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Rapidly Growing Solitary Osteochondroma in the Adult Finger A Case Report [Case Report]

Niemeier, Julia K; Guzzetta, Melissa B; Paksima, Nader
Osteochondromas are common benign bone tumors that are most commonly found in children and adolescents. They are usually slow-growing and located at the metaphysis of the long bones. When present in adults in atypical locations or with concerning features, such as thickened cartilage cap and rapid growth, osteochondromas warrant imaging to assess the risk of malignant transformation into chondrosar- coma and may require surgical excision. Here, we describe the unusual case of an adult male with a rapidly growing osteochondroma of the proximal phalanx that subsequently underwent surgical excision.
PMID: 35643479
ISSN: 2328-5273
CID: 5244782

Blinded Review of Hippocampal Neuropathology in Sudden Unexplained Death in Childhood Reveals Inconsistent Observations and Similarities to Explained Pediatric Deaths

Leitner, Dominique F; McGuone, Declan; William, Christopher; Faustin, Arline; Askenazi, Manor; Snuderl, Matija; Guzzetta, Melissa; Jarrell, Heather S; Maloney, Katherine; Reichard, Ross; Smith, Colin; Weedn, Victor; Wisniewski, Thomas; Gould, Laura; Devinsky, Orrin
AIMS/OBJECTIVE:Hippocampal findings are implicated in the pathogenesis of sudden unexplained death in childhood (SUDC), although some studies have identified similar findings in sudden explained death in childhood (SEDC) cases. We blindly reviewed hippocampal histology in SUDC and SEDC controls. METHODS:Hippocampal H&E slides (n=67; 36 SUDC, 31 controls) from clinical and forensic collaborators were evaluated by 9 blinded reviewers: 3 board-certified forensic pathologists, 3 neuropathologists, and 3 dual-certified neuropathologist/forensic pathologists. RESULTS:Among nine reviewers, about 50% of hippocampal sections were rated as abnormal (SUDC 52.5%, controls 53.0%), with no difference by cause of death (COD) (p=0.16) or febrile seizure history (p=0.90). There was little agreement among nine reviewers on whether a slide was within normal range (Fleiss' kappa=0.014, p=0.47). Within reviewer groups, there were no findings more frequent in SUDC compared to controls, with variability in pyramidal neuron and dentate gyrus findings. Across reviewer groups, there was concordance for bilamination and granule cell loss. Neither SUDC (51.2%) nor control (55.9%) slides were considered contributory to determining COD (p=0.41). CONCLUSIONS:The lack of an association of hippocampal findings in SUDC and controls, as well as inconsistency of observations by multiple blinded reviewers, indicates discrepancy with previous studies and an inability to reliably identify hippocampal malformation associated with sudden death (HMASD). These findings underscore a need for larger studies to standardize evaluation of hippocampal findings, identify the range of normal variation and, changes unrelated to SUDC or febrile seizures. Molecular studies may help identify novel immunohistological markers that inform on COD.
PMID: 34164845
ISSN: 1365-2990
CID: 4918622

The histopathologic characteristics of the gastrointestinal system in SARS-COV-2 infected patients who underwent biopsy or resection [Meeting Abstract]

Ahmed, S; Hoskoppal, D; Lin, L; Suarez, Y; Liu, W; Cho, M; Thomas, K; Guzzetta, M; Hajdu, C; Theise, N; Jour, G; Sarkar, S; Cao, W
Background: In addition to respiratory distress, GI symptoms have been reported in COVID-19 patients at various stages of the disease. Among the GI symptoms that have been reported, diarrhea, nausea, vomiting, abdominal pain and GI bleeding were often seen. Age and comorbid conditions such as obesity, HTN, DM and/or CAD have been considered as risk factors for COVID-19 patients for severe disease. GI manifestations in COVID-19 patients appeared to act as a sign for a serious condition. The virus has been identified in the stool and in rectal swabs of some infected patients, even after a negative nasopharyngeal test. There is a lack of reports on pathological alterations of the GI tract in COVID-19 infected patients.
Design(s): 16 PCR confirmed COVID-19 patients (11 males and 5 females) were included in the study. Biopsy or resection specimens were taken from the esophagus (4), stomach (6), small intestine (5), appendix (3), colon (5) and gallbladder (3). Clinical information including demographics, comorbidities, GI symptoms, related laboratory tests were collected. Histopathologic evaluation was performed and correlated with clinical properties.
Result(s): The age of the patients ranged from 10 to 84 years old, with an average of 47 years. Eight (50%) patients had at least one comorbid condition, two patients (12.5%) had prior history of cancer, and six patients had no significant medical history. Abdominal pain and GI bleeding were the most common presenting symptoms. Histologically, acute and chronic inflammation was seen in 14 of 16, and 15 of 16 cases, respectively. Eight cases showed severe acute inflammation with ulceration. The mucosal changes included nonspecific reactive change, hypermucinous, atrophic/ischemic changes, and necrosis, were indiscriminately noticed in these cases. Four cases showed intraepithelial lymphocytosis. Viral like inclusions were found in four cases. Microthrombi were identified in 5 cases with an average patient age of 60 years. Notably, microthrombi were seen in about 5 out of 8 (62%) patients with comorbidities. The patients with microthrombi had a higher D dimer test value than those without thrombus. Three patients died shortly after operation, and two of them showed microthrombi in the tissue specimens.
Conclusion(s): Acute and chronic inflammation were indiscriminately seen in these cases. Microthrombi were dominantly found in aging patients with comorbidities, suggesting microthrombi in the GI tract may be a histologic indication for severe COVID-19 patients with GI symptoms
EMBASE:634717313
ISSN: 1530-0307
CID: 4857062

