Pathologist On Call: Fluctuating Parathyroid Hormone with Normal Calcium in an Elderly Man

Case:

A 75 year old Alzheimer’s dementia patient.  Parathyroid hormone (PTH) levels were ordered.

Analyte

(Reference

Range)

05/13 10/13 12/13 7/14 10/14 04/15 09/15 03/16 07/16
PTH

(10-65 pg/mL)

869 42 864 47 1180 48
Ca2+

(8.8-10.2 mg/mL)

10.3 10.5 10 10 9.6 10
Vit D

(2-100 ng/mL)

26 21 39 49 39 57 19

 

Why order PTH? 

PTH is ordered to assess for hyperparathyroidism.  There are two forms of hyperparathyroidism: primary and secondary.  Primary hyperparathyroidism can be caused by a parathyroid (PT) adenoma,  PT hyperplasia, or a non-PT malignancy such as squamous cell cancer or multiple myeloma.  Secondary hyperparathyroidism occurs in response to hypocalcemia which can arise from insufficient intake of vitamin D or chronic renal failure (which results in insufficient vitamin D).   There is weak evidence suggesting a positive correlation between PTH and cognitive decline.(1, 2)  Progression of cognitive decline is slowed when PTH and vit D levels are normalized.

Action of PTH: PTH is a peptide hormone that controls calcium levels in the blood. It is secreted as a prohormone and is cleaved in the blood.  The 34 residue N-terminal fragment is active and has a half-life of about 5 minutes.  The C-terminal end has a half-life or 2 hours and is diagnostically insignificant because it is physiologically inactive.  PTH activates receptors on osteoclasts which causes them to release bone calcium.  PTH also increases renal synthesis of 1,25 OH2 vitamin D which, in turn, increases intestinal absorption of calcium.

What would make the PTH level fluctuate so much?

This is most likely a case of incipient normocalcemic primary hyperparathyroidism (NPH).(3-5)  PTH levels are higher than normal but calcium levels are normal.  PTH levels tend to fluctuate. Calcium can also be sometimes elevated as well.   The disease is thought to be a mild or early form of hyperparathyroidism and 20 percent of patients go on to develop worsening hyperparathyroidism. How should NPH be managed?  Parathyroidectomy or monitoring are the primary alternatives; however, the best way to manage this disease is unknown.

 

References

  1. Lourida I, Thompson-Coon J, Dickens CM, et al. Parathyroid hormone, cognitive function and dementia: A systematic review. PLoS ONE 2015;10.
  1. Björkman MP, Sorva AJ, Tilvis RS. Does elevated parathyroid hormone concentration predict cognitive decline in older people? Aging Clinical and Experimental Research 2010;22:164-9.
  1. Shlapack MA, Rizvi AA. Normocalcemic primary hyperparathyroidism-characteristics and clinical significance of an emerging entity. Am J Med Sci 2012;343:163-6.
  1. Lowe H, McMahon DJ, Rubin MR, Bilezikian JP, Silverberg SJ. Normocalcemic primary hyperparathyroidism: Further characterization of a new clinical phenotype. Journal of Clinical Endocrinology and Metabolism 2007;92:3001-5.
  1. Crowley RK, Gittoes NJ. Elevated PTH with normal serum calcium level: A structured approach. Clinical Endocrinology 2016;84:809-13.

 

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-Robert Schmidt, MD, PhD, MBA, MS is currently an Associate Professor at the University of Utah where he is Medical Director of the clinical laboratory at the Huntsman Cancer Institute and Director of the Center for Effective Medical Testing at ARUP Laboratories.

 

 

Forty Things Every Lab Professional Should know

Hello again everyone! Every few posts on Lablogatory I like to take a small departure from updates about my medical school experience and my Zika public health initiative. This time is more of a shameless plug: I am thrilled and honored to be considered one of ASCP’s Top 40 Under Forty for 2017!

