Medical Specialties Commons^™

Neuroblastoma In Adolescents And Children Older Than 10 Years: Unusual Clinicopathologic And Biologic Features, Laura Mccarthy, Katherine Chastain, Terrie Flatt, Eugenio Taboada, Robert E. Garola, John Herriges, Linda D. Cooley, Atif Ahmed

Posters

This poster describes four cases of neuroblastoma diagnosed since 2008 in children greater than 10 years and presents their clinical, histologic and biologic features, emphasizing unusual clinicopathologic characteristics and the role of DNA microarray analysis and Next Generation Sequencing in their management.

Are Serum Leptin Levels Predicted By Lipoproteins, Vitamin D And Body Composition?, Aysha Habib Khan, Syeda Sadia Fatima, Ahmed Raheem, Lena Jafri

Department of Pathology and Laboratory Medicine

BACKGROUND: Both obesity and vitamin D deficiency are important health issues in Pakistan. The connection between body composition, Vitamin D and leptin in young adults is important to be studied as body composition may affect bone health and therefore the possibility of osteoporosis in later life. Few studies have attempted to investigate the effect of body composition and leptin with vitamin D in adolescence. AIM: To investigate the association of serum leptin with body composition, lipids and 25-hydroxyvitamin D (25OHD) in adults. METHODS: This cross-sectional study was conducted on 167 apparently healthy adults. Demographics were recorded, bioelectrical impedance analysis was …

Orthokeratinized Odontogenic Cyst (Ooc): Clinicopathological And Radiological Features Of A Series Of 10 Cases, Nasir Ud Din, Maha Zubair, Jamshid Abdul-Ghafar, Zia Ullah Khan, Zubair Ahmad

Department of Pathology and Laboratory Medicine

Background: Orthokeratinized Odontogenic Cyst (OOC) is a rare, developmental odontogenic cyst which was considered in the past to be a variant of Odontogenic keratocyst (OKC) later renamed as keratocystic odontogenic tumor (KCOT). The treatment of OOC is by enucleation and the prognosis, following enucleation is excellent with a recurrence rate of less than 2%. On the other hand, OKC has a recurrence rate between 8 and 25% after enucleation. Thus it is important to differentiate between the two entities.
Methods: All cases reported in our section as OOC during the period 2013 to 2018 were retrieved from the surgical pathology …

Assessing The Criteria For Definition Of Perimembranous Ventricular Septal Defects In Light Of The Search For Consensus, Justin T. Tretter, Vi-Hue Tran, Seth Gray, Hieu Ta, Rohit S. Loomba, William O'Connor, Diane E. Spicer, Andrew C. Cook, Robert H. Anderson

Pathology and Laboratory Medicine Faculty Publications

Background: Discussions continue as to whether ventricular septal defects are best categorized according to their right ventricular geography or their borders. This is especially true when considering the perimembranous defect. Our aim, therefore, was to establish the phenotypic feature of the perimembranous defect, and to establish the ease of distinguishing its geographical variants.

Methods and results: We assessed unrepaired isolated perimembranous ventricular defects from six historic archives, subcategorizing them using the ICD-11 coding system. We identified 365 defects, of which 94 (26%) were deemed to open centrally, 168 (46%) to open to the outlet, and 84 (23%) to the inlet …

Raised Levels Of Ifn-Gamma And Il-13 Are Associated With Pre-Diabetes Amongst Newly Diagnosed Patients With Tuberculosis, Zahra Hasan, Muhammad Irfan, Qamar Masood, Owais Ahmed, Shoaib Rao, Umme Salama Moosajee, Naseem Salahuddin

Department of Pathology and Laboratory Medicine

Objective: To investigate pre-diabetes and diabetes in newly-diagnosed tuberculosis patients and to assess the association of serum cytokine levels with diabetes status.
Methods: The cross-sectional study was conducted at Indus Hospital and The Aga Khan University Hospital, Karachi from May to November 2015, and included patients of either gender aged 18 years or more with a confirmed diagnosis of tuberculosis who were either newly diagnosed or had received up to 1 month of anti-tuberculosis therapy were included. Patients were enrolled from among those presenting to the clinics at Indus Hospital, Karachi, and the Department of Medicine, Aga Khan University Hospital …

