Pathology and laboratory medicine

of FNA used in these cases helped to establish the diagnosis of IBC in 4 women presenting with a diffusely enlarged and tender breast, resulting in the timely initiation of appropriate management. The technique needs to be assessed in a larger cohort of women with diffusely enlarged breast to evaluate its diagnostic utility.

To compare the severity of Plasmodium vivax malaria with that of P. falciparum malaria, we conducted a retrospective cross-sectional study of 356 adults hospitalized with malaria (2009-2011) in Pakistan. P. vivax and P. falciparum accounted for 83% and 13% of cases, respectively; 79.9% of patients with severe malaria were infected with P. vivax. M alaria is endemic to Pakistan and 64% and 36% of malaria cases are attributed to Plasmodium vivax and P. falciparum, respectively (1). The purpose of this study was to identify the complications of P. vivax among hospitalized malaria patients and compare the prevalence of these complications with those of P. falciparum malaria. The Study We conducted a retrospective cross-sectional study using convenience sampling at the Aga Khan University Hospital in Karachi, Pakistan. Participants were all adult patients (>16 years of age) who were hospitalized with malaria during January 2009-December 2011. Reasons for hospitalization included intravenous antimalarial therapy, management of associated diagnoses, and complications. The following data on patients were retrieved through the hospital's electronic and file records: age, sex, infecting Plasmodium species, malaria diagnosis methods, co-existing conditions, results of biochemical and microbiological investigations, radiographic findings, complications, hospital course, and outcome. Records showed that Giemsa-stained peripheral blood smears, the malaria rapid diagnostic test (RDT), or both, were used for malaria diagnosis. The RDT used antibodies against P. falciparum histidine-rich protein 2 and P. vivax lactate dehydrogenase. For 45 case-patients for which results from peripheral blood smears and RDTs were discordant or unreliable, surface protein-specific PCR was performed by using stored patient blood samples to identify

Chloroquine (CQ) resistance in Plasmodium falciparum has been associated with point mutations in the P. falciparum CQ resistance transporter gene (pfcrt). Previous studies have shown 4-5 independent origins for CQ resistant pfcrt alleles globally, two in South America, one each in Southeast Asia, Papua New Guinea (PNG) and Philippines. In Asia, at least two different alleles corresponding to amino acids 72-76 (CVIET and SVMNT) have been found. The CVIET allele originated in Southeast Asia and then spread to Asia and Africa as well. The SVMNT allele, originating from PNG, has been found in India. This study was undertaken to investigate the genetic background of the CQ resistant pfcrt haplotypes in Pakistan. We genotyped microsatellite markers surrounding the pfcrt gene (six different markers at À12.3, À4.8, À1, 1.5, 3.9, 18.8 kb) in 114 clinical isolates of P. falciparum collected from different regions in Pakistan. Microsatellite analysis showed a significant reduction in genetic variation among the mutant SVMNT pfcrt alleles when compared to wild type alleles. The predominant SVMNT haplotype found in this study shared the same microsatellite haplotype found in both PNG and India. Two isolates with CVIET haplotypes showed similar microsatellite background to those found in Africa and Asia. In conclusion, this study suggests that CQ resistant SVMNT haplotypes in India and Pakistan have a common ancestral origin similar to that of Papua New Guinean isolates.

