and ?? lymphoma. A fine needle aspiration (FNA) was done and the May Grunwald Giemsa (MGG) stained smears revealed numerous foreign body type of giant cells, few epitheloid cell collections and scattered filamentous structures. To delineate the nature of the filamentous structures, Periodic acid Schiff (PAS) staining of the remaining smears was done, which showed that these filamentous structures were fragments of septate fungal hyphae with acute angle branching. A cytological diagnosis of fungal granulomatous lesion was given.
It was suggested that an attempt would be made to retrieve the fungal organism by means of culture from the remnant material in the hub of the needle which was used in the procedure .Both the needles were sealed and were sent to the mycology section of the microbiology department. A microbiological diagnosis of Aspergillus flavus was given.
The presentation of localized invasive aspergillosis can mimic infectious diseases such as mucormycosis and also neoplastic, vascular and neuro-ophthalmic diseases.

Keywords

Aspergillus, exophthalmos, needle hub , remnant.

Introduction
Aspergillus is a fungal mould that is virtually ubiquitous. It may colonize the paranasal sinuses and lungs, as a large number of spores are present in the inhaled air. Under appropriate conditions, the spores may become saprophytic within the host and multiply. Locally aggressive invasive fungal masses may develop, particularly if the host is severely immunocompromised. Rare cases have been reported in immunocompetent individuals, where it follows a chronic and slowly progressive course (3). Aspergillosis often presents with vague complaints and clinical findings, making diagnosis difficult and subsequently, the treatment is delayed and the disease is accelerated (2).The following is a case report of a young immunocompetent agricultural worker who presented with invasive aspergillosis as exophthalmos, where the diagnosis was made by isolating the pathogenic organism by employing the remnant material in the needle hub as the incubating material.

Case Report

A 24 year old male presented to the ophthalmology OPD with the complaint of gradual and painless swelling of the right eye, with accompanying loss of vision. On examination, the right eye had no perception of light. Further, the eye was found to be proptosed in an axial, lateral and downward direction (Table/Fig 1) (Figure-1 A, B). Slit lamp examination of the concerned eye showed pseudocornea formation. An ultrasound B-scan of the posterior segment was anechoic.

Apart from an eosinophilia (20%), the rest of his haematological, serological and biochemical profiles were within the normal range, including non reactive HIV and the Hepatitis B and C antigens. A CT scan of the orbit and paranasal sinuses revealed a moderately well defined, mildly enhancing mass lesion measuring 5x4.6x2cm in the retrobulbar region of right orbit involving intraconal and extraconal compartments along with loss of visualization of lateral wall of ethmoid sinus and a small polyp in maxillary sinus (Table/Fig 1)(Figure1 C). A radiological opinion of orbital neoplasm was made with differential diagnosis of? benign fibrous histiocytoma and ?? lymphoma. A fine needle aspiration (FNA) under radiological guidance was suggested to differentiate between the two. This was performed using 23G needle and two passes were given at two different sites. The MGG stained smears revealed numerous foreign body type of giant cells, few epitheloid cell collections and scattered filamentous structures (Table/Fig 2) (Fig. 2 A, B). Periodic acid Schiff stain of the remaining smears showed these filamentous structures to be fragments of septate fungal hyphae with acute angle branching (Table/Fig 2)(Fig. 2 C, D). A cytological diagnosis of fungal granulomatous lesion was given. No evidence of any orbital neoplasm was present.

To reach a conclusive diagnosis and species identification for therapeutic purpose an intensive cross-departmental discussion was undertaken between the departments of pathology, microbiology, ophthalmology and maxillo-facial surgery and it was suggested that an attempt would be made to retrieve the fungal organism by means of culture from the remnant material in the hub of the needle used in the procedure .Both the needles were sealed and were sent to mycology section of microbiology department. The remnant in the hub of needle was taken with the sterile loop and inoculated in Saboraud’s dextrose broth. After overnight incubation subculture was done on Sabourad’s dextrose agar.
In view of the cytological findings a CT chest was further advised to rule out any evidence of allergic bronchopulmonary aspergillosis, which revealed central bronchiectasis and bronchocoele formation (Table/Fig 1) (Fig. 1 D).