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Looking through the rest of the honorees, I can certainly say I’m in great company. Each person on that list is a prime example of the working values, lessons, and vision that ASCP recognizes in our dynamic field. So, to celebrate my and others’ place on this list, I’ve put together a few thoughts that truly reflect our hard work, talent, and potential as laboratory professionals and what that might mean for each of us. Here are what I consider the “Top 40” lessons that a career in medical laboratory science and laboratory medicine have taught me:

  1. The laboratory is the best melting pot –How many awesome pot-lucks have you had in your breakroom? How many words in new languages have you picked up? All that cultural exposure really contributes to a profound sense of community and humility.
  2. If everything is STAT, nothing is… – need I say more? We know the value of prioritizing and triaging what’s important for patients.
  3. You know a little about a lot of things, and sometimes a lot about a few things – To all my fellow generalists and specialists out there: how good does it feel to directly contribute to a patient’s positive outcome?
  4. Everyone’s got a different TAT – To turn a phrase, we’re all at various stages. Some laboratorians are just starting out and some can “smell” a tricky differential…
  5. Quality control protects everyone – If QC is good, instruments are good. If instruments report good values, results are good.
  6. Accountability is key – Owning up to failures and successes are both important!
  7. Record everything – This is how we protect patients and ourselves as well as improve.
  8. Teamwork is a necessity – It takes a village or, in this case, a full staff…
  9. Serotypes and Stereotypes – We’re not shy! We’re not afraid to jump in and collaborate!
  10. We’re not magicians, but sometimes we are – Impressing other clinicians with our ability to analyze and get results is just part of what we do.
  11. Nurses are our friends – Really, when you’ve got great relationships with the nursing staff you know just how that can make an enormous difference in your work.
  12. Doctors are our friends, too – The best doctors value the laboratory, and its staff!
  13. Ultimately, we’re here for our patients – That’s what it’s all about!
  14. We celebrate each other – How many of your labs have a ‘tech of the year’ award, or service awards? We make sure that we recognize each other’s talents.
  15. We share everything – Life events, stories, experiences, swapping shifts…
  16. Toxic techs are real, but they can be your friend too – All too real in many labs; often they’ve got lots of experience and can be a positive voice for change. Are we listening?
  17. What happens if everyone retires? – Staff turnover can be a challenge, but a combo of great training and communication are key.
  18. What happens if no one retires? Ever? – This occurs too, staff gridlock can be tough to manage and laboratory leadership is part of our role as well.
  19. We ALL have prior experiences – From brand new to near retirement, we’ve all had experience in healthcare; even as patients!
  20. Sometimes, QC just won’t come in range – That’s why relying on protocol and documentation can make all the difference.
  21. Sometimes, things happen even when QC was perfect – Bad days happen! Our drawing board is based on what we do best: analyzing, interpreting, and taking action.
  22. No one can tolerate as much as we can – How many of you have been blamed for hemolysis, or scrutinized for TAT statistics? Let’s call it “character-building experience.”
  23. Trust your training – It’s really your best resource.
  24. Taking initiative is a built-in perk – There will be times when it comes down to one lab tech on a night shift, or one pathologist who’s been paged, to take charge and make decisions.
  25. Watch something, do something, teach something – What better place than a clinical lab to see everything, learn it hands-on, and teach the next person?
  26. Never ending details – All those SOPs really make one appreciate the vast number of details that go into planning anything.
  27. We’re the best part of the hospital for metrics and progress – Diagnostic data comprises 70% of patient information, and 100% of laboratory performance.
  28. Lab week is the best – It feels great to be part of a large family of clinicians in this shared field. It’s also usually around my birthday, so that’s been a personal perk…
  29. Some teachers have years of experience on you – They’ve seen things you may never get the chance to!
  30. Some people will teach you something, even if you’re their supervisor – Everyone brings something to the table, or lab bench, or conference table, or shared microscope.
  31. We choose our words carefully – “These cells are suspicious and require pathology consult with further clinical correlation…” We know our scopes and practices.
  32. We word our choices carefully too – “This specimen was forwarded for pathology review because of our criteria…” We know we’ve got to back up our actions with evidence.
  33. We know office politics, just a little more intense than most people realize – Every hospital has a hierarchy, but laboratorians know we’re all on the same team.
  34. We’ve got an SOP for that – Literally, we have one for everything.
  35. We can come up with solutions with very limited information – Requisitions don’t always carry the highest level of clinically relevant guidance. (Test: Hgb A1c, Note: repeat from 1 hour ago).
  36. Sometimes we cannot find a solution, despite endless information – There are times when laboratory data is not enough to definitively make diagnoses, that’s just part of medicine.
  37. We all have the potential to be laboratory leaders – We’ll all have moments to take initiative and demonstrate our talents at one point or another.
  38. We are all real clinical scientists – The change to calling it “medical laboratory scientists” is one of the best changes ever. In my opinion, we are true clinical and critical scientists.
  39. It’s our job to promote our role and our field!
  40. Never stop learning!

