Journal of Pathology of Nepal <p>The Journal of Pathology of Nepal is the official publication of the Association of Clinical Pathologists of Nepal (ACPN) and all the published articles are Open Access. Please go through the author guidlenes for necessary information and fee for submission, processing, and publication,&nbsp;</p> <p><a href="" rel="license"><img style="border-width: 0;" src="" alt="Creative Commons Licence"></a><br>All articles published in the Journal of Pathology are licensed under a <a href="" rel="license">Creative Commons Attribution 4.0 International License</a>.<br>Journal of Pathology of Nepal is indexed on&nbsp;<a title="Index Copernicus-JPN" href="">Index Copernicus</a>,&nbsp;<a title="DOAJ-JPN" href="" target="_blank" rel="noopener">DOAJ.</a></p> Association of Clinical Pathologists of Nepal (ACPN) en-US Journal of Pathology of Nepal 2091-0797 Utility of reporting urine cytology samples as per the Paris system <p><strong>Background:</strong> Urinary tract cytology is an accurate test for the detection of urothelial malignancy especially high-grade urothelial carcinoma. The Paris System for Reporting Urinary Cytology was introduced to standardize urinary tract cytology reporting. We aim to evaluate the utility of reporting urinary cytology as per this system and correlate with histopathology.</p> <p><strong>Materials and Methods:</strong> This is a descriptive cross-sectional prospective study conducted on urine samples submitted for cytological examination at Kathmandu Medical College Teaching Hospital, Sinamangal, Nepal between 1st November 2020 to 31st July 2021. Ethical consent was taken from the Institutional Review Committee. Urine cytology was reported as per The Paris System for Reporting Urinary Cytology and correlated with the histopathologic diagnosis. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the high-grade and low-grade urothelial lesion.</p> <p><strong>Results:</strong> A total of 104 urine samples were evaluated. Biopsy specimens were available for 38 cases. Urine cytology consisted of 1.92% non-diagnostic cases, 69.23% negative for high-grade urothelial carcinoma, 5.76% atypical urothelial cells, 5.76% suspicious for high-grade urothelial carcinoma, 13.46% high-grade urothelial carcinoma, and 3.84% low-grade urothelial neoplasm respectively. Sensitivity, specificity, negative predictive value and positive predictive value were 90.48%, 82.35%, 86.37% and 87.5% respectively for high grade urothelial carcinoma and 40%, 93.9%,50% and 91.17% respectively for low grade urothelial lesions.</p> <p><strong>Conclusions:</strong> Our study shows that reporting urine cytology as per The Paris System for Reporting Urinary Cytology provides high sensitivity for the detection of high-grade urothelial lesions.</p> Ramesh Dhakhwa Ozone Shrestha Ram Thapa Sailesh Pradhan Copyright (c) 2022 Ramesh Dhakhwa, Ozone Shrestha, Ram Thapa, Sailesh Pradhan 2022-03-31 2022-03-31 12 1 1881 1885 10.3126/jpn.v12i1.41443 Antifungal susceptibility test of biofilm-producing pathogenic Candida albicans isolated from oral cavity of type II diabetic patients and non-diabetic individuals <p><strong>Background:</strong> <em>Candida albicans</em> are found in the mucous membranes of the respiratory, gastrointestinal, and female genital systems as part of the natural flora. Diabetic people are more susceptible to <em>Candida </em><em>albicans</em> infections due to elevated blood glucose and the immune system's failure in fungus eradication. This study aimed to look at <em>Candida </em>carriage and antifungal susceptibility testing of biofilm-producing <em>Candida </em><em>albicans</em> isolated from the oral cavity of type II diabetic patients and non-diabetic individuals.