Background: Various factors determine the outcome of Plasmodium falciparum infection such as parasite load, sequestration, adhesion molecules, and immune mediators. P. falciparum merozoite surface protein-1 (msp-1) and msp-2 genotypes were also found associated with severe disease. We investigated the association between msp-1 and msp-2 genotypes in patients with uncomplicated malaria (UM) and severe malaria (SM). Methods: Twenty-two malaria patients with microscopy-confirmed P. falciparum infection and eight healthy endemic controls were selected for analysis. Nested polymerase chain reaction (PCR) was used to identify P. falciparum genotypes. The plasma concentration of cytokines [tumor necrosis factor-alpha (TNF-a), interleukin-6 (IL-6), and interferon-gamma (IFN-g)] and chemokines [chemokine (C-X-C motif) ligand 9 (CXCL9) and CXCL10] were evaluated using enzyme-linked immunosorbent assay (ELISA). Results: TNF-a levels were significantly higher in both UM (389 pg/mL, p Z 0.020) and SM (771 pg/mL, p Z 0.004) compared with healthy controls, while they were greater in SM (p Z 0.012) as compared to UM. CXCL9 levels were significantly raised in SM as compared to UM and negative controls (NCs). CXCL10 levels were raised in UM (550 pg/mL, p Z 0.001) and SM (1480 pg/mL, p Z 0.01) as compared with NCs. Increased levels of IL-6 were found in patients carrying the FC27 allelic type of msp-2. A higher prevalence of MAD 20 and K1 msp-1 alleles was observed in the SM group compared to UM. Conclusion: Overall, a greater prevalence of MAD 20 alleles and increased serum TNF-a and CXCL9 levels were associated with severe outcome in malaria. Understanding the

Background Plasmodium vivax is the prevalent malarial species accounting for 70% of malaria burden in Pakistan; however, there is no baseline data on the circulating genotypes. Studies have shown that polymorphic loci of gene encoding antigens pvcsp and pvmsp1 can be used reliably for conducting molecular epidemiological studies. Therefore, this study aimed to bridge the existing knowledge gap on population structure on P. vivax from Pakistan using these two polymorphic genes. Methods During the period January 2008 to May 2009, a total of 250 blood samples were collected from patients tested slide positive for P. vivax, at the Aga Khan University Hospital, Karachi, or its collection units located in Baluchistan and Sindh Province. Nested PCR/RFLP was performed, using pvcsp and pvmsp1 markers to detect the extent of genetic diversity in clinical isolates of P. vivax from southern Pakistan. Results A total of 227/250 (91%) isolates were included in the analysis while the remainder wer...

Background: Glucose-6-phosphate dehydrogenase deficiency (G6PD), an x-linked inherited enzymopathy, is a barrier to malaria control because primaquine cannot be readily applied for radical cure in individuals with the condition. In endemic areas, including in Afghanistan, the G6PD status of vivax patients is not routinely determined so the drug is rarely, if ever, prescribed even though it is included as a recommended treatment in local, regional and global guidelines. This study assessed the prevalence and genotype of G6PD deficiency in Afghan populations and examined the need for routine G6PD testing as a malaria treatment and control tool. Methods: A cross-sectional household survey was conducted using random sampling in five Afghan cities to determine the prevalence of G6PD deficiency in Afghan ethnic groups. Filter-paper blood spots were analysed for phenotypic G6PD deficiency using a fluorescent spot test. Molecular analysis was conducted to identify the genetic basis of the disorder. Results: Overall, 45/1,436 (3.1%) people were G6PD deficient, 36/728 (5.0%) amongst males and 9/708 (1.3%) amongst females. Amongst males the prevalence was highest in the Pashtun ethnic group (10%, 26/260) while in Tajik males it was 8/250 (3.2%); in Hazara males it was 1/77 (1.3%) and in Uzbek males is was 0/125. Genetic testing in those with deficiency showed that all were of the Mediterranean type (Med-) characterized by a C-T change at codon 563 of the G6PD gene. Conclusion: Prevalence of G6PD deficiency in Afghanistan varies considerably by ethnic group and is predominantly of the Mediterranean type. G6PD deficient individuals are susceptible to potentially severe and lifethreatening haemolysis after standard primaquine treatment. If the aim of increasing access to radical treatment of vivax is to be successful reliable G6PD testing needs to be made routinely available within the health system.