Retrospective Study Of Patients With Hyperphenylalaninemia: Experience From A Tertiary Care Center In Pakistan, Sibtain Ahmed, Hafsa Majid, Lena Jafri, Aysha Habib Khan, Zeba Zulfiqar Ali, Bushra Afroze

Department of Pathology and Laboratory Medicine

Objective: To assess the clinical and biochemical features as well as outcome of perphenylalaninemia patients.
Methods: The descriptive retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data from January 2013 to February 2017 of plasma amino acid analysed at the Biochemical Genetic Laboratory of patients with phenylalanine levels >120 umol/L. Medical charts of patients registered with the Metabolic Clinics were reviewed, while outside referrals were contacted by telephone to collect data on a pre-structured questionnaire. Data was analysed using SPSS 21.
Results: Of the 18 patients, 13(72%) were males. Overall median age was 606 days …

Tobacco Smoking And Dementia In A Kentucky Cohort: A Competing Risk Analysis, Erin L. Abner, Peter T. Nelson, Gregory A. Jicha, Gregory E. Cooper, David W. Fardo, Frederick A. Schmitt, Richard J. Kryscio

Epidemiology and Environmental Health Faculty Publications

Tobacco smoking was examined as a risk for dementia and neuropathological burden in 531 initially cognitively normal older adults followed longitudinally at the University of Kentucky’s Alzheimer’s Disease Center. The cohort was followed for an average of 11.5 years; 111 (20.9%) participants were diagnosed with dementia, while 242 (45.6%) died without dementia. At baseline, 49 (9.2%) participants reported current smoking (median pack-years = 47.3) and 231 (43.5%) former smoking (median pack-years = 24.5). The hazard ratio (HR) for dementia for former smokers versus never smokers based on the Cox model was 1.64 (95% CI: 1.09, 2.46), while the HR for …

Hematological Profile And Gametocyte Carriage In Malaria Patients From Southern Pakistan, Najia Karim Ghanchi, Mohammad Hassaan Khan, Muhammad Abdullah Arain, Mustafa Bin Ali Zubairi, Ahmed Raheem Buksh, Muhammad A. Khan, Mohammad A. Beg

Department of Pathology and Laboratory Medicine

Background: Malarial infection is a major cause of concern, both worldwide and in Pakistan. Gametocytes are the sexual forms of the parasite that are essential for transmission. They fuse inside the mosquito to develop sporozoites. Gametocytes of the plasmodium parasites, which cause the infection, differentiate into male and female gametocytes. These gametocytes constitute the sexual stage of the malaria parasite and are essential in transmission of the disease from human to vector Anopheles. Gametocytes are affected by factors such as host immunity, drug treatment, reticulocytemia, anemia, low levels of asexual parasitemia and stress to the parasite. The aim of this …

Performance Evaluation Of Cardiac Troponin I Assay: A Comparison Between The Point-Of-Care Testing Radiometer Aqt90 Flex And The Central Laboratory Siemens Advia Centaur Analyzer, Sibtain Ahmed, Lena Jafri, Ahmed Raheem Buksh, Shahid Shakeel, Imran Siddiqui

Department of Pathology and Laboratory Medicine

Background: To validate the point of care testing (POCT) Trop-I analyzer and compare it with a central laboratory-based chemiluminescence immunoassay, in order to evaluate its performance for use in critical care areas. Moreover, for clinical decision-making, it is imperative to know the extent to which patient stratification will differ based on the analytic method being used. In particular, the aim of this study was to evaluate the analytical performance of the point-of-care analyzer and demonstrate the agreement with the central laboratory measurements in patients presenting to the emergency department (ED) with chest pain and suspected acute coronary syndrome (ACS).
Methods: …

Global Monitoring Of Antimicrobial Resistance Based On Metagenomics Analyses Of Urban Sewage, Rene S. Hendriksen, Patrick Munk, Patrick Njage, Bram Van Bunnik, Luke Mcnally, Oksana Lukjancenko, Timo Röder, David Nieuwenhuijse, Rumina Hasan, Sadia Shakoor

Department of Pathology and Laboratory Medicine

Antimicrobial resistance (AMR) is a serious threat to global public health, but obtaining representative data on AMR for healthy human populations is difficult. Here, we use metagenomic analysis of untreated sewage to characterize the bacterial resistome from 79 sites in 60 countries. We find systematic differences in abundance and diversity of AMR genes between Europe/North-America/Oceania and Africa/Asia/South-America. Antimicrobial use data and bacterial taxonomy only explains a minor part of the AMR variation that we observe. We find no evidence for cross-selection between antimicrobial classes, or for effect of air travel between sites. However, AMR gene abundance strongly correlates with socio-economic, …

