Subhraleena Das

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.

Acute leukemic appendicitis in a patient with acute promyelocytic leukemia

Leukemic and lymphomatous infiltration of the appendix is a rare complication. We present the case of a 31-year-old male with acute promyelocytic leukemia who developed acute abdomen on day 11 of induction chemotherapy with idarubicin and cytarabine. After appropriate work-up, a clinical diagnosis of acute appendicitis was made. Despite severe pancytopenia, he successfully underwent laparoscopic appendectomy. The final pathology revealed leukemic infiltration of the appendix. It is hypothesized that the leukemic infiltration may play a role in the development of acute appendicitis. Further, this case demonstrates the need to maintain a high index of suspicion and prompt surgical intervention for surgical pathologies in neutropenic patients.

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.

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.

Bilateral pleural effusions in a 23-year-old man: a clinical puzzle

A 23-year-old man presented with progressive swelling in the left supraclavicular area and worsening dyspnea of 7 days duration. Histories of fever, chills, night sweats, cough or weight loss was denied. Medical and family histories were unremarkable. Physical examination revealed usage of accessory muscles of respiration, facial plethora, acne, multiple dilated veins on chest wall, firm non-tender bilateral supraclavicular lymph nodes and decreased air entry and dullness in both lung bases. Chest X-ray revealed bilateral pleural effusions (Figure 1A). Computed tomography (CT) scan of the neck and chest demonstrated thrombotic occlusion of the superior vena cava, right subclavian, innominate and internal jugular veins, mediastinal fibrosis, subcentimeter mediastinal adenopathy and a mass on the left cardiac atrioventricular wall (Figure 1B and C). Pleural fluid revealed a triglyceride concentration of 799 mg/dl and lactate dehydrogenase (LDH) of 947 U/l with negative cultures and cytology. Lymph node and pleural biopsies were benign. Cardiac magnetic …

A 33-year-old man with chest pain, left upper lobe mass, pulmonary nodules, and bilateral bullae.

A 33-year-old man was referred to our institution for evaluation of multiple pulmonary nodules. The patient had been in his usual state of health until a week prior to admission, when he presented to an outside hospital with complaints of right-sided chest pain. An initial chest radiograph revealed multiple pulmonary nodules, and a CT scan of the chest confi rmed the nodules. The CT scan of the chest also demonstrated a left upper lobe mass. The patient was referred to our institution. A review of systems revealed only the presence of right-sided chest pain for 1 week. The patient had no significant medical history. He had a 15-pack-year smoking history. He denied any travel history or contact with sick people or pets. His family history was significant for lung cancer and breast cancer in his paternal grandmother.

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.