Background: In Pakistan, Plasmodium vivax is endemic causing approximately 70% of the malaria cases. A number of haematological changes, especially thrombocytopaenia have been reported for P. vivax. Several host factors including cell-mediated immune cells, such as IL-1, IL-6 and IL-10 have been documented for P. vivax-induced thrombocytopaenia. However, study on correlation of cytokines and thrombocytopaenia in P. vivax, particularly in patients with severe signs and symptoms has not been reported from Pakistan. Methods: A case control study to correlate TNF, IL-6 and IL-10 in healthy controls and thrombocytopaenic P. vivax-infected patients (both uncomplicated and complicated cases) from southern Pakistan was carried out during January 2009 to December 2011. One Hundred and eighty two patients presenting with microscopy-confirmed asexual P. vivax mono-infection and 100 healthy controls were enrolled in the study at

Plant root hairs are commonly found artifacts in parasitology specimens and may be confused with helminthes by an untrained eye. We report a case of brain tuberculoma where the tissue sample was contaminated with root hair derived from tap water; the presence of this root hair, which mimicked a larva, led to diagnostic confusion. Therefore, tap water should be considered a source of root hair and vegetable matter.

Background: Cytokine-mediated endothelial activation pathway is a known mechanism of pathogenesis employed by Plasmodium falciparum to induce severe disease symptoms in human host. Though considered benign, complicated cases of Plasmodium vivax are being reported worldwide and from Pakistan. It has been hypothesized that P.vivax utilizes similar mechanism of pathogenesis, as that of P.falciparum for manifestations of severe malaria. Therefore, the main objective of this study was to characterize the role of cytokines and endothelial activation markers in complicated Plasmodium vivax isolates from Pakistan. Methods and Principle Findings: A case control study using plasma samples from well-characterized groups suffering from P.vivax infection including uncomplicated cases (n=100), complicated cases (n=82) and healthy controls (n=100) were investigated. Base line levels of Tumor necrosis factor-α (TNF-α), Interleukin-6 (IL-6), Interleukin-10 (IL-10), Intercellular adhesion molecule-1 (ICAM-1), Vascular adhesion molecule-1(VCAM-1) and Eselectin were measured by ELISA. Correlation of cytokines and endothelial activation markers was done using Spearman's correlation analysis. Furthermore, significance of these biomarkers as indicators of disease severity was also analyzed. The results showed that TNF-α, IL-10, ICAM-1and VCAM-1 were 3-fold, 3.7 fold and 2 fold increased between uncomplicated and complicated cases. Comparison of healthy controls with uncomplicated cases showed no significant difference in TNF-α concentrations while IL-6, IL-10, ICAM-1, VCAM-1 and E-selectin were found to be elevated respectively. In addition, significant positive correlation was observed between TNF-α and IL-10/ ICAM-1, IL-6 and IL-10, ICAM-1 and VCAM-1.A Receiver operating curve (ROC) was generated which showed that TNF-α, IL-10, ICAM-1 and VCAM-1 were the best individual predictors of complicated P.vivax malaria. Conclusion: The results suggest that though endothelial adhesion molecules are inducible by pro-inflammatory cytokine TNF-α, however, cytokine-mediated endothelial activation pathway is not clearly demonstrated as a mechanism of pathogenesis in complicated P.vivax malaria cases from Pakistan.

To evaluate the sensitivity and specificity of immunochromatographic test (ICT) malaria p.f/p.v using microscopy as the gold standard diagnosis. Five hundred and sixty patients of both sexes and all age groups with clinical suspicion of malaria were studied. Venous blood was collected for microscopy and ICT. Thick and thin films prepared and stained with Leishman's stain were examined. ICT malaria test was performed and interpreted according to manufacturer's instructions. Data was analyzed using Epi-6. A total of 560 cases were studied, 339 males and 221 females with age ranges between 2 to 73 years. Seventy two (12.85%) cases had parasitaemia (with or without sexual forms). On microscopy 65 (11.6%) cases had asexual-stage parasitaemia and 7 (1.25%) cases had P. falciparum gametocytes only. Thirty two cases were infected with P. falciparum, 29 with P. vivax and 4 had mixed infection. For P. falciparum the ICT was 97.0% sensitive, 98.3% specific, with positive predictive val...

