Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Laryngeal Lymphoma: The High and Low Grades of Rare Lymphoma Involvement Sites Tue, 22 Jul 2014 12:02:38 +0000 The larynx is an extremely rare site of involvement by lymphomatous disease. We present two cases of isolated laryngeal high-grade and another low-grade lymphoma, together with a literature review of laryngeal lymphoma management. Charles Paul Azzopardi, James Degaetano, Alexandra Betts, Eric Farrugia, Claude Magri, Nicholas Refalo, Alexander Gatt, and David J. Camilleri Copyright © 2014 Charles Paul Azzopardi et al. All rights reserved. Acute Rhabdomyolysis Associated with Coadministration of Levofloxacin and Simvastatin in a Patient with Normal Renal Function Tue, 22 Jul 2014 08:06:05 +0000 We report a rare case of severe acute rhabdomyolysis in association with coadministration of levofloxacin and simvastatin in a patient with normal renal function. A 70-year-old Caucasian male was treated due to community acquired pneumonia with levofloxacin in a dosage of 500 mg once and then twice a day. On the 8th day of hospitalization the patient presented with acute severe rhabdomyolysis requiring an intensive care support. After discontinuation of levofloxacin and concomitant medication with simvastatin 80 mg/day, clinical and laboratory effects were totally reversible. Up to now, levofloxacin has been reported to induce rhabdomyolysis mainly in patients with impaired renal function, as the medication has a predominant renal elimination. In our case renal function remained normal during the severe clinical course. According to a recent case report rhabdomyolysis was observed due to interaction of simvastatin and ciprofloxacin. To our best knowledge this is the first case of interaction between simvastatin and levofloxacin to be reported. This case emphasizes the need of close monitoring of creatine kinase in patients under more than one potentially myotoxic medication especially when patients develop muscle weakness. Maria Paparoupa, Sebastian Pietrzak, and Adrian Gillissen Copyright © 2014 Maria Paparoupa et al. All rights reserved. Bilateral Upper Extremity DVT in a 43-Year-Old Man: Is It Thoracic Outlet Syndrome?! Tue, 22 Jul 2014 00:00:00 +0000 Recurrent deep venous thrombosis, involving bilateral upper extremities, is an extremely rare phenomenon. We are presenting a 43-year-old man who was diagnosed with left upper extremity deep vein thrombosis (UEDVT) and was treated with anticoagulation and surgical decompression in 2004. 9 years later, he presented with right arm swelling and was diagnosed with right UEDVT using US venous Doppler. Venogram showed compression of the subclavian vein by the first rib, diagnosing thoracic outlet syndrome (TOS). He was treated with anticoagulation and local venolysis and later by surgical decompression of the subclavian vein. Bilateral UEDVT, as mentioned above, is an extremely rare condition that is uncommonly caused by TOS. To our knowledge, we are reporting the first case of bilateral UEDVT due to TOS. Diagnosis usually starts with US venous Doppler to detect the thrombosis, followed by the gold standard venogram to locate the area of obstruction and lyse the thrombus if needed. The ultimate treatment for TOS remains surgical decompression of the vascular bundle at the thoracic outlet. Hadoun Jabri, Sarbajit Mukherjee, Devang Sanghavi, and Shyam Chalise Copyright © 2014 Hadoun Jabri et al. All rights reserved. Acute Zonal Occult Outer Retinopathy with Atypical Findings Mon, 21 Jul 2014 09:06:41 +0000 Background. To report a case of acute zonal occult outer retinopathy (AZOOR) with atypical electrophysiology findings. Case Presentation. A 23-year-old-female presented with visual acuity deterioration in her right eye accompanied by photopsia bilaterally. Corrected distance visual acuity at presentation was 20/50 in the right eye and 20/20 in the left eye. Fundus examination was unremarkable. Visual field (VF) testing revealed a large scotoma. Pattern and full-field electroretinograms (PERG and ERG) revealed macular involvement associated with generalized retinal dysfunction. Electrooculogram (EOG) light rise and the Arden ratio were within normal limits bilaterally. The patient was diagnosed with AZOOR due to clinical findings, visual field defect, and ERG findings. Conclusion. This is a case of AZOOR with characteristic VF defects and clinical symptoms presenting with atypical EOG findings. Dimitrios Karagiannis, Georgios A. Kontadakis, Artemios S. Kandarakis, Nikolaos Markomichelakis, Ilias Georgalas, Efstratios A. Parikakis, and Stamatina A. Kabanarou Copyright © 2014 Dimitrios Karagiannis et al. All rights