Qap (Anatomical Pathology) 

QAP Peer Review

AP134
Case History: M/50, Left thigh abscess.
Intended diagnosis: Cytomegalovirus infection. Contributed by:PKH
Code Diagnosis Comment Score
anonymous Acute suppurative inflammation with suggestion of viral infection (100%). Enlarged endothelial cells with suggestion of viral inclusion are seen. Advise immunostain for Cytomegalovirus (CMV). Vasculitis is seen but is most likely secondary to the inflammation.  100
anonymous Intravascular lymphomatosis (Malignant lymphoma), 100% Immunohistochemical stains for lymphoid markers for confirmation and tumour typing.  0
anonymous Suppurative inflammation with necrosis, as well as prominent endothelial cells with nuclear inclusion. 100% Necrotizing fasciitis is a possibility, but a diagnosis of which requires clinical correlation. The viral-inclusion body like endohtelial cells need to be further investigated, and immunohistochemical stain for CMV is helpful. Special stains for infective micro-organisms are also useful.  100
anonymous Bacillary angiomatosis (80%) Abscess with CMV infection (20%) the following stains would be performed 1. Warthin Starry stain - to highlight rod shaped Bartonella bacilli 2. CMV immunostain - would be positive in CMV infected cells 3. GMS and Gram stains - to exclude a fungal or Gram positive bacteria respectively as the cause of the abscess. An immunocompromised state and HIV infection should be excluded in the patient.  50
anonymous CMV infection Immunostaining for CMV  100
anonymous CYTOMEGALOVIRUS ENDOTHELIITIS. 100% The diagnosis can be confirmed by immunostain for CMV.  100
anonymous Necrotizing fasciitis and myositis with CMV endotheliatis. (100%) Suggest checking blood for pp65 level and clinical features for the probable causative nature of CMV. Underlying immunodeficiency and/or immunodisregulation need to be excluded.  100
anonymous Thigh-acute suppurative inflammation and CMV vasculitis 100% Inclusions in the endothelial cells can be confirmed to be CMV by immunohistochemistry.  100
anonymous CMV vasculitis with abscess formation (100%) To be confirmd by immunohistochemical studies. Exclude the possibility of immunosuppression.  100
anonymous 1. Metastatic malignant neoplasm 50% DDX: malignant melanoma, intravascular large B-cell lymphoma, carcinoma. 2. Inflammatory reaction due to cytomegalovirus infection 50% 1. Suggest immunohistochemical staining, i.e. S100, HMB45, LCA, CK, CD34 to define the nature of the plump cells. 2. Suggest clinical correlation for presence of primary neoplasm or immunodeficiency status.  50
anonymous CMV vasculitis with myositis. 100% nil  100
anonymous Vasculitic change and rhabdomyolysis, with abnormal endothelial cells seen, features are suspicious of cytomegalovirus infection. - To be confirmed by immunostaining for CMV - The atypical cells in fibrous septa and prominent polymorphs infiltration are unusual for CMV infection per se. Cannot exclude other co-existing infection. Thus require special stains for micro-organisms, e.g. Ziehl Neelsen stain for AFB (particularly atypical mycobacteria), Grocott stain for fungal organisms, Warthin Starry stain for Bartonella organisms (in Bacillary angiomatosis), etc.  100
anonymous Cutaneous bacillary angiomatosis nil  0
anonymous Necrotizing lesion with vasculitis. Suspicious cells around vessels. DDX: lymphoma, some reactive histiocytic cells or CMV. Prbability : 100% Would perform T & B markers, CD68 and CMV to delineate nature of large cells.  100
anonymous Inflammatory lesion, infection to be excluded 80%; Lymphoma 20%. Correlation with clinical history and microbiological studies is necessary. Immunostains for CD34 and LCA to be performed to delineate the nature of the atypical cells around the vessel wall. Immunostains for CMV antigens also be performed to exclude CMV infection.  100
anonymous Cytomegalovirus infection (100%). nil  100