Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Tuberculous Lymphadenitis Mimicking Nodal Metastasis in Follicular Variant Papillary Thyroid Carcinoma Mon, 26 Sep 2016 13:41:12 +0000 Tuberculous (TB) lymphadenitis can mimic cervical node metastasis from papillary thyroid carcinoma (PTC) since the distribution and appearance of affected lymph nodes are similar. We present the case of an asymptomatic 50-year-old Filipino who sought consult for a gradually enlarging anterior neck mass and a single palpable cervical lymph node. Preoperative workup suggested a thyroid malignancy with nodal metastasis. He underwent total thyroidectomy with node dissection where histopathology confirmed follicular variant- (FV-) PTC. Lymph node examination, however, revealed TB lymphadenitis, and the patient was given standard antimycobacterial therapy. This is the first documented case in Southeast Asia, a high TB burden region. This is also the first report involving FV-PTC, which has features between those of conventional PTC and follicular thyroid carcinoma. The case suggests that, in endemic areas, TB should be a differential in the etiology of cervical lymphadenopathy in PTC patients. In developed countries, this differential diagnosis is also valuable because of the increasing incidence of HIV and TB coinfection. Proper preoperative evaluation is important and needs to be highlighted in the formulation of local guidelines. Marc Gregory Yu and Jenny Maureen Atun Copyright © 2016 Marc Gregory Yu and Jenny Maureen Atun. All rights reserved. Myeloid Neoplasms with t(5;12) and ETV6-ACSL6 Gene Fusion, Potential Mimickers of Myeloid Neoplasm with PDGFRB Rearrangement: Case Report with Imatinib Therapy and Review of the Literature Mon, 26 Sep 2016 06:48:24 +0000 We report the second case of ETV6-ACSL6 associated myeloproliferative neoplasm that has received a full course of imatinib therapy. The patient was a 51-year-old previously healthy man who presented with three months of worsening dyspnea and was found to have a white count of 216,000/cmm, of which 84% were eosinophil lineage. Cytogenetic analysis revealed a t(5;12)(q31~33;p13). FISH was negative for PDGFRB rearrangement but additional FISH testing demonstrated an ACSL6 rearrangement. ETV6-ACSL6 gene fusion is a rare abnormality that most often presents as a myeloproliferative-type disorder with prominent eosinophilia or basophilia. Review of the literature yielded a total of 11 previous cases. This gene fusion results in a t(5;12)(q31~33;p13) that mimics the t(5;12) found in ETV6-PDGFRB neoplasms. Identification of the fusion genes involved in t(5;12) in eosinophilia-associated myeloproliferative disorders is crucial to direct an effective treatment plan. In particular, while tyrosine kinase inhibitor therapy is effective in patients with PDGFRB rearrangement, there is little information on imatinib efficacy in patients with ETV6-ACSL6 gene fusion. Our patient was found to be nonresponsive to imatinib therapy. Javier De Luca-Johnson, Jose I. Ruades Ninfea, Lauren Pearson, Joanna Conant, Ronald Bryant, Neil A. Zakai, and Mary E. Tang Copyright © 2016 Javier De Luca-Johnson et al. All rights reserved. Hyperammonemia: What Urea-lly Need to Know: Case Report of Severe Noncirrhotic Hyperammonemic Encephalopathy and Review of the Literature Wed, 21 Sep 2016 13:11:46 +0000 Purpose. A 66-year-old man who presented with coma was found to have isolated severe hyperammonemia and diagnosed with a late-onset urea-cycle disorder. He was treated successfully and had full recovery. Methods. We report a novel case of noncirrhotic hyperammonemia and review the literature on this topic. Selected literature for review included English-language articles concerning hyperammonemia using the search terms “hyperammonemic encephalopathy”, “non-cirrhotic encephalopathy”, “hepatic encephalopathy”, “urea-cycle disorders”, “ornithine transcarbamylase (OTC) deficiency”, and “fulminant hepatic failure”. Results. A unique case of isolated hyperammonemia diagnosed as late-onset OTC deficiency is presented. Existing evidence about hyperammonemia is organized to address pathophysiology, clinical presentation, diagnosis, and treatment. The case report is discussed in context of the reviewed literature. Conclusion. Late-onset OTC deficiency presenting with severe hyperammonemic encephalopathy and extensive imaging correlate can be fully reversible if recognized promptly and treated aggressively. Ruby Upadhyay, Thomas P. Bleck, and Katharina M. Busl Copyright © 2016 Ruby Upadhyay et al. All rights reserved. Recurrence of Acute Page Kidney in a Renal Transplant Allograft Tue, 20 Sep 2016 07:27:06 +0000 Acute Page Kidney (APK) phenomenon is a rare cause of secondary hypertension, mediated by activation of renin-angiotensin-aldosterone system (RAAS). Timely intervention is of great importance to prevent any end organ damage from hypertension. We present a unique case of three episodes of APK in the same renal transplant allograft. Rajan Kapoor, Carlos Zayas, Laura Mulloy, and Muralidharan Jagadeesan Copyright © 2016 Rajan Kapoor et al. All rights reserved. Management of Severe Rhabdomyolysis and Exercise-Associated Hyponatremia in a Female with Anorexia Nervosa and Excessive Compulsive Exercising Mon, 19 Sep 2016 11:37:02 +0000 This case report describes the management of a 49-year-old female with