Hematology Case Study: A 51 Year Old Woman with Fever and Chills

A 51 year old patient presented to the emergency room with abdominal pain and fever. Fever was associated with diaphoresis, chills and headaches. Patient was in Tanzania for 3 months. She was admitted to the hospital while she was there for some unknown infection, details of which are not available.

CBC done revealed normocytic normochromic anemia with a hemoglobin of 9.2 g/dl and thrombocytopenia. Platelet count was 100 K/uL. On review of peripheral blood revealed presence of malarial parasite (ring forms).

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Malaria is an infectious disease caused by Plasmodium parasites. These parasites are primarily spread by the bite of infected female Anopheles mosquitos. There are four main types of Plasmodium (P) species that infect humans:

  • Plasmodium vivax and Plasmodium ovale, which cause a relapsing form of the disease, and
  • Plasmodium malariae and Plasmodium falciparum, which do not cause relapses.

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Malaria must be recognized promptly in order to treat the patient in time.

Microscopy (morphologic analysis) continues to be the “gold standard” for malaria diagnosis. Parasites may be visualized on both thick and thin blood smears stained with Giemsa, Wright, or Wright-Giemsa stains. Giemsa is the preferred stain, as it allows for detection of certain morphologic features (e.g. Schüffner’s dots, Maurer’s clefts, etc.) that may not be seen with the other two. Ideally, the thick smears are used to detect the presence of parasites while the thin smears are used for species-level identification. Quantification may be done on both thick and thin smears.

Various antigen kits are available to detect antigens derived from malarial parasites. These rapid diagnostic tests (RDT) offer a useful alternative to microscopy in situations where reliable microscopic diagnosis is not available.

 

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-Neerja Vajpayee, MD, is the director of Clinical Pathology at Oneida Health Center in Oneida, New York and is actively involved in signing out surgical pathology and cytology cases in a community setting. Previously, she was on the faculty at SUNY Upstate for several years ( 2002-2016) where she was involved in diagnostic work and medical student/resident teaching.
 

The Occurrence of Lewis Antibodies in Pregnancy

A 36 year old woman presented to the delivery room at a local county hospital at 39 weeks’ gestation. The doctor ordered a type and screen on the patient, the blood was drawn and sent to the Blood Bank lab. The Blood Bank tech looked up the patient’s Blood Bank history and noted that an antibody screen done at 28 weeks was positive, with an anti-Lea identified. The Blood Bank’s policy is to have 2 units of blood available for any patient with an antibody. As the Blood Bank tech was working on the sample, the physician sent a STAT order for 2 units RBCs for intrapartum hemorrhage.

Are Lewis antibodies clinically significant? AABB defines a clinically significant antibody as one that causes decreased red blood cell survival of transfused cells, one that causes hemolytic transfusion reaction or one that causes Hemolytic Disease of the Fetus and Newborn (HDFN).3 In the Blood Bank, we would always be cognizant of all three criteria, but in this case, we are particularly concerned with HDFN.

The Lewis system is of great interest in immunohematology because of its unique characteristics. The Lewis blood group system is the only one where the antigens are not produced by the red blood cell itself. We learn in immunohematology that red cell antigens are structures that are usually formed on red blood cell membranes, but Lewis stands alone in that the antigens are glycolipids that are formed in the plasma and then passively absorbed onto the red blood cell membrane. This forms a loose attachment and these antibodies can shed or elute off the RBCs in certain circumstances.

Because Lewis antigens are not formed on RBCs, Lewis antigens are not present at birth and therefore not found on cord blood cells. Cord blood and RBCs from newborns will phenotype as Le(a-b-). The saliva of these newborns will have Lea and/or Leb antigens depending on the genes inherited, but the RBCs will test negative for these antigens at birth. By about 10 days of age, the Lewis antigens can be detected in plasma, and they will shortly thereafter begin to be absorbed onto the RBCs. Yet, children do not exhibit their true Lewis phenotype until about age 6.

The development of Lewis antigens is also unique. Lewis antigens are not antithetical, as they result from the interaction of two fucosyltransferases encoded by the Le and Se genes. The Le gene is needed for the production of Lea antigen and the Se gene is needed to form Leb antigen. The three common Lewis phenotypes, Le(a+b-), Le(a-b+) and Le(a-b-) indicate the presence or absence of the Le and Se transferase enzymes.