Rectal SWAB SARS-COV-2 testing and histologic findings in the small intestine of 18 autopsy patients [Meeting Abstract]

Lin, L; Ahmed, S; Thomas, K; Guzzetta, M; Hoskoppal, D; Cho, M; Suarez, Y; Liu, W; Hajdu, C; Theise, N; Jour, G; Sarkar, S; Cao, W
Background: Digestive symptoms are often seen in COVID-19 patients with poor outcomes. The Viral RNA is mostly positive in the stool of these patients, and has a longer delay before viral clearance. However, its diagnostic value and significance for guiding clinical treatment remain unknown. And the pathologic alterations in the GI tract in COVID-19 patients have not been well defined. We evaluated rectal swab SAS-CoV-2 test and histopathologic changes in the small intestine in autopsy patients.
Design(s): 18 autopsy cases with confirmed SAS-CoV2 infection were included. Nasal, bronchial, and rectal swab SARS-CoV-2 PCR were performed at the time of autopsy. Clinical information included demographics, comorbidities, presenting symptoms, related laboratory tests were collected. Histopathologic evaluation was performed and correlated with clinical properties.
Result(s): 83% (15/18) of patients were male. Median age is 50 years. 7/18 (38.9%) patients had diarrhea in addition to cough, fever and other symptoms. Except in one case, all patients had underlying comorbidities of diabetes, hypertension and /or obesity. In the small intestine, acute inflammation was not seen in any cases. 5/18 displayed mild and one showed moderate chronic inflammation. Hypermucinous change was found in six patients but not associated with diarrhea. 3 cases had microthrombi identified in the sections. Notably, obviously increased D dimer in lab tests were noticed in all patients. Postmortem 17/17 (100%) nasal, 18/18 (100%) bronchial and 7/16 (43.8%) rectal swabs showed SARS-CoV-2 PCR positivity. 3 of 7 (42.9%) patients with diarrhea are positive in rectal swab for SARS-CoV-2.
Conclusion(s): There are no specific COVID-19 changes in the small intestine. More investigations are needed, especially on tissues from different locations of the GI tract. Data from rectal swab testing suggests that it is not ideal for diagnosing COVID-19, guiding treatment, or predicting small intestinal pathology
EMBASE:634717542
ISSN: 1530-0307
CID: 4857032

Testicular Changes Associated With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) [Letter]

Flaifel, Abdallah; Guzzetta, Melissa; Occidental, Michael; Najari, Bobby B; Melamed, Jonathan; Thomas, Kristen M; Deng, Fang-Ming
PMID: 33367666
ISSN: 1543-2165
CID: 4731502

Investigating the Spectrum of Dermatologic Manifestations in COVID-19 Infection in Severely Ill Patients - A Series of Four Cases [Case Report]

Occidental, Michael; Flaifel, Abdallah; Lin, Lawrence H; Guzzetta, Melissa; Thomas, Kristen; Jour, George
PMID: 32896915
ISSN: 1600-0560
CID: 4588872

COVID-19-Induced Neurovascular Injury: a Case Series with Emphasis on Pathophysiological Mechanisms

Gutierrez Amezcua, Jose Manuel; Jain, Rajan; Kleinman, George; Muh, Carrie R; Guzzetta, Melissa; Folkerth, Rebecca; Snuderl, Matija; Placantonakis, Dimitris G; Galetta, Steven L; Hochman, Sarah; Zagzag, David
Coronavirus disease 2019 (COVID-19) is associated with a high inflammatory burden that can induce severe respiratory disease among other complications; vascular and neurological damage has emerged as a key threat to COVID-19 patients. Risk of severe infection and mortality increases with age, male sex, and comorbidities including cardiovascular disease, hypertension, obesity, diabetes, and chronic pulmonary disease. We review clinical and neuroradiological findings in five patients with COVID-19 who suffered severe neurological disease and illustrate the pathological findings in a 7-year-old boy with COVID-19-induced encephalopathy whose brain tissue sample showed angiocentric mixed mononuclear inflammatory infiltrate. We summarize the structural and functional properties of the virus including the molecular processes that govern the binding to its membrane receptors and cellular entry. In addition, we review clinical and experimental evidence in patients and animal models that suggests coronaviruses enter into the central nervous system (CNS), either via the olfactory bulb or through hematogenous spread. We discuss suspected pathophysiological mechanisms including direct cellular infection and associated recruitment of immune cells and neurovirulence, at least in part, mediated by cytokine secretion. Moreover, contributing to the vascular and neurological injury, coagulopathic disorders play an important pathogenic role. We survey the molecular events that contribute to the thrombotic microangiopathy. We describe the neurological complications associated with COVID-19 with a focus on the potential mechanisms of neurovascular injury. Our thesis is that following infection, three main pathophysiological processes-inflammation, thrombosis, and vascular injury-are responsible for the neurological damage and diverse pathology seen in COVID-19 patients.
PMCID:7577845
PMID: 33106782
ISSN: 2523-8973
CID: 4646442