reserved. Prophylactic Appendectomy during Laparoscopic Surgery for Other Conditions Sun, 20 Jul 2014 11:45:39 +0000 Acute appendicitis remains the most common surgical emergency. Laparoscopy has gained increasing favor as a method of both investigating right iliac fossa pain and treating the finding of appendicitis. A question arises: what to do with an apparent healthy appendix discovered during laparoscopic surgery for other pathology. We present a case of unilateral hydroureteronephrosis complicated with rupture of the renal pelvis, due to gangrenous appendicitis with abscess of the right iliopsoas muscle and periappendicular inflammation in a 67-year-old woman, who underwent laparoscopic right annessiectomy for right ovarian cyst few years earlier, in which a healthy appendix was left inside. There is a lack of consensus in the literature about what to do with a normal appendix. The main argument for removing an apparently normal appendix is that endoluminal appendicitis may not be recognized during surgery, leading to concern that an abnormal appendix is left in place. Because of a lack of evidence from randomized trials, it remains unclear whether the benefits of routine elective coincidental appendectomy outweigh the costs and risks of morbidity associated with this prophylactic procedure. Nevertheless, it appears, from limited data, that women aged 35 years and under benefit most from elective coincidental appendectomy. S. Occhionorelli, R. Stano, S. Targa, S. Maccatrozzo, L. Cappellari, and G. Vasquez Copyright © 2014 S. Occhionorelli et al. All rights reserved. Anatomic Variation of Subclavian Artery Visualized on Ultrasound-Guided Supraclavicular Brachial Plexus Block Sun, 20 Jul 2014 00:00:00 +0000 Use of ultrasonography for performance of nerve and plexus blocks has made the process simpler and safer. However, at times, variant anatomy of the visualized structures can lead to failure of blocks or complications such as intravascular injections. This is especially true in case of novice operators. We report a case of a variant branch of subclavian artery, possibly the dorsal scapular artery passing through the brachial plexus nerve bundles in the supraclavicular area. Since this variation in anatomy was visualized in the scout scan prior to the performance of the block, it was possible to avoid any accidental puncture. Hence, a thorough knowledge of the ultrasound anatomy is important in order to identify various aberrations and variations. It is also prudent to perform a preliminary scan, prior to performance of the block to localize the target area and avoid any inadvertent complications. Santvana Kohli, Naveen Yadav, Arunima Prasad, and Sumantra Sarathi Banerjee Copyright © 2014 Santvana Kohli et al. All rights reserved. Concomitant Factors Leading to an Atypical Osteonecrosis of the Jaw in a Patient with Multiple Myeloma Wed, 16 Jul 2014 09:16:49 +0000 Osteonecrosis of the jaw (ONJ) is a site specific osseous pathology, characterized by chronic exposed bone in the mouth, which needs to be reinforced periodically within the medical literature. ONJ is a clinical entity with many possible aetiologies and its pathogenesis is not well understood. The risk factors for ONJ include bisphosphonates treatments, head and neck radiotherapy, dental procedures involving bone surgery, and trauma. Management of ONJ has centred on efforts to eliminate or reduce severity of symptoms, to slow or prevent the progression of disease, and to eradicate diseased bone. This case describes a rare case of ONJ in a 64-year-old Caucasian male diagnosed with multiple myeloma stage III. The lesion was related to a traumatic injury during mastication. Eighteen months ago in the same area the molar 37 was extracted, achieving a complete satisfactory healing, when only 2 doses of zoledronic acid had been administered. Actinomyces bacterial aggregates were also identified in the microscopic analysis. The management of this osteonecrotic lesion included antibiotic treatment and chlorhexidine topical gel administration. The evolution was monitored every two weeks until patient’s death. The authors provide a discussion of the etiology, pathogenesis, diagnosis, and management. This case report may shed light on the controversies about concomitant factors and mechanisms inducing ONJ. Jaume Miranda-Rius, Lluís Brunet-Llobet, Eduard Lahor-Soler, and Josep Anton Giménez-Rubio Copyright © 2014 Jaume Miranda-Rius et al. All rights reserved. Successful Management of Coronary Artery Rupture with Stent-Graft: A Case Report Sun, 13 Jul 2014 11:50:05 +0000 Perforation of coronary arteries is a relatively rare yet life-threatening complication of percutaneus