In pregnancy a mother’s plasma volume increases, and because Lewis antigens are not an integral part of the RBC membrane, they can elute off her RBCs. This causes a decrease in Lewis antigen and some pregnant women, regardless of their true Lewis antigen type, will temporarily type as Le(a-b-). At the same time, because they are now typing Le(a-b-), pregnant women often acquire Lewis antibodies.

Anti-Lea is the most frequently found Lewis antibody, is IgM, and is usually detected at room temperature. In most cases, it is acceptable to give patients with Lewis antibodies RBC units that are crossmatch compatible at 37C without giving antigen negative units. One reason for this is that, as we saw above, Lewis antigens are merely absorbed onto RBCs and can be eluted from transfused red cells within days of transfusion. In addition, when Lewis antigen positive blood is given to Lewis-negative recipients, the Lewis substance in plasma neutralizes antibodies in the recipient. This is why it is extremely rare for anti-Leato cause hemolysis of transfused RBCs. Regardless of Lewis phenotype, RBCs would be expected to have normal in vivo survival.

For an antibody to cause HDFN it must be able to cross the placenta. The antibody must also react with antigens on the red blood cells. Because Lewis antibodies are IgM and do not cross the placenta, and because Lewis antigens are not present on fetal and neonatal erythrocytes, Lewis antibodies have not been implicated in HDFN and this baby is not at risk.

What does this all means in practice? Though the presence of anti-Lewis antibodies in pregnant women is fairly common, both anti-Leaand anti-Leb are naturally occurring IgM antibodies that are not generally considered to be clinically significant. They have low immunogenicity, they do not cause HDFN, they rarely cause hemolysis and do not cause decreased survival of transfused RBCs. This baby is not at risk for HDFN. The mother can safely be transfused with crossmatch compatible RBCs. Her Lea antibodies may be neutralized with a transfusion or will naturally disappear, and her true Lewis phenotype should return within about 6 weeks after delivery.

References

  1. Harmening DM: The Lewis System. In Harmening DM, (6th ed): Modern Blood Banking and Transfusion Practices. FA Davis, Philadelphia 2012, pp. 177-180
  2. Fung, Mark K, ed.: The Lewis System. 18th ed: AABB Technical manual, Bethesda, Md. 2014, pp 304-306
  3. Fung, Mark K, ed.: PreTransfusion testing. 18th ed: AABB Technical manual, Bethesda, Md. 2014, pp 376
  4. D. Radonjic et al, The Presence of antibodies in anti-Lewis system in our pregnant women. Giorn.It.Ost.Gin. Vol. XXXII-n.4.Luglio-Agosto 2010.

 

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-Becky Socha, MS, MLS(ASCP)CM BB CM graduated from Merrimack College in N. Andover, Massachusetts with a BS in Medical Technology and completed her MS in Clinical Laboratory Sciences at the University of Massachusetts, Lowell. She has worked as a Medical Technologist for over 30 years. She’s worked in all areas of the clinical laboratory, but has a special interest in Hematology and Blood Banking. When she’s not busy being a mad scientist, she can be found outside riding her bicycle.

Microbiology Case Study: An 88 Year Old Male with Headache

Case History

An 88 year old male presents with fever, nausea, and headache. The patient reported a diffuse headache accompanied by malaise, fatigue, and nausea without vomiting. He denied confusion, irritability, or a personal and family history of headaches. According to the patient, he frequently attends cookout parties and enjoys fruits, salads, wine, and cheese. Temperature is 38.2 degrees Celsius, blood pressure is 96/65 mmHg, pulse is 102 beats/minute, and respiratory rate is 20 breaths per minute. Physical exam is negative for nuchal rigidity and Kernig sign. Funduscopic exam is negative for papilledema. CBC shows leukocyte count of 16,000/mm3. The patient’s blood culture is positive.

Laboratory Identification

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Image 1. Short gram positive bacilli identified on Gram stain of blood culture (100x oil immersion).
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Image 2. Aerobic growth of round and translucent colonies with a narrow zone of beta hemolysis subcultured from positive blood culture bottle to sheep blood agar plate.

The blood culture was positive for short, gram positive bacilli. Sheep blood agar plate grew round and translucent colonies which have a narrow zone of beta hemolysis as shown on our plate. The organism was catalase positive and motile at 25 degrees Celsius. It showed end over end tumbling motility in a wet prep and an umbrella pattern in semi-solid motility medium. It was identified by MALDI-ToF as Listeria monocytogenes.