I think the last two points need no explanation. Thank you for taking the time to read my “Top 40” Laboratory Lessons. If you have a great lesson you’ve learned, add it to the comments below! Don’t forget to check in next month for another update on my work and don’t forget to vote for ASCP’s Top Five! All the Top 40 Under Forty nominees are eligible to be in the Top Five based on your votes and comments!

Visit HERE, click on my face, and vote today!

Thanks, and see you next month!

 

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Constantine E. Kanakis MSc, MLS (ASCP)CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student at the American University of the Caribbean and actively involved with local public health.

 

Molecular Perspectives of Diffuse Large B-cell Lymphoma

Case

A 100 year old female was seen for follow-up for her hypertension, mild renal impairment, and fatigue. The patient also stated a three week duration of pain in the area of the right upper quadrant that radiates to her back. No other symptoms or concerns were expressed.

An abdominal CT was performed which showed a 6.6 x 2.1 cm soft tissue mass in the right posterior chest wall that also encases the 11th rib. Given the concern for a malignant process, a core needle biopsy was obtained for histology only.

b-cell1
H&E, 20x
b-cell2
H&E, 50x
b-cell3
CD20
b-cell4
CD10
b-cell5
BCL6
b-cell6
MUM1
b-cell7
Ki-67

The H&E stained sections show a diffuse infiltration of atypical lymphoid cells that are large in size with irregular nuclear contours, vesicular chromatin, and some with prominent nucleoli. Frequent apoptotic bodies and mitotic figures were seen. By immunohistochemistry, CD20 highlights the infiltrating cells, which are positive for BCL2, BCL6, and MUM1 (major subset). CD10 is negative within the atypical lymphoid population. CD3 highlights background T-cells. Ki-67 proliferation index is approximately 70%. EBER ISH is negative.

Overall, the findings are consistent with diffuse large B-cell lymphoma, NOS with a non-GCB phenotype by the Hans algorithm.

Discussion

Diffuse large B-cell lymphoma (DLBCL) is the most common B-cell lymphoma in adults comprising 30%-40% of new adult lymphomas. Approximately 50% of patients will be cured, even in advanced cases; however, those that fail conventional therapy ultimately succumb to their illness.1 Up to 30% of patients have refractoriness or relapse after initial therapy with rituximab based regimens, particulary R-CHOP (ritixumab, cyclophosphamide, doxorubicin, vincristine, and prednisone).

In the era of new molecular techniques and in the context of the heterogeneous nature of DLBCL, it has become important to accurately assess cell of origin (COO) as this has prognostic implications. With the seminal paper from Alizadeh and colleagues, gene expression profiling (GEP) by a microarray platform produced the concept of germinal center (GCB) versus activated B-cell (ABC) types of DLBCL.2 In the context of prognosis and R-CHOP therapy, the GCB type has a 3 year PFS of 75% as opposed to the ABC type that has a 3 year PFS of 40% (P<.001).3 Although GEP analysis is considered the ideal modality for determining COO, however, given the constraints of most modern hematopathology practices, surrogate immunohistochemical algorithms were developed to aid in COO determination. Of the multiple algorithms, the Hans algorithm is the most widely used and accepted for IHC determination of COO.

b-cell8
Adapted from Hans et al., Blood, 2004

The COO determination has revealed multiple genetic alterations that are shared between the GCB and ABC phenotype while distinct changes have been identified in each type. Molecular mechanisms at play include, but are not limited to, histone modification, blocks to terminal differentiation, cell cycle activation, PI3K/AKT signaling activation, mTOR pathway activation, as well as a multitude of other signaling cascades. A common shared dysregulated pathway between GCB and ABC types include mutations in CREBBP and EP300, which is in approximately 30% of DLBCL cases and slightly enriched in the GCB group. Mutations/deletions in these genes result in inactivation and alter histone modification subsequently thought to contribute to acetylation of BCL6, which is a key regulatory protein in lymphomagenesis. Up to 33% of DLBCL have mutations in MLL2, which has a broad effect on chromatin regulation and epigenomic alteration. Approximately 35% of DLBCL cases with up to two- to three-fold increase in ABC type cases have genetic alterations in BCL6, particularly chromosomal rearrangements and mutations in the 5’ sequence. Pasqualucci et al also described other factors that lead to BCL6 inactivation, including mutations in MEF2B and FBXO11.4

