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

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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

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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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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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.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
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

Important Notice

Case report
Year : 2010 | Month : October | Volume : 4 | Issue : 5 | Page : 3237 - 3240

Clinical, Imaging And Pathological Features Of Infected Atypical Rathke’s Cleft Cyst With Secondary Pituitary Abscess Formation

AZAD R*, AZAD S**, AHMAD A***, ARORA P****

*MD, Associate Professor, Department of Radiology, SGRR Institute of Medical & Health Sciences, Patel Nagar, Dehradun, India; **MD, Assistant professor, Department of Pathology, ***MD, Assistant Professor, Department of Radiology; ****MCH, Assistant Professor, Department of Neurosurgery

Correspondence Address :
Dr Rajiv Azad,
Associate Professor,
Department of Radiology,
SGRR Institute of Medical & Health Sciences,
Patel Nagar, Dehradun, India- 248001.
Phone- 911352522131
Email- rajivas23@yahoo.com

Abstract

Infected atypical Rathke’s cleft cyst (RCC) is a rare cause of secondary pituitary abscess. A thirty year old afebrile female presented with a two year history of diabetes insipidus with loss of vision in the left eye over a period of one month. Brain imaging showed a large heterogenous sellar and suprasellar mass with left parasellar extension. The lesion demonstrated a thick, partially calcified wall and a central cystic component with an intracystic nodule. Craniopharyngioma was considered as a likely possibility due to lack of awareness of the imaging features of atypical RCC. However, the typical pattern of calcification and the MR signal intensity of the intracystic nodules can provide valuable clues to differentiate this uncommon lesion from craniopharyngioma and can guide the further clinical and operative management.

Keywords

Rathke’s cleft cyst, pituitary, sellar, abscess.

Introduction
Rathke’s cleft cyst (RCC) develops as a macroscopic cyst from the remnant of Rathke’s pouch that persists as a cleft between the pars distalis and the pars nervosa of the pituitary gland. (1) Mostly, it is asymptomatic and its typical imaging morphology shows a nonenhancing, thin walled cyst in the pituitary region. Symptomatic cysts are rare and may have atypical imaging features including parasellar extension, cyst wall thickening with enhancement, peripheral calcification and intracystic nodules, when differentiation from craniopharyngioma becomes important due to a different operative approach. [1-4] Abscess formation in RCC as a cause of sellar and suprasellar abscess is only rarely described.[5-7] We describe here, a case of a young female who had atypical imaging features in an RCC along with abscess formation.

Case Report

A thirty year old female presented with a two year history of polyuria and polydipsia and was treated as a case of urinary tract infection. Recently, she developed complete loss of visual acuity in the left eye over a period of one month. The patient was afebrile and had no symptoms of raised intracranial tension. Her total leukocyte count was however mildly raised. Fundal examination revealed partial left optic atrophy.

CT revealed a bifocal lesion, with the sellar and the suprasellar midline component and the left parasellar component. Central attenuation within the midline component was more than that in CSF, while it appeared close to the grey matter superiorly in the left parasellar component. Dense, curvilinear calcification was seen along the margin of the parasellar component. On post contrast CT; it was found that there was thick, partial wall enhancement in the central component and minimal wall enhancement in the left paracentral component (Table/Fig 1).

(Table/Fig 1): (A-D): Pre and post contrast axial CT (A, B) and post contrast coronal CT (C, D) shows the sellar/suprasellar component to be cystic with central attenuation more than CSF with thickened wall and enhancement (open arrow) while left parasellar component appears partially solid (white arrow) and cystic with dense peripheral calcification (black arrow).

Subsequent MRI revealed mixed signal intensity in the lesion. The midline component was hyperintense superiorly and isointense inferiorly on the T1 weighted sequence and on the T2 weighted sequence, it was hypointense superiorly and iso to hyperintense inferiorly. The left parasellar component was isointense to grey matter on T1 and iso to hyperintense centrally with thick peripheral hypointense signal on T2 (Table/Fig 2).

The imaging features of the midline component suggested a thick walled cystic lesion with probably proteinaceous fluid content, while the left parasellar component appeared to be of soft tissue and cystic consistency. These features, along with a calcified wall, favoured a possibility of craniopharyngioma.

Left pterional burr hole craniotomy was done. The wall of the lesion was excised and a yellowish brown pus like material was drained. As the optic nerve on the left side could not be defined separately from the lesion, complete excision of the sac could not be done.