</p> <p><strong>Materials and Methods</strong><strong>:</strong> This was a cross-sectional analytical laboratory-based study carried out in Dharan Sub-Metropolitan city from June 2018 to November 2018. The 10 mL oral rinse was collected from 50 diabetic patients and 50 healthy control participants. Isolation, identification, biofilm assay, and antifungal susceptibility test of <em>Candida </em><em>albicans </em>were performed by the conventional microbiological procedure. Statistical analysis was used to determine the association between variables.</p> <p><strong>Results:</strong> The <em>Candida</em> carriage was significantly higher in diabetic patients 58% (29/50) than in healthy (control) groups 26% (13/50) (p=0.001). In the antifungal susceptibility test of <em>Candida </em><em>albicans </em>isolated from diabetic patients, 18.75% isolates were sensitive, 81.25% isolates were resistant to fluconazole<em>, </em>43.75% isolates were sensitive, and 56.25% isolates were resistant to amphotericin-B. The biofilm formation and fluconazole drug resistance were found to be statistically significant (p=0.029).</p> <p><strong>Conclusions: </strong>The findings concluded the highest colonization of oral <em>Candida</em> in diabetic patients than in healthy (control) individuals. Emerging antifungal drug resistance is even associated with biofilm formation, which requires the importance of displaying an antifungal susceptibility profile before antifungal therapy.</p> Bijay Kumar Shrestha Jenish Shakya Manita Tumbahangphe Hemanta Khanal Bidhya Dhungana Romika Shrestha Kabita Dhakal Sujata Chauhan Santoshi Ghimire Jyoti Limbu Kaushila Limbu Copyright (c) 2022 Bijay kumar shrestha, Jenish Shakya, Manita Tumbahangphe, Hemanta Khanal, Bidhya Dhungana, Romika Shrestha, Kabita Dhakal, Sujata Chauhan, Santoshi Ghimire, Kaushila Limbu, Jyoti Limbu 2021-03-31 2021-03-31 12 1 1886 1892 10.3126/jpn.v12i1.42388 Mucinous lesions of the appendix: a histopathological study <p><strong>Background:</strong> Mucinous lesions of the appendix are frequently misinterpreted in histopathological examination due to their relative rarity. Our study focuses on interpreting the histopathological spectrum of such lesions and understanding the disease burden of appendiceal mucinous lesions in a tertiary centre.</p> <p><strong>Materials and Methods:</strong> This was a retrospective cross-sectional study conducted in the Department of Pathology. Gross and microscopic findings of appendicectomy specimens with mucinous lesions were analysed and classified according to the latest WHO 2019 recommendation.</p> <p><strong>Results:</strong> Seven hundred and forty appendicectomy specimens were received during the study period out of which nine appendix (1.2%) had mucinous lesions. Five (55.6%) of these lesions had a mucinous neoplasm while four of them (44.4%) were non-neoplastic. The most common lesion was low-grade appendiceal mucinous neoplasm (n=4; 44.4%). Two cases (22.2%) were retention cysts and there was one case each of mucinous adenocarcinoma, appendiceal diverticulosis, and endometriosis-associated mucinous metaplasia of the appendix. The mucinous neoplasms were significantly more common in females (80%). High-grade appendiceal mucinous neoplasms and serrated lesions or polyps weren’t seen in our study.</p> <p><strong>Conclusions:</strong> Mucinous lesions of the appendix are often incidental findings in patients operated for symptoms of acute appendicitis. Low-grade appendiceal mucinous neoplasms are the most common among them. Thorough knowledge of the neoplastic mimics and careful gross, as well as microscopic examination, is a must for proper diagnosis and staging since it has a significant impact on further patient management and prognostication.</p> Oshan Shrestha Reetu Baral Copyright (c) 2022 Oshan Shrestha, Dr. Reetu 2022-03-31 2022-03-31 12 1 1893 1899 10.3126/jpn.v12i1.39338 A comparative study of cell block and cytological smears in FNAC of intra-abdominal lesions <p><strong>Background:</strong> Cell blocks are micro biopsies and are complimentary to cytology smears and give a = more accurate diagnosis. This study aimed to study cell block as an adjunct for FNAC smears in intra- abdominal lesions, and to compare the sensitivity and specificity of the cell block with FNACs of intra- abdominal lesions.