coronary interventions and is encountered in approximately 0.5% of these procedures. According to the type of coronary perforation, various methods of correction are employed, ranging from conservative approach to emergency cardiac surgery. Coronary stent-grafts are composed of two metal stents and a polytetrafluoroethylene layer between them. Advent of such stents enabled efficient endovascular repair of coronary artery perforation. We present a case of coronary artery perforation which had occurred during stent implantation for the treatment of a bridged segment in the distal portion of the left anterior descending artery. This perforation was successfully managed by implanting a stent-graft. Berkay Ekici, Aycan Fahri Erkan, Utku Kütük, and Hasan Fehmi Töre Copyright © 2014 Berkay Ekici et al. All rights reserved. Acute Abdominal Pain after Intercourse: Adrenal Hemorrhage as the First Sign of Metastatic Lung Cancer Sun, 13 Jul 2014 07:45:16 +0000 Although the adrenal glands are a common site of cancer metastases, they are often asymptomatic and discovered incidentally on CT scan or autopsy. Spontaneous adrenal hemorrhage associated with metastatic lung cancer is an exceedingly rare phenomenon, and diagnosis can be difficult due to its nonspecific symptoms and ability to mimic other intra-abdominal pathologies. We report a case of a 65-year-old man with a history of right upper lobectomy seven months earlier for stage IB non-small cell lung cancer who presented with acute abdominal pain after intercourse. CT scan revealed a new right adrenal mass with surrounding hemorrhage, and subsequent FDG-PET scan confirmed new metabolic adrenal metastases. The patient’s presentation of abdominal pain and adrenal hemorrhage immediately after sexual intercourse suggests that exertion, straining, or increased intra-abdominal pressure might be risk factors for precipitation of hemorrhage in patients with adrenal metastases. Management includes pain control and supportive treatment in mild cases, with arterial embolization or adrenalectomy being reserved for cases of severe hemorrhage. Jeremy Wang and Clifford D. Packer Copyright © 2014 Jeremy Wang and Clifford D. Packer. All rights reserved. Postpartum Ovarian Vein and Inferior Vena Cava Thrombosis Thu, 10 Jul 2014 10:00:26 +0000 Postpartum ovarian vein thrombosis (POVT), which generally occurs 2–15 days postpartum, is a rare complication. It can be confused with acute appendicitis, pelvic infection, ovarian torsion, tubo-ovarian abscess, and pyelonephritis. It is associated with morbidity and mortality. Here, we present a patient with postpartum OVT and IVC diagnosed by US and CT findings. She was treated successfully with no further need for any interventional procedures. Harun Arslan, Sibel Ada, Sebahattin Çelik, and Tayfur Toptaş Copyright © 2014 Harun Arslan et al. All rights reserved. Giant Solitary Fibrous Tumor of the Parotid Gland Thu, 10 Jul 2014 00:00:00 +0000 Solitary fibrous tumors (SFTs) are rare tumors that are mostly found arising from the pleura. SFT of the parotid gland is a rare tumor; only a few cases have been described in the literature. SFTs are benign in most cases. Clinically, SFTs usually manifest as well circumscribed, slow-growing, smooth, and painless masses. CT-Scan and MRI are the most sensitive imaging procedures used. The treatment of choice is complete surgical excision of the lesion. Since recurrence and metastasis can take place after several years, a lifelong clinical and imaging regular follow-up is compulsory. In this paper, we describe the diagnostic and therapeutic challenges of the up-to-now biggest parotid SFT. The clinical presentation, surgical management, and pathological and immunohistochemistry findings are described. Octavian Chis and Silviu Albu Copyright © 2014 Octavian Chis and Silviu Albu. All rights reserved. Wolff-Parkinson-White Syndrome Mimics a Conduction Disease Wed, 09 Jul 2014 09:35:10 +0000 Background. It is important to recognise Wolff-Parkinson-White (WPW) syndrome in electrocardiograms (ECG), as it may mimic ischaemic heart disease, ventricular hypertrophy, and bundle branch block. Recognising WPW syndrome allows for risk stratification, the identification of associated conditions, and the institution of appropriate management. Objective. The present case showed that electrophysiological study is indicated in patients with abnormal ECG and syncope. Case Report. A 40-year-old man with Wolff-Parkinson-White syndrome was presented to emergency with syncope. A baseline ECG was a complete right branch block and posterior left hemiblock. He was admitted to the cardiac care unit for pacemaker implantation. The atypical figure