Teen diagnoses her own disease in science class

During an Advanced Placement class in Histology, Jessica Terry from Sammamish, WA found a granuloma in an intestinal biopsy. The amazing part is that she had borrowed her own slides from her pathologist. According to CNN who picked up the story yesterday, June 11, there were no answers. However, in the video excerpt she describes being told she had colitis.

Teen diagnoses her own disease in science class

When evaluating an "intestinal" biopsy for a young person with chronic abdominal pain, you would be looking for signs of colitis such as active inflammation (such as cryptitis or crypt abscesses), chronic architectural changes, and granulomas. These can come in the form of "microscopic colitis" which is basically their way of saying they didnt see anything on the colonoscopy. You also have to keep your eye out for dysplasia, of course.

I feel sorry for the pathologist in this story, because it is all our worst nightmare, to be smeared in the media without being given the opportunity for defense. However, I would also like to know the whole story, because I have a feeling they are leaving something important out here.

Questions:

1. Why after so many years was only one colonoscopy done and only one biopsy?
2. When was that biopsy taken, what was the history given to the pathologist, and was it followed up by another biopsy later?
3. It sounds like she was told she had colitis, even if no granulomas were seen, she should have been worked up appropriately.... did this happen?
4. Did her primary care doctor ever refer her to a GI specialist?
5. Family history of Crohn's?

The way this story was written is fodder for those who wish to badmouth all doctors in general. However, us doctors would like to gather all the facts before going off of hearsay, then find out how this was missed so it doesnt happen again - Quality Assurance.

Here is a link to a good lecture I found somewhere on the great world wide web.
GI Mucosal Biopsy Lecture

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I voted!

It's not over til it's over. Dont forget to vote!

Bluebox

Every week we take turns presenting interesting cases at a conference
we lovingly call "Bluebox". Last week was my turn. I talked about
Wilm's tumor and some guidelines for grossing as well as microscopic
evaluation. It is still a work in progress, but I found a great
website called Scribd, where you
can show off your work in a web-friendly way, while protecting it
somewhat from total plagarism.

Wilms Tumor overview - Upload a Document to Scribd

Interview season is upon us

I have seen posters around the department notifying us of the dates
the interviewees will be here and reception times. How exciting!
Hopefully some of the people that have done rotations here will be a
part of those groups.

Some tips from the experts:

After the interview - Upload a Document to Scribd

Shaggy dogs

Dermatopathology is a terribly interesting field. I'm not sure if I
want to commit to being an expert in this field however. Although, it
probably is one of the higher paying subspecialties. Anyway, during
this month I have been learning from the best and have encountered
some great phrases along the way.

The Shaggy Dog - A case that never ends (due to recuts, slides,
consults, whatever..) Which goes along with the usual definition of
the term which can be used to describe a story that goes on an on with
an anticlimactic end.

The Dog Poop - Termed to describe sneaky melanocytes in the basal
layer which demonstrate cytologic atypia and raise the concern for
melanoma. Basically it's like dog poop in the grass - you don't
notice it until you've stepped in it.

Any other great terms to share?

Wilms tumor

I just read on CNN.com the other day the story of a little 2-year-old boy with a massive Wilm's tumor (approximately 5 kilograms). Sponsored by the Ray Tye Medical Aid Foundation, his parents took him to Jordan to have the surgery. The media declared it a success and left it at that. The pictures show a small boy with a massively distended abdomen. The skin surface shows venous congestion, caput medusae? or striae? Imagining the size of that thing, he must be having trouble breathing, let alone walking or eating or anything else. Now that it is "out", what are the risks of recurrence in this young lad? What are the prognostic factors in Wilm's tumor?

Wilms tumor is the most common primary malignant renal tumor of childhood. The North American approach is to resect the untreated primary tumor then give chemotherapy based on the pathologic analysis. The European approach is to give preoperative chemo, resect, then provide post op chemotherapy.

The first consideration is stage. Was the tumor confined to the kidney or completely resected. Were there positive margins, was there evidence of invasion into blood vessels? Were there local or distant metastases? These are the questions that the media does not ask, but as pathologists we must answer in order to provide the best and most current care to our patients. Stage, presence or absence of anaplasia or metaplasia are all important predictive and prognostic factors that the guide the clinicians in their choices for treatment and therapy. I've only seen a couple of WT so far and they were only 500 grams and pretty darn huge. This young boys life may be prolonged by a generous group of strangers, but will they also help provide the follow up care and chemo that he needs to make a complete recovery, or will they vanish like the media now that the tumor is "out".

The life of a virus

One of the laboratory assistants was sick two weeks ago. Among all the other things, her job includes helping make the slide labels. Next to get sick were the histotechs, they make the slides and give them to us. Guess who got sick next? Yours truly - previewer of slides, and my co-resident. Washing my hands constantly to no avail, the attending was next on the list. :( sorry? It wasnt my fault...