Report Of An Inferior Rectal Nerve Variant Arising From The S3 Ventral Ramus., Graham Dupont, Joe Iwanaga, Rod J Oskouian, R Shane Tubbs

Articles, Abstracts, and Reports

In surgical approaches to the perineum in general and anal region specifically, considering the possible variations of the inferior rectal nerve is important for the surgeon. Normally, the inferior rectal nerve originates as a branch of the pudendal nerve. However, during routine dissection, a variant of the inferior rectal nerve was found where it arose directly from the third sacral nerve ventral ramus (S3). Many cases have described the inferior rectal nerve arising independently from the sacral plexus, most commonly from the fourth sacral nerve root (S4); however, few cases have reported the inferior rectal nerve arising from S3. Herein, …

Neck Movement During Cervical Transforaminal Epidural Injections And The Position Of The Vertebral Artery: An Anatomical Study., Juan J Altafulla, Emre Yilmaz, Stefan Lachkar, Joe Iwanaga, Jacob Peacock, Zachary Litvack, R Shane Tubbs

Articles, Abstracts, and Reports

Background: Cervical transforaminal epidural steroid injections (CTFESIs) are sometimes performed in patients with cervical radiculopathy secondary to nerve-root compression. Neck movements for patient positioning may include rotation, flexion, and extension. As physicians performing such procedures do not move the neck for fear of injuring the vertebral artery, we performed fluoroscopy and cadaveric dissection to analyze any movement of the vertebral artery during head movement and its relation to the foramina in the setting of CTFESI.

Purpose: To determine cervical rotational positioning for optimized vertebral artery location in the setting of cervical transforaminal epidural steroid injections.

Material and Methods: Four sides …

Dermoid Cyst With No Intracranial Extension: A Case Report And Literature Review, Asra Tanwir, Noor Malik, Gohar Javed, Romana Idress

Section of Neurosurgery

Background: Dermoid cysts are cystic inclusion tumors. They comprise hair follicles, sweat glands, and sebaceous glands. They have lining of stratified squamous epithelium. The most common areas involved are face, lower back, and ovaries. Congenital cystic dermoid involving the anterior fontanelle with no intracranial extension is a rare scalp swelling. We present a case of dermoid cyst with no intracranial extension.
Case description: We report a case of 4-month-old child presented with a history of a scalp swelling since birth. The swelling increased in size progressively. Magnetic resonance imaging of the brain revealed extracranial cystic lesion over anterior fontanelle with …

The Utility Of Neutrophil Gelatinase-Associated Lipocalin (Ngal) As A Marker Of Acute Kidney Injury (Aki) In Critically Ill Patients, Shabnum Khawaja, Lena Jafri, Imran Siddiqui, Madiha Hashmi, Farooq Ghani

Department of Pathology and Laboratory Medicine

In current clinical practice, Serum Creatinine (SCr) is a commonly used marker for the diagnosis of acute kidney injury (AKI). Unfortunately, due to a delayed increase in SCr, it is unable to accurately estimate the timing of the injury. The purpose of this study was to assess the ability of plasma neutrophil gelatinase-associated lipocalin (pNGAL) to predict AKI in critically ill adult patients. The study was conducted at the Section of Chemical Pathology, Department of Pathology& Laboratory Medicine in collaboration with Department of Anesthesiology, at Aga Khan University Hospital in Karachi, Pakistan. Subjects in the age groups of18 to …

Expression Of Cyclin D1 In Clear Cell Sarcoma Of Kidney. Is It Useful In Differentiating It From Its Histological Mimics?, Nasir Uddin Ahmed, Khurram Minhas, Jamshid Abdul Ghafar, Arsalan Ahmed, Zubair Ahmad

Department of Pathology and Laboratory Medicine

Background: Clear cell sarcoma of the kidney (CCSK) is a rare malignant pediatric renal neoplasm with a heterogeneous histological appearance which often results in misdiagnosis. There are no specific immunohistochemical markers which can help in differentiating CCSK from other pediatric renal neoplasms. Recently Cyclin D1 has been investigated as a possible marker in this regard. In this study, we aim to determine the usefulness of Cyclin D1 in differentiating between CCSK and other pediatric renal neoplasms and to compare our results with those of recently published studies.
Methods: A total of 48 cases of CCSK, Wilms tumor (WT), renal rhabdoid …

