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   Table of Contents - Current issue
Coverpage
January-June 2019
Volume 10 | Issue 1
Page Nos. 1-107

Online since Tuesday, May 14, 2019

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ORIGINAL ARTICLES  

Toxicological findings in occupants of a crashed commercial aircraft and the legal implications on personal injuries claims Highly accessed article p. 1
John Oladapo Obafunwa, Mathias Ikechukwu Okoye, Francis Adedayo Faduyile, Sunday Shokunle Soyemi
DOI:10.4103/atp.atp_35_18  
Background: A commercial aircraft operated by DANA Air crashed just outside the Lagos International Airport, Nigeria, killing a total of at least 150 people. The crash was accompanied by a fire outbreak. There were no survivors. There is a consideration that some victims might have survived for some time and consequently suffered agonal pain. Materials and Methods: Postmortem examination for the purpose of disaster victim identification, and determination of the cause of death was carried out for the first time in the country. Part of the mass disaster investigation entailed toxicological studies conducted on bodies that were fairly well preserved, and where body fluids were available. A total of 148 victims were positively identified and toxicological samples could only be obtained from 82 of them, comprising the blood, urine, vitreous, and marrow. One hundred and twenty-one samples were collected and of this, only 74 were sufficient for analysis. Results: Toxicology revealed postmortem endogenous alcohol production in 30 victims. Although 27 victims showed morphological features suggestive of carbon monoxide poisoning, only 4 revealed significantly elevated levels of carboxyhemoglobin saturation. Discussion: Some of the victims were apparently alive for some time in the fire that followed the crash, and probably suffered pain during this agonal period. This paper discusses the relevant aspects of personal injury claims and further damages under the Montreal Convention as it relates to possible pain and suffering. Conclusion: The authors opine that the next-of-kin of the victims might be entitled to some compensation based on agonal pain and other loses.
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Pattern of unnatural death among females in niger delta: A retrospective medicolegal study Highly accessed article p. 6
Eseroghene Arthur Ijomone, Obiora Jude Uchendu, Nkadi Francis Nwachokor
DOI:10.4103/atp.atp_54_18  
Background: Unnatural death among women is rarely emphasized but an important public health index of the community and society. Objective: The objective is to study the epidemiologic profile of unnatural death among females using autopsy data. Design: This is a 14-year descriptive retrospective study of all female unnatural death victims within Warri and its neighboring communities subjected to medicolegal autopsy. Materials and Methods: Information on age as well as manner and method of death were extracted from the autopsy report of the cases and subsequently analyzed using Microsoft Office Excel 2007. Results: Ninety-six females were examined in this study, representing 9.9% of the 975 medicolegal performed and 11.4% of the 805 unnatural deaths encountered during the study period. The age range is 1–70 years and the mean age is 29.82 years. These cases represent a mean annual incidence of about seven cases. The peak incidence of unnatural death occurred in the third decade (27.1%), followed by the fourth (19.8%) and fifth (15.6%) decades, respectively. The peak incidence for homicide and accidental deaths is in the third and fourth decades, respectively. Firearm-related death is the leading method of homicide accounting for 24 (53.3%) of the 45 homicide deaths. The use of blunt and sharp weapons each accounts for 10 (22.2%) of the cases. Road traffic accident (RTA) accounts for 28 cases, representing 59.6% of accidental deaths and 29.1% of unnatural deaths. Burns and drowning are the second and third leading causes of accidental death accounting for 11 (23.4%) and 3 (6.4%) of the accidental deaths. Four cases of suicide were encountered with three deaths as a result of ingestion of chemical poisons, while the fourth case was by hanging using rope. Conclusion: The study showed that unnatural deaths in women are mainly accidental, homicidal, and suicidal representing 49.0%, 46.0%, and 4.2% of the cases respectively. RTA, burns, drowning, and poisoning (in descending order) are the major causes of accidental deaths. Firearm, sharp, and blunt injuries (in descending order) are the major methods of executing homicides. The peak age for unnatural death is in the third decade with 75% of the death clustering within the 2nd–4th decade. Education, accident consciousness, parental supervision, and implementation of appropriate policy measures are paramount to reducing such death.