(Table/Fig 2): (A-D): T1W MR Images (A- axial, C- coronal) shows intracystic nodule superiorly within the central cystic component to be typically hyperintense (black arrows). On T2W images (B- axial, D- coronal) it appears hypointense (open black arrows).

Histopathological examination of the lesion revealed a thickened fibrocollagenous cyst wall lined by pseuodostratified columnar epithelium, exhibiting squamoid differentiation at places. There was a dense inflammatory cell infilterate comprising neutrophils, lymphocytes, plasma cells and histiocytes in the deeper tissue, along with focal haemosiderin deposits (Table/Fig 3).

(Table/Fig 3): Photomicrograph shows thickened fibrocollagenous cyst wall having mixed inflammatory cell infiltrate, congested blood vessels and focal hemosiderin deposits (Hematoxylin and eosin, x 100). Inset shows cyst wall lining of pseuodostratified columnar epithelium exhibiting focal squamoid differentiation (Hematoxylin and eosin, x 400).

These findings were suggestive of infected atypical Rathke’s cleft cyst with old haemorrhage. The subsequent pus culture was sterile.

The post operative course was uneventful. The patient was put on parenteral ceftriaxone for one month and was also prescribed desmopressin. Follow up CT after one month showed only a small residual lesion and the patient recovered to finger counting at six feet in the left eye (Table/Fig 4). The symptoms of diabetes insipidus had also resolved. The patient has still been put on a further long term follow-up to exclude recurrence.

(Table/Fig 4): Follow up CT after one month shows only minimal residual lesion.

Discussion

Rathke’s cleft cyst (RCC) forms part of a spectrum of epithelial cystic lesions in and around the sellar region, with a common cell of origin which is derived from the remnants of Rathke’s pouch. Histologically, the lesion spectrum ranges from RCCs (most simple) to craniopharyngiomas (most complex and aggressive). A majority of the RCCs are asymptomatic. Symptomatic RCCs may present with visual disturbances, endocrine dysfunction, raised intracranial tension and uncommonly, diabetes insipidus. (1),[8-11]

On imaging, typical RCCs present as a central, thin walled cystic lesion with a fluid content which is similar to CSF in the sellar and the suprasellar regions. However, atypical features like variable fluid content (ranging from milky white, yellowish or brownish), thick wall, the presence of calcification and parasellar extension lead to a confounding imaging morphology. The imaging features of the cyst will vary according to the predominance of the content (protein, cholesterol or haemorrhage), with high intensity areas on T1 and low intensity areas on T2 weighted imaging, representing a fluid with high protein concentration or haemorrhage. Sometimes, characteristic intracystic soft tissue nodular appearance can be seen, which is hyperintense on T1- weighted images and low signal on T2 weighted images. Retrospectively, this finding was also seen in this case. Pathologically, these intracystic nodules show mucin clumps and biochemical analysis shows cholesterol and protein as the main constituents. The wall of the cyst can be thin or thick. Haemosiderin deposits due to old haemorrhage can also be rarely seen in the wall, as in this case and can lead to the T2 shortening and the blooming effect. Rim like post contrast enhancement can also be noticed with or without the presence of inflammation in the cyst wall. [2-4],[8-13]

Primary pituitary abscess generally occurs within a normal pituitary gland, while secondary pituitary abscess occurs within sellar tumours like adenoma, craniopharyngioma and RCCs. Pituitary abscess may not present with typical systemic symptoms of infection and can only have visual and endocrine symptoms. [5-7]

In this case, the patient was afebrile with predominantly visual symptoms. However, the peripheral smear revealed leukocytosis. On CT imaging, typically an abscess has a thick wall with central attenuation more than in CSF, while on MR, the lesion is homogenously hyperintense on T2 and iso to hyperintense on T1- weighted images(depending on protein content).On post contrast imaging, peripheral enhancement of the lesion may be seen.