Is Excision Of Radial Scars Identified On Cnb Necessary?, K. Nimtz, K. Hookim, Md, A. Sevrukov, Md, T. Tsangaris, Md, A. Willis, Md, A. Berger, Md, M. Lazar, Md

Phase 1

Introduction: Quantifying the risk of upgrade to malignancy with radial scars has been an ongoing challenge, as the published upgrade rate varies widely from 0-40%, making management strategy controversial. The lack of consensus on optimal management highlights the need for further analysis. We sought to identify our institutional upgrade rate of radial scar identified on core needle biopsy (CNB).

Methods: A retrospective review of pathology and radiology databases was performed to identify radial scars found on CNB. We excluded patients with malignancy associated with radial scar and those who did not undergo surgical excision. The upgrade rates to …

High Density Of Tumor-Associated Macrophage Staining Correlates With Poor Clinicopathologic Markers In Head And Neck Squamous Cell Carcinoma: A Meta-Analysis, Alexander Knops, Ba, Ayan Kumar, Bs, Brian Swendseid, Md, Ubaldo E. Martinez-Outshoorn, Md, Larry Harshyne, Phd, Nancy Philp, Phd, Ulrich Rodeck, Md, Phd, Christopher Snyder, Adam Luginbuhl, Md, David Cognetti, Md, Jennifer Johnson, Md, Joseph Curry, Md

Phase 1

Background: Head and neck squamous cell carcinoma (HNSCC) develops within a complex cellular microenvironment that promotes tumor growth, but also represents many potential therapeutic targets. Macrophage presence within that environment has been implicated in the growth, aggression, and persistence of HNSCC. Current literature reports variable degrees of association between tumor-associated macrophage (TAMs) density and clinicopathologic markers of disease.Inconsistent findings may result from grouping of TAM subtypes, which include both M1 (pro-inflammatory) and M2 (immunosuppressive). Our aim is to define the prognostic significance of the phenotypes of tumor-associated macrophages in HNSCC.

Methods: We conducted a meta-analysis of the existing publications investigating …

Cellular Milieu Imparts Distinct Pathological Α-Synuclein Strains In Α-Synucleinopathies, Ronald Gathagan, Chao Peng, Dustin Covell, Coraima Medellin, Anna Stieber, John L. Robinson, Bin Zhang, Rose M. Pitkin, Modupe F. Olufemi, Kelvin C. Luk, John Q. Trojanowski, Virginia M.Y. Lee

Phase 1

Introduction: In Lewy body diseases-including Parkinson's disease, without or with dementia, dementia with Lewy bodies, and Alzheimer's disease with Lewy body co-pathology -α-synuclein (α-Syn) aggregates in neurons as Lewy bodies and Lewy neurites. By contrast, in multiple system atrophy α-Syn accumulates mainly in oligodendrocytes as glial cytoplasmic inclusions (GCIs)

Objective: Our objective was to determine the conformational and biological profiles of a-Syn strains.

Methods: The following methods were used to collect and analyze data: Recombinant α-Syn purification and in vitro fibrillization. Preparation of sarkosyl-insoluble fractions from disease and control brains. Sandwich ELISA. Cell cultures. Stereotaxic injection of sarkosyl-insoluble fraction of …

Labrad : Vol 45, Issue 1 - February 2019, Aga Khan University Hospital, Karachi

LABRAD - Departments of Pathology & Laboratory Medicine and Radiology Archives

• Cardiac Manifestation of Inherited Metabolic Disorders
• Utility of Plasma Homocysteine in Identifying Inherited Metabolic Disorders (IMDs)
• Chediak-Higashi Syndrome, an Inherited Disorder in Phagocytic Function
• Radiology-Pathology Correlation Rare Diseases of Bone
• Dried Blood Spot (DBS) Sampling: A Method for Blood Collection without Venipuncture
• Newborn Screening Program for Congenital Hypothyroidism
• Rare Disease in Dermatopathology
• Screening for Carbohydrate Metabolism Disorders by Sugar Chromatography in Urine
• Hypophosphatasia a Rare Skeletal Disorder