of complete right branch block and posterior left hemiblock was thought to be a “false positive” of conduction abnormality. But the long anterograde refractory period of the both accessory pathway and atrioventricular conduction may cause difficulty in diagnosing Wolff-Parkinson-White syndrome, Conclusion. A Wolff-Parkinson-White Syndrome may mimic a conduction disease. No reliable algorithm exists for making an ECG diagnosis of a preexcitation syndrome with conduction disorders. This can lead to diagnostic and therapeutic dilemmas in the context of syncope. S. Marrakchi, I. Kammoun, and S. Kachboura Copyright © 2014 S. Marrakchi et al. All rights reserved. Clinical Presentation and Magnetic Resonance Findings in Sellar Tuberculomas Wed, 09 Jul 2014 07:33:41 +0000 Background and Importance. Sellar tuberculomas are extremely rare lesions with nonspecific clinical manifestations. The tuberculous infection of the pituitary gland and sellar region is characterized by the presence of an acute or chronic inflammatory reaction and may occur in the absence of systemic tuberculosis. The diagnosis is difficult prior to the surgery. An adequate diagnostic and antituberculous drugs usually result in a good outcome. Clinical Presentation. We report four cases of sellar tuberculoma, 3/1 female/male, age range: 50–57 years. All patients had visual disturbances and low levels of cortisol. Conclusion. The clinical diagnosis of sellar tuberculoma is a challenge and should be suspected when a sellar lesion shows abnormal enhancement pattern and stalk involvement, and absence of signal suppression in FLAIR. Dulce Bonifacio-Delgadillo, Yolanda Aburto-Murrieta, Citlaltepetl Salinas-Lara, Julio Sotelo, Ivonne Montes-Mojarro, and Arturo Garcia-Marquez Copyright © 2014 Dulce Bonifacio-Delgadillo et al. All rights reserved. Cardiac Hemangioma of RVOT in a Patient with Atypical Chest Pain Tue, 08 Jul 2014 06:38:08 +0000 A 40-year-old man presented with atypical chest pain and fatigue from 15 days ago a suspicious mass in the right ventricle based on a bed side transthoracic echocardiography. Preoperative diagnosis of a cardiac hemangioma comes to mind in a minority of cases. In our case, a cardiac tumor was diagnosed and the vascular nature of the tumor was suggested by vascular blush on the coronary angiography. In addition, right ventriculotomy was the approach of choice in our case because of its inaccessibility and its particular location. Hossein Vakili, Isa Khaheshi, Mahnoosh Foroughi, Hamid Ghaderi, Shooka Esmaeeli, and Mostafa Jafari Copyright © 2014 Hossein Vakili et al. All rights reserved. Reversion of Hormone Treatment Resistance with the Addition of an mTOR Inhibitor in Endometrial Stromal Sarcoma Tue, 08 Jul 2014 00:00:00 +0000 Background. Endometrial stromal sarcomas (ESS) are a subtype of gynaecological sarcomas characterized by the overexpression of hormone receptors. Hormone treatment is widely used in ESS but primary or acquired resistance is common. The mammalian target of rapamycin (mTOR) pathway has been suggested to play a key role in the mechanisms of hormone resistance. Recent studies in breast and prostate cancer demonstrate that this resistance can be reversed with the addition of an mTOR inhibitor. This phenomenon has never been reported in ESS. Methods. We report the outcome of one patient with pretreated, progressing low grade metastatic ESS treated with medroxyprogesterone acetate in combination with the mTOR inhibitor sirolimus. Results. Partial response was achieved following the addition of sirolimus to the hormone treatment. Response has been maintained for more than 2 years with minimal toxicity and treatment is ongoing. Conclusion. This case suggests that the resistance to the hormone manipulation in ESS can be reversed by the addition of an mTOR pathway inhibitor. This observation is highly encouraging and deserves further investigation. J. Martin-Liberal, C. Benson, C. Messiou, C. Fisher, and I. Judson Copyright © 2014 J. Martin-Liberal et al. All rights reserved. Familial Thoracic Aortic Aneurysm with Dissection Presenting as Flash Pulmonary Edema in a 26-Year-Old Man Mon, 07 Jul 2014 12:28:40 +0000 We are reporting a case of familial thoracic aortic aneurysm and dissection in a 26-year-old man with no significant past medical history and a family history of dissecting aortic aneurysm in his mother at the age of 40. The patient presented with cough, shortness of breath, and chest pain. Chest X-ray showed bilateral pulmonary infiltrates. CT scan of the chest showed a dissection of the ascending aorta. The patient underwent aortic dissection repair and three months later he returned to our hospital with