Discussion

Listeria monocytogenes is a gram positive bacillus that is isolated from the environment and a variety of animals. It is associated with foodborne outbreaks from dairy and meat products. The most common foods associated with listeriosis outbreaks include unpasteurized raw milk, cold deli meat, hot dogs, raw sprouts, smoked seafood, and soft cheese.1

Listeria commonly infects pregnant women, immunocompromised individuals, and elderly 65 years or older.1 Among pregnant women, Listeria can lead to miscarriages, stillbirths, and newborn meningitis resulting in death.1 In 1985, an outbreak of Listeria due to soft cheese resulted in 142 individuals sick, 10 newborn deaths, 18 adult deaths, and 20 miscarriages.1 Among the immunocompromised and elderly, Listeria can cause septicemia and meningitis. In 2011, a cantaloupe outbreak due to Listeria resulted in 147 people sick in 28 states and 33 deaths.1 The infected population was mostly over the age of 65 years.1 In addition, Listeria can cause acute febrile gastroenteritis in healthy individuals.2 Patients typically present with fever, watery diarrhea, nausea, headache, and pain in joints and muscles.2 Symptoms start 24 hours after the ingestion of bacteria and resolve by themselves in 2 days.2

Treatment of Listeria depends on the severity of symptoms. Although pregnant women with Listeria infection typically present with a self-limited flu-like illness, they are treated with IV ampicillin to prevent infection of the fetus.1 For patients other than pregnant women, the treatment of Listeria infection depends on the severity of symptoms.

References

  1. Information for Health Professionals and Laboratories. (2017, June 29). Retrieved on March 1st, 2018 from https://www.cdc.gov/listeria/technical.html
  2. Say Tat Ooi, Bennett Lorber; Gastroenteritis Due to Listeria monocytogenesClinical Infectious Diseases, Volume 40, Issue 9, 1 May 2005, Pages 1327 1332, https://doi.org/10.1086/429324

 

-Ting Chen, MD is a 1st year anatomic and clinical pathology resident at the University of Vermont Medical Center.

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-Christi Wojewoda, MD, is the Director of Clinical Microbiology at the University of Vermont Medical Center and an Associate Professor at the University of Vermont.

A Snap of the Fingers

In the latest Avengers movie (if you haven’t seen it, beware, there are spoilers ahead), the villain Thanos goes through much trouble to gather all six infinity stones from the far reaches of the galaxy. Once he has them, he snaps his fingers, and half of the people in the universe disappear. While that is not a very nice thing to do, the ability to get something done with a snap of the fingers is very intriguing- especially if that accomplishment could lead to something that improves your lab safety culture. Is that possible? Are there things that can be easily and quickly done that a safety professional can do to help reduce injuries or exposures and improve safety compliance? Of course there are!

One of the easiest safety snaps is a walk-through of the department. If you have developed your “Safety Eyes” enough to see lab safety issues in the department, then the immediate snap fix is taking action to rectify the issue. Many safety issues in the lab are clearly visible, but seeing them is useless if there is no follow-up. If it seems overwhelming, try to pay attention to one thing at a time. On day one, look for PPE issues. Are people wearing the correct shoes? Are their lab coats unbuttoned, or are the sleeves rolled up? What about face protection? Is it used with open specimens and chemicals? Once these issues are seen, make the corrections. On day two, focus on fire safety issues. On day three, look at the physical environment to make sure there are no trip hazards. If you focus on one safety subject each day, you can make quite an impact on safety in just one week. It can be quite powerful.

Another quick snap that can improve a safety culture involves safety drills. Not all drills have to include every staff member and take a long time to complete. Conduct mini drills by asking pointed questions and providing education. Ask one staff member where the spill clean-up kit is located and how to use it. Tell another her computer terminal just caught fire and ask how she would respond.  Tell a co-worker you splashed a chemical in your eyes and need to know the correct first aid response. Ask an employee how to respond if a tornado warning were sounded. If staff is unable to answer these quick quizzes or drills, provide them with the information on the spot. That will lead to a better staff knowledge of safety procedures.