</p> <p><strong>Materials and Methods:</strong> This study was done for three years. FNAC of the intra- abdominal lesions were done and smears were prepared for routine staining (HE, PAP, and MGG), the rest of the material was submitted in 60% ethanol for cell block preparation.</p> <p><strong>Results:</strong> FNACs were done in 102 cases, cell blocks were obtained in 95 cases, and histopathological correlation in 87 cases. The maximum number of cases was between 51-60 years age group. The liver was the most common organ involved with 22 cases(21.56%). Nonneoplastic cases were 17, neoplastic was 85. Statistical analysis was done for benign and malignant cases. Histopathological correlations were available in 71 neoplastic cases. The sensitivity, specificity PPV, NPV, and diagnostic accuracy of combined FNACs and Cell blocks were 98.27%, 100%, 100%, 92.85%, and 98.59% respectively.</p> <p><strong>Conclusions</strong>: FNAC of intra-abdominal lesions is a safe, simple, cost-effective procedure and along with cell blocks gives a precise diagnosis. They can also be used for histochemical stains, immuno- cytochemistry, and in-situ-hybridization.</p> Anita A M MD Hamed Altaf Mali Anuradha G Patil Meenakshi M Copyright (c) 2022 MD Hamed Altaf Mali, ANITA A M, Dr, ANURADHA G PATIL, MEENAKSHI M 2021-03-31 2021-03-31 12 1 1900 1906 10.3126/jpn.v12i1.33054 Usefulness of prostate specific antigen density in detecting prostate carcinoma: A hospital-based study in patients with prostate biopsies <p><strong>Background: </strong>Prostate-specific antigen density has been suggested to enhance the diagnostic efficacy of serum prostate-specific antigen alone in detecting prostate cancer, thereby reducing unnecessary biopsies and associated morbidities. This study aimed to assess the diagnostic performance of prostate-specific antigen density in detecting prostate cancer.</p> <p><strong>Materials and methods: </strong>A retrospective analysis of histologically proven benign and malignant prostate diseases, submitted in the histopathology department was performed from April 2019 to March 2020. The diagnostic performance of prostate-specific antigen density was assessed and its optimum cut-off value was determined using the receiver operating characteristic curves. The diagnostic efficacy of prostate-specific antigen density was also compared with prostate-specific antigen in detecting prostate cancer.</p> <p><strong>Results: </strong>The AUC to predict prostate cancer was 0.89 (95% CI 0.79-0.98. p &lt;0.001) for prostate-specific antigen density. The diagnostic performance of prostate-specific antigen density at cut-off 0.18 ng/ml/cc was better than prostate-specific antigen alone (AUC, 0.838 vs 0.662). Sensitivity was 80% for both prostate-specific antigen density at cut-off 0.18 ng/ml/cc and prostate-specific antigen. But, prostate-specific antigen density had a higher specificity of 87.7 % than prostate-specific antigen (52.3%)and thus it could better distinguish benign diseases from prostate cancer. It would have reduced unnecessary biopsy by 35%.</p> <p><strong>Conclusions: </strong>The diagnostic efficacy of prostate-specific antigen density was good and it was found to be a better predictor of prostate cancer at the cut-off value of 0.18ng/ml/cc when compared to prostate-specific antigen alone.</p> Reshmi Shrestha Shova Kunwar Suman Gurung Anjana Nuri Pokharel Copyright (c) 2022 reshmi shrestha 2022-03-31 2022-03-31 12 1 1907 1913 10.3126/jpn.v12i1.41841 Prevalence of skin cancer based on skin biopsies in Bir hospital, Nepal <p><strong>Background:</strong> Cancer, one of the most dreaded non-communicable diseases has become an important contributor to the global burden of diseases. The incidence of skin cancer is rising. Clinical history, physical examination, laboratory investigations including biopsy are different modalities for the diagnosis of the disease. This study aimed to find the prevalence of skin cancer among patients visiting Bir hospital.