Month: December 2023

Microbiology Case Study: Disseminated Disease Confirmed by Bone Marrow Biopsy in a Patient with HIV

Case History

A 35 year old female patient with a past medical history of uncontrolled HIV, retinitis caused by cytomegalovirus and recurrent colitis presented to the Emergency Department with body pain, fever, severe neutropenia, and diarrhea. CT scan revealed worsening sigmoid/rectal wall thickening. Patient also presented with esophageal candidiasis. Blood workup revealed that the patient had sickle cell disease (HBSC), anemia (Hgb 5.6 gm/dl) that required multiple transfusions, and elevated white blood cell count (up to 17,000). The patient also had leukopenia (neutropenia and lymphopenia), which, in addition to the anemia without hemolysis or bone marrow compensation and CD4 count <50, led to strong suspicious of disseminated mycobacteria infection.  A bone marrow biopsy was performed and AFB staining revealed loose granulomas and numerous acid-fast bacilli seen. Culture of the bone marrow grew out acid-fast bacilli further identified as Mycobacterium avium complex (MAC).

Discussion

Mycobacterium avium complex (MAC) is made up of several nontuberculosis mycobacterial (NTM) species that require genetic testing to be speciated.1 MAC is predominantly made of the slow-growers mycobacteria (SGM) such as M. avium, M. intracellulare, M. chimaera, and M. colombiense.2,3 Most species of nontuberculosis mycobacteria are found in environmental sources. The MAC organisms are found throughout the environment, particularly in the soil and water, mainly in the Southeast of the United States.1 Human diseases are most likely from exposure to environmental sources either through direct inhalation, implantation or indirect consumption or contamination food or water. MAC is considered the most commonly encountered group of slow growers.

The MAC cause pulmonary disease that is clinically similar to tuberculosis, mostly in immunocompromised patients with CD4 cell counts less than 200/μL, such as those with HIV/AIDS. They are the most frequent bacterial cause of illness in patients with HIV/AIDS and immunosuppression.1,4  MAC is also the most common nontuberculosis mycobacterial species responsible for cervical lymphadenitis in children. Additionally, hypersensitivity pneumonitis-like symptoms can occur which were initially thought to be an allergic reaction only, but current studies suggests infection and inflammation. Traditionally, MAC cause chronic respiratory disease, populations such as middle-aged male smokers and postmenopausal females with bronchiectasis (also known as Lady Windermere syndrome). 

Diagnostic testing for pulmonary infection caused by MAC includes acid-fast bacillus (AFB) staining and culturing of the appropriate specimens. Respiratory specimens are the most commonly tested specimen type. If disseminated MAC (DMAC) infection is suspected, culture specimens should include blood and urine. Blood cultures are typically used to confirm the diagnosis of DMAC in an immunocompromised patient with clinical signs and symptoms 5. MAC can also be isolated from bodily fluids and other tissues, such as lymph nodes and bone marrow. If diarrhea is present, stool cultures can be collected. Skin lesions should be cultured if clinically warranted. To determine pulmonary involvement, imaging studies of the chest should be performed. Lymph node biopsy or complete lymph node excision is usually used to diagnose MAC lymphadenitis in children. Skin testing (MAC tuberculin test) has little value in establishing a diagnosis.6 Routine screening for MAC in respiratory or GI specimens is not recommended.

Organisms part of the MAC are not stained well by the dyes used in Gram stain, but instead are acid-fast positive. The ability of an organism to hold onto the carbol-fuchsin stain after being treated with a mixture of ethanol and hydrochloric acid is referred to as “acid-fast.” The high lipid content (around 60%) in mycobacteria’s cell wall makes them acid-fast. SGM require more than 7 days of incubation.  Growth of M. avium species can be visualized in both LJ and 7H11 media 5. Colony morphology can be smooth or rough. Biochemical reactions to both niacin and nitrate reduction are negative. Upon growth, colonies can be identified using the MALDI-TOF mass spectrometry 6. However, depending on the database and technology used, reports from the MALDI-TOF may report MAC as M. avium complex or into the individual subspecies. Molecular techniques such as polymerase chain reaction or whole genome sequencing, as well as high-performance liquid chromatography, are required for species identification. Direct detection of nucleic acid in clinical specimens by PCR methods have been reported, although most tests are laboratory-developed and FDA-approved. Molecular technologies typically target the 16S rRNA gene, the 16S-23S internal transcribed spacer (ITS) region or the heat shock protein 65 (hsp65) gene. Prior to PCR, the AccuProbe test was the first commercial molecular assay for identification of mycobacteria by targeting 16S RNA 7. In Japan, an enzyme immunoassay (EIA) kit was used to detect serum IgA antibodies to MAC-specific glycopeptidolipid core antigen. This could be useful for serodiagnosis of pulmonary infections caused by the MAC. This EIA kit’s sensitivity and specificity have been reported to be 54-92% and 72-99%, respectively 8. Other serologic tests are also being investigated. 

