Oleg Epelbaum

Pulmonary Kaposi's Sarcoma and Its Complications in the HAART Era: A Contemporary Case-Based Review.

The early years of the acquired immunodeficiency syndrome (AIDS) epidemic introduced the global medical community to Kaposi’s sarcoma (KS), a heretofore seldom encountered angiosarcomatous neoplasm associated with human herpesvirus-8. At that time, clinicians treating these KS patients were routinely exposed to the pulmonary manifestations of this malignancy, including characteristic airway lesions, peribronchovascular opacities, and the typically hemorrhagic pleural effusions. They also witnessed uncommon complications of pulmonary KS such as chylous effusions, diffuse alveolar hemorrhage, and immune reconstitution inflammatory syndrome. Since the advent of highly active antiretroviral therapy, the incidence of KS has steadily declined and with that so has clinician familiarity with this disease. Herein, we present four KS cases recently encountered at our institution that illustrate both typical manifestations of pulmonary KS as well as its thoracic complications. The case descriptions are followed by a review of these clinical entities with the aim of restoring awareness among frontline physicians of what is now a rare but not quite extinct AIDS-defining neoplasm.

Update on the spectrum of histoplasmosis among hispanic patients presenting to a New York City municipal hospital: A contemporary case series

Histoplasma capsulatum is the most common endemic mycosis worldwide. Although most of the globes largest urban hubs fall outside this organisms regions of endemicity, clinicians practicing in a metropolis like New York City or Los Angeles must nevertheless remain vigilant for histoplasmosis because of the large immigrant population that is served by its hospitals. H. capsulatum infection ranges from asymptomatic pulmonary infection to life-threatening diffuse pneumonia with dissemination. The early years of the AIDS epidemic first introduced U.S. clinicians working in areas previously unfamiliar with histoplasmosis to newly immunocompromised patients from endemic regions presenting with disseminated H. capsulatum originally acquired in their home countries. Improvement in HIV prevention and therapeutics has reduced the frequency of such cases. Herein we report three cases of histoplasmosis encountered in our New York City institution over the last three years to emphasize that awareness of this infection remains mandatory for the frontline urban clinician.

Clinically Occult Primary Fallopian Tube Carcinoma Presenting as a Malignant Pleural Effusion.

We report the first known case of malignant pleural effusion (MPE) as the sole presenting feature of clinically occult primary fallopian tube carcinoma (PFTC). A 57‐year‐old healthy woman was admitted with dyspnea. Evaluation demonstrated a right pleural effusion, fluid of which was malignant. The immunohistochemical profile, including negative calretinin, favored metastatic adenocarcinoma over mesothelioma but could not identify the primary tumour site. Pleural biopsy was not pursued as it would not have helped localize the primary. Chest, abdomen and pelvic computed tomography (CT) demonstrated only borderline lymphadenopathy in the left para‐aortic lymph node chain that was hypermetabolic on positron emission tomography. Ultrasound and CT showed normal adnexal anatomy. These findings, coupled with an elevated serum CA‐125, prompted empiric neoadjuvant chemotherapy targeting epithelial ovarian carcinoma (EOC) followed by surgery, which revealed a tiny left PFTC with negative peritoneal washings. Sampled left para‐aortic lymph nodes were positive. The pleural effusion resolved after chemotherapy. Malignant pleural disease without peritoneal involvement is more characteristic of PFTC than of EOC, in which MPE is common but almost always accompanies peritoneal carcinomatosis. The extensive lymphatic supply of the fallopian tube promotes distant metastasis of small, seemingly localized tumours. This case is a reminder that the clinician should not be dissuaded from considering carcinoma of Müllerian origin, especially PFTC, as the cause of a MPE even in the face of normal gynecologic imaging. Appropriately broad immunohistochemical staining and careful attention to even minimal lymphadenopathy can be invaluable in pinpointing the primary tumour site in such patients.

Reversal of Fortune: Central Nervous System Blastomycosis.