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Profile of hanging deaths in Lagos, Nigeria: A 9-year retrospective autopsy study p. 11
Francis Adedayo Faduyile, Sunday Sokunle Soyemi, Alban Ikenna Mgbehoma, Daniel Ayodele Sanni
DOI:10.4103/atp.atp_3_19  
Introduction: Hanging is seen worldwide and is the most common method of suicide globally. Hanging in Western nations has been well documented. However, there appears to be a dearth of published data on hanging in Nigeria, Africa. The essence of this work is to look at the morphological characteristics and the epidemiological profile of victims who died from hanging. Materials and Methods: This was a 9-year retrospective autopsy study on hanging deaths from January 1, 2005, to December 31, 2013. The details of the injuries present were recorded in a predesigned format so as to minimize error. Such findings included age, sex, type of hanging, position of knot, number of turns of the ligature, and fracture of hyoid and thyroid cartilages. The findings noted were carefully compiled, tabulated, and analyzed using the Statistical Package for the Social Sciences version 20. Results: There were 22 cases of hanging during the study period representing 0.2% of the total autopsy cases. The mean age was 38 ± 12 years, ranging from 15 to 60 years. This was predominantly a male phenomenon, with males constituting 94.5%, whereas females accounted for only 4.5%. Hanging was most common in the fifth decade (27.3%). This was closely followed by the third and fourth decades. This study revealed that 95.5% had single loop. The knot was most common on the right representing 54.5% and least common at the occiput accounting for 13.6%. Hyoid bone fracture and thyroid cartilage fracture were seen in 22.7% each. Conclusion: This study has shown that the mean age of hanging was in the fourth decade in this environment, with an overwhelming male preponderance. Fixed single loop on the right side was the most common picture and a quarter had fracture of hyoid bone and thyroid cartilage. All the ligature marks were obliquely placed, and no fracture of cervical vertebrae was identified. A future study will be needed to determine what percentage of suicide is hanging in this part of the world.
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Suicide in Warri, Delta State, Nigeria: An autopsy study Highly accessed article p. 16
Obiora Jude Uchendu, Eseroghene Arthur Ijomone, Nkadi Francis Nwachokor
DOI:10.4103/atp.atp_44_18  
Background: Suicide is a neglected public health problem in our environment. Objective: To determine the epidemiologic pattern of suicide cases with respect to sex, age, method, and place. Design: This is a 14½-year descriptive retrospective study of suicide cases reported to the coroner of Delta State, arising from Warri and its environs and subjected to postmortem examination by the authors. Materials and Methods: Information on age, sex, place of death, and method used was extracted and analyzed using Microsoft Office Excel 2007. Results: A total of 21 confirmed cases of suicide were analyzed consisting of 16 (76%) males and 5 (24%) females. The age range of the victims is from 9 to 65 years, with 15 (71.4%) of cases in the 2nd to 4th decades. Hanging, poisoning, and firearm were the methods used in 17 (80.95%), 3 (14.29%), and 1 (4.8%) of the cases, respectively. The scene of the suicide included the deceased's home, bush, workplace, and police custody in 16 (76.2%), 2 (9.5%), 2 (9.5%), and 1 (4.8%) of the cases, respectively. Conclusion: The study showed that suicide is a relatively rare problem, affecting mainly young males. The preferred place is usually the victim's homes. Hanging is the preferred method by males. There is a need to improve the welfare and mental health care of young people in the society as well as restrict the sales of poisoning through government policy in the country.
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Molecular subtyping of carcinoma of the female breast in a tertiary teaching hospital in Northern Nigeria Highly accessed article p. 20
Asma'u Usman, Yawale Iliyasu, Akinfenwa Taoheed Atanda
DOI:10.4103/atp.atp_51_18  
Background: Cancer of the breast is globally the most common female cancer including in Nigeria. Newer treatment modalities are based on tumor immunophenotyping, thus the need to characterize these tumors among women with the disease in Northern Nigeria. Aims: This study aims to classify carcinomas of the breast diagnosed in the pathology laboratory of a teaching hospital based on their expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2/neu (HER2/neu) overexpression. Methodology: The histology slides of 478 carcinomas of the breast as well as the ER, PR, and HER2 immunohistochemistry records of 118 stained cases were retrieved and reviewed. Results: Age range of cases was from 20 to 80 years (mean = 46.9 ± 13). The most common histomorphologic entity was invasive carcinoma (NST) which accounted for 73.2% of cases. These were followed in frequency by invasive lobular carcinoma accounting for 6.8% of cases and invasive papillary carcinoma representing 6.5% of cases. Overall, 169 cases (37.6%) were Grade III tumors while Grades II and I tumors accounted for 35.1% and 27.3% of cases, respectively. Triple-negative tumors were the most common molecular subtype and comprised 46.6% of all cases. Luminal B (LUMB) was the least common and accounted for 8% of all cases. HER2 overexpression and LUMA were seen in 17.9% and 28.8% of cases, respectively. Conclusion: Carcinoma of the breast in the population studied occurs at a younger age than among Caucasians. The tumors are characterized by preponderance of invasive carcinoma (NST), high histological grade, and triple-negative phenotype.