While this may not aid in the direct detection of MAC infection, a complete blood count (CBC) in DMAC patients frequently shows anemia and, on rare occasions, pancytopenia due to bone marrow suppression caused by the infection, though either leukocytosis or leukopenia may be present. Hypogammaglobulinemia may be another possibility 9. Patients with DMAC typically have elevated transaminase and alkaline phosphatase levels on liver function tests. An HIV test should be performed if pulmonary or disseminated MAC infection is suspected.

            MAC is extremely resistant to antituberculosis medications, and a combination of up to six medications is often needed for effective treatment. The preferred medications at the moment are ciprofloxacin, rifabutin, ethambutol, or azithromycin combined with one or more of these other medications 4. For patients with HIV, azithromycin is currently advised as a preventative measure. Of note, preventive treatment of MAC colonization in asymptomatic patients is also not advised. The Clinical and Laboratory Standards Institute (CLSI) recommends performing antimicrobial susceptibility testing using broth microbroth dilution technique. Breakpoints for clarithromycin, amikacin, moxifloxacin, and linezolid are reported 10. Although ethambutol, rifampin, and rifbutin are useful, no official breakpoints are available as there are no strong correlation studies showing the relationship between minimal inhibitory concentrations (MIC) and clinical outcomes.

Figure 1. Acid-fast staining of the bone marrow aspirate revealed many acid-fast bacilli (left, 100X; right, 50X).

References

1.            Akram SM, Attia FN. Mycobacterium avium Complex. StatPearls. Treasure Island (FL) ineligible companies. Disclosure: Fibi Attia declares no relevant financial relationships with ineligible companies.: StatPearls Publishing Copyright © 2023, StatPearls Publishing LLC.; 2023.

2.            Miskoff JA, Chaudhri M. Mycobacterium Chimaera: A Rare Presentation. Cureus. 2018;10(6):e2750.

3.            Murcia MI, Tortoli E, Menendez MC, Palenque E, Garcia MJ. Mycobacterium colombiense sp. nov., a novel member of the Mycobacterium avium complex and description of MAC-X as a new ITS genetic variant. International journal of systematic and evolutionary microbiology. 2006;56(Pt 9):2049-2054.

4.            Kwon YS, Koh WJ, Daley CL. Treatment of Mycobacterium avium Complex Pulmonary Disease. Tuberculosis and respiratory diseases. 2019;82(1):15-26.

5.            Hamed KA, Tillotson G. A narrative review of nontuberculous mycobacterial pulmonary disease: microbiology, epidemiology, diagnosis, and management challenges. Expert review of respiratory medicine. 2023:1-16.

6.            Body BA, Beard MA, Slechta ES, et al. Evaluation of the Vitek MS v3.0 Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry System for Identification of Mycobacterium and Nocardia Species. Journal of clinical microbiology. 2018;56(6).

7.            Ichiyama S, Iinuma Y, Yamori S, Hasegawa Y, Shimokata K, Nakashima N. Mycobacterium growth indicator tube testing in conjunction with the AccuProbe or the AMPLICOR-PCR assay for detecting and identifying mycobacteria from sputum samples. Journal of clinical microbiology. 1997;35(8):2022-2025.

8.            Hernandez AG, Brunton AE, Ato M, et al. Use of Anti-Glycopeptidolipid-Core Antibodies Serology for Diagnosis and Monitoring of Mycobacterium avium Complex Pulmonary Disease in the United States. Open forum infectious diseases. 2022;9(11):ofac528.

9.            Gordin FM, Cohn DL, Sullam PM, Schoenfelder JR, Wynne BA, Horsburgh CR, Jr. Early manifestations of disseminated Mycobacterium avium complex disease: a prospective evaluation. The Journal of infectious diseases. 1997;176(1):126-132.