ABC type DLBCL often displays canonical pathway activation of NF-ƙB signaling, which ultimately promotes survival, proliferation, and inhibition of apoptosis. This potentially is a result of alterations in the CBM signalosome (CARD11, BCL10, and MALT1) with up to 10% of ABC-DLBCL cases having a mutation in CARD11. Another modality of ABC activation is through the B-cell receptor signaling pathway in which 20% of cases harbor a CD79A or CD79B mutation.  Interestingly enough, recurring mutations in MYD88 occur in ~30% of ABC-DLBCLs, which results in upregulation of NF-kB and Janus kinase-signal transducers. Other important genetic alterations include involvement by signaling pathways of spleen tyrosine kinase (SYK), PI3K, Bruton tyrosine kinase (BTK), and protein kinase C-β (PKC-β).

GCB type DLBCL often expresses CD10, LMO2, and BCL6 and has a less understood and distinct pathway when compared to ABC-DLBCL. The most common alterations include t(14;18) IGH-BCL2 (30-40%), C-REL amplification (30%), EZH2 (20%) and PTEN mutations (10%). These changes are almost never seen in ABC-DLBCL.

b-cell9.png
Adapted from Pasqualucci et al., Semin Hematol, April 2015

Although the findings in GCB and ABC type DLBCL are described, they are not absolute and multiple studies done by whole exome sequencing (WES) and whole genome sequencing (WGS) have elucidate further complexities and genetic changes. In 2015, data from Novak and colleagues revealed CNAs and mutations that were associated EFS, which also underscored the important 24 month milestone for survival.5 Morin et al in 2013 described 41 novel genes in DLBCL which demonstrated just how complex and heterogeneous DLBCL truly is (see figure below).6

b-cell10.png
Adapted from Morin et al., Blood, 2013.

As common as DLBCL is, there is much to be understood not only for lymphomagenesis, but for correct classification and risk stratification. Many targeted therapies have been designed and are in trials at the moment, but given the nature of DLBCL and its heterogeneity, more work on the molecular front is needed. Modalities for assessing COO are currently on the market but are not widely used. Perhaps COO determination by IHC may be an antiquated method, but it is currently the standard by which most pathologists practice. Overall, DLBCL in all its forms is not a uniform entity that can easily be defeated, but requires thought and diligence in achieving a cure.

 

  1. Lohr, JG et al. “Discovery and prioritization of somatic mutations in diffuse large B-cell lymphoma (DLBCL) by whole-exome sequencing,” Proc Natl Acad Sci USA. 2012; 109(10): 3879-3884
  2. Alizadeh AA, et al. “Distinct types of diffuse large B-cell lymphoma identified by gene expression profiling,” Nature 2000, 403:503-11
  3. Sehn, L and Gascoyne, R “Diffuse large B-cell lymphoma: optimizing outcome in the context of clinical and biologic heterogeneity,” Blood. 2015;125(1):22-32
  4. Pasqualucci, L and Dalla-Favera, Riccardo, “The Genetic Landscape of Diffuse Large B Cell Lymphoma,” Semin Hematol. 2015 April; 52(2): 67-76
  5. Novak, AJ et al. “Whole-exome analysis reveals novel somatic genomic alterations associated with outcome in immunochemotherapy-treated diffuse large B-cell lymphoma,” Blood Cancer Journal (2015) 5
  6. Morin, R et al. “Mutational and structural analysis of diffuse large B-cell lymphoma using whole-genome sequencing,” 2013;122(7):1256-1265

 

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-Phillip Michaels, MD is a board certified anatomic and clinical pathologist who is a current hematopathology fellow at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. His research interests include molecular profiling of diffuse large B-cell lymphoma as well as pathology resident education, especially in hematopathology and molecular genetic pathology.

Safety Success in the Anatomic Pathology Laboratory

The pathologist walked into the histology laboratory every morning to say hello to the staff. As he did so, he drank from his cup of coffee.

The gross room was very small, and the eyewash station was placed on the faucet in the only sink in the room. One foot above the sink were the sharp ends of all of the cutting tools that hung on the wall. That was also the hand washing sink.

The morgue was the only space in the hospital where chemical waste could be stored before being picked up. The waste containers were not dated, and a funnel was left in the opening of one of them.