Patient was then enquired for any past history of surgical procedure done in the nasal region owing to the absence of ethmoid bone on CT (Table/Fig 1)(Fig. 1 C). He told about a surgery for nasal obstruction at another centre 2 years back, subsequent to which he was put on some long term oral treatment. Patient expressed his inability to procure any relevant documents regarding aforementioned treatment as they were lost over a period of time. Medical records retrieved from the other centre revealed that a polypectomy operation was done; the histopathological examination of the excised tissue suggested fungal infection for which he was put on anti-fungal therapy.

Meanwhile, the culture was kept at 22 degrees and 37 degrees in separate BOD (biological oxygen demand) incubators. After 2 weeks velvety yellow to green colonies of fungal growth were obtained. The morphological characters were seen by preparing LCB (Lactophenol cotton blue) smears which showed, conidiophores of variable length, which were rough , pitted and spiny, the phialides were single and double covering the entire vesicle and pointing out in all directions. So a microbiological diagnosis of Aspergillus flavus was given. The case was finally diagnosed as that of invasive aspergillosis with an unusual presentation.

Discussion

Aspergillus species rank closely behind Candida species in causing invasive fungal infections in humans. Primary lesions can be localized in the eyes, paranasal sinuses, external ears and larynx in apparently healthy individuals (4). In an immunocompromised host, it occurs in the form of cutaneous, sino- orbital, pulmonary, central nervous system or disseminated infection (1). There are more than 185 species of aspergillus and over 95% of all infections are caused by A. fumigatus, A. flavus and A. niger. A. fumigatus alone accounts for a large majority of cases of both invasive and non invasive aspergillosis. In the present case, however, A. flavus was isolated from the culture, which is also reported to be the cause in many case reports of sinus mycosis from India and Sudan (1). Aspergillus organism has a characteristic microscopic appearance, but culturing the organism is necessary for it’s identification. Aspergillus, on being incubated on a fungal medium at 30 degree centrigade in 45% humidity, yields the growth. Colonial morphology and microscopic examination of sporulating forms allows the confirmation of the diagnosis (5).

Locally aggressive invasive fungal masses may develop, particularly if the host is severely immunocompromised with one or more predisposing factors such as neutrophil defects, corticosteroid use, HIV infection, diabetes mellitus, alcoholism, prosthetic devices or trauma and advanced age. But the clinical syndrome and the pathological spectrum depends on the underlying lung architecture, host immune response and the degree of inoculum (2), (6). Rarely has invasive aspergillus infection been described in immunocompetent patients, as in the present case.

Invasive aspergillosis of the paranasal sinuses may present with rhinorrhoea, nasal obstruction or facial pain (7). The paranasal sinuses offer the fungus good conditions for subsistence and chronic infection may lead to the development of mycetoma. The chronicity of sinusitis results from inflammatory mucosal swelling around the ostia which hampers ventilation and drainage (8). In the present case, the orbital involvement was secondary to the infection of the sinuses, as elicited by the patient’s past history. The extension of the sinus infection is either direct or through osseous structures like the lamina papyracea or through haematogenous spread by valve-less venous plexus to the orbit, brain or skin. Aspergillus has a propensity for vascular invasion which results in thrombosis, haemorrhage and the formation of mycotic aneurysm (7).

The presentation of localized invasive aspergillosis can mimic infectious diseases such as mucormycosis and also neoplastic, vascular and neuro-ophthalmic diseases (1). In our case, the patient presented with proptosis and loss of vision, which is a very atypical presentation and so the clinical and radiological diagnosis of orbital tumour was made. CT scans usually reveal enhancing soft tissue masses, sometimes with bone destruction (8). Invasive aspergillus infection of the sinuses involving the adjoining structures is a well documented cause of morbidity and mortality in an immunocompromised host (7).