10.         CLSI. [Performance Standards for Susceptibility Testing of Mycobacteria, Nocardia spp., and Other Aerobic Actinomycetes, 1st ed. CLSI M62. Clinical and Laboratory Standards Institute; 2018

-Dr. Abdelrahman Dabash is currently a PGY-2 pathology resident at George Washington University. He was born in Dakahlia, Egypt, and was raised in Al-Khobar, KSA. He attended the Faculty of Medicine at Cairo University, where he received his doctorate degree. He worked as an NGS analyst for 2 years prior to coming to GWU. His academic interests include Gastrointestinal pathology, hematopathology, and molecular pathology. In his spare time, he enjoys playing soccer, swimming, engaging in outdoor activities, and writing Arabic calligraphy. Dr. Dabash is pursuing AP/CP training.

-Rebecca Yee, PhD, D(ABMM), M(ASCP)CM is the Chief of Microbiology, Director of Clinical Microbiology and Molecular Microbiology Laboratory at the George Washington University Hospital. Her interests include bacteriology, antimicrobial resistance, and development of infectious disease diagnostics.

Undetermined, Undetermined

I like to think most people who go into healthcare professions do so with the hope of helping others. For those of us who do autopsies, the greatest sense of reward comes when we can explain to someone how and why their loved one died. Inevitably, though, there will be situations where we need to accept what we don’t know – despite how disappointing it may be. In these situations, the most intellectually honest course of action is to issue a manner of “undetermined.”

Let’s recap briefly what we know about manners of death (see https://labmedicineblog.com/2022/11/25/please-dont-tell-me-i-died-of-cardiac-arrest/ for a more in-depth discussion). Manner of death describes the circumstances in which the cause of death is sustained, and there are five choices in most jurisdictions – natural, accident, homicide, suicide, or undetermined. Natural deaths are those due entirely to non-traumatic diseases (like cancer or coronary artery disease). Accidental deaths involve trauma or toxicity without an intention to harm. Homicide is death at the hands of another person, whereas suicide is death at one’s own hands. The final option is undetermined.

There are two main pathways by which we can arrive at an “undetermined” manner. There can either be 1) reasonable competing evidence between two manners of death, or 2) we may be unable to identify a cause of death due to loss or destruction of bodily tissue. Let’s look at some examples.

In the first pathway, consider an autopsy of a person with a single gunshot wound to the head. In a readily accessible region like the temple or beneath the chin, this wound could easily be self-inflicted. While this would be a “typical” location for a suicidal injury, such a wound could also be inflicted by another person. There are indicators we look for at autopsy which favor one scenario over the other. For example, most suicidal gunshot wounds (broadly speaking, of course) are contact wounds or intra-oral. A self-inflicted gunshot wound to the back of the head would be unusual, but (contrary to popular conception), not impossible depending on the firearm used. However, the same type of pattern could be elicited with another person holding a firearm to that individual’s head. We may examine the length of the firearm to determine if it’s possible for the decedent to have pulled the trigger themselves (keeping in mind that other items like a cane, coat hanger, or even the decedent’s toe, may have been used to depress the trigger). Similar questions can arise in autopsies of people who have fallen from height. There is no way an autopsy can tell with certainty whether an individual was pushed, fell accidentally, or left the edge of an elevated structure intentionally. The cause of death in both situations is undisputed – a gunshot wound in the first, and blunt force injuries in the second. This is why contextual information, like scene photographs and investigative records, is indispensable for forensic pathologists. Without context, we have no way to discern homicides, suicides, and accidents. Occasionally even with context, there can be competing narratives (one witness claims a gunshot wound was self-inflicted, while another claims it was inflicted by the first) or suspicious circumstances to cast doubt. Without clear cut evidence to support one story, the manner of undetermined is appropriate.

The second pathway by which we reach an undetermined manner is when extensive decomposition or other soft tissue loss (such as fire damage) interferes with our ability to determine a cause of death. Think of completely skeletal remains discovered in an abandoned building. Sometimes, indicators of potentially lethal injuries can still be identified – for example, a gunshot wound of the skull or knife marks on a rib. But, as the aphorism goes, “an absence of evidence isn’t necessarily evidence of absence” – a bullet or blade could be lethal while only striking soft tissue (especially in regions like the abdomen or neck). If we cannot rule out non-natural causes of death, the best choice for manner is “undetermined.”

