--- a
+++ b/processing/MACCROBAT/28320420.txt
@@ -0,0 +1,31 @@
+An 18-year-old college student was referred from the University Clinic for having low hemoglobin (Hg 4.7 g/dl).
+He was completely well till one month back when he presented with easy fatigability, postural dizziness, palpitation and dyspnea.
+He gave history of 30 kg weight loss over the past 6 months.
+On physical examination, he looked pale, not jaundiced or cyanosed.
+His vital signs were all within normal limits, except for an elevated heart rate (98/min).
+Cardiovascular, respiratory and abdominal examinations were unremarkable.
+Primary investigations in our hospital revealed low hemoglobin level (5.1 g/dl), low iron (<10 ug/dl), and a positive occult blood test.
+A provisional diagnosis of microcytic hypochromic anemia for further workup was made.
+Bone marrow aspirate and trephine biopsy revealed normocellular marrow, depicting normal trilineage hematopoiesis.
+Upper GI endoscopy showed erosive antral gastritis with patchy ulcerative inflammation.
+Abdominal ultrasound showed a slightly enlarged liver with a rounded echogenic lesion in the anterior wall of the right lobe suggestive of hemangioma.
+The spleen was slightly enlarged and normal in echogenicity with no focal lesions.
+Computed Tomography (CT) scan of the abdomen and pelvis showed a fairly large well defined soft tissue mass located in the anterior upper pelvis and engulfing jejunal loops causing bowel wall thickening.
+The patient underwent an exploratory laparotomy and excision of the jejunal mass.
+Macroscopic examination revealed an 11 × 8 × 2 cm annular mass located within the jejunal wall ulcerating through the mucosa and extending to the serosal surface.
+Microscopic examination revealed a tumor situated in the muscularis propria and extending to the mucosa and the serosa.
+The neoplastic cells were arranged in predominantly pseudoalveolar pattern (Fig.1a,b).
+They were polygonal in shape with variable amount of eosinophilic to clear cytoplasm (Fig.1c).
+The nuclei were oval with vesicular chromatin and inconspicuous nucleoli.
+Scattered osteoclast-like multinucleated giant cells were also identified (Fig.1b,c).
+Frequent mitotic figures and necrosis were noted.
+All lymph nodes were not involved by tumor.
+Immunohistochemically, the neoplastic cells were strongly and diffusely positive for S-100 protein (Fig.1d).
+They were also positive for vimentin.
+Melanocytic markers (HMB45 and Melan A), neuroendocrine markers (chromogranin A, synaptophysin and CD56), smooth muscle actin, desmin, CD34, CD117, cytokeratin and LCA were all negative in the neoplastic cells.
+Fluorescein in situ hybridization (FISH) analysis for EWSR1 break apart probe on paraffin-embedded tumor showed evidence of a 22q12 rearrangement in 197 out of 205 (96%) of interphase nuclei scored.
+The native state of EWSR1 break apart probe will be seen as two adjacent or fused (overlapping) red/green (yellow) signals.
+However, EWSR1 gene rearrangement presented as one red and one green separated signal (Fig.1e).
+The patient did not receive chemotherapy or radiotherapy.
+During the clinical follow up, the patient remained disease free for 3 years until he presented with local recurrence.
+The treatment plan was surgical resection but the patient sought medical advice in a different institution where he died of the disease a year later.