Background: Mucormycosis is a rare fatal infection caused by a ubiquitous fungus from the order of Mucorales, which can have varying clinical presentations. Immunocompromised patients are particularly susceptible to mucormycosis and can suffer fatal consequences if not treated adequately. COVID-19 infection with its immunomodulatory properties has been associated with a wide range of secondary bacterial and fungal infections. We present a case of rapidly progressive rhinocerebral mucormycosis post-COVID-19 infection with the subsequent development of several complications associated with the disease. Case Report: A 62-year-old male patient with a history of hypertension and diabetes mellitus type II, presented 14 days post-COVID-19 recovery with right facial swelling, erythema, and right eye proptosis. Throughout his disease, the patient developed blindness and cranial nerve palsies. He was also found to have palatal necrotic lesions, consistent with the diagnosis of mucormycosis. The patient’s disease was complicated by Garcin syndrome, meningitis, orbital apex syndrome, cavernous sinus thrombosis, brain infarction, and hemorrhage. Despite all measures and interventions, the patient died. Conclusion: COVID-19 infection and its treatments are associated with an increased risk of secondary fungal infections like mucormycosis. As such, a high index of suspicion is needed amongst healthcare workers for the early diagnosis and treatment of such opportunistic infections since prompt treatment is associated with a marked improvement in outcome. Furthermore, optimal glucose control and judicious use of corticosteroids in COVID-19 patients decreases the risk of developping such life threatening superinfections.
Deparaffinization of formalin-fixed paraffin embedded (FFPE) tissues with xylene currently remains a major challenge to the biomedical community. We developed an efficient xylene-free protocol to isolate proteins from archived FFPE human tissue sections. A total of 79 different types of FFPE tissue sections of 8 µm thickness were obtained from various archived FFPE specimens. Deparaffinization was conducted by gently washing each section with around 1 ml of hot distilled water (≈80°C). The deparaffinized tissues were homogenized in lysis buffer, and the isolated proteins were quantified and efficiently resolved using western blot analysis for the presence of Protein kinase B (PKB/AKT) and β-actin. Moreover, a significant amount of proteins was successfully isolated with an average of 2.31 µg/µl. The migration pattern of AKT and β-actin obtained from the specimens was similar to the positive control obtained from protein lysates prepared from in vitro cultured MDA231 cancer cell lines. AKT was successfully identified in all specimens, and β-actin protein was resolved with an efficiency higher than 80%. The entire extraction procedure requires only 20 minutes. This newly developed technique is an efficient, safe, cost-effective, and rapid method to isolate proteins from FFPE tissue sections adequate for molecular analysis.
Background: Pilonidal sinus rarely affects the penis. This disease is only discussed in case reports, around 26 cases in the literature, and never in textbooks or guidelines. Along with the scarce data in the literature, most of the reported cases were managed differently, and the diagnosis, which could only be confirmed with specimen histopathology, was delayed. Besides the case report of a rare penile disease, the purpose of this paper is to suggest a management plan for suppurative penile lesions to avoid delay in diagnosis and treatment. Case Report: We encountered a case of penile pilonidal sinus that was initially treated as an abscess based on an ultrasound result. The quick relapse and the suspicious second ultrasound of a hair-like septum in the lesion led to excision and histopathologic confirmation. Penile swelling in patients with a history of Papaverine or any vasoactive drugs injections, trauma, penile prosthesis, diabetes mellitus, intra-abdominal abscess, Tuberculosis, intravenous drug abuse, systemic symptoms, and signs of infection should be managed as an abscess; drainage, appropriate antibiotherapy, and management of risk factors and causes. Discussion: The usual clinical presentation of pilonidal disease of the penis consists of tender penile swelling, dyspareunia, and purulent discharge, as well as erectile dysfunction which was reported in only one case. In contrast to penile abscess, the presentation usually includes a tender penile swelling, and systemic symptoms such as fever, chills, and night sweats. Physical examination of this patient revealed a non-specific tender, pus-pointing, and pus-containing lesion with mildly erythematous edges, located near the coronal sulcus Conclusion: Pilonidal cyst of the penis is a rare disease with delayed management in the literature because of misdiagnosis caused by confusion with penile abscess. Though ultrasound could narrow the differential diagnosis, the clinical presentation remains the cornerstone in differentiating between penile abscess and pilonidal sinus.