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Histopathological spectrum of gastrointestinal lesions seen in university of uyo teaching hospital, South–South Nigeria p. 27
Chukwuemeka Charles Nwafor, Nkem Nnenna Nwafor, Emmanuel Benjamin Etuk, Obioha Kanu
DOI:10.4103/atp.atp_40_18  
Introduction: This is a retrospective study of all gastrointestinal tract (GIT) specimens seen in University of Uyo Teaching Hospital over a 10-year period from January 1, 2008 to December 31, 2017. Materials and Methods: Data were extracted from the departmental registers, patient request forms, and duplicate copies of histology reports of all cases seen. Results: GIT specimens accounted for 4.3% of all specimens. Majority of them were inflammatory lesions, distantly followed by malignant lesions. Inflammatory diagnoses were seen in all parts of the GIT with the appendix accounting for 76.3% of the inflammatory lesions. Appendicitis was the most common diagnosis, while negative appendix was the second most common diagnosis. In all sites except the anus, males were affected more than females in a sex ratio of 1.5:1. Age groups 10–39 years accounted for 79.9% of all appendix inflammatory lesions, with age group 20–29 contributing the highest. Age groups 40–59 had most gastritis cases. Age group 50–59 years accounted for most malignant lesions, with the majority seen in the colon. Adenocarcinomas distantly followed by squamous cell carcinomas were the most common histologic malignant diagnoses made. Conclusion: The pattern of GIT lesions seen in our institute has been documented and this will serve as a baseline data for future local studies.
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Salivary adenoid cystic carcinoma: A clinicohistologic study in a nigerian tertiary institution p. 34
Oluseyi Folake Ajayi, Oladunni Mojirayo Ogundana, Abdulwarith Olaitan Akinshipo, Adetokunbo Babajide Olawuyi, Onatolu Odukoya
DOI:10.4103/atp.atp_65_18  
Background: Adenoid cystic carcinoma (ADCC) is a slow-growing salivary gland tumor with high recurrence and mortality rates. Histologic variants present variable aggression. This has not been investigated in Nigeria. This study aimed to investigate association of histologic variants with clinical aggression in Nigerian cases. Patients and Methods: Fifty-nine ADCC from 363 salivary gland tumors were selected from the departmental oral biopsy archives. Clinical data were retrieved, and hematoxylin and eosin sections were reviewed for confirmation and categorization into solid, cribriform, and tubular (modified Perzin, Spiro and van Weert systems). Estimated mean tumor growth rates (EMTGRs) were computed and matched with histologic variants. Statistical analysis was Chi-square, Kruskal–Wallis, and Mann–Whitney's test. P value was ≤0.05. Statistical package was SPSS. Results: Age ranged between 7 and 83 years (mean 49.2 ± 16.8 years). About 75.1% occurred in the 4th–6th decade (P = 0.02). Most common histologic variant was predominantly cribriform no solid (PCNS) pattern (40.7%). In major salivary glands, there was association between histologic variant and EMTGR (P = 0.025). PCNS had the highest EMTGR (0.840) followed by predominantly solid (PS) (EMTGR, 0.744). These were significantly higher than predominantly tubular no solid (PTNS) (EMTGR, 0.442) and predominantly tubular 30% solid (EMTGR, 0.115). In minor glands, there was also association between histologic variants and EMTGR (P = 0.017). However, the highest EMTGR (0.509) occurred in PTNS followed by PCNS (0.428). These were significantly higher than PS (0.259) with the least EMTGR. Conclusion: Trend of clinical aggression of histological variants based on EMTGR of ADCC varies depending on the type of salivary gland (major vs. minor).