Alcohol-related deaths in medical autopsies at an academic institution: An underreported finding [Meeting Abstract]

Hong, Tran T; Guzzetta, M
Background: The "opioid epidemic" is overshadowing the fact that alcohol use disorder is more prevalent than opioid use disorders. According to WHO, alcohol directly contributes annually to over three million deaths worldwide and is a causal factor in over 200 diseases. In comparison, 118,000 people died from opioid use in 2015 worldwide. Despite more reportable deaths from harmful alcohol use, the number is underestimated because alcohol-related deaths are underreported.
Design(s): We performed a retrospective review of autopsy cases in our pathology database using the key terms "chronic alcoholism", "chronic alcoholic", "chronic alcohol", "chronic ethanol", "alcoholic", "alcohol", "ethanol", and "etoh" from 2004 to 2019. Cases positive for one or more key terms had autopsy report and medical record reviewed to see if alcohol-related death was reported on the Final Autopsy Diagnosis (FAD).
Result(s): 247 cases were positive for one or more key terms. In 91 cases the patient explicitly denied alcohol use, and FAD did not report alcohol-related death. 62 cases did not have documentation of the patient's alcohol usage. 19/62 cases had autopsy findings that raised the possibility of alcohol-related death. These cases had complications from end stage liver disease associated with splenomegaly, esophageal varices, ulcers, jaundice, and ascites. Alcohol use disorder was not clinically confirmed, so the associated autopsy report could not causally attribute alcohol use to death. 66 cases had a clinical diagnosis of alcohol use disorder. 34/66 cases reported alcohol-related death on the FAD; 97% were from chronic use, and 2.9% from acute intoxication. 32/66 cases reported the disease and not alcohol-related death.
Conclusion(s): At our institution, alcohol-related deaths are underreported on the FAD. Although alcohol is a known causal factor in acute and chronic pancreatitis, liver disease, several cancers, cardiac dysrhythmia and other diseases, 48.5% autopsy cases reported the disease itself and not alcohol-related death. Alcohol-related death may be further underreported by issues that surfaced during our study. Patients who die from alcohol use may not get an autopsy. Also, patients may not disclose their true alcohol use. Another issue is clinicians may fail to document alcohol use in the medical chart. It is important to report alcohol-related deaths on the FAD because underreporting may have implications on public health awareness and affect funding for future research and disease prevention
EMBASE:631879303
ISSN: 1530-0285
CID: 4472582

Clostridium Sordellii as an Uncommon Cause of Fatal Toxic Shock Syndrome in a Postpartum 33-Year-Old Asian Woman, and the Need for Antepartum Screening for This Clostridia Species in the General Female Population

Guzzetta, Melissa; Williamson, Alex; Duong, Scott
Clostridium sordellii (C. sordellii) is an anaerobic gram-positive rod most commonly found in the soil and sewage but also as part of the normal flora of the gastrointestinal tract and vagina of a small percentage of healthy individuals. C. sordellii infection is considered to result from childbirth, abortion, and/or gynecological procedures. Although many strains of C. sordellii are nonpathogenic, virulent toxin-producing strains exist. Infection with this organism typically manifests as a patient experiencing septic shock rapidly followed by end-organ failure. Identification of C. sordelli has been successful by traditional culture, mass spectrometry methods, and via molecular methods. Herein, we present a fatal case of C. sordellii infection of a postpartum 33-year-old Asian woman. The organism was isolated by culture and identified using matrix-assisted laser desorption/ionization-time-of-flight (MALDI-TOF) technology. With the advent of rapid detection methods, antepartum screening for the fatal Clostridium species should be implemented in the general female population.
PMCID:4985774
PMID: 27371657
ISSN: 1943-7730
CID: 2180402

Primary CNS T-cell lymphoma of the spinal cord: case report and literature review [Case Report]

Guzzetta, Melissa; Drexler, Steven; Buonocore, Brian; Donovan, Virginia
Primary central nervous system lymphoma (PCNSL) accounts for 1% of all lymphoma diagnoses and as many as 6% of all central nervous system (CNS) tumors. Most cases of PCNSL are of B-cell type; few are of T-cell lineage. PCNSL mainly occurs intracranially; primary spinal-cord lymphoma only occurs rarely. Moreover, intramedullary presentation without intracranial lesions is virtually unknown. Herein, we present a case of primary T-cell CNS lymphoma limited to the intramedullary spinal cord in an 82-year-old white man, along with a review of the literature on this condition and similar conditions.
PMID: 25918197
ISSN: 1943-7730
CID: 2180412