</p> <p><strong>Materials and Methods:</strong> This was a retrospective study carried out in the National Academy of Medical Science, Bir Hospital from Baishakh 1st 2071 to 30th Poush 2075. It included all the skin malignancies and pre-invasive lesions received and diagnosed in the Department of Pathology.</p> <p><strong>Results:</strong> A total number of 1555 skin biopsies were obtained in the past five years where we diagnosed a total of 165 (10 %) cases as malignant which included the premalignant cases too. The most affected age group was 66 to 75 years (29 %) with 55% male and 45%females. Our data showed head and neck was the most common site occupying 67% of the total case followed by lower limbs 15%. Our study also revealed that 40% of malignant cases were basal cell carcinoma which was followed by squamous cell carcinoma comprised 36% and malignant melanoma(15%).</p> <p><strong>Conclusions:</strong> In this study, basal cell carcinoma was the most common malignancy followed by squamous cell carcinoma and malignant melanoma. Head and neck was the most common site.</p> Sumida Tiwari Pradip Koirala Sujan Shrestha Niraj Parajuli Copyright (c) 2022 Sumida Tiwari 2022-03-31 2022-03-31 12 1 1914 1917 10.3126/jpn.v12i1.43033 Correlation of cytomorphology with flowcytometric immunophenotyping in patients of acute leukemia in tertiary care hospital <p><strong>Background:</strong> Morphological diagnosis of leukemias may sometimes not correlate with flow cytometry diagnosis. Classification of hematological neoplasm by the World Health Organization gives priority to cytogenetic, molecular biology, and even patient history, in an attempt to classify patients primarily regarding prognosis. Cytomorphology and immunophenotyping complement each other. Morphology is burdened by a high degree of subjectivity. That is why correlation of information provided by the two techniques is still absolutely necessary. The aim of our study was to correlate between cytomorphological findings and immunophenotyping results on a group of patients investigated for acute leukemia.</p> <p><strong>Materials and Methods:</strong> Study was conducted in department of pathology in Chirayu Medical College and Hospital, Bhopal from December 2018 to September 2019. Cases were diagnosed as acute leukemia based on complete blood count and bone marrow aspirate/peripheral smear.These cases were sent to flowcytometry for immunophenotyping for further confirmation.</p> <p><strong>Results:</strong> Total 74 cases of acute leukemias were diagnosed, out of which 30 were Acute myeloid leukemia and 44 were Acute lymphoblastic leukemia. There was 95.95% correlation between diagnosis on cytomorphology and flowcytometry. Two cases remain unclassified on cytomorphology which turn out to be Acute myeloid leukemia on flowcytometry. One case of Acute myeloid leukemia on cytomorphology was diagnosed as Acute lymphoblastic leukemia on flowcytometry.</p> <p><strong>Conclusions:</strong> Inclusion of flowcytometry in routine diagnostic workup of acute leukemia ensures proper characterization as well as management. Major challenges for the near future are the standardization of technical procedures, data interpretation, and reporting.</p> Garima Pandey Rahsmi Nichlani Farah Jalaly Naila Durrani Manal Ashraf Ali Copyright (c) 2022 Farah Jalaly, Garima Pandey, Rahsmi Nichlani, Naila Durrani, Manal Ashraf Ali 2022-03-31 2022-03-31 12 1 1918 1922 10.3126/jpn.v12i1.34365 Histopathological study of round cell tumors of the head and neck region in a tertiary care hospital: A retrospective study <p><strong>Background: </strong>Small round cell tumors are heterogeneous, highly aggressive malignant tumors occuring in unusual sites with overlapping clinical and radiographic features. Their diagnosis is challenging using conventional histopathologic approaches because of indistinct features in small biopsy samples and hence immunohistochemistry is a must. This study was undertaken to evaluate the pattern, common types, age, sex distribution of round cell tumors of the head and neck region and to obtain morphological immunohistochemistry correlation.