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Proinflammatory cytokine profile in head and neck squamous cell carcinoma patients: Preliminary report p. 40
Victor I Akinmoladun, Clara A Akinyamoju, Fabian Edem, Eniola J Ezeyi, Olatubosun G Arinola
DOI:10.4103/atp.atp_49_18  
Background: Head and neck squamous cell carcinoma (HNSCC) is one of the most common malignant neoplasms globally. Tobacco and alcohol use are predominant risk factors. Inflammation plays a major role in the etiopathogenesis of cancers and cytokines influence activation, growth, and differentiation of several target cells. This study aimed at profiling head and neck cancer patients with regards to the serum level of proinflammatory cytokines and disease stage. Materials and Methods: This study involved thirty newly diagnosed cases of HNSCC and thirty apparently healthy comparable group. Five milliliter of venous blood was collected from the antecubital vein of each individual. The blood samples dispensed in plain bottles were allowed to clot and retract; serum was stored at −20°C until analysis. Cytokine assay was carried out by enzyme-linked immunosorbent assay technique using a commercial kit. Results: The study group was made up of 19 (63.3%) males and 11 (36.7%) females. The ages ranged from 19 to 92 years with a mean of 59.1 ± 19.1 years. The comparative group was made up of 14 (46.7%) males and 16 (53.3%) females with a mean age of 63.2 ± 7.5 years. The oral cavity was the most common site of SCC [6 (20.0%)]. The cases were mostly advanced in 28 (93.3%, Stages III and IV). Serum interleukin-1 IL-1 (β), IL-6, IL-8, TNF – α, and IFN – γ were elevated in the test cases relative to the controls. This however, was only statistically significantly so with IL-6 and IL-8. The mean values for both cytokines for all tumor sites were exceeded in nasopharyngeal carcinoma. Conclusion: Serum IL-6 and IL-8 appear to be significant in the pathology of head and neck cancer and could be explored for possible roles in the management of HNSCC.
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Osteosarcoma of the jaws seen in a Nigerian tertiary health institution p. 44
Benjamin Fomete, Rowland Agbara, Ezekiel Taiwo Adebayo, Davis Sunday Adeola
DOI:10.4103/atp.atp_32_18  
Introduction: Jaw morbidity and mortality among African descend are rarely caused by bone tumors of malignant origin. Osteosarcoma being the most frequent primary malignant bone tumor account for 5.3%–9.5% of malignancies in some part of Africa, Nigeria, included. Its late occurrence and higher survival rate helps to differentiate it from that of a long bone and other locations. Patients and Methods: This is a retrospective study of patients seen at the Oral and Maxillofacial Clinic between January 2003 and December 2015. Results: Osteosarcoma constituted about 3% of all tumor seen within the study period with a high male dominance (60%). The mean age was 31.3 years, and the mandible was 74.3% more affected than the maxilla. Conclusion: Osteosarcoma of the jaws remains a challenge to the oral and maxillofacial surgeon in this part of the world.
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Survey of antimicrobial consumption in a university teaching hospital in Southern Nigeria p. 48
Agantem Emmanuel Ekuma, Echey Ijezie, Tiemah Akpabio, Ifeanyi Abraham Onwuezobe
DOI:10.4103/atp.atp_50_18  
Background: There is increasing use of antimicrobial agents worldwide and especially in low- and middle-income countries. Point prevalence studies of antimicrobial consumption can be used to determine intervention areas for antimicrobial stewardship programs. This point prevalence study was conducted in preparation for antimicrobial stewardship program in our hospital. Methods: Data on antimicrobial consumption was collected from patients in the hospital during 4 weeks by hospital doctors. Data was entered into the Global Point Prevalence Survey internet-based application, downloaded, analyzed, and presented in frequencies and percentages. Results: Of 197 patients surveyed across 21 wards, 62.4% had one or more antimicrobial agents. Metronidazole was the most frequently prescribed agent, whereas cephalosporins were the most frequent class prescribed. Community-acquired infection was the most common indication for antimicrobial therapy, whereas skin and soft-tissue infections were the most common diagnosis. Reason for prescription was stated in notes of 61.4% of patients, whereas 34.8% had stop or review dates documented. There was no record of the use of biomarkers to guide antimicrobial treatment. Conclusion: There is a high antimicrobial prevalence in our institution with cephalosporins as the most frequently prescribed class of antimicrobials. Community-acquired infections are the most common indication for an antimicrobial prescription but are surpassed by medical and surgical prophylaxis combined. There is a need for clinicians in this institution to use guidelines and microbiology laboratory reports to guide antimicrobial prescribing to reduce the antimicrobial prevalence among patients.