Composite lymphoma is a rare entity of lymphoma where two types of lymphoma are present synchronously. We recently encountered two cases of composite lymphomas that are not rare in the morphology and pathology only, but also rare in the site of involvement and presentation. In this report we present a case of composite lymphoma that presented as primary splenic lymphoma, the second case presented with GI symptoms due to its presence in the colon.
Mantle cell lymphoma (MCL) is a rare subtype of B-cell non-Hodgkin lymphoma (NHL) with an annual incidence of 5 per million people. Ophthalmic lymphoma is also rare, accounting for 5%–10% of all extranodal NHL.1 Primary involvement of ocular adnexa constitutes 8% of all nondisseminated NHL of extranodal origin.2 According to the largest study published of 353 cases of ocular adnexal lymphomas, mantle cell lymphoma is rare and comprises only 5% of ocular adnexal lymphomas (32% bilateral and 63% with prior lymphoma).3 Furthermore, intraocular involvement of MCL is extremely rare.4 We report a case of a 70-year-old man with a history of mantle cell lymphoma in relapse who presented with conjunctival and choroidal involvement. A 70-year-old man with a history of systemic mantle cell lymphoma in relapse presented with acute redness, blurry vision, and black spot in the right eye. No pain was reported. He was being treated for his mantle cell lymphoma with a new regimen of chemotherapy (Ibrutinib + rituximab) and had undergone a bone marrow transplant 1 year before presentation with a relapse 20 days later. His history goes back to 7 years before presentation when his MCL was diagnosed and remission achieved with R-Hyper-CVAD/cytarabine/MTX chemoimmunotherapy regimen, which employs rituximab, hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone, alternating with high-dose methotrexate and cytarabine. However, the patient relapsed 6 years later and was treated with the chemoimmunotherapy regimen (R-ICE), which combines rituximan, ifosfamide, carboplatin, and etoposide phosphate, followed by autologous hematopoietic cell transplantation (auto-HCT), but he relapsed 20 days post auto-HCT. The patient was subsequently treated with ibrutinib + rituximab. On examination, his visual acuity was counting fingers at 2 m in the right eye and 20/25 in the left. Ocular motility and intraocular pressures were normal. Hertel exophthalmometry measurements were within normal limits. Ectropion was noted in both eyes. Slit lamp examination of the right eye showed 2 pink salmon-patch lesions 15 × 10 mm and 25 × 10 mm in size involving the inferotemporal and the superonasal aspect of the conjunctiva, respectively (Fig. 1). There was a white pseudohypopyon and +3 cells in the anterior chamber.Figure 1.: Clinical photographs and B-scan ultrasound images of the right eye at diagnosis (A–C) and posttreatment (D and E). (A), 15 × 10 mm lesion of the inferotemporal conjunctiva. (B), 25 × 10 mm lesion of the superonasal conjunctiva. (C), B-scan Ultrasound shows a choroidal mass (double arrows) with serous retinal detachment (arrow). (D), Clinical image shows resolution of the conjunctival lesions 2 weeks posttreatment. (E), B-scan Ultrasound 2 weeks posttreatment shows resolution of choroidal mass with residual retinal detachment.Dilated fundus exam revealed a subretinal mass with serous retinal detachment. B-scan showed a choroidal lesion (Fig. 1). An magnetic resonance imaging of the brain and orbits showed posterior retinal detachment of the right eye with irregular thickening of the choroid anteriorly with homogenous enhancement. There were no orbital lesions. The patient was scheduled for conjunctival biopsy and an anterior chamber tap. The cytological examination of the conjunctival biopsy touch prints revealed the presence of numerous atypical lymphoid cells showing mostly medium to slightly large size cells with frequently increased nucleocytoplasmic ratios. Nuclei were round or partially clefted and contained relatively open chromatin with occasionally small nucleoli. The cytoplasm was scanty and basophilic with no granules or Auer rods seen. Conjunctival biopsy showed diffuse proliferation of medium sized lymphoid cells occupying extensively the lamina propria. They stained positive for CD5, Cyclin D1, Pax5, CD20, and BCL2; and negative for TDT and CD34. K167 staining was extremely positive (Fig. 2). The immunophenotypic analysis of 100,000 acquired events from conjunctival lesion and anterior chamber cells showed results that were comparable within the 2 analyzed samples. T lymphoid cells represented almost 20% of the total nucleated cells and expressed all the tested pan T-cell markers (CD3, CD5, and CD7). B lymphoid cells were significantly increased representing 70%–80% of the total counted nucleated cells. They were monoclonal and expressed mostly the following immunophenotype: CD5+, CD10−, CD19 (dim), CD20++, CD22+, CD23−, CD34−, CD45+, CD79b+, CD200−, LAMBDA+ (Fig. 2). The findings were consistent with ocular infiltration by mantle cell lymphoma showing immunophenotypic features comparable to those previously described at diagnosis from bone marrow aspirate 7 years before this presentation except for a significantly decreased intensity of CD19 expression. The patient was also referred back to oncology for management of systemic condition.Figure 2.: Conjunctival biopsy (A–C) and Immunophenotyping (D) of lymphoma cells. (A), hematoxylin and eosin (H&E) staining (20×). (B), Cyclin D1 by immunostaining (20×). (C), Pax5 by immunostaining (20×). (D), Immunophenotyping of lymphoma cells (population in red) by flow cytometry as performed on ocular fluid showing CD5+, CD10−, CD19 (dim), CD20++, CD22+, CD23−, CD34−, CD45+, CD79b+, CD200−, LAMBDA+.The chemotherapy regimen was changed to ibrutinib, rituximab, gemzar, oxaliplatin, and dexamethasone. On follow-up, 2 weeks later, visual acuity was improved markedly to 20/25 in the right eye. On slit lamp examination, the conjunctival lesions resolved completely, the pseudohypopyon was reduced, and the anterior chamber cells decreased to +1. Dilated examination showed only mild subretinal fluid inferiorly with no mass. B-scan done confirmed mild subretinal fluid inferiorly and resolved choroidal mass. On follow-up, 2 weeks later, the findings were rather stable except for complete absence of anterior chamber cells and almost totally resolved pseudohypopyon. Dilated fundus examination and B-scan showed no tumor recurrence and decreased subretinal fluid inferiorly. The patient passed away few months after the last follow-up. As the patient was lost to follow up, the reason of death remained unknown. Our patient presented with unilateral ocular adnexal lymphoma with involvement of the conjunctiva by 2 separate lesions and was known to have mantle cell lymphoma in relapse. In addition, he had intraocular lesions involving the choroid and anterior segment. Lymphoma can present in the eye and orbit as 2 forms: primary lymphoma or secondary extension of a known primary lymphoma.5 Therefore, our patient represents a rare case of secondary ocular and ocular adnexal lymphoma of the mantle cell type. Intraocular involvement with MCL is extremely rare with only 7 case reports in the literature (Table 1).6 Although involvement of the ocular adnexal region (OAR) with MCL is more common in secondary (63%) compared to primary (37%) disease,3 involvement of the intraocular region appears to be almost always associated with a prior history of systemic disease. Rowley et al7 reported the only case of primary intraocular MCL presenting as a choroidal mass. The remaining 6 reports described secondary ocular involvement; however, none of the cases consisted of unilateral ocular and adnexal involvement like our case. To the best of our knowledge, our case is unique as it is the first to involve unilaterally the choroidal and adnexal regions simultaneously. Table 1 - Mantle Cell Lymphoma With Intraocular Involvement. Authors, (Year) Sex/Age Primary/Secondary Ocular and Adnexal Involvement Cytologic Features Treatment after Ocular Involvement Time to Respond + Status Reid et al. (2014)5 M/71 y Secondary Left eye iris Not reported Chemo/XRT Improved 90 days later. Worsened 120 d post chemo/XRT. Died 2 wks after last examination Agarwal et al. (2015)6 M/58 y Secondary Right iris and anterior chamber Blastic variant Systemic Ibrutinib and intravitreal injections of MTX, ranibizumab, and Rituximab. Ibrutinib therapy tapered after 3 mo due to concern of side effects Partial Remission at 1 wk and 3 mo Rowley et al. (2000)7 M/57 y Primary Left choroidal mass Small lymphocytes, convoluted nuclei, single nucleolus EBRT 34 Gy No disease recurrence 34 mo after EBRT Ahn et al. (2010)12 M/57 y Secondary Bilateral choroidal involvement Not reported Dexamethasone + EBRT 2000 cGy (200 cGy × 10 fractions) + Bortezomib for systemic involvement Almost complete regression of ocular disease 2 wks after treatment but progression of systemic adenopathy Chappelow et al. (2008)13 F/51 y Secondary Bilateral pan ocular involvementa Not reported Prednisone. EBRT 14 Gy (2 Gy × 7 fractions) + Tositumomab started 1 wk later for widespread cutaneous involvement Bilateral resolution of ocular disease 1 wk after EBRT initiation. Ocular examination unremarkable 7 wks after presentation Economou et al. (2007)14 M/71 y Secondary Bilateral iris Polygonal lymphoid cells Fludarabine + cytosine arabinoside achieved partial regression in 2.5 mo. One month later, right iris recurrence was treated with Rituximab + EBRT 100 Gy (20 Gy × 5 fractions) Complete resolution of ocular involvement 7.5 mo after initial ocular presentation. Paratracheal involvement 12 mo after initial ocular presentation led to death from bilateral pneumonia 4 mo later Pei et al. (2019)15 M/59 y Secondary Bilateral ciliary body masses Small malignant cells EBRT 40 Gy (2 Gy × 