Ankur Sinha

Severe Pulmonary Hypertension Due to Adult-Onset Still’s Disease

A 29-year-old female with adult-onset Still’s disease (AOSD) presented with progressive shortness of breath both on rest and on exertion, increased abdominal girth, and swelling in both legs. She was on oral prednisone and was recently started on canakinumab (interleukin-1 antagonist) for joint pain and rash of AOSD. Echocardiogram showed severely dilated right ventricle, dilated pulmonary artery, moderately reduced right ventricular systolic function, but with normal left ventricular systolic function. Computed tomography with contrast ruled out pulmonary embolism. Blood tests ruled out other rheumatologic diseases. The patient was diagnosed with right-sided heart failure likely secondary to AOSD. Right heart catheterization was needed but could not be performed because of severely dilated pulmonary artery. The patient was transferred to a higher center for further management and possible cardiopulmonary transplant.

Mixed Adenoneuroendocrine Carcinoma of the Gastroesophageal Junction: A Rare Find

Neoplastic lesions that demonstrate neuroendocrine features are rare. However, esophageal tumors containing both adenocarcinomatous and neuroendocrine components are exceedingly rare. Mixed adenoneuroendocrine carcinomas (MANECs) are gastrointestinal tumors with both adenocarcinomatous and neuroendocrine differentiation. They have a tendency for early metastases but clinically manifest relatively late. Imaging studies are often nonspecific with regard to tumor type, and a histopathologic study of biopsy material is required for definitive diagnosis. The overall prognosis is poor. The current report describes a rare case of gastroesophageal MANEC tumor, with approximately 60% neuroendocrine and 40% adenocarcinomatous components. Since there is a dearth of concrete management guidelines for MANECs, we present possible management options to add to the existing literature.

Cryptococcal meningitis masquerading as normal pressure hydrocephalus in an immune-competent adult

We report a case of acute cryptococcal meningitis (CM) masquerading as normal pressure hydrocephalus (NPH) in an immune-competent female. An 85-year-old human immunodeficiency virus-negative female presented to the emergency room for altered mental status and difficulty walking. She was increasingly lethargic, with urinary incontinence and gait instability. A previous computed tomography was reported to have ventricular dilatation out of proportion to the degree of cortical atrophy. Magnetic resonance scan of the brain revealed ventricular dilatation and subtle debris layering the occipital horns of the lateral ventricles. A working diagnosis of NPH had been made considering the clinical symptoms and imaging. She became febrile to 103°F. Lumbar puncture was then performed which showed increased protein, decreased glucose, and mononuclear pleocytosis. India ink preparation of the cerebrospinal fluid was positive for Cryptococcus along with a positive cryptococcal antigen test. The patient was started on treatment for CM, but the patient continued to deteriorate further and died on the same day. Blood cultures subsequently grew Cryptococcus neoformans as well.

Adult Onset Dysphagia: Right Sided Aortic Arch, Ductus Diverticulum, and Retroesophageal Ligamentum Arteriosum Comprising an Obstructing Vascular Ring

A 49-year-old African American male patient with no past medical history was admitted because of 3 months of difficulty swallowing solid and liquid foods. He had constant retrosternal discomfort and appeared malnourished. The chest radiograph revealed a right sided aortic arch with tracheal deviation to the left. A swallow study confirmed a fixed esophageal narrowing at the level of T6. Contrast enhanced Computed Tomography (CT) angiogram of the chest and neck revealed a mirror image right aortic arch with a left sided cardiac apex and a prominent ductus diverticulum (measuring 1.7 × 1.8 cm). This structure extended posterior to and indented the mid esophagus. A left posterolateral thoracotomy was performed and the ductus diverticulum was resected. A retroesophageal ligamentum arteriosum was found during surgery and divided. This rare combination of congenital anatomical aberrations led to severe dysphagia in our patient. Successful surgical correction in the form of resection of the ductus diverticulum and division of the retroesophageal ligamentum arteriosum led to complete resolution of our patients symptoms.

Very Severe Aplastic Anemia During Treatment With Doxycycline.

To the Editor:CASE REPORTA 42-year-old male presented to the emergency department with 3 weeks history of fatigue and epistaxis. On initial blood work, he was found to have pancytopenia with hemoglobin of 4.7 g/dL, platelet count of 4000, and absolute neutrophil count of 160. He has no significant f

Electrocardiogram Changes with Acute Alcohol Intoxication: A Systematic Review

Background: Acute alcohol intoxication has been associated with cardiac arrhythmias but the electrocardiogram (ECG) changes associated with acute alcohol intoxication are not well defined in the literature. Objective: Highlight the best evidence regarding the ECG changes associated with acute alcohol intoxication in otherwise healthy patients and the pathophysiology of the changes. Methods: A literature search was carried out; 4 studies relating to ECG changes with acute alcohol intoxication were included in this review. Results: Of the total 141 patients included in the review, 90 (63.8%) patients had P-wave prolongation, 80 (56%) patients had QTc prolongation, 19 (13.5%) patients developed T-wave abnormalities, 10 (7%) patients had QRS complex prolongation, 3 (2.12%) patients developed ST-segment depressions. Conclusion: The most common ECG changes associated with acute alcohol intoxication are (in decreasing order of frequency) P-wave and QTc prolongation, followed by T-wave abnormalities and QRS complex prolongation. Mostly, these changes are completely reversible.

A Diagnostic Surprise: Primary Hodgkin’s Lymphoma of the Lung:

An 81-year-old male presented to the emergency room with a 3-month history of progressive shortness of breath, productive cough with white sputum, and generalized weakness with 10-pound weight loss in 2 months. On presentation, the patient was afebrile, with blood pressure of 93/55 mm Hg and oxy-hemoglobin saturation of 92% on 2 liters of oxygen via nasal cannula. Complete blood count with differential was significant for white count of 12 400/mL. Brain natriuretic peptide level was 454 ng/mL. Postero-anterior chest radiograph showed multiple round opacities in the lung fields. Computed tomography scan of the chest confirmed multiple round densities in both the lung fields along with mild mediastinal lymphadenopathy. Core needle biopsy was performed. Immunohistochemical stains were positive for CD30 and CD15 in a population of large atypical cells amid a background of CD3-positive nonneoplastic cells. These results were in support of the diagnosis of classical Hodgkin’s lymphoma of the lung with histological appearance confirming nodular sclerosis type. The patient was started on chemotherapy but was readmitted in 20 days for acute respiratory distress and suffered cardiac arrest and subsequently died. This case highlights the fact that although primary pulmonary Hodgkin’s lymphoma of the lung is a rare entity, it should be thought of as a differential while evaluating lung masses. In these cases, definite diagnosis can only be made by biopsy and histology. Early commencement of chemotherapy and regular follow-up with oncology is essential.

The Giant Rheumatoid Nodule: A Case Report

Rheumatoid arthritis is one of the most common debilitating rheumatological disorders. A subcutaneous rheumatoid nodule usually occurs in advanced cases of rheumatoid arthritis and is also a hallmark of the chronicity of the disease. They are also the most common extra-articular manifestation of rheumatoid arthritis. We present a case of a giant rheumatoid nodule, developed on the left elbow.