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Prevalence and factors associated with cryptococcosis among human immunodeficiency virus-infected patients of a tertiary hospital in Northwestern Nigeria p. 52
Yahaya Mohammed, Adebola T Olayinka, Fatima J. Giwa, Aisha A. Abubakar
DOI:10.4103/atp.atp_62_18  
Background: Cryptococcosis is an important opportunistic infection and major contributor to mortality in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patients. There have been increasing reports of varied prevalence for cryptococcosis among HIV patients in Nigeria. Aims: The aim of this study was to determine the prevalence and factors associated with risk of cryptococcosis among HIV/AIDS patients from Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto. Materials and Methods: A descriptive cross-sectional study at HIV clinic of UDUTH, Sokoto, Nigeria, was conducted. The participants were HIV positive enrolled by systematic random sampling. Information on sociodemographics and clinical features of the participants was recorded. Blood was collected to determine the CD4 count/presence of cryptococcosis among the participants. Their CD4 counts were determined, and the presence of cryptococcal antigen was detected in the blood sample using IMMY CrAg LFA (cryptococcal antigen lateral flow assay test kit). Statistical analysis using Epi Info version 7.2/SPSS version 20.0 was done. Univariate, bivariate, and multivariate analyses were done. Results: Of 326 HIV-positive patients recruited, 36 of them were positive to cryptococcal antigen (prevalence of 11%). The highest proportion of patients positive to cryptococcosis (13 [36.1%) had CD4 values <50 cells/μL. Weight loss was the most common presenting symptom (11 [30.6%]) among those who were Cryptococcus positive. Conclusions: This study demonstrates that cryptococcosis is a burden among HIV patient in Sokoto, and its occurrence is associated with decreasing levels of CD4.
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Prevalence of anemia among pregnant women attending ante-natal clinic in a tertiary health-care facility: A study in an area under insurgency in Northeastern Nigeria p. 59
Hadiza Tikau Idi, Sani Awwalu, Usman Abjah, Aliyu Ahmadu Babadoko, Aisha Indo Mamman, Aliyu Dahiru Waziri, Adamu Abdullahi Atterwahmie
DOI:10.4103/atp.atp_67_18  
Context: Anemia in pregnancy is a very common event in the developing world. Pregnancy is associated with high nutritional demands which may culminate in third-trimester anemia. Most studies conducted on the prevalence of anemia in North Eastern Nigeria were before the onset of the current insecurity. Aims: The aim of this study is to determine the prevalence of anemia among women in the third trimester of pregnancy attending Antenatal Clinic in the Federal Medical Centre, Nguru, Yobe State, Nigeria. Settings and Design: A cross-sectional descriptive study involving 200 women in the third trimester of pregnancy. Subjects and Methods: Semi-structured questionnaires were utilized to collate age, parity, and date of last child birth (LCB). Hematocrit levels were determined using an automated hematology analyzer. Hematocrit levels were stratified according to the World Health Organisation's classification as follows: <21.0%-severe, 21.0%–29.9%-moderate, 30.0%–32.9%-mild anemia, and ≧33.0%-not anemic. Data were analyzed using SPSS version 20.0. Continuous variables were summarized using means and standard deviations. Chi-square and Pearson correlation analyses were conducted to determine relationships. A value of P ≤ 0.05 was considered statistically significant. Results: The mean age, parity, LCB, and hematocrit of the study participants were 26.35 ± 6.17 years, 3.72 ± 2.75, 2.03 ± 1.62 years, and 32.64 ± 7.06%, respectively. The overall prevalence of anemia (hematocrit <33%) was 46.5% with mild, moderate, and severe anemia present in 40 (20%), 39 (19.5%), and 14 (7.0%), respectively. The Pearson correlation analysis between parity and hematocrit levels was weak, negative, and statistically significant (r = −0.144, P = 0.042). Chi-square analysis revealed a significant relationship between parity and anemia (χ2 = 13.166 (df, 6), P = 0.039). Conclusion: The prevalence of the third-trimester anemia in Northeastern Nigeria is of severe public health significance and is associated with parity.