In Pakistan, Plasmodium vivax contributes to major malaria burden. In this case, a pregnant woman presented with P. vivax infection and which was not cleared by chloroquine, despite adequate treatment. This is probably the first confirmed case of chloroquine-resistant vivax from Pakistan, where severe malaria due to P. vivax is already an emerging problem.

We report a fatal case of disseminated strongyloidiasis in a patient with multiple myeloma receiving chemotherapy. A fifty-seven years old man presented with severe diarrhoea and vomiting, fever, weight loss and dysphagia due to mouth ulcers. Despite broad-spectrum intravenous antibiotics, albendazole (anti protozoal) and supportive treatment, the patient died of Gram-negative sepsis.

Plasmodium vivax is the most common specie causing malaria outside Africa with approximately 13.8 million reported cases worldwide. We report case of P. vivax infection with cerebral involvement. A nine year old boy presented with high grade fever accompanied by projectile vomiting and abnormal behavior later he developed seizures, shock, and unconsciousness. P. vivax monoinfection was diagnosed based on peripheral smears and PCR. After antimalarial therapy, patient made full recovery. Current case highlights increasing trend of cerebral complications caused by P. vivax.

Background Malaria is a life-threatening, multisystem disease caused by the plasmodial parasite with a global incidence of approximately 229 million annually. The parasites are known to have unique and crucial interactions with various body tissues during its life cycle, notably the liver, spleen, and recent work has shown the bone marrow to be a reservoir of infection. Methods This study is a case series of patients in whom examination of bone marrow revealed malarial parasites. A retrospective record review of 35 parasite-positive bone marrow specimens examined at Aga Khan University Hospital (AKUH), Karachi, Pakistan, over the years 2007 to 2015 was conducted. Bone marrow aspirates were collected as per International Council for Standardization in Haematology (ICSH) guidelines. Results The median age of patients was 22 years (range 1–75), and 60 % (n = 21) were male. 22 patients had evidence of Plasmodium falciparum, 12 had evidence of Plasmodium vivax and 1 patient had a mixed i...

Background Malarial infection is a major cause of concern, both worldwide and in Pakistan. Gametocytes are the sexual forms of the parasite that are essential for transmission. They fuse inside the mosquito to develop sporozoites. Gametocytes of the plasmodium parasites, which cause the infection, differentiate into male and female gametocytes. These gametocytes constitute the sexual stage of the malaria parasite and are essential in transmission of the disease from human to vector Anopheles. Gametocytes are affected by factors such as host immunity, drug treatment, reticulocytemia, anemia, low levels of asexual parasitemia and stress to the parasite. The aim of this study was to observe the hematological parameters, age and gametocyte carriage in an area of seasonal malaria transmission.

Hydatid disease is a frequently encountered entity in endemic areas and constitutes a serious health problem. The lung is the second most commonly affected organ after the liver. In three of four cases of pulmonary hydatid cyst, the cyst is solitary. The early phase after primary infection is always asymptomatic. Primary symptoms in patients with pulmonary cystic echinococcosis include cough, fever, and chest pain. The clinical and radiological manifestations for the hydatid cyst in the lung depend on the integrity of the cyst. Bronchial fistulization is an important event in the evolution of the cyst. In cases of dubious orientation after the initial study, ultrasonography, conventional tomography, and magnetic resonance imaging prove helpful in delineating the disease accurately. For a specific serologic diagnosis, the immunoglobulin G enzyme-linked immunosorbent assay and immunoelectrophoresis are preferred. Despite the efficacy of new chemotherapeutic regiments, the mainstay of treatment for thoracic hydatidosis remains essentially surgical. In general chemotherapy is used as a complement to surgical treatment to avoid recurrence of the disease. Regardless of the surgical methods adopted, the removal of the parasite intoto, prevention of its dissemination, maximum preservation of pulmonary function, and the immediate obliteration of the remaining cavity are the imperative basis for effective therapy. The most frequent post-surgical complications are pleural infection and prolonged air leakage. The operative morbidity and recurrence rates have been reported with variation. Education of the population in endemic areas regarding the disease transmission cycle and institution of appropriate prophylaxis are essential steps to eradicate the disease completely.