20 fractions) bilaterally + intravitreal MTX in left eye Complete remission of symptoms in 1 mo. Disappearance of ciliary body masses in 12 mo. Relapsed 29 mo after EBRT with peripheral LN involvement and rapid deterioration. Death 1 mo later from chemo side effects Our case M/70 y Secondary Right uvea and conjunctiva Blastic variant Ibrutinib + Gemcitabine + Oxaliplatin + Dexamethasone + Rituximab Complete resolution of ocular lesions 2 wks after treatment. Patient passed away few months later (unknown cause of death) aCutaneous eyelid nodules bilaterally; salmon patch of right bulbar conjunctiva; Pseudohypopyon, iris thickening, vitreous infiltration bilaterally.Chemo/XRT = chemotherapy/radiotherapy; EBRT = external beam radiation therapy; LN = lymph node; MTX = methotrexate. MCL is classified into 4 subgroups or variants based on the cytology: small cell, marginal zone-like, pleomorphic, and blastoid. The blastoid and pleomorphic variants behave more aggressively than other MCL variants.8 Median overall survival time is 14.5 months for the rare blastoid variant as compared to 53 months for patients with more common forms of MCL such as those composed of homogeneous population of small- to medium-sized cells, confirming the very poor prognosis of the blastoid variant.9 Our patient cytological examination showed atypical lymphoid cells consistent with blastoid variant with medium to slightly large sized cells and frequently increased nucleocytoplasmic ratios. Our patient relative prolonged survival (7 y) can be partly explained by the addition of rituximab to his chemotherapy regimen. The leukemic cells from the anterior chamber tap and ocular lesions had decreased CD19 antigen expression as compared to those from the bone marrow aspirate. This finding can be due to the effect of the ocular medium on these cells. Many treatment regimens have been evaluated for recurrent MCL with various success rates. There is no clear consensus on the optimal treatment regimen for MCL. Also, several studies reported different responses to treatment of recurrent MCL with ocular and OAR involvement (Table 1). In general, treatment of localized OAL is with external beam radiotherapy (EBRT), while systemic disease is treated with chemoimmunotherapy with or without EBRT. EBRT is the gold standard treatment in isolated conjunctival lymphoma with 5-year local control rates ranging from 89% to 100%. The optimal dosing of EBRT is unclear but doses higher than 35 Gy exacerbated post-treatment toxicity and morbidity while low, fractionated doses alleviated it.10 Combining chemotherapy with rituximab for stage IVE MCL is superior to chemotherapy alone with better 10-year disease-specific survival.11 Our patient with systemic involvement of MCL was treated with a chemoimmunotherapy-based regimen including iburtinib, rituximab, gemzar, oxaliplatin and dexamethasone. Our patient’s median survival in relation to initial diagnosis of his systemic disease was favorable when compared with studies that employed regimens without rituximab,9 which might be due to the efficacy of this molecule in treating MCL. In summary, this case presents an extremely rare example of secondary ophthalmic MCL unilaterally involving the conjunctiva and the choroid. Although more studies are needed to establish best management options, early diagnosis with tissue biopsy and a combination of chemoimmunotherapy appears to be effective for secondary ocular and ocular adnexal MCL. The immunophenotypic study of both ocular and peripheral leukemic cells is important, especially when immunotherapy is planned. More studies of ocular and adnexal MCL are needed to better characterize its clinical behavior and to enable meaningful conclusions regarding treatment response. Disclosures The authors have no conflicts of interest to disclose
Background: Mature teratomas are common tumors in the pediatric population. They can arise in the central nervous system and often require surgical resection. They are classified as non-germinomatous germ cell tumors and their recurrence are extremely rare. Case Presentation: We are reporting the case of a 6-year-old boy who was diagnosed with mature pineal teratoma after he presented with signs of acute hydrocephalus. Histopathology did not reveal any other germ cell tumor component. He underwent a complete resection of the mass, with no adjuvant chemotherapy. Nine years post-operatively, magnetic resonance imaging results showed recurrence of the pineal tumor as a germinoma. Chemotherapy and radiotherapy resulted in significant shrinkage of the mass and resolution of the clinical symptoms. Conclusion: This case illustrates the possibility of the late recurrence of a germinoma after the complete removal of a mature intracranial teratoma. It also raises the issue of whether mature teratomas should be treated with adjuvant therapy after surgical resection to prevent their recurrence as another germ cell tumor.