new complaints of back pain. CT angiography showed a new aortic dissection extending from the left carotid artery through the bifurcation and into the iliac arteries. The patient underwent replacement of the aortic root, ascending aorta, total aortic arch, and aortic valve. The patient recovered well postoperatively. Genetic studies of the patient and his children revealed no mutations in ACTA2, TGFBR1, TGFBR2, TGFB2, MYH11, MYLK, SMAD3, or FBN1. This case report focuses on a patient with familial TAAD and discusses the associated genetic loci and available screening methods. It is important to recognize potential cases of familial TAAD and understand the available screening methods since early diagnosis allows appropriate management of risk factors and treatment when necessary. Sabry Omar, Tyler Moore, Drew Payne, Parastoo Momeni, Zachary Mulkey, Ralph Paone, and Kenneth Nugent Copyright © 2014 Sabry Omar et al. All rights reserved. Drug-Induced QT Prolongation as a Result of an Escitalopram Overdose in a Patient with Previously Undiagnosed Congenital Long QT Syndrome Tue, 01 Jul 2014 11:55:44 +0000 We present a case of drug-induced QT prolongation caused by an escitalopram overdose in a patient with previously undiagnosed congenital LQTS. A 15-year-old Caucasian female presented following a suicide attempt via an escitalopram overdose. The patient was found to have a prolonged QT interval with episodes of torsades de pointes. The patient was admitted to the telemetry unit and treated. Despite the resolution of the torsades de pointes, she continued to demonstrate a persistently prolonged QT interval. She was seen by the cardiology service and diagnosed with congenital long QT syndrome. This case illustrates the potential for an escitalopram overdose to cause an acute QT prolongation in a patient with congenital LQTS and suggests the importance of a screening electrocardiogram prior to the initiation of SSRIs, especially in patients at high risk for QT prolongation. Paul Singh and J. Martin Maldonado-Duran Copyright © 2014 Paul Singh and J. Martin Maldonado-Duran. All rights reserved. Dentigerous Cyst or Adenomatoid Odontogenic Tumor: Clinical Radiological and Histopathological Dilemma Tue, 01 Jul 2014 10:40:28 +0000 Adenomatoid odontogenic tumor (AOT) is a well-recognised slow growing benign tumor derived from complex system of dental lamina or its remnants. This lesion is categorised into three variants of which the more common variant is follicular type which is often mistaken for dentigerous cyst. We present a case of AOT in a 14-year-old male who was misdiagnosed as dentigerous cyst. Clinical radiological and therapeutic characteristics of the case are commented on in detail. Shivesh Acharya, Ashima Goyal, Vidya Rattan, Kim Vaiphei, and Sarabjot Kaur Bhatia Copyright © 2014 Shivesh Acharya et al. All rights reserved. Unloading of Right Ventricle and Clinical Improvement after Ultrasound-Accelerated Thrombolysis in Patients with Submassive Pulmonary Embolism Tue, 01 Jul 2014 07:16:51 +0000 Acute pulmonary embolism (PE) can be devastating. It is classified into three categories based on clinical scenario, elevated biomarkers, radiographic or echocardiographic features of right ventricular strain, and hemodynamic instability. Submassive PE is diagnosed when a patient has elevated biomarkers, CT-scan, or echocardiogram showing right ventricular strain and no signs of hemodynamic compromise. Thromboemboli in the acute setting increase pulmonary vascular resistance by obstruction and vasoconstriction, resulting in pulmonary hypertension. This, further, deteriorates symptoms and hemodynamic status. Studies have shown that elevated biomarkers and right ventricular (RV) dysfunction have been associated with increased risk of mortality. Therefore, aggressive treatment is necessary to “unload” right ventricle. The treatment of submassive PE with thrombolysis is controversial, though recent data have favored thrombolysis over conventional anticoagulants in acute setting. The most feared complication of systemic thrombolysis is intracranial or major bleeding. To circumvent this problem, a newer and safer approach is sought. Ultrasound-accelerated thrombolysis is a relatively newer and safer approach that requires local administration of thrombolytic agents. Herein, we report a case series of five patients who underwent ultrasound-accelerated thrombolysis with notable improvement in symptoms and right ventricular function. Sachin Kumar Amruthlal Jain, Brijesh Patel, Wadie David, Ayad Jazrawi, and Patrick Alexander Copyright © 2014 Sachin Kumar Amruthlal Jain et al. All rights reserved. Superior Mesenteric Artery Syndrome in