It can be difficult to oversee safety for a clinical laboratory, but often the people responsible for it have a clinical lab background, so the understanding of the regulations is clear. However, if you are responsible for the anatomic pathology (AP) areas as well, you may need to broaden the scope of your safety learning. Each of the lab safety situations mentioned above are real, and detecting and resolving those and other issues is important. Knowing the regulations for histology, cytology, and the morgue settings is a good place to start. Next, spend some time in those areas, and learn the processes that occur every day. Ask questions and look at procedures.

Bio-safety regulations in the AP lab are no different than for clinical laboratory staff. Many specimens, body parts and cadavers may be handled, and Standard Precautions should be used. That includes the use of gloves, lab coats, and face protection.

Chemical hygiene is also important in the AP lab, and since these areas tend to utilize many more chemicals than others, the management of them can seem daunting. Be sure to keep an updated chemical inventory which designates carcinogens, reproductive toxins and acute toxins. Ensure all staff have access to Safety Data Sheets (SDS) and that they have been trained to properly store chemicals. That means strong acids and bases should be stored near the floor, and they should never be stored together. Other incompatible chemicals should be separated as well. Ensure that proper spill supplies are available, and that staff can clean up various types of chemical spills. Conducting spill drills is a great way to keep staff ready for the real event.

Exposure monitoring should occur depending on what chemicals are used in the area. Managing chemical safety also includes ensuring proper labeling of all chemical containers. Primary container should have current Globally Harmonized System (GHS) compliant labels, and secondary containers also need adequate labeling. Secondary containers may be labeled using a GHS format or NFPA and HMIS conventions may be used.

Chemical or Hazardous waste handling must also be monitored closely in AP areas. If chemical waste is stored in the lab in a Satellite Accumulation Area, the containers should not be dated, and they should be stored at or near the point of waste generation. Central Accumulation Areas are areas where waste is stored before it is removed from the site. In these areas, containers must be dated, and a log should be kept for weekly checks of the areas. Weekly checks include looking for container leaks, dates on containers, and making sure containers remain closed. All chemical waste containers must remain closed unless someone is actively working with them. Never leave an open hazardous waste container open or with a funnel in it while unattended.

Special safety consideration should be given to tissue cutting in the histology area. Microtome and cryostat use presents specific sharps dangers because of the large sharp blades in use. If a blade guard is included with the equipment, train staff to always engage it before placing hands near the blade. Use magnet-tipped implements to remove the blades and rubber-tipped forceps to install new ones. Follow manufacturer guidelines for cryostat decontamination, but avoid using formaldehyde fumes for that purpose.

If laboratory staff is exposed to formaldehyde concentrations greater than 0.1 parts per million in their routine work, there is a safety training program that is required by OSHA. This formaldehyde training needs to be administered at the time of initial job assignment and whenever a new exposure to formaldehyde is introduced into the work area. The training must also be repeated annually.

As a lab safety officer, I learned over time how to work with and coach pathologists for safety. There is no more coffee consumed in the lab. The cramped gross room was remodeled to improve safety. Understanding the issues and reporting them was the key to getting this done. It took a difficult inspection by the EPA to teach me how to properly handle chemical waste. Today the representative from the state is my best reference, and she is willing to come to the labs and help us with waste regulation compliance. If your background is clinical, don’t ignore the special considerations in the anatomic pathology areas. Use your resources to learn what happens there, and understand the regulations so that employees in every area of the lab can work safely.

 

Scungio 1

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 60 Year Old Male with Longstanding Skin Lesions

Case History

A 60 year old male from Louisiana presents to his family doctor with a chief complaint of longstanding skin lesions for approximately the last two years. On physical exam, there are several sharply defined reddish-brown plaques on his upper back and extremities. He reports sensory loss involving his chest, back and upper extremities. The lesions have not responded to conventional topical anti-fungal treatments. Punch biopsies along the margin of the most active lesion were obtained and sent to the Microbiology laboratory for bacterial, fungal and mycobacterial cultures and to the Pathology Department for histologic diagnosis.