A third quick snap is the five minute review. Many lab safety professionals struggle keeping up with the latest safety regulations and incorporating them to maintain up-to-date procedures. Set aside a quick five minutes every day, whether it is in the morning or at the end of the day. Use that time to peruse safety articles or news stories and updates. Use internet alerts or sign up for safety newsletters to get this information and stay in the know about the latest regulatory changes and updates. Take another five minutes and look at one safety policy each day. Updating all of them can be daunting, and it can be accomplished one fast piece at a time. Use the information you learn about updates and apply it each day to maintain a current set of lab safety procedures.

Lastly, use time with staff as a quick snap to raise safety awareness. Make sure you talk about safety at every staff huddle, at meetings, and even at on-on-one interactions. It doesn’t take long to bring up a safety topic or to tell a safety story at each meeting. You can even staff about their perception of the safety culture in conversations, in passing or during an annual evaluation. These quick injections of safety into these staff interactions are a powerful tool to raise safety awareness and to let the staff know where safety stands with departmental priorities.

While it would be fantastic if one snap of the fingers using magical stones could fix all lab safety problems, it’s not very realistic. However, even though the safety culture challenges in some labs seem daunting, if tackled one at a time, bit by bit every day, significant progress can be made. Choose one of the quick snaps above this week, and you will be surprised at the difference that can be made by the end of the week. Gather a team of “Safety Avengers,” and the process will go even faster!

 

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Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.

Microbiology Case Study: A 45 Year Old Woman with Breast Abscess

Case History

Our patient is a 45-year-old female who presents to the Emergency department with breast pain. She was diagnosed with granulomatous mastitis 3 months prior. She was treated with 3 weeks of steroids, but they were stopped when the mass was unchanged and the patient was experiencing increasing breast tenderness. Since then she and has undergone several procedures to drain her right breast abscess, the most recent being five days prior. The woman has been treated with sequential courses of sulfamethoxazole–trimethoprim and metronidazole without improvement. On this visit, the abscess was again drained and sent to the microbiology laboratory for culture. The Gram stain showed no bacteria and 3+ polymorphonuclear cells. After 48 hours incubation there was scant growth on the blood agar plate and no growth on the chocolate, MacConkey or CNA plates. The colonies growing on the blood plate were tiny, white, and lipophilic (Image 1).

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Image 1. Small, white, lipophilic colonies growing on blood agar plate at 48 h incubation.  There was no growth of this organism on chocolate or MacConkey agars this time point.

Discussion

The organism was identified as Corynebacterium kroppenstedtii.

Colonies on the blood agar plate were identified as Corynebacterium kroppenstedtii using MALDI-TOF mass spectrometry for identification. C. kroppenstedtii is catalase positive, non-motile and a facultative anaerobe. It grows better on 5% sheep blood agar than chocolate agar, as is the case for many Corynebacterium spp. Corynebacterium come in two varieties, lipophilic such as Corynebacterium jeikeium, and luxuriantly growing, such as Corynebacterium straitum. C. kroppenstedtii is part of the former lipophilic group, forming small colonies after extended incubation.  Lipids such as Tween-80 can added to the media to improve growth of lipophilic Corynebacterium such as C. kroppenstedtii, but clinically this is not routinely performed. When viewed on a gram stain, the bacteria are rod-shaped gram positive diptheroids with typical coryneform morphology. Both MALDI-TOF and 16S rRNA sequencing can accurately identify C. kroppenstedtii to the species level.

C. kroppenstedtii is a relatively newly recognized species within the Corynebacterium genus. It was first described in a case series of young Polynesian women with histological evidence of lobar mastitis, from which C. kroppenstedtii was identified from >40% of the patients’ abscesses. Since that time, isolation of C. kroppenstedtii has been clinically associated with breast abscesses and granulomatis mastitis. C. kroppenstedtii is a highly lipophilic bacterium. Its cell wall lacks many mycolic acids, which may explain its propensity to grow in lipid-rich sites such as mammary glands. C. kroppenstedtii typically affects women of reproductive age and can be difficult to diagnose due to the slow growing nature of the lipophilic organism and the relatively few organisms present in abscess specimens.

Prior to identification by MALDI-TOF MS and 16s rRNA sequencing this patient’s culture would have been reported as rare or 1+ “dipthroid,” “coryneform,” or “Corynebacterium spp.” Without knowing the clinical significance of this organism, the culture results could easily be dismissed as contaminating skin flora.

