The Abstract Submission site is open for ASCP 2019. Last year, ASCP had a record number of submissions and we aim to bring in even more this year. ASCP’s selection process is known as highly competitive, and as a result, presenters receive close attention from big-name faculty and industry contacts. Some have even gained immediate funding opportunities to expand their research.
Abstracts can be submitted until 11:59pm CST on March 20th. Submit your abstract HERE.
One of most well-known names of generations, besides perhaps Millennials, are the Baby Boomers. The Baby Boomers generation is currently the largest generation. Of all the generations, they cover the largest span of time (those born from 1946 to 1964). In large parts of the world, there was a big surge in births after the Second World War. That war had a significant influence on their values, perceptions, attitude, and approach to work.
One of the major aspects that make Baby Boomers stand out from previous generations is that this was really the first generation in which women started to work outside the home in large numbers, at least in the Western Hemisphere. This has a major influence on the home and work environment. In the United States, the children of Baby Boomers often had a latchkey around their neck so that they could go home after school without their parents being there.
Baby Boomers played a large role in shaping today’s society; they used music as a political tool, they increased focus environmental conservation, they were involved with the civil rights and women’s rights movements, and they are politically informed and outspoken. It is also the first generation in which both divorce and homosexuality became accepted. Overall, this generation is known for optimism, adaptability, having a strong work ethic, and being team-oriented.
Even though technology did not become part of daily life until Generation X, Baby Boomers witnessed enormous technological milestones, such as the first orbit around earth, landing a man on the moon, and the creation of the first nuclear power plant. All these events set the stage for later advances, and Baby Boomers are typically interested in learning how to use technology, although it does not come as natural to them as future generations. They also have tend to work longer and retire later in age, mainly because they link their self-worth to their job. In other words, their work ethic becomes their “worth ethic.” Knowing this when working with them is important, as they appreciate recognition in forms of awards, title changes, and public acknowledgement for their contributions.
Because this generation spans such a long time (and because some Boomers had children later in life due to second and third marriages), Baby Boomers are parents to both Generation X and Generation Y. There is a lot to learn from this generation, so next time you work with one ask for some of their insights and understanding. This generation makes great mentors, especially because they are likely to have children of mentee age.
-Lotte Mulder earned her Master’s of Education from the Harvard Graduate School of Education in 2013, where she focused on Leadership and Group Development. She’s currently working toward a PhD in Organizational Leadership. At ASCP, Lotte designs and facilitates the ASCP Leadership Institute, an online leadership certificate program. She has also built ASCP’s first patient ambassador program, called Patient Champions, which leverages patient stories as they relate to the value of the lab.
Here is an interesting fact: there are two sub-sets of Baby Boomers. The first ones are the “Save-The-World Revolutionaries” of the ’60s and ’70s. The second set of Boomers are the career climbers, the yuppies, of the ’70s/’80s. The most profound characteristic of a Baby Boomer is their work ethic. They identify with their job, profession, or their career. So much so, that this generation has remained in the workforce beyond the age of 70.
In a lot of ways, I’m the typical Baby Boomer woman. I married the first time just before I was 20 years old. Divorced in my early 30’s and moved forward in my career because that’s what the “Boomer Women” did. They worked inside and outside of the home.
As a laboratory professional that left the bench many decades ago, and now working in the field of Organizational Leadership and Development, I am approaching the age of 70. I’m starting to realize my retirement day is closer than I’d like. Like others of my generation, this concerns me because I am defined by my career! The thought of not working left me searching for my identity so much that I started seeing a therapist last year. I was, and am fortunate to work for an incredible organization that doesn’t judge one by their age. They look at the skills and competencies one brings to the table. I’m consciously working on succession planning so that my institutional knowledge remains with the organization and its people. It also helps to have two gifted professionals who wanted to learn from me and grow. Then it takes a manager like mine who supports me through this often painful process. I am blessed with that kind of support. Sometimes the work ethic equals “worth ethic” in the body, mind, and spirit of a Baby Boomer, which is something to keep in mind when working with this generation.
-Catherine Stakenas, MA, is the Senior Director of Organizational Leadership and Development and Performance Management at ASCP. She is certified in the use and interpretation of 28 self-assessment instruments and has designed and taught masters and doctoral level students.
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).
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.
- 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.
- Johnson, Matthew G., et al. “The brief case: recurrent granulomatous mastitis due to Corynebacterium kroppenstedtii.” Journal of clinical microbiology 54.8 (2016): 1938-1941.