Tissue sections

mycolep1
Image 1. Section from the right upper extremity skin punch biopsy demonstrates a normal basket-weave stratum corneum and normal epidermis with nodular superficial and deep granulomatous inflammatory infiltrate. A Grenz zone, a narrow layer beneath the epidermis that is not infiltrated or involved in the same way as are the lower layers of the dermis, is noted (H&E, 40x).
mycolep2
Image 2. Inflammation engulfing eccrine glands in the deep portion of the dermis (H&E, 100x).
mycolep3
Image 3. Portion of punch biopsy demonstrating perineural inflammation consisting predominantly of mononuclear cells (H&E, 400x).
mycolep4
Image 4. Fite stain highlighting numerous acid fast bacilli within macrophages surrounding the eccrine glands (1000x oil immersion).

 

On histologic examination of the skin biopsy, nodular, superficial and deep granulomatous inflammation was noted surrounding eccrine glands and engulfing nerves (Images 1-3). Fite staining illustrated numerous acid fast bacilli (Image 4) and, given the geographic location of the patient and clinical symptoms, was felt to be highly suggestive of Mycobacterium leprae. The case was sent for confirmatory testing by polymerase chain reaction (PCR). All cultures collected were negative.

Discussion

Mycobacterium leprae is a chronic, granulomatous disease which presents as anesthetic skin lesions and peripheral neuropathy with nerve thickening. While rare in the United States (US) today, historically it was one of most prominent pathogens in Mycobacterium genus apart from M. tuberculosis. In the past, leprosy (also known as Hansen’s disease) was prevalent throughout Europe, but due to systematic control programs aimed at underserved and rural locations, the number of cases drastically decreased and countries with the majority of recent cases include India, Brazil and Indonesia. According to National Hansen’s Disease Registry, a total of 178 cases were reported in the US in 2015. Of these, 72% (129) of cases were reported in Arkansas, California, Florida, Hawaii, Louisiana, New York and Texas. Transmission to those who are in prolonged and close contact with an infected person is thought to occur via shedding from the nose. While humans are the only known reservoir of leprosy, infections with organisms indistinguishable from M. leprae have been detected among wild armadillos in parts of the southern US.

The diagnosis of M. leprae is largely a clinical one as the organism is not able to be grown on artificial media, but histology and confirmatory PCR are useful adjuncts. Skin biopsies should be full thickness and include the deep dermis. Ideally, the most active edge of the most active lesion should be biopsied. There is a spectrum of M. leprae which ranges from few lesions and a paucity of bacilli (tuberculoid leprosy) to widespread skin involvement with numerous bacilli (lepromatous leprosy).  Histologically, there are granulomatous aggregates of epithelioid cells, multinucleate giant cells and lymphocytes and inflammation often engulfs sweat glands and nerves. Small lesions that have poorly defined borders and are found on the elbows, knees or ears are where bacilli tend to be located. A Fite stain is useful to highlight the acid fast bacilli located in the macrophages within the inflammatory nodules. M. leprae PCR can also be performed on blood, urine, nasal cavity specimens and skin biopsies as a sensitive diagnostic technique. PCR can also be used to detect certain genes that confer resistance to common treatment drugs such as rifampin, ofloxacin and dapsone.

As with other mycobacterial diseases, the treatment for M. leprae infections consists of a long term multidrug regimen. The six most commonly used medications include rifampin, dapsone, clofazimine, minocycline, ofloxacin, and clarithromycin.

 

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-Katie Tumminello, MD, is a fourth year Anatomic and Clinical Pathology resident at the University of Mississippi Medical Center. 

Stempak

-Lisa Stempak, MD, is an Assistant Professor of Pathology at the University of Mississippi Medical Center in Jackson, MS. She is certified by the American Board of Pathology in Anatomic and Clinical Pathology as well as Medical Microbiology. She is the director of the Microbiology and Serology Laboratories.  Her interests include infectious disease histology, process and quality improvement and resident education. 

Hematopathology Case Study: A 7 Year Old Transplant Patient with Neck Swelling

A 7 year old male with a history of restrictive cardiomyopathy status-post orthotopic heart transplant in June, 2010 that was on maintenance doses of tacrolimus and mycophenolate mofetil presented to his primary pediatrician left neck swelling. Starting in January 2017, the patient began with neck pain and swelling in the context of a recent gastrointestinal illness. Per CT report of the neck, a rim enhancing well-defined suppurative level III lymph node measuring 1.4 x 1.2 x 2.1 cm with adjacent soft tissue inflammatory changes extending into the left parapharyngeal space was identified. The patient was subsequently started on antibiotics and was discharged home with some improvement of swelling and pain.

