Transfusion-transmitted virus (TTV) has been reported from a number of hemodialysis (HD) units from various countries throughout the world. TTV has been associated with liver diseases, viral hepatitis B, and C. Clinical details and information regarding TTV prevalence from India are insufficient. The prevalence and clinical significance of TTV infection were studied in New Delhi, India in HD patients. Serum samples were derived from 75 patients on maintenance HD, and 75 age- and sex-matched voluntary blood donors were examined for TTV viremia by nested polymerase chain reaction (PCR) using primers derived from UTR (A) region of the TTV genome. The prevalence of TTV DNA in patients on HD (83%) was significantly (p<0.05) higher than in blood donors (43%). Clinical background including the mean age, sex, mean duration of HD, and mean alanine aminotransferase (ALT) levels did not differ significantly between TTV DNA-positive and -negative HD patients. Fifty-four (72%) TTV-positive HD patients and 7 (56%) TTV-negative HD patients had blood transfusion histories (p>0.05). Among TTV-positive patients, Hepatitis B virus (HBV) co-infection was present in 14.2% cases while hepatitis C virus (HCV) co-infection was absent. Persistent elevation of ALT levels was observed in 7(9.3%) HD patients; 3 (43%) of them were TTV positive and 4 (57%) were TTV negative (p>0.05). All 3 TTV-positive patients with elevated ALT levels were co-infected with HBV. Patients with TTV infection alone showed normal ALT levels. Prevalence of TTV infection is high in North Indian patients on maintenance HD. Also, none of the exclusively TTV DNA-positive patients had clinical or biochemical signs of liver disease. TTV seems to spread through parenteral routes. More often, TTV seems to be associated with parenterally transmitted virus HBV, indicating a parenteral mode of TTV transmission. The pathogenicity of TTV remains unclear from the present study.

BackgroundThe incidence of extrahepatic bile duct malignancies is about 2–3.6% of all gastrointestinal malignancies. Primary carcinoma of cystic duct is a rare condition comprising a fraction of all extrahepatic bile duct malignancies with less than 70 cases reported worldwide. Majority of these cases were reported from East Asia. There is paucity in such case being reported from Indian subcontinent. We present a case of primary carcinoma of the cystic duct encountered during laparoscopic cholecystectomy.Case presentationA 65-year-old lady presented to us with symptomatic gall stone disease. Investigations revealed a distended gall bladder with multiple stones. Patient was taken up for laparoscopic cholecystectomy, during surgery a stony hard structure was found at cystic duct-common bile duct junction which was not amenable for clear dissection. Procedure was converted to open, and the patient underwent cholecystectomy with resection of common bile duct with Roux-en-Y hepaticojejunostomy and regional lymphadenectomy. Histopathological findings revealed it to be moderately differentiated adenocarcinoma of the cystic duct.ConclusionPrimary carcinoma of cystic duct is a rare condition where early diagnosis can be difficult and if accidentally detected may add to surgeon’s dilemma. Proper surgery with en-bloc resection of gallbladder, cystic duct, common bile duct, and regional lymphadenectomy is the mainstay of treatment. The prognosis of carcinoma of cystic duct is better than extrahepatic bile duct malignancies. The old classification system has outlived its time and is more rigid in definition which is not practical in advanced cases; the new classification systems of this century offer better insight into understanding the tumor characteristics and prognosis.

Amyloid goiter is an atypical presentation of an already rare disease, amyloidosis, which uncommonly comes across in previous review of literature. A patient presented with respiratory distress, which aroused a dilemma on diagnosis because the presentation mimicked that of malignancy. A high index of attentiveness should be kept whenever amyloid deposits are seen on fine needle aspiration cytology, as they are also established in medullary carcinoma. Amyloid deposits have been traced in goiter; however, it was astonishing to observe this condition causing a rapidly growing goiter, large enough to cause respiratory distress. The confirmative diagnosis rested on the histopathology of the specimen.

Extragenital malignant mixed Mullerian tumor (MMMT) is a rare tumor in females, and it is even more rarely encountered among the multiple genital malignancies. There are some reports of extragenital MMMTs associated with synchronous or metachronous gynecologic tumors of Mullerian duct origin. We recently encountered an MMMT of broad ligament which is associated with papillary serous cystadenocarcinoma of the ovary and endometrioid adenocarcinoma arising in atypical polypoid adenomyoma endometrium in a 76-year-old woman. This case is presented for its rarity and unique presentation. To our knowledge, ours is the first reported case of this unique combination of multiple synchronous genital malignancies.

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Hereditary spherocytosis (HS) is an inherited membranopathy characterized by phenotypic and genotypic heterogeneity. This study describes the clinico-hematological profile of 70 HS patients diagnosed at a tertiary care center in North India over a period of five years. Patients commonly presented with intermittent jaundice (82.9%), pallor (80%) and dark colored urine (11.4%). The common signs were splenomegaly (92.9%), hepatomegaly (50%), cholelithiasis or choledocholithiasis (36.8%) and hemolytic facies (10%). Family history was contributory in 28.6% patients. Blood transfusion (BT) requirement was present in 35.7% patients. Unconjugated and conjugated hyperbilirubinemia was seen in 89.1 and 10.9% patients respectively. At presentation, the hemoglobin ranged from 3-14 g/dl with a mean of 9.37 g/dl (SD2.43). Spherocytes were seen in 88.6% and incubated Osmotic fragility test (OFT) was positive in 88.2% patients. The Eosin-5-maleimide (EMA) flow cytometric test was done in 28 patients. Mean fluorescence intensity (MFI) for normal subjects was 11861.5 (SD-883.51) and for confirmed HS patients was 7949.3 (SD1304.1). Taking the MFI range of 5341.1-10 557.5 for HS, eight cases of suspected HS/undiagnosed hemolytic anemia with a negative (n=5) or equivocal (n=3) incubated OFT were diagnosed as HS. An increase in HbF level was seen in 10 cases ranging from 2.1 to 17.7% with a mean of 5.66%, three of these had associated beta thalassaemia trait. Twelve patients (17%) underwent splenectomy and 91% of them did not require any BT post-splenectomy. Among the patients treated conservatively 49% had persisting pallor and 16.3% had transfusion requirement.

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