Blood cultures and a wound swab were sent for microbiological analysis. Laboratory Findings Wound cultures grew methicillin-resistant Staphyloccocus aureus thought to represent colonization rather than true infection. Blood cultures flagged positive in one anaerobic bottle only at 30 hours.
A gram smear showed gram-negative cocci Image 1. Anaerobic blood plates grew pinpoint colonies Image 2.
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Veillonella species are gram negative cocci. They are lactate fermenting, obligate anaerobes and are considered normal flora of the intestines and oral mucosa.
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As such, they are usually regarded as a contaminant. They have, however, been implicated in osteomyelitis, prosthesis infections, and endocarditis. They are particularly associated with poor oral hygiene, chronic periodontitis, and smoking. They have important implications in dental disease due to their ability to form biofilms. They are frequently resistant to ampicillin and have also been noted to be resistant to tetracyclines in periodontal patients. PCR has also been developed, but is not routinely used. This was considered a contamination due the absence of symptoms and isolation in one bottle only.
A follow up blood culture was negative. Routine wound care was resumed.
Surgical Pathology Dissection - An Illustrated Guide | William H. Westra | Springer
The patient is a 6 year old who developed abdominal pain 2 days prior to admission. The patient was in school when the abdominal pain began, resulting in the patient doubling over in pain. The pain resolved within 1 hour, however, because the initial presentation was an unremitting abdominal pain, the patient was taken to an outside hospital for evaluation. There was no vomiting, diarrhea, or constipation. On physical exam, the patient was very tender to palpation in the right lower quadrant and was unable to tolerate deep palpation.
A computed tomography scan was subsequently ordered which showed a large mass in the pelvic peritoneum. The patient was admitted to surgery for an exploratory laparotomy, with resection of the pelvic mass. Received fresh in the Surgical Pathology laboratory is a The margins are inked black and the specimen is serially sectioned revealing glistening, gray-tan soft tissue with focal areas of yellow discoloration and softening. Along one edge of the specimen, there is a 4.
Portions of the fresh specimen are submitted in glutaraldehyde for electron microscopy if needed, RPMI for cytogenetics, and are snap-frozen as well. Touch preparations are also made and gross photographs are taken. Representative sections are submitted as follows:.
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Histologically, the mass is composed of sheets and nests of small round cells along thin fibrous septa, giant multinucleated cells, and rare strap cells. The margins are positive, although the specimen is unoriented.
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Venous and lymphatic invasion is absent. Immunohistochemical IHC stains are ordered and the results are listed below:. In addition to the IHC stains, a portion of tissue was sent for cytogenetics testing, which showed a chromosomal translocation at t 2;13 q35;q Based on the histologic appearance, IHC stains, and cytogenetic testing, the specimen was signed out as an alveolar rhabdomyosarcoma with a pathologic stageof pT2b, N0, MX.
Following the diagnosis, the patient was placed on a chemotherapy regimen of Vincristine, Adriamycin, Etoposide and Cytoxan, as well as radiation therapy.
The most common locations of rhabdomyosarcoma are in the head and neck region, followed by the genitourinary system, extremities and then torso. The World Health Organization classification of skeletal muscle tumors divided rhabdomyosarcoma into four types based on histology:. Although it is most common in teenagers, ARMS affects all ages. Most patients will present with a painless soft tissue mass, but based on the size and location of the mass, it may cause mass effect. A quarter of patients will have metastasis at the time of diagnosis, most commonly to the bone marrow, bones, and lymph nodes.
Grossly, ARMS presents as a solid, well-defined mass with a fleshy, tan-gray cut surface. Histologically, it is composed of small, blue, round cells and occasional round to spindle shaped rhabdomyoblasts. When compared to embryonal rhabdomyosarcoma, the rhabdomyoblasts in ARMS are slightly larger. ARMS is broken down into two subtypes: the classic subtype and the solid subtype. In the classic subtype, the tumor is composed of nests of cells that adhere to the edges of fibrous septa, resembling pulmonary alveoli hence the name alveolar rhabdomyosarcoma.