a Patient with Cerebral Palsy Thu, 26 Jun 2014 10:53:26 +0000 Superior mesenteric artery syndrome involves compression of the third part of the duodenum due to narrowing of the area between the aorta and the superior mesenteric artery (SMA). We will describe the case of a 34-year-old with cerebral palsy who presented with abdominal pain, nausea, vomiting, and weight loss and was diagnosed with SMA syndrome via CT-imaging. With failure of conservative measures, our patient underwent a duodenojejunostomy after which improvement in her weight as well as relief of her abdominal symptoms was noted. Given the rarity of this syndrome, physicians need to keep a high index of suspicion in order to prevent the damaging consequences. Adi Neuman, Bhavita Desai, Daniel Glass, and Wassim Diab Copyright © 2014 Adi Neuman et al. All rights reserved. Regional Pericarditis or an Alternate Diagnosis? Thu, 26 Jun 2014 08:04:55 +0000 Lovely Chhabra, Mohammadtokir Mujtaba, and David H. Spodick Copyright © 2014 Lovely Chhabra et al. All rights reserved. Primary Small Cell Neuroendocrine Carcinoma of Paranasal Sinuses Wed, 25 Jun 2014 09:39:07 +0000 Small cell neuroendocrine carcinoma of the paranasal sinuses is an extremely rare and aggressive neoplasm. Despite aggressive management, the tumor carries a poor prognosis, with a high risk of local recurrence or distant metastases. The management strategy is based on that for pulmonary small cell cancer and includes platinum-based chemotherapy combined with radiotherapy. We are reporting a case of an 89-year-old female patient diagnosed with small cell carcinoma of right-sided ethmoid and sphenoid sinuses. The tumor was found to have invaded the right orbit and anterior cranial fossa. Metastases to cervical lymph nodes and bone were also found. Due to the extended stage and poor prognosis of the patient, the management plan is palliative chemoradiotherapy. Maliha Khan, Sobia Nizami, Aibek E. Mirrakhimov, Benjamin Maughan, Justin A. Bishop, and William H. Sharfman Copyright © 2014 Maliha Khan et al. All rights reserved. Gastrointestinal Involvement in Lipoid Proteinosis: A Ten-Year Follow-Up of a Brazilian Female Patient Thu, 19 Jun 2014 05:30:26 +0000 Lipoid proteinosis is a rare autosomal recessive disease characterized by the deposition of hyaline material in the skin and internal organs. The main clinical features are hoarseness and typical skin lesions. In this report we describe the endoscopic and radiologic findings in a Brazilian female patient presenting extensive gastrointestinal involvement and the evolution of the detected lesions in ten years of follow-up. Initial upper endoscopy and colonoscopy showed a similar pattern of multiple yellowish nodules throughout the esophagus, stomach, duodenum, and colons. Histological analysis confirmed the diagnosis of lipoid proteinosis. In addition, small bowel follow through demonstrated numerous well defined, round, small filling defects throughout the jejunum. Ten years later, the esophageal lesions remained the same, but none of the previous alterations were detected in the stomach, duodenum, and colons. In conclusion, lipoid proteinosis may affect all gastrointestinal organs with the same pattern of macroscopic and microscopic lesions. Some lesions may regress with increasing age. Juliana Custódio Lima, Cristiane Kibune Nagasako, Ciro Garcia Montes, Irene Harumi Kamata Barcelos, Rita Barbosa de Carvalho, and Maria Aparecida Mesquita Copyright © 2014 Juliana Custódio Lima et al. All rights reserved. A Large Cardiac Mass: Diagnosis of Caseous Mitral Annular Calcification and Determining Optimum Management Strategy Tue, 17 Jun 2014 00:00:00 +0000 A 64-year-old woman with dizziness and blurry vision underwent an evaluation for a possible stroke with a head-neck CT scan and a transthoracic echocardiogram. The head-neck CT scan was unremarkable, but the echocardiogram was notable for a  cm heterogeneous echodensity attached to the mitral valve. After a transesophageal echocardiogram and chest CT scan, the mass was determined to be a caseous mitral annular calcification, CMAC. This entity is a rare variant of MAC with an estimated prevalence of 0.068%. Echocardiographic techniques can distinguish CMAC from other intracardiac masses such as tumor, cyst, or abscess. CMAC is associated with cerebrovascular accidents; however, optimal treatment is controversial given the rarity of this clinical finding. Management strategies should be tailored based on the patient’s presentation, risk factors, and overall clinical circumstances. Emanuel A. Shapera, Afshin Karimi, and Luis R. Castellanos Copyright © 2014 Emanuel A. Shapera et al. All rights reserved. Lupus