</p> <p><strong>Material and Methods: </strong>It is a retrospective study of 99 cases which fulfilled the inclusion criteria. Paraffin blocks were retrieved and were reviewed by two independent expert observers and immunohistochemistry was repeated whenever necessary.</p> <p><strong>Results: </strong>Final diagnosis was given based on the immunohistochemistry pattern and our study showed 8 spectrums of round cell tumours. Lymphoma was the most common followed by neuroendocrine carcinoma. Most B-cell Non Hodgkin Lymphoma, undifferentiated carcinomas and Neuroendocrine carcinomas were observed in older group whereas, Ewing sarcoma /Primitive Neuro Ectodermal Tumour and T cell NHL were seen more in younger group. According to sex wise distribution, 70 (70.7%) cases were male and 29 (29.3%) females with male to female ratio of 2.4:1.</p> <p><strong>Conclusions</strong>: Round cell tumors can occur at any sites of the head and neck region. There are certain morphologic features for each tumor which may help the surgical pathologist to come to a probable diagnosis in addition to careful search of the detailed history, location of tumor, presentation, radiological findings and ultimately correlating with immunohistochemistry.</p> Zhuvi Zhuvithsii Anupam Sarma Shiraj Ahmed Lopa Mudra Kakoti Jagannath Dev Sharma Tarali Pathak Sawmik Das Amal Chandra Kataki Copyright (c) 2022 Z Zhuvithsii, Anupam Sarma, Shiraj Ahmed, Lopa Mudra Kakoti, Jagannath Dev Sharma, Tarali Pathak, Sawmik Das, Amal Chandra Kataki 2022-03-31 2022-03-31 12 1 1923 1928 10.3126/jpn.v12i1.35056 Histopathological pattern of adult renal tumours in a tertiary cancer center <p><strong>Background:</strong> Renal tumours are 16<sup>th</sup> most common malignancies in the world accounting for 2.2% of all new malignancies and 1.8% of all cancer deaths. Histopathological classification of renal tumours along with tumour grade and stage is proven to have prognostic value.</p> <p><strong>Material and Methods:</strong> This was a retrospective study conducted in Department of Pathology at B.P. Koirala Memorial Cancer Hospital Bharatpur from January 2017 to December 2019 including cases of partial and radical nephrectomies of patients more than sixteen years of age.</p> <p><strong>Results: </strong>Total 78 nephrectomy specimens were received out of which 70 (89.7% consisted of malignant tumour and 8 (10.3%) were benign lesions. Clear cell type renal cell carcinoma was the most common malignant tumour consisting of 57 (81.4%) cases of renal cell carcinoma, followed by papillary type 9(12.9%), Cchromophobe (4.3%) and one case (1.3%) of multiloculated cystic renal neoplasm was noted. Renal cell carcinoma was seen in age range of 26 to 80 years with majority of patients more than 50 years of age, while a small peak (14.3%) was noted in female patients of 31 to 40 years of age.</p> <p><strong>Conclusions: </strong>This study found increased incidence of renal cell carcinoma among female patients of 31 to 40 years of age in contrast to studies done in the Western population.</p> Ranjan Bhatta Greta Pandey Nandita Kumari Jha Shankar Bastakoti Ishan Dhungana Suraj Upreti Copyright (c) 2022 Ranjan Bhatta Dr, Greta Pandey, Nandita Kumari Jha, Shankar Bastakoti, Ishan Dhungana, Suraj Upreti 2022-03-31 2022-03-31 12 1 1929 1932 10.3126/jpn.v12i1.41857 A study of serum calcium, phosphorous and magnesium level in hypothyroid cases <p><strong>Background:</strong> Hypothyroidism is an endocrine disorder occurred either due to its impaired activity or hormonal deficiency. Trace elements are required as a cofactor for many enzymes in various metabolic pathways which are regulated by thyroid hormone. Hence, thyroid disorders are linked with disturbances in various metabolisms. So, the purpose of this study is to evaluate whether serum calcium, magnesium, and phosphorus level are deranged or not in hypothyroid cases.