- Paviour, Sue, et al. “Corynebacterium species isolated from patients with mastitis.” Clinical Infectious Diseases 35.11 (2002): 1434-1440.
-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.
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.
- 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.
- 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.
- Ansell, S. (2014) Hodgkin lymphoma: 2014 update on diagnosis, risk stratification, and management. Am J Hematol 89: 771–779.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Darabi, K., Tester, W., Daskal, I. and Cohn, J. (2015) Syncytial variant of nodular sclerosing Hodgkin’s disease. Blood 104: 4533–4533.
-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
-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.
A 51-year-old man was hospitalized for swelling of his left middle finger. He was in a normal state of health until 6 months prior, when he sustained an injury to his left third finger from a catfish while fishing in Florida in brackish water. The patient claimed he had caught a catfish and was stabbed by one of the spines of the fish in the middle portion of his finger. It became infected and he was prescribed a couple different courses of antibiotics, the details of which are not entirely clear. About one week leading up to his hospitalization, the finger became more swollen, and he had prominent lymphangitic streaking up the left arm as high as the upper bicep, with pain. He did not have any fevers, chills, or night sweats. Initial blood cultures taken were negative. He was admitted for three days on vancomycin/cipro, with resolution of the lymphangitic streaking but ongoing prominence of the swollen left third finger. MRI showed prominent tenosynovitis of the left 3rd finger tendon sheath, though the second, fourth, and fifth digits were also involved. Surgical debridement was recommended at the time but he preferred to pursue medical management. He was started on cipro/doxy/clarithro empirically at the time.
The infection was refractory to medical management. About 3 weeks later, his left third finger “burst open” with a draining sinus tract and purulent discharge (Image 1). He still denied any systemic symptoms such as fever, chills, night sweats. He was seen by infectious disease and orthopedic surgery and subsequently consented to radical tenosynovectomy for suspected mycobacterial chronic tenosynovitis.
Tissue biopsy was sent for surgical pathology and culture. Histopathologically, the lesion showed chronic lymphohistiocytic and granulomatous inflammation; no microorganisms were identified on special stains. However, AFB culture was positive in the LJ slant and speciation was confirmed (Image 2).
Mycobacterium marinum was identified at a reference laboratory. Although infection with M. marinum is uncommon, the epidemiology of M. marinum disease is distinctive from other non-tuberculous mycobacterial species. The natural habitat of M. marinum is aquatic, and can be found in both fresh and salt water, including marine organisms, swimming pools, and fish tanks. The annual incidence is estimated at 0.27 cases per 100,000 adult patients.1 The infection is typically limited to the skin, mostly involving limbs, with rare spread to deeper structures reported.
M. marinum causes cutaneous disease as a consequence of exposure to water, usually in the context of a minor abrasion, laceration, puncture wound, or bite wound. Skin infections can occur from putting one’s hand into a contaminated fish tank, resulting in the condition called fish tank granuloma.
Histopathology often demonstrates suppurative granulomatous inflammation. In the microbiology laboratory, M. marinum is a photochromogen, meaning it produces pigment when cultured and exposed to light. Culture growth is optimal at 32°C over 7-14 days. Therefore, cooler extremities, particularly hands, are affected more often than central areas. Providers should be aware that M. marinum may cause a positive tuberculin skin test.2
M. marinum is a slow growing organism that is readily detected by acid fast smear and culture techniques. Confirmation of the presence or absence of mycobacteria in clinical specimens has traditionally required culture. However, traditional methods of identifying mycobacterial isolates to the species level are slow, based upon growth characteristics on solid media and subsequent biochemical tests, requiring additional weeks for subcultures. Newer techniques include MALDI-TOF MS, 16S ribosomal DNA sequencing, PCR-restriction length polymorphism analysis (PRA), and high-performance liquid chromatography (HPLC).
M. marinum infection responds slowly to appropriate antibiotic therapy. Infected patients may require treatment for 2 weeks or up to 18 months. M. marinum infection sequelae include persistent ulceration, draining sinuses, or septic arthritis.
- Akram SM, Bhimji SS. Mycobacterium Marinum. 2017. StatPearls.
- Lewis et al. Fish tank exposure and cutaneous infections due to Mycobacterium marinum: tuberculin skin testing, treatment, and prevention. CID. 2003;37(3):390-7.
-Thomas Rogers, DO is a 4th year anatomic and clinical pathology resident at the University of Vermont Medical Center.
-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.