It is very difficult to treat C. kroppenstedtii in abscesses, with the most effective treatment requiring both surgical drainage of the abscess and long term antibiotic use. It is fairly difficult to get antibiotics to the site of infection, so antibiotics that test as susceptible in the laboratory may not eradicate the pathogen. Our patient’s isolate of C. kroppenstedtii was susceptible to ciprofloxacin, clindamycin, doxycycline, and intermediate to penicillin. She remains on ciprofloxacin therapy, but has ongoing right breast tenderness. She had another surgical drainage of her breast abscess a week after this case, and the culture also grew 1+ C. kroppenstedtii with 3+ PMN seen on Gram stain, so her infection has not yet been resolved.
References

  1. Tauch, Andreas, et al. “A Microbiological and Clinical Review on Corynebacterium Kroppenstedtii.” International Journal of Infectious Diseases, vol. 48, 2016, pp. 33–39., doi:10.1016/j.ijid.2016.04.023. ScienceDirect.
  2. Johnson, Matthew G., et al. “The brief case: recurrent granulomatous mastitis due to Corynebacterium kroppenstedtii.” Journal of clinical microbiology 54.8 (2016): 1938-1941.
  3. Paviour, Sue, et al. “Corynebacterium species isolated from patients with mastitis.” Clinical Infectious Diseases 35.11 (2002): 1434-1440.

 

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-Carolyn Wiest, MT(ASCP) graduated from Michigan State University with a BS in molecular genetics and is a medical technologist at NorthShore University HealthSystem.  Her interests are in microbiology and molecular diagnostics. 

-Erin McElvania, PhD, D(ABMM), is the Director of Clinical Microbiology NorthShore University Health System in Evanston, Illinois.

The Syncytial Variant: A High-Risk Subgroup Amongst the Traditionally Well-Behaved Classic Nodular Sclerosis Hodgkin Lymphomas

Lymphoid neoplasias are traditionally categorized as Hodgkin Lymphomas or Non-Hodgkin Lymphomas. Hodgkin Lymphomas are typically characterized by both expansive reactive lymphocytes and a paucity of the interspersed, malignant Reed-Sternberg (RS) Cell. These RS cells are large neoplastic B-Cell variants with ‘owl-eye’ nucleoli within multilobed nuclei. The background reactive lymphocytes are non-neoplastic cells drawn by secreted RS cytokines (IL-5, IL-6, IL-13, TNF, and GM-CSF), which often result in presenting B symptoms (fevers, chills, and night sweats). Histiocytes, granulocytes, and plasma cells are also commonly identified. Confirmatory immunohistochemistry staining for RS cells involves CD30 positivity, CD15 positivity, and negativity for CD20 and LCA (CD45) staining. The two major types of Hodgkin Lymphoma are recognized as Nodular Lymphocyte Predominant Hodgkin Lymphoma (NLPHL) and Classic Hodgkin Lymphoma (CHL). In NLPHL, B-Cell immunophenotype is generally preserved and is histologically recognized by a nodular predominance of small lymphocytes and RS cell variants, called lymphocyte predominant (LP) or popcorn cells (formerly called L&H cells for lymphocytic and/or histiocytic RS cell variants), which exhibit muted, lobed nuclei and smaller nucleoli. The Classic Hodgkin Lymphomas are categorized histologically as Nodular Sclerosis CHL (NSCHL), Lymphocyte Rich CHL (LRCHL), Mixed Cellularity CHL (MCCHL), and Lymphocyte Depleted CHL (LDCHL).

Nodular Sclerosis Classic Hodgkin Lymphoma (NSCHL) comprises over 70% of all CHL and is characterized by broad, fibroblast-poor collagen banding surrounding at least one nodule and by RS cells with lacunar morphology. The RS cells tend to have a larger amount of cytoplasm than those in other types of classic Hodgkin lymphoma. When fixed in formalin, this excess cytoplasm causes their membranes to retract so that the cells seem to be sitting in lacunae. Typically, EBV association is uncommon, CD30 is almost always expressed, CD15 is expressed in 75-85% of cases, and PAX5 is weakly positive. Most cases do not express T-Cell antigens (CD4, CD3, CD8), but when they do (~5% of cases), they can be difficult to distinguish from ALK-negative Anaplastic Large Cell Lymphomas (PAX5 positivity can help to rule out ALCL). True T-cell marker expression on RS cells has been seen (usually weak) and is associated with a poorer prognosis.