Flare: An Uncommon Presentation of Disseminated Gonorrhea Sun, 15 Jun 2014 11:39:56 +0000 Gonorrhea is one of the most common sexually transmitted diseases in the US with 700,000 annual cases. Although most cases of gonorrhea are localized, approximately 0.5–3% become disseminated. Here we discuss a rare case of a patient with systemic lupus erythematosus (SLE) who developed septic shock from disseminated gonorrhea infection (DGI). Our patient is a 24-year-old woman with SLE, mixed connective tissue disease with cutaneous vasculitis, and lupus nephritis who presented with several weeks of malaise and generalized body aches associated with a diffuse rash along her fingers, palms, and trunk. Infectious workup was unrevealing with the exception of a positive gonorrhea test obtained from a cervical swab. Given her symptoms of tenosynovitis, the appearance of her skin lesions, and her positive gonorrhea test, she was diagnosed with septic shock secondary to DGI. With antibiotic treatment, the patient reported a dramatic improvement of the pain in her swollen joints and her rash receded. Patients diagnosed with SLE carry an increased risk of gonorrhea regardless of whether or not they are being treated for their SLE. Although it is well-documented that SLE is associated with severe DGI, few describe it resulting in overt septic shock. Uyen To, Joyce Kim, and David Chia Copyright © 2014 Uyen To et al. All rights reserved. Acute Sciatic Neuritis following Lumbar Laminectomy Sun, 15 Jun 2014 06:49:32 +0000 It is commonly accepted that the common cause of acute/chronic pain in the distribution of the lumbosacral nerve roots is the herniation of a lumbar intervertebral disc, unless proven otherwise. The surgical treatment of lumbar disc herniation is successful in radicular pain and prevents or limits neurological damage in the majority of patients. Recurrence of sciatica after a successful disc surgery can be due to many possible etiologies. In the clinical setting we believe that the term sciatica might be associated with inflammation. We report a case of acute sciatic neuritis presented with significant persistent pain shortly after a successful disc surgery. The patient is a 59-year-old female with complaint of newly onset sciatica after complete pain resolution following a successful lumbar laminectomy for acute disc extrusion. In order to manage the patient’s newly onset pain, the patient had multiple pain management visits which provided minimum relief. Persistent sciatica and consistent physical examination findings urged us to perform a pelvic MRI to visualize suspected pathology, which revealed right side sciatic neuritis. She responded to the electrical neuromodulation. Review of the literature on sciatic neuritis shows this is the first case report of sciatic neuritis subsequent to lumbar laminectomy. Foad Elahi, Patrick Hitchon, and Chandan G. Reddy Copyright © 2014 Foad Elahi et al. All rights reserved. Cholangiocarcinoma Presenting with Hypercalcemia and Thrombocytopenia Sun, 15 Jun 2014 00:00:00 +0000 Malignant hypercalcemia and thrombocytopenia may result from bone metastasis of cholangiocarcinoma (CC). Our case was 53-year-old man admitted to emergency department with symptoms of anorexia, weight loss, nausea, vomiting, and general fatigue in February 2012. His laboratory findings showed hypercalcemia and thrombocytopenia. CT showed a large multinodular mass in the right lobe and, extending through left lobe of the liver. We considered the diagnosis of hypercalcemia of malignancy with elevated calcium levels and suppressed PTH level with the existence of skeletal bone metastasis and the absence of parathyroid gland pathology. Treatment of hypercalcemia with IV saline, furosemide, and calcitonin improved the patient symptoms. After the 8th day of admission, calcium level, thrombocytopenia, and other symptoms were normalized. Patient was sustained surgically inoperable and transferred to medical oncology department for the purpose of palliative chemotherapy and intended radiotherapy for bone metastasis. Hypercalcemia relapsed 4 weeks after discharge and patient died at the 5th month after admission due to disseminated metastasis. We should be aware of CC with symptomatic hypercalcemia and rarely low platelet count. The correction of hypercalcemia provides symptomatic relief and stability of patients. Muharrem Battal, Bünyamin Gürbulak, Ozgür Bostanci, Müveddet Banu Yılmaz, Yasar Ozdenkaya, and Oguzhan Karatepe Copyright © 2014 Muharrem Battal et al. All rights reserved. Disseminated BCG: Complications of Intravesical Bladder Cancer Treatment Thu, 12 Jun 2014 07:22:25 +0000 Intravesical bacillus Calmette-Guerin (BCG) has been established as an effective treatment of superficial bladder cancer (Parker and Kommu, 2013). However, major side effects, including pneumonitis, sepsis, and even death, may occur in <5% of patients (Gonzalez et al., 2003). Here we present a case of severe disseminated Mycobacterium bovis following intravesical BCG administration. Our patient is a 76-year-old gentleman with newly diagnosed superficial transitional cell carcinoma of the bladder who recently received his first intravesical BCG treatment. He initially presented with hemoptysis and was found to have extensive patchy infiltrates bilaterally. He was treated for pneumonia with antibiotics and then with steroids for hypersensitivity pneumonitis but continued to deteriorate. Due to the temporal proximity of his exposure to BCG, we administered treatment for presumed disseminated BCG infection with rifampin, isoniazid, and ethambutol. Within a 48-hour period, the patient improved dramatically. The reported cases of infection from intravesical BCG illustrate an insidious onset with initial symptoms of low-grade fevers and cystitis but may progress to pneumonitis. If the symptoms persist for more than 7 days or if there is clinical deterioration, RIPE therapy (with rifampin, isoniazid, pyridoxine, and ethambutol) and a fluoroquinolone should be administered for a 6–9-month course along with steroids for 4–6 weeks (Naudžiunas et al., 2012). Uyen To, Joyce Kim, and David Chia Copyright © 2014 Uyen To et al. All rights reserved. Strongyloidiasis and Diffuse Alveolar Hemorrhage in a Patient with Systemic Lupus Erythematosus Thu, 12 Jun 2014 06:51:44 +0000 The presence of Strongyloides stercoralis infection in patients with systemic lupus erythematosus (SLE) has been described previously. Strongyloides stercoralis hyperinfection syndrome (SHS) that usually develops in patients under immunosuppressive therapy may affect a variety of organs, but the presentation with diffuse alveolar hemorrhage (DAH) is rare with only a few cases described in the literature. We present the case of a 36-year-old Hispanic female with a past medical history relevant for SLE and a recent diagnosis of lupus nephritis and hypertension. The patient who developed sudden and progressive abdominal pain and respiratory distress, with the presence of bilateral crackles and severe hypoxemia, is currently under treatment with steroids and cyclophosphamide for worsening of lupus nephritis. The patient underwent endotracheal intubation and mechanical ventilation, and computed tomography showed the presence of bilateral pulmonary infiltrates suggestive of DAH. Bronchoalveolar lavage was done and showed the presence of filariform larvae, morphologically consistent with Strongyloides stercoralis. Treatment with ivermectin was started and patient responded to treatment with improvement of clinical status. In conclusion, the development of SHS in patients with lupus, especially when receiving immunosuppressive therapy, is a severe and potentially fatal complication. Early detection and treatment may decrease mortality. Fernando Gonzalez-Ibarra, Parag Chevli, Lindsey Schachter, Maninder Kaur, Sahar Eivaz-Mohammadi, Basheer Tashtoush, Jioty Matta, Amer K. Syed, and Valentin Marian Copyright © 2014 Fernando Gonzalez-Ibarra et al. All rights reserved. Histoplasmosis Presenting as Granulomatous Hepatitis: Case Report and Review of the Literature Mon, 09 Jun 2014 11:46:50 +0000 Background. Histoplasma capsulatum is the most common endemic mycosis in the United States and is a frequent cause of opportunistic infection in immunodeficient hosts. Histoplasmosis is most often self-limiting and goes unrecognized in the immunocompetent population but can progress to disseminated histoplasmosis in patients with an impaired immune system. Liver involvement as a part of disseminated histoplasmosis which usually originates in the lung is well known. However, extrapulmonary hepatic histoplasmosis as a primary manifestation is extremely rare. Case Presentation. We report a rare case of histoplasmosis that presented as persistent fever and abnormal liver function tests in a 66-year-old female with rheumatoid arthritis, receiving infliximab. Conclusion. Emphasizing histoplasmosis as a major cause of acute granulomatous hepatitis and fever of unknown origin in cell mediated immunodeficient population, this case highlights the need for high index of suspicion and the importance of prompt diagnosis since any delay of treatment can be life threatening in this population. Nancy A. Rihana, Manasa Kandula, Ana Velez, Kumud Dahal, and Edward B. O’Neill Copyright © 2014 Nancy A. Rihana et al. All rights reserved.