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Pathology Case Study

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Robyn Pretorius

on 11 April 2014

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Transcript of Pathology Case Study

Phase 2
Phase 1
Phase 4
Phase 3
References
.
.
History:
Miss B is 42 years old, known with RVD on 1st line HAART (CD4 421), VL<40
Known with previous Stage IIIB Cervical Carcinoma for which she received radiotherapy
Also suffering from urinary incontinence, irregular vaginal bleeding and passing faeces per vagina=post-radiotherapy for Cervical Ca
Presented with thyroid mass (anterior neck mass) more than 1 year ago
Diagnosed with papillary carcinoma in Jan 2013-never followed up
Now referred again for bilateral thyroid lobe nodules that are palpable
Pathology
[1] MedlinePlus. 2013. Thyroid Cancer. [ONLINE] Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001213.htm. [Accessed 08 April 14].
[2] Robert Ferry Jnr. 2013. Thyroid Nodule. [ONLINE] Available at: http://www.medicinenet.com/thyroid_nodules/article.htm. [Accessed 08 April 14].
[3] NHLS
[4]Lin, JD, 2011. Papillary Thyroid Carcinoma with Different Histological Patterns. Chang Gung Medical Journal, [Online]. 34, 23-34. Available at: http://memo.cgu.edu.tw/cgmj/3401/340102.pdf [Accessed 09 April 2014].
[5] Gupta et al, (2013), Follicular variant papillary carcinoma without MVs [ONLINE]. Available at: http://www.jcdr.net/ReadXMLFile.aspx?id=2747 [Accessed 09 April 14].
[6] Wikipedia. 2013. Medullary Thyroid Cancer. [ONLINE] Available at: http://en.wikipedia.org/wiki/Medullary_thyroid_cancer. [Accessed 10 April 14].
[7]Dr. Alan L. Gillen, (2010), E. coli Gram stain (Wiki commons image). E. coli are Gram-negative bacteria, thus red or pink colored. The red color is due to a counterstain, called safranin. [ONLINE]. Available at: http://www.answersingenesis.org/articles/aid/v5/n1/genesis-pathogenic-e-coli [Accessed 10 April 14].
[8] Collier, I, 2006. Human Virology. 2nd ed. Oxford: Oxford University Press.
[9] Maartens, G. Cotton, M. Wilson, D. Venter, F, 2012. Handbook Of HIV Medicine. 3rd ed. Cape Town: Oxford University Press.
[10] Unknown, (2014), HIV antibody [ONLINE]. Available at: http://www.rnceus.com/fl2hiv/test2.html [Accessed 10 April 14]
[11] AidsMap. 2013. CD4 cell counts. [ONLINE] Available at: http://www.aidsmap.com/CD4-cell-counts/page/1254931/. [Accessed 10 April 14].
[12] WHO. 2013. Chapter 7: Clinical guidance across the continuum of care: antiretroviral therapy. [ONLINE] Available at: http://www.who.int/hiv/pub/guidelines/arv2013/art/en/. [Accessed 10 April 14].
[13] Dublin institute of technology, (2010), Bethesda classification [ONLINE]. Available at: http://www.google.com/patents/WO1997048329A1?cl=en [Accessed 09 April 14].
[14] fce-studymode, (2010), pathology of cervical cancer [ONLINE]. Available at: http://fce-studymode.netdna-ssl.com/images/upload-flashcards/407108/954191_m.png [Accessed 09 April 14
[15] Kruger,TF; Botha, MH, 2011. Clinical Gynaecology. 4th ed. South Africa: Juta.
[16] Faculty of Health Sciences; University of Cape Town, Division of Clinical Pharmacology. The South African Medicines Formulary, 11th ed. Cape Town: Health and Medical Publishing Group; 2013.
[17] Prof Apfelstaedt (2011). 'Surgical Thyroid Disease', lecture notes distributed in the topic 52353 271 The Endocrine System. Stellenbosch University, Tygerberg On September 2011.
[18] Longmore, M et al. 2010. Oxford Handbook of Clinical Medicine. 8th ed. Oxford: Oxford University Press
[19] Bird, A. Jacobs, P. 1983. Basic Haematology 2nd ed. Cape Town: University of Cape Town
[20]









The Curious Case of Miss BB
Pathology Case Study
Wanele Ganya-16223098
Wandile Ganya-16227859
Farzaana Singh-15748677
Shane Rosenberg-15695816
Rudolf Pretorius-15710009
Robyn Pretorius-15677621
Daylen Rutledge-15759504

Potential Danger Signs
Haematology
Chemical Pathology
Cytology (Anatomical Pathology)
References
Patient is chronically ill
IV line in situ
No oxygen mask
Vitals stable
General exam: conjunctival pallor/small axillary and submental lymph nodes
CVS/Resp/GIT unremarkable
Visible anterior neck mass/thyroid mass noted L>R, no pain, mobile, firm & smooth, no LAD, no voice change/breathing or swallowing difficulties
Clinical Examination
The patient did not present with any dangers signs or symptoms. However, what we would need to have looked out for is the following:
Difficulty in swallowing [1]
Hoarseness or change in voice [1]
Neck swelling with possible compression symptoms [1]
Differential Diagnosis
Thyroid masses: [2]
Single thyroid nodules/thyroid adenomas
Multinodular goitre
Thyroid cyst
Papillary, follicular or medullary thyroid cancer
Metastatic disease
Lymphoma [2]
Lymphadenopathy secondary to infection (e.g. TB)
Microbiology
Virology
Treatment and
Management
Thyroid:
cytologically compatible with papillary Ca; with squamous metaplasia, nuclear inclusions, thick colloid=FVPTC [3]
FVPTC more distant metastases but better long-term survival [4]
[5]
Cytology (Anatomical Pathology)
Thyroid:
cytologically compatible with papillary Ca; with squamous metaplasia, nuclear inclusions, thick colloid=FVPTC [3]
FVPTC more distant metastases but better long-term survival [4]
Thyroid:
TSH normal [3]
Expected with malignancy
NB! Calcitonin [6]
CMP & Albumin:
All results normal [3]
U&E:
All results normal [3]
-Urine sent away for MC&S (Microscopy, Culture & Sensitivity) [16]

