Sujith V Cherian

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.

Hemophagocytic Lymphohistiocytosis: An Uncommon Presentation of Enteropathy-Associated T-Cell Lymphoma

Introduction Enteropathy-associated T-cell lymphoma (EATL) is a rare peripheral T-cell lymphoma. It has an annual incidence rate of 0.5-1 per million with a male preponderance. It most commonly occurs in the small bowel and usually presents with multiple circumferential jejunal ulcers. EATL exist in two forms: type 1 (classical) and type 2. It has a strong association with longstanding celiac sprue, especially EATL type 1. Hemophagocytic lymphohistiocytosis (HLH) is a clinical syndrome which can occur secondary to infections, autoimmune diseases, malignancies, or in immunocompromised patients like transplantation recipients. The occurrence of HLH secondary to EATL is uncommon. We report a case of newly diagnosed celiac disease which was associated with EATL and presented as HLH.

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.