Two histologic variants of NSCHL have been proposed: a fibrocystic variant (FV) and a syncytial variant (SV). The FV contains abundant fibroblasts and histiocytes in the setting of difficultly identified RS cells. The SV describes the finding of RS cells in prominent, sheet-like aggregates forming cohesive lacunar nests in the center of nodules (Figure 1). The SV represents 5-16% of all cases of NSCHL (Ben-Yehuda-Salz et al. 1990), though some suspect it may be as high as 25% (Sethi, T., et al. 2017).

Advancements in chemoradiation therapies have improved the long-term survival of patients of with CHL. Today, more than 85% of patients with early stage CHL will be cured of the disease (Ansell, S., et al. 2014). The 5-year overall survival for early stage CHL is 95% and for advanced disease is 82%. Overall, the prognosis of NSCHL is better than that of other types of CHL.

Initial studies examining the prognostic significance of grading of NSCHL based on cytological and tumor microenvironment features showed an association of higher grade (based on the British National Lymphoma Investigation (BNLI) criteria (Bennett et al. 1981; MacLennan et al. 1989)) with a poorer prognosis (MacLennan et al. 1989; Wijlhuizen et al. 1989; Ferry et al. 1993). However, since the advent of combination chemotherapy and the relatively good prognosis of NSCHL today, the significance of such grading or further classification has been called into question. Importantly, grading based on proposed histological features has declined in the last two decades because such advances in therapy can actually obscure the differences seen in less-effectively treated patients. As such, grading is not currently deemed necessary for routine clinical purposes.

Despite the broadly recognized clinical favorability of NSCHL, slowly accumulating evidence of poor clinical outcomes associated with the syncytial NSCHL histological variant is only now beginning to declare itself with strong evidence. While BNLI grading may no longer be a useful clinical tool, variant typing may instead prove effective as both a prognostic and alternative treatment indicator.

Small case studies have reported aggressive disease in SV NSCHL since the first histologic case was described. Clinical behavior has included presenting with a considerable mediastinal mass, significant B symptoms, and advanced stage at diagnosis. Despite these case reports, it was not until recently that systematic analysis of progression free survival and complete therapy response among morphology and immunophenotype SV confirmed cases in patients with similar treatment regimens (combination doxorubicin, bleomycin, vinblastine, and dacarbazine, or ABVD) was conducted (Sethi, T., et al. 2017).

Sethi, T., et al evaluated 167 patients with NSCHL: 43 patients with SV were compared with 124 patients with typical NSCHL on patient characteristics, disease variables, treatment administered, and outcome at Vanderbilt University Medical Center between 1995 and 2014. The rate of complete treatment response was lower in the SV variant as compared with typical NSCHL with standard induction therapy, 74% versus 87% (p= 0.05). Patients with SV had a shorter progression free survival and experienced disease relapse. The median progression free survival for the entire cohort was 174.7 months. The median progression free survival in the SV group was 17.02 months which was significantly shorter compared with that of the typical NS group, which was not reached (p < 0.0001).

The BNLI criteria for the grading of NSCHL (Grades I-II) are based on the amount of sclerosis, the degree of nodular cellularity, and the number of atypical neoplastic cells. Most SV cases are grade II because of the number of atypical cells present. However, most grade II cases are not syncytial variants. Therefore, BNLI grade alone is not an accurate depiction of the clinicopathologic features of this disease. In the same way, it may also not be the best determinant of disease prognosis, therapeutic indication, or investigative classification.

Patients with Syncytial Variant Nodular Sclerosis Classic Hodgkin Lymphoma experience a lower than expected rate of complete therapeutic response with shorter progression-free than non-SV NSCHL treated with standard therapy. Syncytial Variant NSCHL should therefore be recognized as a high-risk subgroup within the otherwise traditionally docile NSCHL classification. It is time the SV finally be considered a true histopathologic variant in future trials involving novel agents to assess treatment response. While a majority of patients with SV NSCHL can likely be successfully salvaged with high-dose therapy and autologous stem cell transplantation, studies of novel agents such as conjugated antibodies or immunotherapeutic agents should be considered in these patients to improve complete response rates and to avoid the need for toxic salvage therapies.