-Microscopy – Leucocytes & Erythrocytes > 750 000/ml

-Culture – E.Coli

-Antibiotic susceptibility for E.Coli:
-Resistant to: ampicillin, amoxycillin; 2nd , 3rd & 4th gen. cephalosporins; ciprofloxacin and cotrimoxazole

-Sensitive to: Aminoglycosides and Ertapenem

-Report comment: poor clinical response to β-lactamase inhibitors; multi-resistant organism

-Contact precautions to prevent spread of organism in ward.

[7]
Cervical: [15]

Pathophysiology:
exposure to carcinogens – disrupts normal metaplasia – dysplasia in TZ. This is precursor of cervical carcinoma.
Cytology:
pap smear
Histopathology:
when Pap smear indicates HSIL (or LSIL on 2 occasions within 3 months) biopsy is needed to confirm diagnosis histologically. How? Colposcopic guidance – staining with acetic acid or Lugol’s iodine. If TZ not visualised – LLETZ or cold-knife conisation.

HIV
HPV
Side-room and special investigations
The following relates to the investigation of anaemia:
Ward Hb*
Urine dipstix*
ESR*
FBC
Peripheral smear*
Iron studies*
FBC results:
RCC-3.2 (low)
Hb-8.5 (low)
HCT-0.3 (low)
MCV-85 (N)
MCH-29.5 (N)
WCC-4.14 (N)
RDW-15.4 (high)
Platelets-389 (N)
NORMOCYTIC NORMOCHROMIC ANAEMIA
A peripheral smear would have shown a
shift reticulocytosis, erythroid hyperlplasia
and polychromasia.

Most obvious cause in our case is :
Recent Blood Loss
Chronic Diseases
Haemolytic disorders
Hypoplastic anaemas
Infiltrated Bone marrow
Renal Disease
Liver Disease
As provided in the history and lab results
Presentation:
Many possible presentations – cervical disease most relevant.

Possible symptoms and signs:
- vaginal bleeding between/after sex;
- dysparaunia
- fullness of the pelvis
- condylomata
- Cauliflower-like growths

Workup:
Colposcopy –
hard, irregular cervix
Biopsy for histology –
squamus cell ca in a background of HSIL
Also possible – Pap smear, viral DNA


Complications:
Persistent infection can lead to neoplastic changes
Co-infection with HIV can increase risk of oncogenesis


Prevention
- Vaccination - gardasil (quadrivalent) and cervarix (bivalent)
- Screening - state protocol

Further info:
- Immunosuppressed pt
- Folate deficiency aids cervical carcinogenesis
- High risk HPV infections for carcinoma usually do not develop
condylomata.
- Incidence of cervical Ca in RSA 1 in 39
- Self-sampling of cervical tissue, Viral DNA screening and the
resource-limited setting



Background [8]
Lentivirus (Latin lentus=slow): HIV-1 & HIV-2
HIV-1 is common in Southern Africa & is the cause for the global epidemic
HIV-2 is largely restricted to West Africa
Hallmark of disease=gradual decline in CD4 cells
Diagnosis [8,9]
HIV markers during infection
HIV RNA in plasma
HIV p24 antigen
HIV antibody (e.g. viral env protein antibody)
Screening: Rapid HIV antibody tests (blood, serum, saliva)
Diagnosis: ELISA and always followed by second confirmary test detecting different antibodies
[10]
HIV monitoring
CD4 cell count (400 – 1600 per ml3).
CD4 percentage esp. in children (≈ 40%).
Viral load (VL) detected using quantitative PCR (< 40 copies/mL) [11].

Failure
Virological failure: Plasma viral load above 1000 copies/ml based on two consecutive viral load measurements after three months, with adherence support [8, 11, 12].

Case of Miss B
WHO stage IV.
Her viral load shows suppression of viral replication thus good response to therapy.
CD4 cell count: Normal.

[13]
[14]
Cervical Carcinoma
Surgery; conisation; LLETZ; simple excision; hysterectomy
Chemotherapy and radiation
Haematology
Thyroid Carcinoma [17]
Pre-op:
CT scan (U&E)
FBC
Informed consent
Surgery:
Total thyroidectomy + complete neck dissection
Post-op:
RAI
Radiotherapy
Chemotherapy
Thyroid Hormone Replacement Therapy
Assess severity of blood loss
Miss B=haemodynamically stable
Hb not <7
Blood transfusion not necessary
Find source of bleeding and stop it
Manage the underlying cause of chronic disease
Ensure adequate iron stores
UTI
Ertapenem
Fosfomycin
Nitrofurantoin
Full transcript