The patient then presented again with continued neck swelling, although painless this time, and the patient’s cardiologist was contacted, who recommended a decrease in tacrolimus dosing. An otolaryngology evaluation was requested and given the concerning findings, the patient was admitted for further work-up, including a biopsy with a lymphoma protocol.

burlym1

burlym2

burlym3
BCL6
burlym4
BCL2
burlym6
EBER

 

burlym5
Flow Cytometry

 

Results

Flow cytometry revealed a kappa restricted CD10 positive mature B-cell population.

On biopsy examination, a population of monotonous lymphoid cells that are large in size with round to mildly irregular nuclear contours, open chromatin, and multiple inconspicuous nucleoli are present in a diffuse pattern. Abundant apoptotic bodies and mitotic figures are noted and occasional “starry sky” features are present. By immunohistochemistry, BCL6 highlights the neoplastic lymphocytes while BCL2 highlights background T-cells. EBER is negative.

Overall, despite a negative t(8;14) IGH/MYC translocation, the findings are best considered to be of an EBV-negative post-transplant lymphoproliferative disorder with morphologic features consistent with Burkitt lymphoma.

Discussion

Post-transplant lymphoproliferative disorders (PTLD) are a relatively rare complication in a variety of transplants that occurs in 2-10% of post-transplant patients. Overall, following a solid organ transplant (SOT), PTLD development is 1-5% of recipients with the highest incidence in intestinal and multivisceral transplantations (5-20%). Another factor is EBV status of the recipient, for which those that are EBV-naïve and lack cellular immunity to EBV are susceptible to graft-mediated EBV infection and ultimately developing an increased incidence in early PTLD. This population is overrepresented by pediatric transplant recipients1.

The presentation is highly variable and ranges from benign proliferations to overt lymphoproliferative disorders. Classifications for PTLD include early lesions, which are oligo- or polyclonal proliferations of EBV positive B cells have either a predominant infectious mononucleosis-like proliferation or a plasmacytic hyperplasia form. Polymorphic PTLD is a similar concept to the early proliferative lesions but the host architecture of the native structure is disrupted. Lastly, monomorphic PTLD is an entity that fulfills criteria for a non-Hodgkin lymphoma and is diagnosed according to the criteria of non-transplant associated lymphomas. Within pediatric registry studies, monomorphic PTLD accounts for 35-83% of all PTLD cases. B-cell lymphomas, particularly DLBCL, comprise the vast majority of monomorphic PTLD with plasmacytoma and T-cell lymphoproliferative disorders much less common2.

In this particular case, with the patient having been 7 years post-transplant and negative studies for EBV present, it is not surprising that germinal center phenotypic markers are highly expressed, such as CD10 and BCL6, which has been well elucidated by Jagadeesh, et al. Although not many genetic studies have been performed on post-transplant B-cell lymphomas, regardless of EBV status, there is some data demonstrating trisomies of 9 and/or 11 with translocations 8q24.1 (C-MYC), 3q24 (BCL6), and 14q32 (IGH). Rinaldi et al. noticed a lack of genetic lesions characteristic of postgerminal center derivation, such as gain of chromosome 3 (FOXP1, BCL6, and NFKBIZ) and 18q (BCL2 and NFATC1) together with losses of 6q (PRDM1 and TNFAIP3) in post-transplant DLBCL.  A number of DNA mutations have also been described including genes associated with somatic hypermutation (SHM) such as PIM-1, PAX5, C-MYC, and RhoH/TTF. These particular mutations are also found to be independent of EBV status1.

Overall, post-transplant lymphoproliferative disorders occur in a variety of transplant settings across many age groups and can be dependent on EBV and CMV status as well as the type and degree of immunosuppression. Although many variations take place in PTLD, patients with the monomorphic type are diagnosed according to their non-transplant counterparts. Current perspective includes further analysis of molecular and cellular mechanisms incorporated into research projects, which could better aid in prognostic implications and future therapeutics.

  1. Morscio, et al. “Molecular pathogenesis of B-cell posttransplant lymphoproliferative disorder: What do we know so far?” Clinical and Developmental Immunology 2013.
  2. Mynarek, et al. “Posttransplant lymphoproliferative disease after pediatric solid organ transplantation,” Clinical and Developmental Immunology 2013.