</p> <p><strong>Materials and Methods:</strong> A prospective study was carried out in a total of 112 cases of hypothyroid and euthyroid subjects aged 20-50 years involving both male and female individuals. Thyroid function test, serum calcium, phosphorous and magnesium activities were measured in both the study population.</p> <p><strong>Results:</strong> Serum calcium was significantly lower while serum phosphorous and magnesium levels were significantly higher in hypothyroidism (p&lt;0.001). There was a significant negative correlation between Thyroid Stimulating Hormone (TSH) and calcium (r-value -0.282, p0.035) while, there was a significant positive correlation between TSH and serum phosphorous and magnesium (r-value 0.593, p&lt;0.001) and (r-value 0.513, p&lt;0.001) respectively.</p> <p><strong>Conclusions:</strong> Our study, suggests that there was a significant change in the levels of serum calcium, phosphorous, and magnesium in thyroid dysfunction. Assessing the level of serum calcium and phosphorous can be fairly used as an index of bone resorption. So, preventive measures like supplementation of minerals can be initiated early in those who are at risk of rapid bone loss and to prevent osteoporotic fractures.</p> Arun Dhungana Naveen Shreevastva Subash Pant Baburam Pokharel Copyright (c) 2022 Arun Dhungana, Mr. kumar, Dr. subash, Dr. Baburam 2022-03-31 2022-03-31 12 1 1933 1937 10.3126/jpn.v12i1.40422 Histopathological findings on endometrial biopsy in a tertiary care center of Nepal: a retrospective cross-sectional study <p><strong>Introduction: </strong>Abnormal uterine bleeding is the most common presentation in endometrial pathology and endometrial biopsy is the investigation of choice. This study aimed to describe the histological findings of patients who underwent endometrial biopsy to estimate the most common endometrial diseases in Nepali women.</p> <p><strong>Materials and methods: </strong>This retrospective cross-sectional study was conducted using hospital records, and included females who underwent endometrial biopsy at a tertiary level hospital from 1 April 2018 to 31 March 2020. Histopathological findings were categorized into eight groups, and patients were divided into three age groups to obtain the relative occurrence of each type of disease at different ages</p> <p><strong>Results:</strong>342 female patients were included in the study, among which 97 were pregnancy-related and 245 were non-pregnancy-related. The mean age of the patients was 41.63 years (± 11.45 years). In 28 cases (8.2%) of the 342 total cases, the endometrial biopsy sample was deemed inadequate. Among the non-pregnancy-related cases, normal physiological changes were the most common reported finding (n=93, 38.0%), followed by abnormal physiologic changes (n=68, 27.8%). Premalignant conditions (n=15, 6.1%) and malignancy (n=5, 2.0%) were less common.</p> <p><strong>Conclusions: </strong>Normal physiological changes and disordered proliferative endometrium are the most common findings in an endometrial biopsy. Endometrial hyperplasia and malignancy are less common, and usually found in women more than 40 years in age.