References

  1. Sethi T., et al. Differences in outcome of patients with syncytial variant Hodgkin lymphoma compared with typical nodular sclerosis Hodgkin lymphoma. (2017) Ther. Adv. Hematol. 8(1):13-20.
  2. Granot, N., et al. Syncytial variant of nodular sclerosing Hodgkin lymphoma in children: A prognostic factor? (2018) J. Ped. Hem. & Onc. 35;1:33-36.
  3. Ansell, S. (2014) Hodgkin lymphoma: 2014 update on diagnosis, risk stratification, and management. Am J Hematol 89: 771–779.
  4. Bennett, M., Maclennan, K., Easterling, M., Vaughan Hudson, B., Jelliffe, A. and Vaughan Hudson, G. (1983) The prognostic significance of cellular subtypes in nodular sclerosing Hodgkin’s disease: an analysis of 271 non-laparotomised cases (BNLI report no. 22). Clin Radiol 34: 497–501.
  5. Ben-Yehuda-Salz, D., Ben-Yehuda, A., Polliack, A., Ron, N. and Okon, E. (1990) Syncytial variant of nodular sclerosing Hodgkin’s disease. A new clinicopathologic entity. Cancer 65: 1167–1172.
  6. Ferry, J., Linggood, R., Convery, K., Efird, J., Eliseo, R. and Harris, N. (1993) Hodgkin disease, nodular sclerosis type. Implications of histologic subclassification. Cancer 71: 457–463.
  7. Maclennan, K., Bennett, M., Tu, A., Hudson, B., Easterling, M., Hudson, G. et al. (1989) Relationship of histopathologic features to survival and relapse in nodular sclerosing Hodgkin’s disease. A study of 1659 patients. Cancer 64: 1686–1693.
  8. Wijlhuizen, T., Vrints, L., Jairam, R., Breed, W., Wijnen, J., Bosch, L. et al. (1989) Grades of nodular sclerosis (NSI-NSII) in Hodgkin’s disease. Are they of independent prognostic value? Cancer 63: 1150–1153.
  9. Strickler, J., Michie, S., Warnke, R. and Dorfman, R. (1986) The “syncytial variant” of nodular sclerosing Hodgkin’s disease. Am J Surg Pathol 10: 470–477.
  10. Van Spronsen, D., Vrints, L., Hofstra, G., Crommelin, M., Coebergh, J. and Breed, W. (1997) Disappearance of prognostic significance of histopathological grading of nodular sclerosing Hodgkin’s disease for unselected patients, 1972–92. Br J Haematol 96: 322–327.
  11. Hess, J., Bodis, S., Pinkus, G., Silver, B. and Mauch, P. (1994) Histopathologic grading of nodular sclerosis Hodgkin’s disease. Lack of prognostic significance in 254 surgically staged patients. Cancer 74: 708–714.
  12. Darabi, K., Tester, W., Daskal, I. and Cohn, J. (2015) Syncytial variant of nodular sclerosing Hodgkin’s disease. Blood 104: 4533–4533.

Austin Headshot

-Austin McHenry is an M3 at Loyola University Stritch School of Medicine in Maywood, IL. Austin is past-president of the pathology intrest group SCOPE (Students Curious about Outrageous Pathology Experiences) and is a recent recipient of ASCP’s Academic Excellence and Achievement in Pathology Award. Follow Austin on Twitter @AustinMcHenry

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-Kamran M. Mirza, MD PhD is an Assistant Professor of Pathology and Medical Director of Molecular Pathology at Loyola University Medical Center. He was a top 5 honoree in ASCP’s Forty Under 40 2017. Follow Dr. Mirza on twitter @kmirza.

Ebola 2018

Approximately two years after Liberia, the hardest hit and last of the 6 countries to be affected in the largest Ebola outbreak since discovery of the disease in 1976, was declared Ebola-free, the virus has again reared its head. This time, its in the Democratic Republic of the Congo (DRC).

