1. Case Study 33 Henry Armah, M.D., M.Phil.

2. Question 1 Clinical history: 53-year-old male who presented with severe back pain and right lower extremity weakness. He was a chronic alcoholic, did not smoke, and did not use illicit drugs. Spinal MRI showed a heterogeneously enhancing extradural mass at the level of the T6 vertebral bone. An intraoperative consultation was requested. Describe the microscopic findings on this smear slide? Click here to view slide.here

3. Answer 1. Necrotic debris. 2. Acute inflammatory cells. 3. Rare atypical cells.

4. Question 2 What is your intraoperative diagnosis? (A: Category such as Defer, Reactive/Non-neoplastic, or Neoplastic; B: More specific diagnosis or statement)

5. Answer 1. Reactive. 2. Necrosis, Acute Inflammation, and Rare Atypical Cells.

6. Question 3 The permanent section from the intraoperative specimen has returned from histology. Describe the microscopic findings on this H&E slide? Click here to view slide.here

7. Answer Fragments of devitalized bone, remodeled woven bone and fibroadipose tissue with extensive acute necroinflammatory infiltrate, early necrotizing granulomatous inflammation with multinucleated giant cells and epithelioid histiocytes, and scattered fungal forms.

8. Question 4 What additional studies would you like to perform based on the findings of the permanent section?

9. Answer 1. Gram stain. 2. Grocott/GMS stain. 3. AFB stain. 4. FiteN stain.

10. Question 5 What do you see on this Gram stain slide? Click here to view slide.here

11. Answer Gram stain is negative for bacterial organisms.

12. Question 6 What do you see on this Grocott/GMS stain slide? Click here to view slide.here

13. Answer Grocott/GMS stain highlights irregular branching septate fungal organisms.

14. Question 7 What do you see on this AFB stain slide? Click here to view slide.here

15. Answer AFB stain is negative for mycobacterial organisms.

16. Question 8 What do you see on this FiteN stain slide? Click here to view slide.here

17. Answer FiteN stain is negative for nocadia.

18. Question 9 What is your final diagnosis?

19. Answer Fungal Associated Necrotizing Granulomatous Inflammation.