Amarinder Singh Garcha

Recurrent renal cell cancer presenting as gastrointestinal bleed

We present an unusual case of renal cell cancer (RCC) which relapsed with duodenal metastasis and unveiled itself by gastrointestinal (GI) bleeding. An 80-year old Caucasian gentleman with history of renal cell cancer status post nephrectomy 11 mo previously, presented with syncope and melena. Computed tomography scan of the abdomen revealed heterogeneous soft tissue mass in the right nephrectomy bed invading the duodenum. Upper GI endoscopic biopsy confirmed the presence of recurrent renal cell cancer. However, due to extensive metastatic disease, the patient was placed on palliative chemotherapy as surgical options were ruled out. Our case report reiterates the fact that renal cell carcinoma can recur with gastrointestinal manifestations and, although a rarity, it should be considered in a patient with a history of malignancy who presents with these symptoms.

Diabetic ketoacidosis complicated by generalized venous thrombosis: a case report and review.

Venous thromboembolism is a rarely described complication of diabetic ketoacidosis (DKA). We describe a 21-year-old male patient with poorly controlled type 1 diabetes mellitus who was admitted with DKA, presumably secondary to noncompliance, whose clinical picture was complicated by generalized thrombosis involving multiple venous locations including renal vein, pulmonary vasculature, external iliac and common iliac veins. The patient had no family history of any coagulation disorders and a hypercoagulabilty work-up remained negative. The patient was subsequently anticoagulated with heparin and discharged home on warfarin. To the best of our knowledge, this is the first reported case of multiple venous thromboses occurring as a complication of DKA with no other risk factors. We also reiterate that although rare, venous thrombosis should always be considered as a potential complication of DKA.

Hypercalcemia: An Unusual Manifestation of Uterine Leiomyoma

We present a case of hypercalcemia in a 79-year-old female likely secondary to uterine leiomyoma. To the best of our knowledge, hypercalcemia due to a benign tumor has only been described in five cases. Of these above five cases, uterine leiomyoma was thought to be the cause of hypercalcemia in three cases.

Thigh Abscess Caused by Yersinia enterocolitica in an Immunocompetent Host

Yersinia enterocolitica is primarily a gastrointestinal tract pathogen known to cause gastroenteritis, although it may produce extra-intestinal infections like sepsis and its sequelae. However, primary cutaneous infections are extremely rare. We present a case of Y. enterocolitica thigh abscess in an immunocompetent adult. The portal of entry is unclear in this case. He did many outdoor activities that involved skin injuries and exposure to soil and contaminated water. Hence, direct inoculation as a result of exposure to contaminated water is postulated in the absence of evidence for a gastrointestinal route of infection.

Review of Tolvaptan in the Treatment of Hyponatremia

Hyponatremia is a very common electrolyte disorder and is a significant independent predictor of medical prognosis and costs. Tolvaptan is a vasopressin receptor antagonist developed for the treatment of hyponatremia. It has its principal application in the treatment of euvolemic and hypervolemic hyponatremia. Its major role is in the treatment of heart failure (HF), cirrhosis and the syndrome of inappropriate antidiuretic hormone secretion (SIADH). While at present tolvaptan has not demonstrated long term survival benefit with its use, it clearly has proven short term efficacy in the management of hyponatremia by demonstrating improvement in serum sodium levels at an acceptable rate without evidence of over-correction.

Intravenous immunoglobulin-associated renal failure in a patient with post-transfusion purpura.

Intravenous immunoglobulin (IVIG), initially developed for immunodeficiency disorders, has now been used for multiple autoimmune diseases and infections. These are generally well tolerated, with few adverse effects. Acute kidney injury has been described in very rare instances. We report an interesting case of a 59-year-old African American male with a pertinent history of diabetes mellitus, hypertension, endocarditis, and peripheral vascular disease, who was diagnosed with post-transfusion purpura. He was then treated with IVIG and subsequently developed an acute worsening of renal function in a time span of 3 days. The etiology remained elusive even after an extensive workup. Renal biopsy was done finally, which showed findings suggestive of osmotic nephropathy that was traced to the sucrose used as a stabilizing agent in the IVIG. In light of the increasing use of IVIG, it is therefore highly recommended that clinicians are well aware of this side effect of IVIG.

Anticoagulant-resistant thrombophilia in a patient with polycythemia vera: a case report.

Mechanical valve thrombosis is a rare condition in an adequately anticoagulated patient in the absence of underlying thrombophilia. We report a case of a 76-year-old male with mechanical prosthetic mitral valve thrombosis as the presenting feature of polycythemia vera. The patient was treated with thrombolysis at the time of acute presentation and subsequently maintained on low molecular weight heparin, low-dose aspirin, phlebotomy and hydroxyurea. Hemoglobin, leucocytosis and platelet count were controlled for almost 4 years after which the patient suffered a second, fatal episode in the setting of therapeutic anti-Xa level. This case report highlights the thrombotic risks associated with polycythemia vera. The proposed mechanisms of hypercoagulability in polycythemia vera are reviewed. To the best of our knowledge, mechanical valve thromboses as the presenting feature of polycythemia vera has not been reported previously.

A 52-Year-Old Smoker With an Incidental Pulmonary Nodule

52-year-old man was referred to our institution for evaluation of a pulmonary nodule. The patient presented to his primary-care physician with worsening cough a month prior to the current presentation when a chest radiograph revealed a questionable nodule in the right upper lung. The patient underwent a CT scan of the chest with contrast, which confi rmed the presence of a 9-mm nodule in the right upper lung. The patient was referred for work-up of this pulmonary nodule. Review of symptoms was positive only for the presence of cough associated with mucoid expectoration for the past few months. The patient had no signifi cant medical history, was a smoker (35-pack-year smoking history), and currently smoked 5 cigarettes/d. He denied any contact with sick peo ple or pets, travel, or history of malignancy in his family.

Persistent Dyspnea in a 59-Year-Old Woman Receiving Immunosuppressants

59-year-old woman was admitted to our institution with worsening shortness of breath and fatigue. Eight months earlier, she had received a living donor kidney transplant. She had been doing well on immunosuppressants, which were azathioprine, sirolimus, prednisone, and sulfamethoxazole-trimethoprim; sirolimus was started 2 months prior to her current admission. Two weeks before this presentation, the patient was admitted for similar complaints with fever, and her condition was diagnosed as pneumonia and urinary tract infection complicated by gram-negative bacteremia. Subsequently, she was given meropenem and discharged with a 21-day prescription. Two weeks later, she presented to the transplant clinic with worsening fatigue and shortness of breath and was admitted. The patient’s medical history was signifi cant for hypertension, hyperlipidemia, and end-stage renal disease secondary to hemolytic uremic syndrome. She was a nonsmoker and denied a history of contact with sick persons, pets, or travel. There was no family history of malignancy.