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Pattern of blood procurement and utilization in a university hospital in Southeast Nigeria p. 63
Chide Okocha, Ann Abiola Ogbenna, Nkiru Ezeama, John Aneke, Theodora Ezeh
DOI:10.4103/atp.atp_59_18  
Background: Blood is a scarce commodity and every effort needs to be made to use it judiciously and avoid wastage. This study reviewed the pattern of blood procurement, ordering, and utilization at a hospital-based blood bank. Materials and Methods: This was a retrospective study in which data on blood procurement methods, pattern of requisition of blood, and outcome of issued blood were obtained from blood bank registers over a 2-year period at the Nnamdi Azikiwe University Teaching Hospital blood bank. Results: Approximately, 99% of donors were family replacement donors. In 2014, total blood donated was 4003 which exceeded the request for red blood cell (RBC) transfusion by 921 units. The highest request for blood was from the accident and emergency and 90% of blood issued were used. Overall percentage wasted of RBCs was 19.8% and the major contributors to these were antenatal clinic and labor ward both having 80% and 55.8% issued blood returned to blood bank unused. Conclusion: The proportion of wasted units of RBC is high. Designing and adhering to maximum blood ordering schedule and blood transfusion guidelines with efforts toward converting family replacement donors to voluntary blood donors will help in maintaining a steady supply of safe blood.
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CASE REPORTS Top

Death in the work place; Accident or homicide? The role of death scene examination p. 68
Chukwuemeka Charles Nwafor, MD Ekpo, NN Nwafor, JO Obafunwa
DOI:10.4103/atp.atp_48_18  
Death scene examination is an essential component of a complete medico-legal autopsy. The present case is that of a 58-year-old male who died very late at night in an unclear circumstance. He had suffered severe multiple craniofacial fractures, and injuries to the left hand and digits (defense wounds), mimicking homicidal death. The altered scene was examined 4 weeks after the incident, and with the autopsy conducted at the same time, the manner of death was concluded to an accident.
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Adenomyoma with transitional glandular epithelium coexisting with Schistosomiasis p. 74
Kabir Aliyu Suleiman, Ishak Lawal, Nasir Abdullahi, Jamiu Muhammad Bello
DOI:10.4103/atp.atp_38_18  
Adenomyomas are uncommon tumor-like masses that differ from adenomyosis mainly in that they are circumscribed nodular masses. It may be located within the myometrium, or it may involve or originate in the endometrium and grow as a polyp. Endometrial polyps account for about 2% of the manifestation of adenomyomas. Adenomyoma may occur between ages 22 and 60 years. This case is a very rare variant of adenomyoma with transitional epithelium coexisting with schistosomiasis within leiomyomatous smooth muscle. We believe that this is the first reported case of adenomyoma with transitional glandular epithelium coexisting with schistosomiasis in Nigeria and there was no reported case or any work of such in all the English literatures searched, hence the need to report the case.
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Epithelioid haemengioendothelioma: A report of two cases p. 77
Friday Titus Nyaku, Theophilus Maksha Dabkana, Haruna A Nggada, Joasaih Miner Njem, Stanley Tella Bwala, Yakubu Mohammed Gana
DOI:10.4103/atp.atp_52_18  
Epithelioid hemangioendothelioma (EHE), is a rare vascular tumor, described for the first time in 1975 by Dail and Liebow as an aggressive bronchoalveolar-cell carcinoma. The aetiology is still a dilemma to this day. Studies about suggestive hypothesis are ongoing. Most of the times, it affects lung, liver, and bones, but can arise from any part of the body. It has a very low prevalence of one in one million. Because of its heterogeneous presentation and rarity - represents <1% of all the vascular tumours, it is often misdiagnosed and not suitably treated, leading to a poor prognosis in some cases. Over 50%–76% of the patients are asymptomatic in the early stage of the disease. A small number of them complain of respiratory symptoms. Bone metastases might cause pathological fractures or cord compression if they arise in vertebrae. Imaging is necessary to determine extend of spread, the involvement of surrounding tissues, and potentially the cleavage plan. It is important to recognize the expression of vascular markers (Fli-1 and CD31 are endothelial-specific markers), and the microscopic evidence of vascular differentiation to make a correct diagnosis, as many pulmonary diseases show multiple nodular lesions. Because of its rarity, there is no standard treatment for EHE.
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Tubal choriocarcinoma in a ruptured ectopic pregnancy p. 81
Kabir Aliyu Suleiman, Ishak Lawal, Sulaiman Kolapo Abubakar-Akanbi
DOI:10.4103/atp.atp_39_18  
Choriocarcinoma represents the most malignant entity in the spectrum of gestational trophoblastic disease. It can result from molar gestation in most instances and occasionally can arise after a term pregnancy, abortion, and ectopic pregnancy. Choriocarcinoma associated with tubal pregnancy is extremely rare and aggressive in its course with the incidence of 0.76%–0.4% of all ectopic pregnancies. This case report is from a 32-year-old female G2P1 + 0A1 whose last menstrual period was 4 months before presentation. She presented with a 2-day history of lower abdominal pain and vomiting. Histological sections of the fallopian tubal tissue showed extensive hemorrhage, necrosis and invasion by bizarre trophoblastic cells with large pleomorphic nuclei, irregular nuclear borders, and clumped chromatin.