 

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-Phillip Michaels, MD is a board certified anatomic and clinical pathologist who is a current hematopathology fellow at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. His research interests include molecular profiling of diffuse large B-cell lymphoma as well as pathology resident education, especially in hematopathology and molecular genetic pathology.

Hematopathology Case Study: A 54 Year Old Male with Acute Onset of Progressive Neck Swelling

Case History

A 54 year old male with a diagnosis of HIV (last CD4 count was 301 on 11/2016) currently on HAART presented to the Beth Israel Deaconess Medical Center (BIDMC) ED on 2/28/2017 with an acute onset of progressive neck swelling over the course of 4-5 days. Laboratory values on presentation was significant for a LDH of 1061 IU/L. Other laboratory values were stable. Upon CT imaging with contrast of the neck, an extensively necrotic right cervical lymphadenopathy was present and was extending into the supra- and infraclavicular chain. No mediastinal or hilar lymphadenopathy was noted.

On 3/1/2017, the patient underwent an ultrasound guided core needle biopsy of the right cervical mass (see images). By immunohistochemistry, the neoplastic cells are positive for CD138 and MUM1. PAX5 shows dim and heterogeneous staining in a subset of cells while CD79a highlights a minor component of the lymphoid population. CD3 and CD5 are positive in T-cells occupying a small subset of the lymph node. CD20, BCL2, BCL6, BCL1, CD30, CD56 and HHV8 are negative. By Ki-67 immunostaining, the proliferation index approaches 100%. In-situ hybridization for Epstein-Barr virus encoded RNA (EBER ISH) is positive in a major subset of cells.

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CD20 (left) and CD3
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MUM1 (left) and CD138
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EBER ISH (left) and Ki-67

By cytogenetic analysis, only two cells were available for metaphase interpretation and it showed a translocation between the long arms of chromosomes 8 and 14 and by FISH, a t(8;14)(q24.1;q32) was noted, indicating an IGH/MYC rearrangement.

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Overall, the morphologic, immunophenotypic, and cytogenetic findings in conjunction with the clinical features of a HIV positive male and EBV association, the diagnosis is in keeping with a plasmablastic lymphoma.

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Discussion

Plasmablastic lymphoma is a diffuse proliferation in which the cells resemble immunoblasts but share an immunophenotype similar to that of plasma cells. First described in the oral cavity, especially among HIV infected patients, it can present in a variety of extranodal sites, such as skin, soft tissue, and gastrointestinal tract. Although uncommon, plasmablastic lymphoma has its highest incidence among HIV infected individuals. Most patients are at stage III or IV at presentation with an intermediate to high risk IPI score. The tumor cells of plasmablastic lymphoma are invariably infected by Epstein-Barr virus (EBV) and are consistently negative for HHV8. According to Balague et al.2, up to 39% of plasmablastic lymphomas demonstrate a MYC translocation, all of which involved the IGH gene. Generally, plasmablastic lymphoma displays a complex karyotype, although some cases display an isolated MYC rearrangement without a complex karyotype. Taddesse-Heath et al.3 has shown a small cohort that is positive for gains in odd-numbered chromosomes 3, 5, 7, 9, 11, and/or 15, similar to that seen in plasma cell myeloma. The clinical course of plasmablastic lymphoma is quite aggressive with most patients dying within one year after diagnosis. Current first line treatment for plasmablastic lymphoma is dose-adjusted EPOCH with or without bortezomib, intrathecal prophylaxis, and possible autologous stem cell transplantation in first remission candidates. Future directions of therapy include chimeric antigen receptor (CAR) T-cells and small molecular inhibitors against the MYC bromodomain4.

References

  1. Swerdlow, S., et al., WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, 4th. ed., IARC press: 2008
  2. Balague, O., et al., “Plasmablastic lymphomas are genetically characterized by frequent MYC translocations [abstract],” Mod Pathol 2009; 22:255A.
  3. Taddesse-Heath, L., et al., “Plasmablastic lymphoma with MYC translocation: evidence for a common pathway in the generation of plasmablastic features,” Mod Pathol 2010; 23:991-999.
  4. Castillo, J., et al., “The biology and treatment of plasmablastic lymphoma,” Blood 2015; 125:2323-2330.

 

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-Phillip Michaels, MD is a board certified anatomic and clinical pathologist who is a current hematopathology fellow at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. His research interests include molecular profiling of diffuse large B-cell lymphoma as well as pathology resident education, especially in hematopathology and molecular genetic pathology.