Clinical Genome Sequencing In An Unbiased Pediatric Cohort., Isabelle Thiffault, Emily G. Farrow, Lee Zellmer, Courtney D. Berrios, Neil Miller, Margaret Gibson, Raymond Caylor, Janda L. Jenkins, Deb Faller, Sarah E. Soden, Carol J. Saunders

Manuscripts, Articles, Book Chapters and Other Papers

PURPOSE: We report for the first time, the use of clinical genome sequencing (GS) in an unbiased pediatric cohort. We describe the clinical validation, patient metrics, ordering patterns, results, reimbursement, and physician retrieval of results for the first consecutive 80 cases.

METHODS: Clinical GS was performed for both inpatients and outpatients undergoing etiologic evaluations. Results were reported in the electronic medical record. Evidence of report retrieval by clinicians and whether interpretation was concordant with laboratory report was obtained through retrospective chart review.

RESULTS: Twenty definitive diagnoses were made in 19 patients (24%; n = 80). Except for two partial gene …

Effects Of Am80 Compared To Ac261066 In A High Fat Diet Mouse Model Of Liver Disease, Marta Melis, Xiao-Han Tang, Steven E. Trasino, Viral M. Patel, Daniel J. Stummer, Jose Jessurun, Lorraine J. Gudas

Publications and Research

The roles of retinoids in nonalcoholic fatty liver disease (NAFLD) remain unclear and a better understanding may lead to therapies that prevent or limit NAFLD progression. We examined the actions of retinoic acid receptor (RAR) agonists- AM80 for RARαand AC261066 for RARβ2- in a murine model of NAFLD. We fed wild type C57Bl/6 mice a chow or a 45% high fat diet (HFD) for 12 weeks, followed by 4 additional weeks with the HFD+AM80; HFD +AC261066; or HFD. The HFD+AM80 group showed greater hyperglycemia and glucose intolerance compared to other groups. Histopathological evaluation of the livers showed the highest degree …

Model-Based Virtual Patient Analysis Of Human Liver Regeneration Predicts Critical Perioperative Factors Controlling The Dynamic Mode Of Response To Resection., Babita Verma, Pushpavanam Subramaniam, Rajanikanth Vadigepalli

Department of Pathology, Anatomy, and Cell Biology Faculty Papers

BACKGROUND: Liver has the unique ability to regenerate following injury, with a wide range of variability of the regenerative response across individuals. Existing computational models of the liver regeneration are largely tuned based on rodent data and hence it is not clear how well these models capture the dynamics of human liver regeneration. Recent availability of human liver volumetry time series data has enabled new opportunities to tune the computational models for human-relevant time scales, and to predict factors that can significantly alter the dynamics of liver regeneration following a resection.

METHODS: We utilized a mathematical model that integrates signaling …

Assessing The Utilization Of High-Resolution 2-Field Hla Typing In Solid Organ Transplantation., Yanping Huang, Anh Dinh, Steven Heron, Allison Gasiewski, Carolina Kneib, Hilary Mehler, Michael T. Mignogno, Ryan Morlen, Larissa Slavich, Ethan Kentzel, Edward C. Frackelton, Jamie L. Duke, Deborah Ferriola, Timothy Mosbruger, Olga A. Timofeeva, Steven S. Geier, Dimitri Monos

Department of Pathology, Anatomy, and Cell Biology Faculty Papers

HLA typing in solid organ transplantation (SOT) is necessary for determining HLA-matching status between donor-recipient pairs and assessing patients' anti-HLA antibody profiles. Histocompatibility has traditionally been evaluated based on serologically defined HLA antigens. The evolution of HLA typing and antibody identification technologies, however, has revealed many limitations with using serologic equivalents for assessing compatibility in SOT. The significant improvements to HLA typing introduced by next-generation sequencing (NGS) require an assessment of the impact of this technology on SOT. We have assessed the role of high-resolution 2-field HLA typing (HR-2F) in SOT by retrospectively evaluating NGS-typed pre- and post-SOT cases. HR-2F …

Enhancing Cognitive Engagement Of Pre-Clinical Undergraduate Medical Students Via Video Cases And Interactive Quizzes In Problem-Based Learning, Syeda Sadia Fatima, Kulsoom Ghias, Kauser Jabeen, Saniya Sabzwari