Gestational trophoblastic neoplasms (GTNs) encompass a wide spectrum of diseases, of which choriocarcinoma is one of the most common. Choriocarcinoma occurs mainly in relation to pregnancy and rarely after the menopause. It has the potential to metastasize to organs other than the uterus.We describe a 62-year-old woman who presented with postmenopausal bleeding 11 years after the menopause. Pelvic ultrasound and abdominal/pelvic computerized tomography showed an intrauterine mass. Choriocarcinoma was diagnosed by Pipelle endometrial biopsy with positive staining for beta-human chorionic gonadotropin (hCG) and KI 67 along with an elevated serum beta-hCG level. The tumor was managed with multiple cycles of multidrug chemotherapy and follow-up based on serum beta-hCG levels according to the guidelines of the International Federation of Gynecology and Obstetrics (FIGO).This case report highlights that choriocarcinoma, a tumor normally associated with pregnancy, can present after the menopause.
Protein detection methods in formalin-fixed paraffin embedded (FFPE) tissue blocks are widely used in research and clinical setting in order to diagnose or to confirm a diagnosis of various types of diseases. Therefore, multiple protein extraction methods from FFPE tissue sections have been developed in this regard. However, the yield and the quality of proteins extracted from FFPE tissues are significantly reduced in blocks stored for longer periods of time. Regardless the protein extraction method used, tissue sections must be first deparaffinized with xylene, and then washed in serial dilutions of ethanol in order to remove the toxic organic solvent "xylene" and rehydrate the tissue. The objective of this study was first to develop a method to deparaffinize FFPE blocks that excludes the use of toxic solvent "xylene". Second minimize the time required to perform the extraction. Here we describe a method where:•The entire paraffin embedded blocks are deparaffinized and rehydrated using only hot distilled water as a substitute for both xylene and ethanol•The entire procedure takes about 15 min•Deparaffinized blocks are immediately homogenized in lysis buffer, and the obtained lysate analyzed by Western blot. With this new modified technique, we were able to successfully detect actin and AKT proteins in lysates from blocks embedded in paraffin for up to 9 years.