However, this case had the atypical imaging morphology, probably due to intracystic fluid containing pus and haemorrhage, along with a thick fibrocollagenous wall containing hemosiderin deposits. In addition, the left parasellar extension of the lesion with coarse left peripheral calcification led to a probable imaging diagnosis of craniopharyngioma. Retrospectively, however, lack of speckled or floccular calcification should have favoured a possibility of atypical RCC. (3) Necrotic pituitary neoplasm and epidermoid cysts are other imaging possibilities, although calcification is uncommon in these lesions. [1-3]

The lesion was approached by the left transpterional approach due to the presumptive preoperative diagnosis of craniopharyngioma, instead of a transsphenoidal approach, which is generally recommended for abscess. (6),(7)

The colour of the pus can be variable and thick yellowish brown material was drained in this case, probably due to haemorrhage and superadded infection. Acinetobacter iwoffi, Staphylococcus epidermidis, Staphylococcus aureus and Streptococcus pyogenes can be isolated from the pus culture, but mostly, the culture is sterile. Histologically, the lesion is characterized by a thickened fibrocollagenous cyst wall which is lined by pseuodostratified columnar epithelium, exhibiting squamoid differentiation at places due to squamous metaplasia. [5-7]

Parenteral antibiotics like vancomycin, ceftriaxone and metronidazole for at least four weeks, are recommended following surgical drainage. (6),(7) Long term follow up is however required to detect recurrence in cases with the histopathological features of squamous metaplasia in the cyst wall. (9),(14),(15)

Conclusion

Atypical RCC can be considered in the differential diagnosis of a heterogenous mass in the sellar and the suprasellar regions if the typical patterns of peripheral calcification and intracystic nodules are seen. The knowledge of this lesion may help in planning the correct operative approach. However, histopathology may be required to diagnose superadded infection and haemorrhage.

References

1.
Osborn AG. Miscellaneous tumors, cysts, and metastasis. In: Patterson AS, editor. Diagnostic neuroradiology, 1st ed. St. Louis: Mosby; 1994. p. 626-70.
2.
Nakasu Y, Nakasu S, Nakajima M, Itoh R, Matsuda M. Atypical Rathke's cleft cyst associated with ossification. Am J Neuroradiol 1999;20:1287-9.
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Lee CH, Seo EK, Cho YJ, Kim SJ. Large Ossified Rathke's Cleft Cyst - A Case Report and Review of the Literature. J Korean Neurosurg Soc 2008;44:256-8.
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Raghunath A, Sampath S, Devi BI, Chandramouli BA, Lal GJ, Chickabasaviah YT, Bharath RD. Is there a need to diagnose Rathke's cleft cyst pre operatively? Neurol India 2010;58:69-73.
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Thomas N, Wittert GA, Scott G, Reilly PL. Infection of a Rathke’s cleft cyst: a rare cause of pituitary abscess. J Neurosurg 1998; 89: 682.
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Celikoglu E, Boran BO, Bozbuga M. Abscess formation in Rathke's cleft cyst. Neurol India 2006;54:213-4.
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Vates GE, Berger MS, Wilson CB. Diagnosis and management of pituitary abscess: a review of twenty-four cases. J Neurosurg 2001;95:233-41.
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Kucharczyk W, Peck WW, Kelly WM, Norman D, Newton TH. Rathke cleft cysts: CT, MR imaging and pathologic features. Radiology 1987;165:491-5.
9.
Mukherjee JJ, Islam N, Kaltsas G, Lowe DG, Charlesworth M, Afshar F, et al. Clinical, radiological and pathological features of patients with Rathke’s cleft cysts:tumors that may recur. J Clin Endocrinol Metab 1997;82:2357-62.
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Harrison MJ, Morgello S, Post KD. Epithelial cystic lesions of the sellar and parasellar region: a continuum of ectodermal derivatives ? J Neurosurg 1994;80:1018-25.
11.
Naylor MF, Scheithauer BW, Forbes GS, Tomlinson FH, Young WF. Rathke cleft cyst: CT, MR, and pathology of 23 cases. J Comput Assist Tomogr 1995;19:853–9.
12.
Hayashi Y, Tachibana O, Muramatsu N, Tsuchiya H, Tada M, Arakawa Y, et al. Rathke cleft cyst: MR and biomedical analysis of cyst content. J Comput Assist Tomogr 1999;23:34-8.
13.
Byun WM, Kim OL, Kim D. MR imaging findings of Rathke's cleft cysts: significance of intracystic nodules. AJNR Am J Neuroradiol 2000;21:485–8.
14.
Kim JE, Kim JH, Kim OL, Paek SH, Kim DG, Chi JG, et al. Surgical treatment of symptomatic Rathke cleft cysts: clinical features and results with special attention to recurrence. J Neurosurg 2004;100:33-40.
15.
Aho CJ, Liu C, Zelman V, Couldwell WT, Weiss MH. Surgical outcomes in 118 patients with Rathke cleft cysts. J Neurosurg 2005;102 :189-93.

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