Pongsathorn Kue-A-Pai

Extensive loculated ascites in hepatic amyloidosis

Context: Amyloidosis is a disease of extracellular deposition of misfolded proteinaceous subunits, which could be systemic or localized disease. Though hepatic amyloidosis was not uncommon in autopsy series, most cases of hepatic amyloidosis were asymptomatic. Ascites, jaundice, portal hypertension, and gastrointestinal bleeding from esophageal varices were reported in literature. Case report: A 42-year-old man with end-stage renal disease on hemodialysis and recent small bowel obstruction presented with chronic abdominal pain. Computed tomography of abdomen and pelvis showed extensive loculated ascites and multiple small bowel loops tethered to adhesions and hepatomegaly. Finally, hepatic venography and liver biopsy confirmed hepatic amyloidosis with portal hypertension. The patient was waiting for liver transplant for definite treatment. Conclusion: We report a rare case of hepatic amyloidosis with prior small bowel obstruction presented with extensive loculated ascites and multiple small bowel loops tethered to adhesions.

A rare case of ecthyma gangrenosum associated with methicillin-resistant Staphylococcus aureus infection

Ecthyma gangrenosum (EG) is a well-recognized dermatological condition caused by gram-negative bacillary infection, particularly Pseudomonas aeruginosa. Association with gram-positive cocci is very rarely reported in the literature. To the best of our knowledge, we describe the third case of EG caused by methicillin-resistant Staphylococcus aureus in a patient with AIDS who presented with multiple typical necrotic lesions.

Warburg effect associated with transformed lymphoplasmacytic lymphoma to diffuse large B-cell lymphoma

Warburg effect is a rare metabolic complication in hematologic malignancies, commonly presented with lactic acidosis and hypoglycemia. Mechanism explained by abnormality of mitochondrial oxidative phosphorylation in cancer cells and energy production is mostly dependent on anaerobic respiration or glycolysis pathway to meet large tumor demand. We present a case with history of lymphoplasmacytic lymphoma and Waldenstörm macroglobulinemia, partial response to chemotherapy. Lymphoplasmacytic lymphoma transformed to diffuse large B-cell lymphoma, which is aggressive and rapid progression, leading to Warburg effect. Patient developed more than 10-cm retroperitoneal mass less than 1 year, and his symptoms were progressively worsening within 3 weeks. Warburg effect represents poor prognosis no matter with or without hypoglycemia. Treatment of choice is cytoreduction with early chemotherapy. Our patient died 2 days after Warburg effect occurred.

A rare case of symptomatic gastric sarcoidosis

### Learning Point for Clinicians Always think about sarcoidosis in patient with multi-organ involvement. Endoscopic appearance of gastric sarcoidosis can be normal. The diagnosis requires biopsy. A 65-year-old Caucasian male presented to our institute with a 3-week history of anorexia, nausea and watery diarrhea accompanied by a 1-week history of fever, dry cough and mild shortness of breath. Physical examination was only remarkable for red subcutaneous nodules at left thigh. Initial laboratory investigations, including complete blood cell count, blood chemistry, liver function test and serum angiotensin converting enzyme, were within normal range. His stool studies including stool culture, stool for Giardia antigen, Cryptosporidium antigen and Clostridium difficile toxins were all negative. His initial chest X-ray was unremarkable but his computed tomography …

Tubulointerstitial Nephritis and Uveitis Syndrome in an Older Adult: A Case Report and Review of the Literature

1. Levine S, Caruso L, Brett B et al. Replicating a Chief Resident Immersion Training in Geriatrics (CRIT). J Am Geriatr Soc 2012;60:S13–S14. 2. Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff 2008;27:759–769. 3. Health educators and foundations release competencies and action strategies for interprofessional education. J Prof Nurs 2011;27:195–196. 4. Institute for Healthcare Improvement Open School [on-line]. Available at http://www.ihi.org/offerings/IHIOpenSchool/Courses/Pages/OSInTheCurriculum.aspx Accessed April 16, 2013.