PRESENTATION When a patient presents with simultaneous lung and brain lesions, the clinician is likely to invokemetastatic malignancy as the unifying explanation, which will usually be the correct one—but not always. In our case, a 73-year-old man originally from Bangladesh with a history of hypertension, diabetes mellitus, and curatively resected renal cell carcinoma and prostate adenocarcinoma, both more than 10 years before this presentation, was evaluated in the emergency department for an acutely depressed level of consciousness after involuntary movements of the left upper extremity. His level of consciousness rapidly improved in the course of his emergency department stay, and he experienced left upperextremity weakness when he regained speech. The working diagnosis was a partial seizure with secondary generalization followed by Todd’s paralysis of the left upper extremity.

Lactobacillus Empyema in a Patient With Schizophrenia

Lactobacillus species are anaerobic gram-positive rods that are part of the normal human flora as well as commercially available probiotic formulations. Although their pathogenicity in the normal host has been the subject of debate, lactobacilli have been associated with serious infections in immunosuppressed patients and those with predisposing risk factors. We report a case of a patient with a history of schizophrenia who presented with an empyema, cultures of which identified Lactobacillus acidophilus and Lactobacillus rhamnosus as the causative organisms. To our knowledge, this is the first case of Lactobacillus parapneumonic pleural space infection reported from the Western Hemisphere.

A 66-year-old woman with fever, cough, and a tongue lesion.

A 66-year-old woman presented with acute onset of fever, chills, and productive cough associated with right-sided chest pain. During a recent hospitalization for dyspnea, she had been diagnosed with Coombs-positive autoimmune hemolytic anemia and had been taking a tapering dose of prednisone starting approximately 6 weeks prior to admission. In the interim, her dyspnea had resolved on treatment with steroids. At the time of presentation, her prednisone dose was 40 mg. Additional medical history included VTE, for which the patient was receiving anticoagulation therapy, and steroid-induced diabetes mellitus. Many years earlier, she had been treated for TB in her home country. The patient had immigrated to Queens, New York, from a Nepalese village 8 years prior. While still in Nepal, she had worked on a farm and had been in close proximity to cows. In Queens, she lived with her family in a house with a small garden but had no pets. Recent travel included a visit to Nepal 9 months ago and a trip to Syracuse, New York, one month prior to presentation. She was a never smoker and did not consume alcohol.

A 47-Year-Old Returning Traveler With Shock

A 47-year-old man with no significant past medical history, originally from Indonesia, was brought to the ED of an urban US medical center after being found collapsed on the sidewalk in respiratory distress and with an altered sensorium. Upon arrival to the ED, he was tachypneic, with increased work of breathing and an oxygen saturation of 88% on 100% nonrebreather mask, so he was immediately intubated. Following intubation, he became profoundly hypotensive, requiring aggressive crystalloid resuscitation and vasopressor support. Broad-spectrum antimicrobials were administered, including ceftriaxone, vancomycin, levofloxacin, and oseltamivir. Further history elicited subsequently from family members revealed that the patient had returned from a 2-week vacation in Indonesia 6 days prior to presentation. According to relatives, he appeared to be in his usual state of health upon his return and was not seen by anyone thereafter, but in the interim he reportedly had an episode of epistaxis, and text messages received from him became progressively more bizarre.

Not your ‘Garden Variety’ Atelectasis

133 A 20-year-old Ecuadorian woman had a positive purified protein derivative (PPD) test during routine prenatal evaluation. A chest radiograph (CXR) performed at that time was normal. Treatment for latent tuberculosis infection was not initiated. She had an uneventful delivery and then presented more than one year later with cough, fever and night sweats. Posteroanterior and lateral CXR performed in the emergency department revealed atelectasis of the right upper lobe (RUL), with superomedial retraction of the minor fissure (Figure 1A and 1B). Sputum cultures for acid fast bacilli (AFB) subsequently grew Mycobacterium tuberculosis, and the patient was started on a multidrug regimen, which was narrowed once the organism was confirmed to be sensitive. To further evaluate the nature of her RUL atelectasis, computed tomography (CT) of the chest was performed following administration of intravenous contrast, which was consistent with compression of the RUL bronchus by an adjacent mediastinal lymph node (Figure 1C and 1D). Bronchoscopic inspection undertaken to exclude neoplasia revealed a mass-like protrusion at the level of the RUL bronchial orifice that was covered with normal-appearing mucosa (Figure 1E and 1F). Endobronchial biopsies of this entity were negative for malignancy and granulomas. The patient’s RUL atelectasis was, thus, attributed to extrinsic obstruction by a tuberculous mediastinal lymph node.