An undetermined manner of death can understandably frustrate family members or law enforcement. I always try to explain that manner determinations are, as one of my mentors says, “written on paper and not in stone.” We reserve the right to change the ruling in the future if additional evidence comes to light. As forensics pathologists our primary responsibility is to speak honestly and truthfully, and sometimes that means admitting the limitations of our science.

-Alison Krywanczyk, MD, FASCP, is currently a Deputy Medical Examiner at the Cuyahoga County Medical Examiner’s Office.

Microbiology Case Study: A Case of Alpha-Gal Syndrome and Information on the Lone Star Tick

A 72 year old male presented to UVMMC in July, after being found unconscious and not breathing in his home. The patient presented with swelling of the throat and tongue, which had obstructed his airway. In addition to the swelling, the patient also presented with a hive-like rash along his upper torso and arms along with low blood pressure. The patient was successfully treated by an injection of epinephrine and asked about food allergies, as his clinical presentation was indicative of anaphylaxis. Having declared no food allergies, the patient was asked what he had eaten before the episode, noting that he had a beef burger for dinner hours earlier, which was not unusual for his diet. The attending physician noted the time between the man’s last meal and symptoms of anaphylaxis, which seemingly ruled out a food allergy. The patient was eventually discharged home, with recommendations to monitor his diet and return if symptoms resumed.

Two days later, the patient returned to UVMMC with coughing, shortness of breath, swelling of his tongue and throat, and heartburn. Once again, the patient was treated with injectable epinephrine, which alleviated his symptoms. When asked again about his diet, the man mentioned that hours earlier at dinner he had pork chops, which was also not unusual for his diet. Upon closer examination, a circular rash was observed on the patient’s right shoulder and the patient was tested for Lyme Disease. While awaiting the results of the test, the patient was asked about any exposures to ticks. Upon the mention of tick exposure, the man recalled seeing one a week prior crawling on his arm while he was watering his garden. Insisting that he did not feel a bite and quickly brushed the tick off of his arm, the man described the tick as being brown with a singular white dot on the center of its body. When the Lyme Disease test returned negative, the attending physician ordered a blood test, looking for specific antibodies to alpha-gal. The test returned positive, and the man was diagnosed with Alpha-Gal Syndrome (AGS) from exposure to a Lone Star Tick (Amblyomma americanum) bite. The patient was then referred to an allergist for symptom management.

Figure 1. Image of the rash discovered on the patient’s right shoulder

Lone star ticks (Amblyomma americanum) are aggressive human-biting ticks that actively seek out potential hosts through the use of CO2 trails and vibrational movements.4 This strategy is a distinct behavior when compared to other tick species that commonly employ the ‘ambush strategy’ involving lying in wait for a potential host to pass by.4,5 A complete life cycle for a lone star tick involves three distinct stages, including a larval, nymph and adult stage.3 While the bite of a larval tick is considered less dangerous due to it feeding for the first time and being less likely to have exposure to infected hosts, there is a risk that certain pathogens can be passed from the mother tick to the larvae.4 All three stages of the Lone Star tick’s life cycle require a blood meal from three different hosts, and all stages will feed on humans along with other vertebrate animals.3 These ticks live primarily in areas of woodlands where there is plenty of undergrowth and tall grasses.5

Due to changes in the climate, such as shorter, milder winters and an increased abundance of preferred hosts, the Lone Star tick has increased in both abundance and distribution over the last several decades.3 Despite these concerning trends, these ticks are commonly found throughout the eastern, southeastern, and south-central regions of the United States.3 Because Lyme Disease places such a huge burden on public health populations, the Lone Star tick is often overshadowed in public health messaging by black-legged ticks such as “deer” ticks (Ixodes scapularis) due to their Lyme-carrying abilities.4 In contrast, the Lone Star tick is incapable of transmitting the spirochete that causes Lyme Disease (Borrelia burgdorferi)3, which is a reason why the patient’s blood test was negative for the pathogen in the current case.