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Invasive cribriform carcinoma of the male breast p. 83
Abdulrazzak O Lawal, Adekoyejo A Phillips, Nnamdi O Orah, Adetola O Daramola, Fatimah B Abdulkareem
DOI:10.4103/atp.atp_46_18  
Male breast cancer is rare and it accounts for about 1 % of all breast cancers. Men of African and Jewish descent have higher risk of developing breast cancer. Invasive cribriform carcinoma of the breast, which has a good prognosis, is rarer particularly in male patients and only few cases have been reported in the literature. A young adult male presented with a painless, left breast mass of one-year duration at the surgical out-patient department of the Lagos University Teaching Hospital. On examination, a 24x16x6 cm mass, involving all four quadrants, attached to the overlying skin and underlying structure, was palpated in the left breast. It was non-tender and there was no differential warmth. Imaging studies revealed a Breast Imaging Reporting and Data System (BIRADS) IV lesion. On histopathology examination, an infiltrating carcinoma which was disposed in a cribriform pattern was seen. The neoplasm comprised of fairly monomorphic cells that exhibited increased nucleocytoplasmic ratio, moderate eosinophilic cytoplasm, vesicular nuclei and prominent nucleoli. Immunohistochemistry for estrogen receptor, progesterone receptor and HER-2 revealed a luminal A tumour. A diagnosis of invasive cribriform carcinoma of the breast was made. We report the first known case of invasive cribriform carcinoma of the breast in a male patient from Nigeria.
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Recurrent distal epithelioid sarcoma with post-auricular metastatic nodule in a young adult female p. 86
Modupeola O Samaila, Balarabe Kabir, Mudasiru Lawal, Ahmed Mai, Emeka S Nwabuoku
DOI:10.4103/atp.atp_58_18  
Epithelioid sarcoma (ES) is a rare slow-growing aggressive tumor of uncertain histogenesis that preferentially affects young adult males with the mean age of 27 years at presentation. A 19-year-old female represented to our hospital with 3 months history of slow-growing left posterior auricular nodule. She first presented 3 years earlier with 8 years history of a circumscribed regrowing painless right-hand mass located between the middle and ring fingers which had previously been excised twice at a private hospital without the histopathological diagnosis. The mass at presentation measured 8 cm × 8 cm in diameter and was covered by an intact skin with a healed surgical scar. A tru-cut biopsy was diagnosed ES-based on the cytomorphology of malignant epithelioid cells arrayed in nests, vague alveolar pattern with foci of pseudoangiomatous growth. Tumor was CD34 + focally. She had four courses of chemotherapy and tumor en bloc excision with the excision of the 3rd and 4th hand-digit with hand reconstruction. Tissue microscopy showed ES with the resection margins involvement and was CD34+, Vimentin +, epithelial membrane antigen +, S100−, and Desmin −. She did well for a year until the development of the posterior auricular nodule which was morphologically similar to the hand mass. Chest X-ray and hand radiograph revealed no lesions. ES is a distinct clinicopathologic tumor fraught with recurrences as seen in this female whose age of occurrence appears to be 9 years anecdotally. ES may be misdiagnosed due to nonspecific clinical symptoms, radiological, and pathological findings. Distant metastasis often involves lymph nodes, lungs, scalp, and bone, though the posterior auricular location was seen in this case. Large tumor size, recurrences, inadequate excision, and cutaneous metastasis are bad prognostic factors despite the young age and female sex of our patient.
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Ovarian fibrosarcoma: Case report of a rare lesion p. 90
Ebunoluwa S Daramola, Olubanji A Oguntunde, Lateef A Odukoya, Kehinde S Okunade, Adeyemi A Okunowo, Adekunbiola A. F Banjo, Rose I Anorlu
DOI:10.4103/atp.atp_43_18  
Ovarian fibrosarcoma is an extremely rare ovarian neoplasm and much rarer in the young. We present the case of a 35-year-old Nigerian woman who presented with ovarian mass with histologic and immunohistochemical profile in keeping with fibrosarcoma. She had an uneventful surgery and had postoperative chemotherapy with a combination of carboplatin and paclitaxel. She is currently on follow-up at the gynecology clinic.
