And the winner is:

... a Kijabe alum, Josh Lieberman.  Thanks for submitting the answers, Josh!

In addition to the Strandjord-Clayson award he got today (CONGRATULATIONS!!!!) for his laboratory medicine achievements, he also will be awarded the coveted Tab Stealing Monkey Award for skill in Kijabe related histopahtologic diagnostic skills.

I'm putting the answers below the original post in small font with explanations.

Quick trio of cases! Can you diagnose them all?

Anatomic pathologists and pathology enthusiasts - check out these cases.  These are fairly routine cases from Kijabe.  Can you get them?  First to email me (Thomas Long) with all 3 correct diagnoses will be recognized on the blog.  Differential diagnoses will not be accepted.  One guess per case.

Case 1:  The patient is a 28 year old Kenyan man with HIV.  He complained of dysphagia and the oesophago-gastro-duodenal (OGD) endoscopy showed a mass.  Biopsy is pictured below.  What is your diagnosis?

Case 2:  A 36 year old Kenyan woman presents with a cervical mass.  Radical hysterectomy with lymph node dissection is performed.  Mass and lymph node are pictured.  Diagnosis?

Case 3:  Now for some cytology.  A 45 year old Kenyan man presents with a left inguinal mass.  FNA is performed.  Diagnosis?

ANSWERS:

1.  This nodule in the esophagus of someone who has HIV and is likely immunocompromised contains numerous foamy macrophages and especially on highest power (oil immersion, 100x) clearly shows intracellular organisms morphologically suspicious for histoplasmosis.

2.  The pictures are intentionally from lower power.  There is a solid-appearing invasive carcinoma.  The most common diagnosis and the one that comes to mind first would generally be squamous cell carcinoma, but the lesson here is that not all that is solid is squamous.  If you look carefully, there are gland-forming lumens, most easily identified on the lymph node metastasis.  Additionally, the cells are rounder and less angulated than typical squamous cells, and there is no keratinization or other obvious squamous feature other than somewhat eosinophilic cytoplasm.  Here is a higher power view of more obvious gland formation:

3.  This cytologic specimen is first positive for a epithelioid to spindled, cohesive malignancy.  But the nuclear features (round with some prominent nucleoli) and especially the abundant cytoplasmic pigment with a somewhat granular quality, are highly suspicious and essentially diagnostic of melanoma, in this case metastatic to an inguinal lymph node.  This patient had a primary on the foot, and this likely falls into the category of acral melanoma, which is the most common form of melanoma in African Americans, and probably also Africans.  We saw a couple of cases (both fairly advanced), and that's about all the skin cancer we saw during my rotation.

Mt. Kenya Trip Part 1: Moses Camp

In recent news, Rochelle and I survived the trip to Mt. Kenya!  Spoiler alert:  we made it to the top!  I'm still recovering, catching up on pathology work, preparing for a trip to the Masai Mara, and going through pictures.   Here are a few of the pictures from the first day to our "base camp" at Old Moses on the mountain's Northwest flanks.  An amazing day ending with a fun time at climbers camp.

Assembling the team and fitting everybody into the van.

Making some last minute purchases.  US gear is everywhere here, and we found this lady rocking a UW Huskies hat!

Sammy (our guide) and I with more of the team in Philip's van.  He's holding a wrapped up chapati (flatbread) that we just bought on our last minute stop.  We're just about ready for the last leg of the drive.

We get our first great view of Mt. Kenya from the road.  The mountain is an extinct stratovolcano volcano that spreads out over many miles and is truly massive.  It is estimated to have once been taller than Kilamajaro!  Its broad flanks were formed of massive lava flows and its central eroded spires are impressive.  We, of course, much closer in the coming days!

At the national park gate.  The porters and cook pack our groceries.  I was really not used to this concept.  This is the anti ultra light.  Light is not even a thing in this world of mountaineering, though.  It's all about men, backpacks, and sweat.  And having a professional guide is a good idea on Mt. Kenya.

A truly unique wildflower!

On Mt. Kenya, the vegetation progresses from subalpine tropical forest (below) to a brief bamboo forest (not pictured), to rosewood forest (above), to moor.

Dueling dying rosewoods.

We've reached the moor and are following the road to Moses camp, seen on the hill ahead.  Mt. Kenya is getting closer!

We got fairly close to an Eeland antelope.  These are the size of a small cow.

Sun sets just as we reach Moses Camp.

Made it!

Saw a dik dik while taking in the view at the camp.  This guy is more like the size of a large housecat.

The dining area at Old Moses.  The climbers bunks are behind the doors to the left.

We had a great time eating, drinking, and wearing Rochelle's puffy jackets the first night!