Despite being incapable of carrying Lyme Disease, symptoms associated with a Lone Star tick bite may present similarly to that of Lyme Disease including the presence of a rash on the skin.3,4 While similar, this rash is considered distinct from the rash observed in Lyme Disease and has been termed Southern Tick-Associated Rash Illness (STARI).3 While the specific etiologic agent has not yet been identified, the rash is often accompanied by fatigue, headache, fever, and muscle pains and will usually present within seven days of a tick bite.3 While no diagnostic test is available to distinguish STARI from Lyme disease, diagnosis is usually based on symptoms, geographic location, possibility of a tick bite, and the presentation of the rash which is typically a red circle expanding to around 8cm in diameter.3

Lone Star ticks can transmit a variety of bacterial and viral pathogens, but they are most commonly associated with Alpha-Gal Syndrome (AGS).2,3,4,5 Alpha-Gal refers to the sugar molecule galactose-alpha 1,3-galactose, which is commonly found in most mammals except people, fish, reptiles, and birds.2 The sugar molecule is found in meats (pork, beef, rabbit, lamb, venison, etc.), as well as in mammalian products such as gelatin, cow’s milk, or milk products.2 Lone Star ticks transmit this sugar to humans by feeding on hosts and maintaining trace amounts of alpha-gal within their salivary glands, which is then injected into the next host.2,4 In humans, the immune system reacts to alpha-gal in the bloodstream similarly to a foreign invader, initiating an IgE-mediated allergic response.4 Symptoms will often vary between each individual but can include hives, nausea, vomiting, heartburn, dizziness or fainting, and anaphylaxis, among many other symptoms.2,4

It is estimated that between 2010 and 2022, more than 110,000 people were suspected of having AGS, and diagnosis is usually confirmed by blood tests which look for specific antibodies to the sugar.2 Interestingly, not every exposure to alpha-gal will result in an allergic reaction, and unlike food allergies where exposure can result in immediate reaction symptoms, it could take up to several hours after ingestion of an animal product containing alpha-gal for symptoms to appear in AGS patients.4 Unfortunately, there is no treatment for AGS, but patients are typically managed by an allergist with recommendations of carrying an injectable epinephrine device, avoiding foods containing alpha-gal, taking antihistamines as needed, and monitoring or adjusting other medications which may be manufactured using gelatin capsules.2,4

References

1 [Figure 1 Image]: ACP Internist. (n.d.). MKSAP Quiz: Evaluation for a Skin Eruption [website]. Accessed online on December 5th 2023 from, https://acpinternist.org/archives/2016/10/mksap.htm

2 CDC. (2023). Alpha-gal Syndrome [website]. Accessed online on November 17th 2023, from https://www.cdc.gov/ticks/alpha-gal/index.html

3 CDC. (2018). Lone star tick a concern, but not for Lyme disease [website]. Accessed online on November 17th, 2023 from https://www.cdc.gov/stari/disease/index.html

4 Kennedy, A. C., BCE1, & Marshall, E. (2021). Lone Star Ticks (Amblyomma americanum):: An Emerging Threat in Delaware. Delaware journal of public health, 7(1), 66–71. https://doi.org/10.32481/djph.2021.01.013

5 Vermont Department of Health. (2023). Information on Ticks in Vermont [website]. Accessed online on November 17th, 2023 from https://www.healthvermont.gov/disease-control/tickborne-diseases/information-ticks-vermont

-Maggie King is a Masters student in the Department of Pathology and Laboratory Medicine at the University of Vermont.

-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.

Trust Your Gut

A 20 year old female patient referred herself to a surgical oncologist specializing in sarcomas after she presented to an outside hospital for a sudden onset of epigastric pain. The patient also reported a one-year history of decreased appetite without nausea, vomiting, or weight loss. The outside institution performed an abdominal ultrasound and identified a large nonvascular heterogenous masslike lesion in the left upper quadrant not definitively associated with the spleen or kidney. The mass measured 12.1 x 9.9 x 10.7 cm. The radiologist’s overall impression was a hematoma; however, a CT scan with contrast was recommended to further classify the lesion. Instead, an MRI was performed, and the same radiologist described the lesion as having a thick irregular enhancing rind with enhancing septations and central necrosis. With the lesion appearing distinct from adjacent organs, a retroperitoneal sarcoma was posited on imaging. Reviewing the outside imaging and clinical history, the surgical oncologist referred the patient to interventional radiology for an ultrasound-guided biopsy of the left-sided retroperitoneal mass.

When the cytologist arrived in the procedure room for the time-out, the radiologist informed her of the surgical oncologist’s and outside radiologist’s opinions of a retroperitoneal sarcoma. A 17-gauge coaxial needle was advanced into the peripheral and non-necrotic aspect of the retroperitoneal mass, and multiple 22-gauge fine needle aspirations were obtained and handed to the cytologist. She prepared two air-dried smears and two alcohol-fixed slides. The air-dried smears were stained in our Diff-Quik (DQ) set-up and deemed adequate. The pathologist’s immediate cytologic evaluation was “tumor cells present.”