Toluene-induced renal tubular acidosis: an easily missed cause of hypokalemic paralysis ☆ ☆☆ ★

We thank Chiang et al for their article on “Unilateral paralysis associated with profound hypokalemia” [1]. The authors demonstrated an interesting case of idiopathic distal renal tubular acidosis (RTA) with hypokalemic paralysis. Distal RTA is commonly associated with autoimmune disorders; however, the authors already ruled out these possibilities by a complete medical workup. We applaud the authors for their thorough presentation, especially the insignificant history of glue sniffing. Inhalation of toluene can cause distal RTA though several mechanisms [2]. Toluene inhibits collecting duct proton secretion. In addition, metabolism of toluene produces the organic acids including hippuric acid and benzoic acid. These are buffered by sodium bicarbonate, resulting in the production of sodium hippurate and sodium benzoate. Anion gap metabolic acidosis occurs when effective intravascular volume is decreased and urinary excretion is limited [3].

Sister Mary Joseph's nodule: What lies beneath?

Dear Editor, We recently had a 79-year-old male with no significant medical history who was referred to our hospital for a pulmonary embolism. During examination a 5 cm × 5 cm fungating mass was discovered on his belly [Figure 1]. Patient reported that the mass has been present for months and gradually increasing in size. A computed tomography scan of chest, abdomen and pelvis revealed no other abnormality. The biopsy of mass revealed moderately differentiated adenocarcinoma with stain consistent with tumor of lower gastrointestinal tract. A colonoscopy confirmed adenocarcinoma of transverse colon. Figure 1 A 5 cm ×5 cm fungating mass on patients periumbilical area This rare manifestation of metastatic disease was recognized by a surgical assistant of Dr. William Mayo, Sister Mary Joseph, whose name has since been used to explain these umbilical nodules.[1] These metastatic lesions are mostly from gastrointestinal (52%) and gynecological neoplasms (28%), most commonly from the stomach (23%), colon (15%), pancreas (10%), and ovary (16%), and less frequently from the uterus, cervix, gallbladder, and small intestine.[2] Metastatic lesions can reach the umbilicus via spread through lymphatic ducts, the venous network, arterial spread, contiguous extension, or even through iatrogenic seeding with laparoscopy. These different pathways may help explain why there is such a wide group of malignant tumors that can produce these nodules.[3] The presence of these lesions is often a poor prognostic factor, as these patients have advanced metastatic disease at the time of initial diagnosis. In several studies, the average survival after the appearance of these nodules was approximately 10-11 months.[4] Sister Mary Joseph nodule is a rare first manifestation of colon cancer. Physicians should be aware of this unusual presentation of colon cancer.

Purple urine bag syndrome.

A 44-year-old man with Downs syndrome and neurogenic bladder which required a suprapubic catheter presented with fever and change in his urine color for one day. Physical examination revealed a temperature of 38.3°C, blood pressure of 60/30 mmHg, pulse rate of 120/min and urine with purple discoloration in the urine catheter and bag (Figure 1). A urine dipstick test indicated the presence of leukocytes, positive nitrate and a pH value of 8.5. The patient was resuscitated with intravenous crystalloid fluid and empiric antibiotics (vancomycin and piperacillin/tazobactam) were started. The patients urine culture subsequently grew Enterococcus faecalis. His antibiotic was changed to levofloxacin as per sensitivity analysis. The patient responded well to treatment as his fever subsided and improved and his urine color gradually returned to yellow. Fig. 1. Purple discoloration of urine in the urine catheter and bag. Purple urine bag syndrome (PUBS) is a rare condition characterized by purple discoloration of urine in a urine catheter and bag typically seen in patients with chronic debilitation with a history of long-term indwelling urinary catheter [1]. The pathogenesis of this discoloration is associated with tryptophans metabolism as intestinal bacteria metabolize tryptophan to indole and later converted to indican by the liver. Indican, in turn, is excreted and broken down in the urine into indirubin (red) and indigo (blue) in an alkaline environment by sufatase or phosphatase-containing bacteria, such as Providencia stuartii, Providencia rettgeri, Proteus mirabilis, Klebsiella pneumoniae, Escherichia coli, Enterococcus spp., etc. [2] PUBS is generally a benign process but it provides a clue to the presence of an underlying urinary tract infection. The discoloration usually gradually disappears after antibiotic treatment and good urologic sanitation, as seen in our patient [1, 3].