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Pathology/biopsy report of d12 mass and d 10 vertebral collapse.-kindly advise

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Biopsy result(Section shows fibrocollagenous stroma infiltrated by granuloma composed of epitheloid histiocytic aggregates,multinucleate giant cells some of Langhans type and patchy area of necrosis.bony spicules are also seen.ther is no evidence of malignancy.impression:NECROTISING GRANULOMATOUS INFLAMMATION WITH FOCI OF NECROSIS.BIOPSY LESION D10 AND D12 VERTEBRA.-POSSIBILIY OF TUBERCULOSIS MAY BE CONSIDERED.SUGGEST CLINICAL CO RELATION.
Kindly advise on:
1.whteher biopsy report suggest of any type of malignancy.
2.can TB be considered?
3.as the patient has been wiping off fungus which grew on the false roofing inn the UK once every 15 days for the past many years wherther the pathology could be due to a fungal infection?
4.can this paatinet be put on empirical TB treatment and followed up after 3 months with a repeat PET scan(if she continues to remain asyptomatic till then)?
5.patient has been provided with paraffin block with tissue sample and will shortly be supplied with an image of the slide which was reported by the pathologist.can this block be used for all/any further tests?
Regards
Dr.N.Ananth
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PATIENT HISTORY FOR CO RELATION:
c/o backache since November 2012-
under  NHS for treatment of backpain in mid December(was put on paracoetomol,pain killers and developed gastritis)
backpain  and inability to lie down since mid jan 2013(with minimal relief of pain)
Open MRI( tesla )report ,Lab reports(elevated SGPT-91 and mildly elevated crp 6)  enclosed herewith.
Relevant past history:
Married since 10 yrs with 2 healthy children 8 yrs(f) and 6 yrs(M)(both LSCS with Tubectomy)
Place of stay:2003-2006-SUDAN(3 yrs),2007-Present-United Kingdom.(6 yrs).
Severe hairfall with alopecia gradually increasing since 2010(scalp picture enclosed herewith)
Time line of events:
Nov 1st week-pain started
26.12.12&14.02.2013-consulted primary care Dr at NHS and put on pain killers and developed severe gastritis with naproxen.
09.01.13 & 19.02.13-consulted physio-developed pain on deep palpation by physiotherapist and later on 19.02.13  was advised MRI.
20.02.13- primary care Dr  orders for MRI –same done in 25.02.13 and reported.

PATIENT HAS BEEN SHIFTED TO INDIA:
PET-CT REPORTED:
Hypermetabolic destructive lytic lesion  involving d 10 vertebral body and lt transverse process of d 12 vertebra with associated soft tissue component.focal hypermetabolic lesions in the lt femur and lt scapula.hypermetabolic rt supraclavicular and mediastinal adenopathy.
Imaging possibilities1. tuberculosis 2. Brucellosis
Echo findings:Trivial MR+/TR+ mild PAH ,CRVSP + 46 mm hg.
Relevant lab results:
ESR-63 mm/hr
CA19-9:24.1(normal < 37) & Ca 125-6.3U/ml(normal < 37)
SGPT 41(normal below  35)
T4-11.3(normal upto 11)mcg/dl
Hb-10.8gm/dl-WBC-5700/cu mm DC-lymphocytes 17%(normal 20-45%)
Monocytes 6%(normal 2-10%)
LDH:273 IU/L(normal-250-480)
"patient underwent robotic spinal stabilisation surgery(7th post op day)and has been discharged home.
labs and investigation reports :
VASCULITIS WORKUP:ANA-negative,dSDNA negative,ANCA-negative,ENA(IgG test)-Sm,Sm/RNP,SSA(Ro),SSA(La),Scl70,Jo-1+negative,Serum ferritin92(10-120)ng/ml,Iron binding capacity-355(250-425)microgm/dL,Angiotens.Convverting enzyme(ACE) -serum-25(9-67)U/L,Brucella Agglutination-negative,Geneprobe MTB Direct Detection(Tissue)-MTB Complex not detected,Tisue smear-negative,no AFB Seen,No fungal elements seen-few pus cells-and no bacteria seen.CEA Antigen serum1.57(<3)ng/ml-normal.
MANTOUX TEST:POSITIVE AT 48 HRS-INDURATION(  )ERYTHEMA(      ).
TB IGRA TEST(Immuno Gamma interferon release assay) for TB-negative.
Biopsy result(Section shows fibrocollagenous stroma infiltrated by granuloma composed of epitheloid histiocytic aggregates,multinucleate giant cells some of Langhans type and patchy area of necrosis.bony spicules are also seen.ther is no evidence of malignancy.impression:NECROTISING GRANULOMATOUS INFLAMMATION WITH FOCI OF NECROSIS.BIOPSY LESION D10 AND D12 VERTEBRA.-POSSIBILIY OF TUBERCULOSIS MAY BE CONSIDERED.SUGGEST CLINICAL CO RELATION.
POSITIVE LABS:
25 HYDOxY VITAMIN D -LOW-4(NORMAL ABOVE 30 ng/ML)
SERUM IRON 23(50-170)ng/dL.
Patient is now on rifampin(600 mg),INH 300 mg,Ethambutol 1000mg,pyridoxine 20 mg for 9 months.-
is due for infectious disease review/oncology review next week.

Answer
Hello:

Here are the answers to your specific questions:
1)Based on the description this is not malignant
2) A necrotizing granulomatous inflammation is seen in infections - the commonest cause is tuberculosis , but it can be fungal also. In addition there are other disease which can present with similar histology.

3)There are special stains to detect fungus in the biopsy specimen.
4) The treating doctor will be be able to tell you more about treatment, if 3 month course will produce result or not. I am not an expert at that. However, Rifampicin is a potent drug and kills the TB bacteria rapidly.
5) The paraffin block can be used for other test and stains on the tissue.

Mantoux test is positive if a person has been stayed in India and has been vaccinated. It is important to know how much is the induration and does it indicate infection.

In addition the patient is anemic (low Hb and low serum iron) most likely iron deficiency anemia.
She also has low levels of Vit D
ESR is high indicating presence of a chronic disease.

Follow up after few months would show if the condition is improving or not

Pathology

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Neha Dahiya MD

Expertise

Help patients understand the medical terminology of their lab results and / or tissue biopsy reports.

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I am a pathologist and director of clinical laboratory services. I have been a practicing pathologist for last 9 years in a 350 bed multi specialty hospital laboratory in India.

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Indian association of pathologists and microbiologists.
International Academy of Cytology
International association of Pathologists - Indian division
Indian association of Cytology

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MD (pathology) MBA

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