Abstract Background: Formalin fixed paraffin embedded (FFPE) tissues remains the standard method for fixation and storage of tissues for clinical pathology use. Protein extraction from these tissues remains challenging due to the reduced quality and amount of extracted proteins. Despite multiple successful attempts, isolation of proteins from FFPE tissue sections necessitates routine use of xylene, a highly toxic organic solvent. We previously showed that proteins can be efficiently extracted with a novel technique that utilizes hot distilled water as a substitute for xylene with a quality adequate for western blot analysis. However, its major drawback is the need to use an entire or major part of the paraffin-embedded tissue block. To address these issues we developed a new xylene-free method for protein extraction from FFPE tissue sections of around 8 μm thickness. Methods: A total of 44 different types of FFPE tissues sections of 8 μm thickness were obtained from various archived FFPE specimens which include: 17 colorectal cancer (5-6 years), 7 breast cancer (3 years), 3 thyroid cancer (2 years), 4 ovarian cancer (2 years), 8 uterine cancer (1 year), and 5 prostate cancer (1 year). Deparaffinization was conducted by gentle treatment of each section with hot distilled water (≈90°C) for less than 10 seconds. Deparaffinized tissues were then placed in a cell lysis buffer and Laemli buffer and incubated at 100°C for 5-10 minutes. The extracted proteins were quantified using NanoDrop Spectrophotometer and evaluated using western blot analysis for the presence of AKT and beta-actin. Results: Using this method, a significant amount of proteins was successfully isolated with an average amount of 2.670 μg/μl ± 0.623 or 1068 μg/8 μm tissue section. Compared to the standard protein extraction method using xylene the amount of proteins extracted in this experiment is at least four times greater. Protein extracts were of good quality and efficiently analyzed by western blot experiment. Moreover, the isolated proteins showed a similar migration pattern compared to the positive control protein on SDS-PAGE but with better bands’ intensity and clarity. Protein kinase B (PKB/AKT) was successfully identified in all specimens, and beta-actin protein was resolved with an efficiency higher than 80%. Hence, this technique has enabled us to efficiently extract and detect selected proteins from archived samples for up to 6 years. Conclusion: We developed an efficient, safe, cost-effective, and rapid method to isolate proteins from FFPE tissues sections and adequate for western blot analysis. Hence, utilizing this technique can further aid in the identification of tissue protein biomarkers of various diseases, monitor cancer progression, and improve the diagnosis. It remains to be determined if this method of protein extraction form FFPE is adequate for use in proteomic analyses. Citation Format: Anthony Mansour, Noha Bejjani, Carole Dagher, Rajaa Chatila, Wissam H. Faour. Optimized xylene-free protein extraction method from formalin-fixed paraffin-embedded tissue sections for western blot analysis. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr LB-288. doi:10.1158/1538-7445.AM2015-LB-288
