Mashrafi Ahmed

Pyogenic liver abscess and the emergence of Klebsiella as an etiology: a retrospective study

Objectives Pyogenic liver abscess (PLA) is a significant, though uncommon, cause of morbidity in the United States. Recently, Klebsiella has emerged as an important cause of PLA. We analyzed the clinical course, microbiology, and treatment outcomes of patients discharged with PLA. In addition, we sought to examine the incidence of and risk factors for Klebsiella liver abscess (KLA). Methods We reviewed the charts of patients who discharged with PLA from two teaching hospitals in West Texas between January 1, 2007 and December 31, 2011. Results We identified 49 cases of PLA. Abscess cultures were positive in 23 (48%) patients. The mean age of the cohort was 56 years (range: 20–83 years). Sixty percent were male. The most frequent conditions associated with PLA were intra-abdominal infections (ten cases; 20%), diabetes mellitus (nine cases; 18%) and malignancy (nine cases; 18%). Klebsiella was the most commonly isolated species from the abscess cultures (seven cases; 30% of all positive abscess cultures). We used univariate and logistic regression analyses to identify the risk factors for KLA. Controlling for age, only malignancy was identified in our cohort as a risk factor for a Klebsiella liver abscess. The overall mortality was 2%. Conclusion Klebsiella is emerging as an important cause of liver abscesses. Malignancy may be an important risk factor for Klebsiella liver abscess.

Extramedullary plasmacytoma mimicking colon carcinoma: an unusual presentation and review of the literature

A 72-year-old woman presented to outpatient clinic with fatigue, light-headedness, dyspnoea and dark stool suggestive of lower gastrointestinal bleeding. She was previously diagnosed with multiple myeloma and completed 9 cycles of chemotherapy with bortezomib, lenalidomide and dexamethasone. She had very good partial response. A CT scan of the abdomen revealed a 9 cm mass at the hepatic flexure of the large intestine with an apple core deformity causing a marked narrowing of the lumen. Colonoscopy confirmed a large, nearly obstructing ulcerative mass in the distal right colon. The patient underwent a right hemicolectomy, distal ileal resection and lymph node dissection. Histopathology confirmed the mass as a plasmacytoma. Postoperatively, the patient was started with bortezomib and liposomal doxorubicin followed by carfilzomib. She showed excellent response to the chemotherapy.

A Fatal Case of Hepatic Portal Venous Gas Associated With Hemodialysis

Hepatic portal venous gas is a rare cause of acute abdomen caused by leakage of air from the gastrointestinal tract to the portal venous system. The mortality is high, particularly when associated with intestinal ischemia or necrosis. We describe a fatal case of hepatic portal venous gas and pneumatosis intestinalis due to hemodialysis-related hypotension and severe atherosclerotic disease.

Gynaecomastia: an unusual presenting symptom of bladder cancer

A 74-year-old man presented to the outpatient clinic with painful gynaecomastia. A detailed physical examination to sort out possible causes of the gynaecomastia, including intracranial tumour, liver cirrhosis, hyperthyroidism, and adrenal and testicular tumour, was negative. No offending agent was found in his medication list. A CT scan of the head and ultrasound of the scrotum did not show any mass lesion. His serum β-human chorionic gonadotropin (β-hCG) and oestradiol levels were elevated. A CT scan of the abdomen and pelvis revealed bladder wall thickening with soft tissue mass. A cystoscopic biopsy confirmed transitional cell carcinoma with muscle invasion. The patient was started on chemotherapy but responded poorly. This case report describes the β-hCG and oestradiol-secreting transitional cell carcinoma of the bladder presenting as gynaecomastia in an older man.

Leptomeningeal carcinomatosis from oesophageal cancer, presenting as meningitis

A 47-year-old woman presented with headache, neck pain, dizziness, nausea and vomiting for 4–5 days. She also had a history of weight loss and difficulty in swallowing. On physical examination, she had nuchal rigidity with a positive Kernigs sign. Cerebrospinal fluid analysis revealed mild pleocytosis but some atypical cells were also noted. Cytopathological analysis of the atypical cells showed high nuclear/cytoplasmic ratios and eccentric nuclei with prominent nucleoli, consistent with malignancy. A CT scan of the head and neck showed multiple lytic lesions involving the left calvarium, and diffuse thickening and enhancement of meninges over the left cerebral area. Extensive osteolytic lesions were also noted on the vertebral bodies, pedicles and lamina, at multiple levels of the cervical spine. An endoscopy revealed a mass at the gastro-oesophageal junction, and biopsy confirmed moderately differentiated adenocarcinoma of the oesophagus. The patient was started on chemotherapy along with radiation therapy.

Tumefactive multiple sclerosis presenting with tonic-clonic seizure.

A 37-year-old Hispanic man with no medical history presented with sudden onset of two episodes of witnessed seizure. On arrival to the emergency room, he experienced another episode of generalised tonic–clonic seizure witnessed by the physician and nurses. His seizure was accompanied by tongue biting and postictal confusion, but neither bowel nor bladder incontinence. Each episode lasted nearly 15–20 s and resolved without intervention. The patient did not have a similar event in the past and family history was negative for seizure disorder. He was not on medication at home and denied recreational drug use. On physical examination, he …

Orbital metastasis from prostate cancer

An 82-year-old man presented with proptosis, progressive throbbing pain and blurry vision in the right eye, gradually worsening over the past 3 weeks. The patient was diagnosed with prostate cancer and had undergone a radical prostatectomy nearly 14 years prior. After the surgery, his prostate-specific antigen (PSA) levels remained normal on regular follow-up, although he did not visit an oncologist for the past 4 years. He did not report bony pain, weight loss or headache. His thyroid function was normal. CT of the orbit showed a soft tissue mass within the right orbit, with bony destruction of the greater wing of sphenoid, …

Adenocarcinoma of the lung presenting with massive subcutaneous emphysema

A 47-year-old woman presented to the emergency department (ED) with severe shortness of breath with a choking sensation for the past 4 h. In the early morning, she had called her primary care physician with mild shortness of breath and was advised to take an albuterol inhaler for her chronic obstructive pulmonary disease (COPD). Despite following the general practitioners advice, her condition worsened with development of facial and neck swelling. She did not have any history of bee sting or consumption or contact with any allergic substance. On arrival at the ED, she displayed significant swelling (figure …

Lung herniation in the implantable cardioverter defibrillator pocket

A 47-year-old Caucasian man with the medical history of hypertension, hypercholesterolaemia and non-ischaemic cardiomyopathy with ejection fraction (EF) of 25–30% presented with pain in the left upper chest wall. Nearly 2 months earlier, he had undergone implantable cardioverter defibrillator (ICD) placement surgery for low EF. The initial attempt to place the biventricular lead was unsuccessful. Subsequently, he had epicardial lead placement performed by the cardiothoracic surgeon with repositioning of the ICD generator above the previous pocket. One week prior, he noticed a small bulging over the area of recent surgery, particularly during coughing. It got worse and, the day prior …