Images 1-3: Retroperitoneum, Left-side, Ultrasound-guided FNA: DQ-stained smear.

The following morning, the cytologist primary screened the Papanicolaou-stained slides and H&E-stained cell block sections in addition to the DQ smears, with the former preparations presented below.

Images 4-7: Retroperitoneum, Left-side, Ultrasound-guided FNA. 4-5: Pap-stained smear; 6-7: H&E Cell Block section (400X).

The cytologist entered her results as positive for malignant cells with a note of “atypical cells in papillary fragments” and gave the case to the pathologist for the final interpretation. The pathologist reviewed the slides prior to ordering immunostains. He paused and thought, “there’s something about the morphology and her age… it just doesn’t make sense for this to be a retroperitoneal sarcoma. It doesn’t look like a sarcoma. The cells are just too round or ovoid, bland, and poorly cohesive, and the fibrovascular cores – I just don’t think this is a sarcoma. Maybe a melanoma? Or some type of renal tumor? The cytoplasmic vacuolization could suggest this, but the mass is distinct from the kidney, so it can’t be. The nuclear grooves are intriguing, almost like a papillary thyroid carcinoma. A neuroendocrine tumor is also possible, the delicate papillary fronds though… Hmm. But where would it be originating from? How could this be distinct from other organs in the abdominal cavity?” He hemmed and hawed, glancing over our list of in-house immunostains. With only nine pre-cut unstained sections associated with the three H&E cell block levels, the pathologist ordered additional unstained recuts. He knew this was going to be a challenge due to the discrepancy between the clinical history and the morphology. 

With proper positive and negative controls, the tumor cells show positive staining for AE1/AE3, Cam 5.2, vimentin, CD99 (dot-like), CD56, beta catenin (nuclear), PR, AMACR, and SOX11, while negative staining for CK7, CK20, PAX-8, RCC, chromogranin, synaptophysin, GATA-3, EMA, GFAP, S100, calretinin, WT-1, E-cadherin, and p53 (wild type pattern). The proliferative index by Ki-67 is low at <1%.

Images 8-10: Retroperitoneum, Left-side, Ultrasound-guided FNA. 8: beta catenin (nuclear)-positive; 9: AMACR-positive; 10: SOX11-positive.

The combination of morphology with the extensive immunoprofile of the tumor is consistent with solid pseudopapillary neoplasm (SPN) of the pancreas.

Had there been any mention of the tumor involving or replacing the pancreas, this diagnosis and workup would have been much more straightforward. SPNs, albeit rare, account for 30% of tumors in women within their third or fourth decade of life.1 This patient presented with the most common SPN symptoms of abdominal pain and early satiety, but the mass appearing extrapancreatic on imaging posed a diagnostic challenge, as extrapancreatic SPNs are rare.2-3 Fortunately, SPNs are low-grade malignant neoplasms that respond well to surgical resection, and this patient is doing just fine after her distal pancreatectomy. In this case, both the patient and our pathologist listened to their guts with the patient pursuing advanced medical care for something much more complicated than a hematoma and the pathologist relying on his morphology expertise despite an odd clinical presentation.

References

  1. La Rosa S, Bongiovanni M. Pancreatic solid pseudopapillary neoplasm: key pathologic and genetic features. Archives of Pathology & Laboratory Medicine. 2020;144(7):829-837. doi:10.5858/arpa.2019-0473-ra
  2. Dinarvand P, Lai J. Solid pseudopapillary neoplasm of the pancreas: a rare entity with unique features. Archives of Pathology & Laboratory Medicine. 2017;141(7):990-995. doi:10.5858/arpa.2016-0322-rs
  3. Cheuk W, Beavon I, Chui D, Chan JKC. Extrapancreatic solid pseudopapillary neoplasm. International Journal of Gynecological Pathology. 2011;30(6):539-543. doi:10.1097/pgp.0b013e31821724fb

-Taryn Waraksa-Deutsch, MS, SCT(ASCP)CM, CT(IAC), has worked as a cytotechnologist at Fox Chase Cancer Center, in Philadelphia, Pennsylvania, since earning her master’s degree from Thomas Jefferson University in 2014. She is an ASCP board-certified Specialist in Cytotechnology with an additional certification by the International Academy of Cytology (IAC). She is also a 2020 ASCP 40 Under Forty Honoree.