Multinucleated giant cells with a peripherally located nuclei may also be present. In the solid subtype, there will be nests and sheets of neoplastic cells that are separated by thin fibrovascular septa, but will not form in the classic alveolar pattern Image 2. Due to the various appearances of rhabdomyosarcoma, it has become important to integrate immunohistochemical IHC stains and molecular testing into the diagnosis.
The most common IHC stains that are used to determine the rhabdomyoblastic differentiation of a sarcoma is through the use of Myogenin and Myogenic differentiation 1 MyoD1 stains, in which both stains will be positive in rhabdomyosarcoma. To go along with IHC stains, molecular testing has been shown to be affective with determining the type of rhabdomyosarcoma. There have been two translocations that have been identified in ARMS.
In order to determine the best treatment course, patients who are diagnosed with rhabdomyosarcoma are divided into a low risk, intermediate risk or high risk group based on the pathologic stage, clinical stage and clinical group. In the above Clinical Staging System, a favorable site is defined as occurring in the orbit, biliary tract, head and neck region excluding parameningeal and genitourinary region excluding prostate and bladder.
Any other site not listed is considered unfavorable. Next, a clinical group is assigned based on the extent of the disease using the Clinical Grouping System below, which again is put out by the IRS group:. When compared to embryonal rhabdomyosarcoma, which is the most common type of rhabdomyosarcoma, ARMS has a worst prognosis. The IRS group clinical group and stage can help to predict the overall outcome of the patient, with the standard treatment regimen composed of surgery, radiation therapy and chemotherapy.
His job involves the macroscopic examination, dissection and tissue submission of surgical specimens, ranging from biopsies to multi-organ resections. Cory has a special interest in head and neck pathology, as well as bone and soft tissue pathology. Cory can be followed on twitter at iplaywithorgans. For most people working in laboratory medicine, their first encounter with transgender patients likely arose from an issue involving the Electronic Health Record HER. For me, I was called into the reference lab, because an abnormally high estradiol result was found by the referring lab.
While these may not specifically happen to all of you, I hope they can be informative or help you anticipate future problems. Transgender issues came up at one of our institutions when providers were getting dozens of messages in their in-baskets about new flagged lab results for multiple patients. This is very annoying, because they have to address each of these messages or they are out of compliance with the hospital.
An investigation revealed that all of the patients involved were transgender patients.
In order to get estradiol, sold as oral contraception pills, the pharmacy had to administratively change their sex in the EHR for approval, then change it back. This moved their corresponding reference ranges out of sync, which triggered a new results flag. Changing the sex back triggered other flags and more messages. This was finally resolved after a committee was convened and several meetings occurred, but no one would have anticipated this type of issue arising from a simple action to get patients their medicine. Sometimes transgender patients have their sex changed legally.
If an EHR only includes one sex entry instead of gender and sex assigned at birth, then certain lab errors may prevent processing of important samples. The pregnancy test for a transgender man could be auto-rejected. This can be an issue even for providers in front of the patient as was recently reported in a case to the NEJM about a transman who was mistaken as obese instead of pregnant and miscarried their child.
Similarly, a prostate biopsy from a transgender woman could be auto-rejected by a surgical pathology system as an inappropriate specimen type for the patient. Even further, an EHR could fail to prompt a provider from making a prostate cancer risk assessment in a transgender woman, which could result in improper screening. I would recommend that EHR includes three separate fields sex assigned at birth, gender, and legal sex to fully recognize transgender patients and provide optimal personalized healthcare to them.
His clinical research interests include understanding how the lab intersects with transgender healthcare and improving genetic variant interpretation. There are multiple types of risk assessments required when managing a laboratory safety program. Risk assessments can be used to determine whether or not to add an emergency eyewash station, and all lab chemicals need to be assessed for the hazards they pose. Westra , Ralph H. Hruban , Timothy H. Phelps , Christina Isacson , F.
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