First adventure! Hell's Gate (part 1)

This adventure has been well photographed and blogged about in the past, but the adventure is worth a fresh look! There's a reason why Rochelle goes here every year.  Follow me on a photo Journey...

Hell's gate is a place where a much larger Lake Naivasha once covered the valley floor, and its outflow carved deep basalt canyons.  Today, hot springs and runoff from nearby mountains carves a slot canyon which is a highlight of visiting the park (see pics below).

The terrain is great for wildlife viewing and rock climbing on the spires and cliffs.  The location was actually the inspiration for the setting of Disney's The Lion King, and I learned that visits were made to survey the scenery for animation of the movie.  I was thinking the slot canyon must be the badlands where scar makes his home and ambushes Mufasa.

Poster at the entry gate.

Closer details...

One of the spires where rock climbing gear is already set up for tourists.  We didn't have time, but Rochelle and I were tempted to try as we have both dabbled a bit in rock climbing.

Zebras and scenery.

I think this was a private group.  There were some great cracks!

Warthog family.

Gorgeous!

This juvenile giraffe was peeking at us while snacking on the shrubbery.

Thompson's gazelles and some other beasts.

The slot canyon (actually the outlet, toward the end of the journey)

Whistling thorn.  A most interesting plant! Ants actually make their homes in the plant's red-brown nodes and come out to defend the plant if disturbed.

Masai come to the park and help tend to it, and are friendly to this touristy guy.

Can you identify all the skulls?

Overlooking the slot canyons.

Toughest move of the day.  Pic doesn't do it justice.

Hot springs feeding into gorge.

An introduction to Kijabe

I thought I would give a bit of context on the place we've called home for the last two weeks.

The hills below Kijabe descending into the Rift Valley become more arid.  Note that the big "trees" are cacti.

Kijabe is more of a campus than a town, centered around the AIC Kijabe Hospital, AIC-CURE International Children's Hospital of Kenya, Rift Valley Academy, and Moffatt Bible College.  It all started with the Rift Valley Academy, which was started in part by wealthy American patrons.  In fact, the cornerstone was laid by Teddy Roosevelt while he was in Safari in Kenya.  These institutions have created a community around them that is quite distinct from the surrounding area and "Kijabe Town" which is a small railroad stop located down in the Great Rift Valley below where the Kijabe Hospital sits higher up on the steep hills rising to the east of the valley.

On a hike through the countryside close to Kijabe

The main commercial part of the Kijabe community.  On the left is the Supa Duka or super market, middle is butcher shop, and right with the umbrella is Mama Chiku's one of the 3 local restaurants.

The main community of Kijabe is at an altitude of about 2200 meters, which puts it just above the Malaria zone.  Its lush surroundings are quite different from the arid lands at the bottom of the valley, and the climate is actually surprisingly cool.  Up above Kijabe, the highlands rise even higher, to about 2700 meters.  These are known as the Kijabe Hills or Kikuyu Escarpment, named for the local tribe, the Kikuyu.  We've hiked up to the top of them several times so far to prepare for ascending Mt. Kenya.   

At the top of the escarpment - are we in Kenya, or the Sound of Music?

We've had a fair bit of rain since we got here, which is unusual, as we are getting into the middle of the dry season.  Kijabe means "place of the wind," but it has been a little less windy than usual, so I'm told.

Rivulets of rain come down the road in front of the Sitaplex.  Ginger is covering herself with a white lab coat (we didn't bring rain coats because the day started out sunny and beautiful!) as she makes her way up the road

The view from our living room with the hospital among the trees, and the view of the Rift Valley obscured by rain.

We work in the pathology department of a large, >100 year old mission hospital.  The department sees about 3,100 surgical pathology cases per year.  We are the only pathologists at the moment, so we take care of all that come in while we're here.  Volunteer pathologists like us do what we can, but even on a good year, only 60-70% of the time is covered.

Histology.  Tissue processor in the right-hand corner.

Workspace.  Microscopes are covered.  Functional chairs:  optional.   Can of Tab:  MANDATORY.

Pathology is at the end of a busy hallway adjacent to the radiology suite and the clinical lab, and oh yeah, the urinal.  Oh well, at least we have some natural light.

Histotechs working on the day's slides.

One thing has been a clear and welcome difference from Seattle:  a slower and more laid-back pace of life.  While this requires patience for those of us who are accustomed to life in the US, going slowly and deliberately, or pole pole as they say in Swahili, is a way of life that leads to a palpable and infectious feeling of relaxed happiness.  I've been thoroughly enjoying myself  :)

This T shirt pretty much sums it up!