Timeline of the Outbreak:

  • May 3, 2018: a district in the Province of Equateur, DRC, reported 21 cases of undiagnosed illness with 17 deaths. Samples from 5 of these cases were sent to the Institute National Recherche Biomedicale in Kinshasa.
  • May 7: Ebola virus was confirmed by RT-PCR.
  • May 8, 2018: Ebola outbreak declared.
  • May 21: 628 contacts of confirmed or suspected cases listed.
  • May 25: 58 cases and 27 deaths.
  • June 1: the outbreak is contained in the Province of Equateur. This Province covers an area of 130442 km2 and has a population of 2,543,936. Equateur as 16 health zones and 284 health centers – this works out as 1 health center for every 9,000 people! The WHO warns that this outbreak has the potential to expand, and while at the moment there is no international spread, the Congo’s neighbors have been placed on alert. The WHO has distributed personal protective equipment, infrared thermometers, and rapid diagnostic tests to health centers in Equateur as well as neighboring countries.

The WHO considers laboratory diagnostics on of the pillars of the Ebola response. They recommend “strengthening diagnostic capabilities” as part of a strategic approach to the prevention, detection, and control of Ebola. In fact, laboratory diagnostics might be a key to how this epidemic plays out, versus the previous outbreak in West Africa wherein six African countries were affected and over 11,000 patients died. This time, there are rapid tests tests available ranging from lateral flow to molecular.

As part of the DRC’s National Laboratory Strategy developed in response to the outbreak, the GeneXpert confirmatory Ebola PCR test is being used a key sites in mobile laboratories. As of June 1, the WHO has deployed four mobile labs through out Equateur including the epicenter of the outbreak. Government Health Centers are equipped with rapid lateral flow tests: the ReEBOV Antigen Rapid Test released under Emergency Use Approval in 2015. According to WHO documents, this test has a sensitivity of 91% and specificity of 84.6%. Both positives and negatives should be confirmed with RT-PCR. The following is the guidance for the use of rapid tests:

Special settings where rapid antigen for Ebola may be beneficial:

  1. In the investigation of suspected Ebola outbreaks in remote settings where PCR tests are not immediately available. While awaiting confirmatory testing, action can be taken to: a) isolate test-positive patients, b) repeat daily testing on patients who initially tested negative but remain symptomatic, c) mobilize transport of samples for confirmatory testing and initiate outbreak-management procedures.
  2. In settings where the number of cases and suspects arriving for triage and care cannot be managed with the existing health staff and laboratory facilities.

Example situations where rapid antigen detection tests should NOT be used:

  • Individual case management – including for establishing definitive diagnosis or making therapeutic decisisions
  • Certification of Ebola virus-free status prior to medical care for other illnesses
  • Release of Ebola patients from Ebola Treatment Centers
  • Pooled blood samples for community-based testing
  • Testing blood before transfusion
  • Active case finding without confirmatory PCR
  • Any setting where action (quarantine, referral, care) based on results is not possible
  • Airport screening

So to summarize, currently in the Province of Equateur, suspected cases are tested by rapid test for initial triage, then samples are sent to the nearest lab for confirmation (positive or negative) by PCR. A suspected case cannot be released until there is a negative test by PCR. Suspected cases that initially negative by the rapid test are isolated from cases that are initially positive.

What about outside Equateur? I talked to Dr. Tim Rice, a friend and colleague serving as a missionary physician in Vanga, Congo. Vanga is the in Province of Bandundu, the northern neighbor of Equateur. While this province has not had a reported case of Ebola, they are getting ready. I asked him about their readiness plan and any laboratory capabilities they had. They have a rapid test: Ebola rapid lateral flow test from STADA Diagnostik (Germany). This assay detects the Ebola virus antigen VP 40 with a sensitivity of 92% and specificity of 98% (according to the package insert). Serum and throat swabs are acceptable specimens, although it is not clear which matrix was used to determine the performance characteristics. The package insert states that the performance characteristics are still being evaluated. Dr. Rice said they use the rapid test with patients with potential exposure and severely ill with fever.  Someone arriving from the Equatorial province with a fever, even if not severely ill, would be tested and isolated. They are to call the local health department for help in obtaining the correct confirmatory samples, properly storing the sample, alerting the regional and national leaders, and transporting the sample properly protected the 10 hours overland to Kinshasa for confirmatory PCR testing at the Institute National Recherche Biomedicale.

The response to the 2018 Ebola outbreak has been impressive and I sincerely hope that with the benefits of laboratory diagnostics and a vaccine, the world will be spared the devastation experienced in the previous outbreak.

 

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Sarah Riley, PhD, DABCC, is an Assistant Professor of Pediatrics and Pathology and Immunology at Washington University in St. Louis School of Medicine. She is passionate about bringing the lab out of the basement and into the forefront of global health.