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Polypoid cystitis in a 3-year-old child: A rare occurrence p. 93
Almustapha Aliyu Liman, Muhammed Ahmed, Sannom Mildred Yates, Murtala Abubakar
DOI:10.4103/atp.atp_61_18  
Polypoid cystitis is a rare, benign, reactive, exophytic urinary bladder mucosal lesion whose etiology has been attributed to chronic non-specific injury to bladder mucosa. It is most commonly seen in patients with indwelling catheter. It is a recognized mimic of bladder neoplasms. The findings at imaging studies are not well known. We report a case in a three years old child who presented with a severe form of the disease on a background of resistant E. coli infection. The patient was treated with antibiotics, and surgical resection of the mass and patient has been on follow-up since. The present case is notable in that it occurred in a child with no known predisposing factor except for history suggestive of recurrent bacterial urinary tract infection.
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Primary cutaneous coccidioidomycosis in a human immunodeficiency virus-positive patient: Case report and literature review p. 96
Ballah Akawu Denue, Akilayhel Auta Ndahi, Haruna Asura Nggada
DOI:10.4103/atp.atp_66_18  
Coccidioidomycosis is a recognized opportunistic infection among persons infected with human immunodeficiency virus (HIV). Compared with immunocompetent persons, HIV-infected patients are at risk of symptomatic and progressive disease since the control of coccidioidal infection requires intact cellular immune function. We report a case of a 28-year-old HIV positive woman, who presented with 3 months' history of widespread pruritic hyperpigmented nodular skin lesions. The histopathological evaluation of excisional biopsy was consistent with cutaneous coccidioidomycosis. Chest X-ray showed no lesion in the lung. Abdominopelvic ultrasound revealed no abnormality. The patient had end-stage HIV disease (AIDS) with CD4 lymphocyte cell count of 66 cells/μL, and HIV-1 RNA viral load of 128,763 copies/ml. Even though up to 50% of patients with coccidioidomycosis could develop cutaneous involvement, this tends to occur following pulmonary and or systemic disease. Primary cutaneous coccidioidomycosis is rare, and this possibility should be considered in the evaluation of HIV-positive patients, even in nonendemic areas of the world.
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Fulminant hepatitis with negative viral serological markers: A possible case of occult hepatitis B virus infection p. 100
Kenneth Ogar Inaku, Okokon Ita Ita, Francis Awusha Ogar, Lucy Abosede Inaku
DOI:10.4103/atp.atp_68_18  
Infection with hepatitis B virus (HBV) shows variable clinical manifestations ranging from asymptomatic carrier state, acute, chronic, fulminant, and occult HBV infection (OBI). OBI is defined as the presence of HBV viral DNA in the liver (with or without detectable HBV DNA in serum) of hepatitis B surface antigen-negative individuals tested with the currently available assays. A cutoff of HBV DNA if present is expected to be <200 IU/ml. As high as 20% of individuals with OBI carriage evidenced by HBV DNA detection could be nonreactive for anti-hepatitis B core or any other serological evidence of exposure to HBV. With a reported prevalence of 5.4% among blood donors in Ile Ife, Nigeria, OBI is a risk factor for chronic liver disease and hepatocellular carcinoma. Given the sensitivity of our diagnostic tools in this environment, it is likely that most cases of OBI are going undiagnosed among many blood donors. We present a case of fulminant hepatitis with negative serological markers for viral hepatitis in a 25-year-old male.
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Smear and Xpert MTB/RIF negative tuberculosis: A lingering dilemma in children and the HIV infected – Two case reports p. 104
Lawal Waisu Umar, Maria Ahuoiza Garba, Elwan Ahmad
DOI:10.4103/atp.atp_63_18  
Confirmatory diagnosis of tuberculosis (TB) in children and human immunodeficiency virus-infected individuals continues to pose a challenge in resource-limited settings. Although the Xpert MTB/RIF assay is sensitive and rapid, its ability to detect Mycobacterium tuberculosis is low in smear-negative TB, a compelling situation to resort to empirical therapy based on high index of suspicion. We report two cases clinically suspected to be TB in whom repeated sputum smear microscopy and Xpert MTB/RIF tests were negative, but based on high index of suspicion and the World Health Organization recommended clinical criteria, both were commenced on anti-TB therapy and made remarkable recovery at treatment completion.
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