A long term follow up is advocated due to the high recurrence rate of the infection. The reason of poor response to treatment in our case could be the invasion of the bone and the walls of the blood vessels which affected the poor penetration of the drugs and also the past non-complaint behaviour of the patient towards the anti-fungal treatment (1). However; early diagnosis of the orbital involvement of fungal sinusitis continues to be a challenge. Any type of paranasal aspergillosis may progress to or may be associated with a more aggressive disease, illustrating the importance of the early recognition of this increasingly encountered disease. While the imaging of the sinuses and the adjoining structures provide complementary diagnostic evidence, the demonstration of fungus in the tissues guides the treatment and the isolation of fungi confirms the diagnosis. There is no uniformly accepted, completely effective treatment. Management often involves surgical debridement and amphotericin B local irrigation, followed by systemic administration of intravenous amphotericin B usually. Response to treatment depends on the early diagnosis and the initiation of antifungal treatment (6).

This case is worth reporting because of its unusual presentation and the method employed to retrieve the fungal organism to conclusively reach a diagnosis. It is therefore proposed by our observations that the protocol of immediate disinfection of the needles used after an FNA procedure (either by incinerating them in a needle destroyer or in hypochlorite solution) be desisted from. A time gap of discarding the needles used in the procedure by a few minutes (time required in staining the smears and viewing them) can go a long way in reaching an appropriate diagnosis, especially in cases of lesions of infective aetiology.

The exact causative organisms can be isolated from the remnant material in the needle hub as was observed in our study, which can in the end, lead to specific managements.

However, more and larger sample studies have to be undertaken regarding the utility of this retrieval method in employing it for isolating the causative organism in cases of frank or suspected infective lesions. This case highlights the importance of clinico-pathological correlations where inter departmental discussions led to a conclusive diagnosis of invasive aspergillosis which alleviated the patient’s anxiety regarding the suggested neoplastic nature of the lesion he was suffering from.

Key Message

1. The presentation of localized invasive aspergillosis can mimic infectious diseases such as mucormycosis and also neoplastic, vascular and neuro-ophthalmic diseases.
2. This case is worth reporting because of its unusual presentation and the method employed to retrieve the fungal organism to conclusively reach a diagnosis. The exact causative organisms can be isolated from the remnant material in the needle hub, as observed in our study, which can in the end lead to specific managements.

References

1.
. Naik NM, VemgantiGK, Honavar SG.Primary orbital aspergilloma of the exenterated orbit in an immunocompromised patient. Ind J Med Micro 2006; 24 :233-34.
2.
. Aggarwal S, Kang A, Sharma V, Sharma DR, Sharma ML. Invasive aspergillosis involving multiple paranasal sinuses- a case report. Ind J Med Micro 2005; 23: 195-197.
3.
. Kameswaran M, Al-Wadei A, Khurana P, Okafor BC. Rhinocereberal aspergillosis. J Laryngol Otol 1992; 106: 981-85.
4.
. Mitchel RB, Tolley N, Croft CB, Gallmore A. Aspergillosis of larynx. J Laryngol Otol 1994; 108: 883-5.
5.
. Sivak –Callcot JA, Livesly N, Nugent RA, Rasmussen SL, Sae Rootman P. Localised invasive sino-orbital aspergillosis: characteristic features. Br J Ophthalmol 2004; 88: 681-87.
6.
. Sharda DM, Arunkumar G, Vandana KE, Rao PS.Sino-orbital aspergillosis in a diabetic patient. IJMM 2006; 24:138-40.
7.
. Ashdown BC, Tien RD, Felsberg GJ. Aspergillosis of brain and paranasal sinuses in immunocompriomised patients: CT and MR imaging findings. AJR 1994; 162: 155-59.
8.
. Swaboda H, Ulrich R. Aspergilloma in the frontal sinus expanding into the orbit. J Clin Pathol 1992; 45:629-30.
9.
. Richardson MD. Aspergillus and Penicillum species Part vii: Monomorphic septate filamentous systemic pathogenic fungi. In, Ajello L, Hay RJ (eds) Topley and Wilson’s Microbiology and Microbial Infections 9th edition. New York, Oxford University Press, 1998; 281-312.

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