'/%3e%3cpath id='l' d='M-26.25 0h52.5v-12h-40.5v-16h33v-12h-33v-11H25v-12h-51.25z'/%3e%3cpath id='k' d='M-31.5 0h12v-48l14 48h11l14-48V0h12v-70H14L0-22l-14-48h-17.5z'/%3e%3cpath id='b' fill-rule='evenodd' d='M0 0a31.5 35 0 0 0 0-70A31.5 35 0 0 0 0 0m0-13a18.5 22 0 0 0 0-44 18.5 22 0 0 0 0 44'/%3e%3cpath id='d' fill-rule='evenodd' d='M-31.5 0h13v-26h28a22 22 0 0 0 0-44h-40zm13-39h27a9 9 0 0 0 0-18h-27z'/%3e%3cpath id='n' d='M-15.75-22C-15.75-15-9-11.5 1-11.5s14.74-3.25 14.75-7.75c0-14.25-46.75-5.25-46.5-30.25C-30.5-71-6-70 3-70s26 4 25.75 21.25H13.5c0-7.5-7-10.25-15-10.25-7.75 0-13.25 1.25-13.25 8.5-.25 11.75 46.25 4 46.25 28.75C31.5-3.5 13.5 0 0 0c-11.5 0-31.55-4.5-31.5-22z'/%3e%3cuse xlink:href='%23a' id='o' transform='scale(31.5)'/%3e%3cuse xlink:href='%23a' id='p' transform='scale(26.25)'/%3e%3cuse xlink:href='%23a' id='r' transform='scale(21)'/%3e%3cuse xlink:href='%23a' id='q' transform='scale(15)'/%3e%3cuse xlink:href='%23a' id='s' transform='scale(10.5)'/%3e%3cg id='m'%3e%3cclipPath id='c'%3e%3cpath d='M-31.5 0v-70h63V0zM0-47v12h31.5v-12z'/%3e%3c/clipPath%3e%3cuse xlink:href='%23b' clip-path='url(%23c)'/%3e%3cpath d='M5-35h26.5v10H5z'/%3e%3cpath d='M21.5-35h10V0h-10z'/%3e%3c/g%3e%3cg id='h'%3e%3cuse xlink:href='%23d'/%3e%3cpath d='M28 0c0-10 0-32-15-32H-6c22 0 22 22 22 32'/%3e%3c/g%3e%3cg id='a' fill='%23fff'%3e%3cg id='f'%3e%3cpath id='e' d='M0-1v1h.5' transform='rotate(18 0 -1)'/%3e%3cuse xlink:href='%23e' transform='scale(-1 1)'/%3e%3c/g%3e%3cuse xlink:href='%23f' transform='rotate(72)'/%3e%3cuse xlink:href='%23f' transform='rotate(-72)'/%3e%3cuse xlink:href='%23f' transform='rotate(144)'/%3e%3cuse xlink:href='%23f' transform='rotate(216)'/%3e%3c/g%3e%3c/defs%3e%3crect width='100%25' height='100%25' x='-50%25' y='-50%25' fill='%23009b3a'/%3e%3cpath fill='%23fedf00' d='M-1743 0 0 1113 1743 0 0-1113z'/%3e%3ccircle r='735' fill='%23002776'/%3e%3cclipPath id='g'%3e%3ccircle r='735'/%3e%3c/clipPath%3e%3cpath fill='%23fff' d='M-2205 1470a1785 1785 0 0 1 3570 0h-105a1680 1680 0 1 0-3360 0z' clip-path='url(%23g)'/%3e%3cg fill='%23009b3a' transform='translate(-420 1470)'%3e%3cuse xlink:href='%23b' y='-1697.5' transform='rotate(-7)'/%3e%3cuse xlink:href='%23h' y='-1697.5' transform='rotate(-4)'/%3e%3cuse xlink:href='%23i' y='-1697.5' transform='rotate(-1)'/%3e%3cuse xlink:href='%23j' y='-1697.5' transform='rotate(2)'/%3e%3cuse xlink:href='%23k' y='-1697.5' transform='rotate(5)'/%3e%3cuse xlink:href='%23l' y='-1697.5' transform='rotate(9.75)'/%3e%3cuse xlink:href='%23d' y='-1697.5' transform='rotate(14.5)'/%3e%3cuse xlink:href='%23h' y='-1697.5' transform='rotate(17.5)'/%3e%3cuse xlink:href='%23b' y='-1697.5' transform='rotate(20.5)'/%3e%3cuse xlink:href='%23m' y='-1697.5' transform='rotate(23.5)'/%3e%3cuse xlink:href='%23h' y='-1697.5' transform='rotate(26.5)'/%3e%3cuse xlink:href='%23j' y='-1697.5' transform='rotate(29.5)'/%3e%3cuse xlink:href='%23n' y='-1697.5' transform='rotate(32.5)'/%3e%3cuse xlink:href='%23n' y='-1697.5' transform='rotate(35.5)'/%3e%3cuse xlink:href='%23b' y='-1697.5' transform='rotate(38.5)'/%3e%3c/g%3e%3cuse xlink:href='%23o' x='-600' y='-132'/%3e%3cuse xlink:href='%23o' x='-535' y='177'/%3e%3cuse xlink:href='%23p' x='-625' y='243'/%3e%3cuse xlink:href='%23q' x='-463' y='132'/%3e%3cuse xlink:href='%23p' x='-382' y='250'/%3e%3cuse xlink:href='%23r' x='-404' y='323'/%3e%3cuse xlink:href='%23o' x='228' y='-228'/%3e%3cuse xlink:href='%23o' x='515' y='258'/%3e%3cuse xlink:href='%23r' x='617' y='265'/%3e%3cuse xlink:href='%23p' x='545' y='323'/%3e%3cuse xlink:href='%23p' x='368' y='477'/%3e%3cuse xlink:href='%23r' x='367' y='551'/%3e%3cuse xlink:href='%23r' x='441' y='419'/%3e%3cuse xlink:href='%23p' x='500' y='382'/%3e%3cuse xlink:href='%23r' x='365' y='405'/%3e%3cuse xlink:href='%23p' x='-280' y='30'/%3e%3cuse xlink:href='%23r' x='200' y='-37'/%3e%3cuse xlink:href='%23o' y='330'/%3e%3cuse xlink:href='%23p' x='85' y='184'/%3e%3cuse xlink:href='%23p' y='118'/%3e%3cuse xlink:href='%23r' x='-74' y='184'/%3e%3cuse xlink:href='%23q' x='-37' y='235'/%3e%3cuse xlink:href='%23p' x='220' y='495'/%3e%3cuse xlink:href='%23r' x='283' y='430'/%3e%3cuse xlink:href='%23r' x='162' y='412'/%3e%3cuse xlink:href='%23o' x='-295' y='390'/%3e%3cuse xlink:href='%23s' y='575'/%3e%3c/svg%3e)