</p> Amar Narayan Shrestha Barun Babu Aryal Anurag Adhikari Ayusha Poudel Ramhari Rouniyar Bidur Khatiwada Copyright (c) 2021 Amar Narayan Shrestha, Barun Babu Aryal, Anurag Adhikari, Ayusha Poudel, Ramhari Rouniyar, Bidur Khatiwada 2022-03-31 2022-03-31 12 1 1938 1942 10.3126/jpn.v12i1.38595 Perimenopausal invasive complete hydatidiform mole: a rare encounter <p>Invasive mole, classified under the gestational trophoblastic diseases, comprises of hydropic chorionic villi invading the underlying myometrium, blood vessels or extra-uterine sites. They are usually diagnosed clinically and are treated with chemotherapy. Thus, surgery is rarely performed owing to good response to chemotherapy and preservation of fertility, since most women are in reproductive age. Thus, these specimens are rarely encountered by the pathologists. Here, we report a case of invasive mole in a 48 year old female with persistent elevation of serum beta HCG levels and completed family status who underwent hysterectomy and was diagnosed as a case of invasive mole on histopathologic examination.</p> Aasiya Rajbhandari Karishma Malla Vaidya Bibhuti Dahal Copyright (c) 2021 Aasiya Rajbhandari, Bibhuti Dahal, Dr. 2022-03-31 2022-03-31 12 1 1943 1945 10.3126/jpn.v12i1.33932 Dedifferentiated chordoma, a case report <p>Dedifferentiated chordoma is a rare variant of chordoma, exhibiting simultaneous presence of&nbsp; conventional chordoma and component of high grade sarcoma. It occurs either de novo or in the form of high grade transformation of a conventional chordoma in a setting of recurrence or radiotherapy induced changes. Despite similar clinical manifestations, it shows significantly poorer survival among all variants of chordomas, making an accurate diagnosis important. We, herein, report a case of large chordoma in a 65 years old female, arising de novo in sacrum, where dedifferentiated component was present only focally, highlighting the importance of adequate grossing.</p> Girishma Shrestha Paromita Roy Indu Arun Argha Chatterjee Gautam Biswas Copyright (c) 2022 Girishma Shrestha, Paromita Roy, Indu Arun, Argha Chatterjee, Gautam Biswas 2022-03-31 2022-03-31 12 1 1946 1949 10.3126/jpn.v12i1.42213 Lupus anticoagulant: a clinical and laboratory diagnostic dilemma <p>Lupus anticoagulants are a group of diverse autoantibodies that interfere in vitro in phospholipid-dependent clotting tests, and inhibit both the common and intrinsic pathways of coagulation. Paradoxically, they are implicated to cause hypercoagulability, thrombotic events in vivo in varied clinical settings like obstetrics and oncology.</p> <p>A 56-year female was referred to the laboratory with complaint of repeated de novo clotting of drawn plasma samples. She was a post-operative case of surgery for superior mesenteric venous thrombosis, and a previously diagnosed case of squamous cell carcinoma of the buccal mucosa, not on treatment. The patient was evaluated clinically for new onset hypercoagulability and the history of exposure to heparin was negative, which ruled out heparin induced thrombocytopenia. The differential diagnosis were lupus anticoagulant, staphylococcal septicemia, and thrombotic thrombocytopenic purpura. On advanced work up, inhibitor screen was negative, dilute Russell's viper venom time was positive.</p> Shalini Trivedi Pooja Jain Nutan Dixit Manoj Arun Udita Singhal Copyright (c) 2022 Shalini Trivedi, Pooja Jain, Nutan Dixit, Manoj Arun, Udita Singhal 2022-03-31 2022-03-31 12 1 1950 1954 10.3126/jpn.v12i1.37703 Multiple bone fractures with a hidden aetiology-A case report <p>A patient presented with fracture of multiple bones, on investigations, showed primary hyperparathyroidism due to an adenoma in the inferior parathyroid gland. The bones showed typical changes of hyperparathyroidism in the form of osteitis fibrosa. The cause for the bone lesion was not evident initially and the patient had to undergo extensive investigations for myeloma and metastatic deposit, since parathyroid cause was not at all suspected by the clinician. This case indicates that whenever one deals with bone pathology, parathyroid lesions as a cause should also be thought of and appropriate workup should be done for an early diagnosis and treatment.</p> P. Sankaran Jayalakshmy Sreelekshmi K. Thunoli Asiq N. Siddeeque Copyright (c) 2022 P. Sankaran Jayalakshmy, Sreelekshmi K. Thunoli, Asiq N. Siddeeque 2022-03-31 2022-03-31 12 1 1955 1959 10.3126/jpn.v12i1.30547