Department of Biological & Biomedical Sciences

Background: Problem-based learning (PBL) is one of the main pedagogical approaches utilized in the undergraduate medical education (UGME) program at a private medical college in Karachi, Pakistan. Video-enhanced cases and formative assessments were introduced at the end of PBL sessions to evaluate their effectiveness in enhancing student engagement.
Methods: A mixed methods study was conducted with Year 2 medical students (n=102; divided into 11 groups) and faculty (n=11) facilitating the PBL process. Of the 10 PBL cases, five were converted to video-enhanced cases and five were kept as paper-based, “traditional” cases. “Micro” videos were used to introduce clinical scenarios, augmented …

Differentiating Noninvasive Follicular Thyroid Neoplasm With Papillary-Like Nuclear Features From Classic Papillary Thyroid Carcinoma: Analysis Of Cytomorphologic Descriptions Using A Novel Machine-Learning Approach., S. Maleki, A. Zandvakili, S. Gera, S. D. Khutti, A. Gersten, S. N. Khader

Journal Articles

Background:Recent studies show various cytomorphologic features that can assist in the differentiation of classic papillary thyroid carcinoma (cPTC) from noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). Differentiating these two entities changes the clinical management significantly. We evaluated the performance of support vector machine (SVM), a machine learning algorithm, in differentiating cases of NIFTP and encapsulated follicular variant of papillary thyroid carcinoma with no capsular or lymphovascular invasion (EFVPTC) from cases of cPTC with the use of microscopic descriptions. SVM is a supervised learning algorithm used in classification problems. It assigns the input data to one of two categories …

The Conscientious Autopsy., A. K. Williamson

Journal Articles

No abstract provided.

Practical Guidance For Clinical Microbiology Laboratories: Viruses Causing Acute Respiratory Tract Infections, C. L. Charlton, E. Babady, C. C. Ginocchio, T. F. Hatchette, R. C. Jerris, Y. Li, M. Loeffelholz, Y. S. Mccarter, M. B. Miller, S. J. Drews, +4 Additional Authors

Journal Articles

No abstract provided.

Protease-Mediated Growth Of Staphylococcus Aureus On Host Proteins Is Opp3 Dependent, Mckenzie K. Lehman, Austin S. Nuxoll, Kelsey J. Yamada, Tammy Kielian, Steven D. Carson, Paul D. Fey

Journal Articles: Pathology and Microbiology

Staphylococcus aureus has the ability to cause infections in multiple organ systems, suggesting an ability to rapidly adapt to changing carbon and nitrogen sources. Although there is little information about the nutrients available at specific sites of infection, a mature skin abscess has been characterized as glucose depleted, indicating that peptides and free amino acids are an important source of nutrients for the bacteria. Our studies have found that mutations in enzymes necessary for growth on amino acids, including pyruvate carboxykinase (ΔpckA) and glutamate dehydrogenase (ΔgudB), reduced the ability of the bacteria to proliferate within a …

Cecal Perforation In The Setting Of Campylobacter Jejuni Infection, Seema Jain, Weston Betrner, Dane Olevian, Dhiraj Yadav

Faculty & Staff Scholarship

Campylobacter infection is the leading cause of bacterial gastroenteritis worldwide, yet life-threatening complications are extremely rare. We present a 32-year-old previously healthy man who presented with dysentery from Campylobacter jejuni, which was complicated by cecal perforation and secondary bacterial peritonitis.

Systemic P-Anca Vasculitis With Fatal Outcome, Arising In The Setting Of Methimazole Use., S. Hacking, N. N. Uppal, N. Khan, M. Ionescu, V. Bijol

Journal Articles

Here we report a fatal case of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) due to methimazole use in a 64-year-old woman. She was initially hospitalized for abdominal pain and possible colitis, and subsequently developed hematuria, renal failure, and hemoptysis. The serologic work-up revealed positive antinuclear antibody (ANA) and perinuclear-antineutrophilic cytoplasm antibodies (p-ANCA), with positive antimyeloperoxidase. Three weeks following admission, the patient was found to be pulseless, and expired. At autopsy, microscopic review included widespread transmural necrotizing vasculitis and crescentic glomerulonephritis in the kidney, and diffuse pulmonary alveolar hemorrhage; focal coronary artery intimal vasculitis and necrotizing pericarditis were also noted. Several …