restricting-type anorexia nervosa and excessive compulsive exercising associated with rhabdomyolysis, high levels of serum creatine kinase (CK) (3,238 U/L), and marked hyponatremia (Na+: 123 mEq/L) in the absence of purging behaviours or psychogenic polydipsia; it is the first case report to describe exercise-associated hyponatremia in a patient with anorexia nervosa. The patient, who presented with a body mass index (BMI) of 13.4 kg/m2, was successfully treated by means of an adapted inpatient version of an enhanced form of cognitive behavioural therapy (CBT-E). Within a few days, careful water restriction, solute refeeding, and the specific cognitive behavioural strategies and procedures used to address the patient’s excessive compulsive exercising and undereating produced a marked reduction in CK levels, which normalised within one week. Exercise-associated hyponatremia also gradually improved, with serum sodium levels returning to normal within two weeks. The patient thereby avoided severe complications such as cerebral or pulmonary oedema or acute renal failure and was discharged after 20 weeks of treatment with a BMI of 19.0 kg/m2 and improved eating disorder psychopathology. Marwan El Ghoch, Simona Calugi, and Riccardo Dalle Grave Copyright © 2016 Marwan El Ghoch et al. All rights reserved. The Association of Pseudohypoparathyroidism Type Ia with Chiari Malformation Type I: A Coincidence or a Common Link? Wed, 14 Sep 2016 07:03:16 +0000 A 19-month-old boy was referred for progressive weight gain. His past medical history included congenital hypothyroidism and developmental delay. Physical examination revealed characteristics of Albright Hereditary Osteodystrophy, macrocephaly, and calcinosis cutis. He had hypocalcemia, hyperphosphatemia, and elevated Parathyroid Hormone levels. Genetic testing revealed a known mutation of GNAS gene, confirming the diagnosis of Pseudohypoparathyroidism Type Ia (PHP-Ia) (c.34C>T (p.G1n12X)). He had a normal brain MRI at three months, but developmental delay prompted a repeat MRI that revealed Chiari Malformation Type I (CM-I) with hydrocephalus requiring neurosurgical intervention. This was followed by improvement in attaining developmental milestones. Recently, he was diagnosed with growth hormone deficiency. This case suggests the potential association of CM-I with PHP-Ia. Larger studies are needed to assess whether CM-I with hydrocephalus are common associations with PHP-Ia and to define potential genetic links between these conditions. We propose a low threshold in performing brain MRI on PHP-1a patients, especially those with persistent developmental delay to rule out CM-I. Early intervention may improve neurodevelopmental outcomes and prevent neurosurgical emergencies. Paria Kashani, Madan Roy, Linda Gillis, Olufemi Ajani, and M. Constantine Samaan Copyright © 2016 Paria Kashani et al. All rights reserved. Henoch Schonlein Purpura as a Cause of Renal Failure in an Adult Thu, 08 Sep 2016 13:03:11 +0000 Henoch Schonlein purpura (HSP) is an immune mediated disease associated Immunoglobulin A (IgA) deposition within the affected organs. While the disease is commonly seen in the pediatric age group, it is rarely seen in adults. We report the case of a 93-year-old Caucasian lady who presented with nonthrombocytopenic purpuric rash and acute kidney injury after an episode of bronchitis. Rapid and progressive deterioration of renal function prompted a kidney biopsy, which showed findings consistent with IgA nephropathy confirming the diagnosis of HSP. The patient was treated with high dose intravenous methylprednisolone followed by oral prednisone; however, her kidney disease progressed to end stage renal disease requiring hemodialysis. HSP is usually a self-limiting disease in children. However, adults are at an increased risk of severe renal involvement including end stage renal disease. Purpuric skin rash with renal involvement should raise suspicion for HSP. This is the oldest known patient with HSP. Shweta Kukrety, Pradeepa Vimalachandran, Rajesh Kunadharaju, Vishisht Mehta, Agnes Colanta, and Mahmoud Abu Hazeem Copyright © 2016 Shweta Kukrety et al. All rights reserved. A Case of Malignant Biliary Obstruction with Severe Obesity Successfully Treated by Endoscopic Ultrasonography-Guided Biliary Drainage Tue, 06 Sep 2016 11:51:41 +0000 Here, we present a case of malignant biliary tract obstruction with severe obesity, which was successfully treated by endoscopic ultrasonography-guided biliary drainage (EUS-BD). A female patient in her sixties who had been undergoing chemotherapy for unresectable pancreatic head cancer was admitted to our institution for obstructive jaundice. She had diabetes mellitus, and her body mass index was 35.1 kg/m2. Initially, endoscopic retrograde cholangiopancreatography (ERCP) was performed, but bile duct cannulation was unsuccessful. Percutaneous transhepatic biliary drainage (PTBD) from the left hepatic biliary tree also failed. Although a second PTBD attempt from the right hepatic lobe was accomplished, biliary tract bleeding followed, and the catheter was dislodged. Consequently, EUS-BD (choledochoduodenostomy), followed by direct metallic stent placement, was performed as a third drainage method. Her postprocedural course was uneventful. Following discharge, she spent the rest of her life at home without recurrent jaundice or readmission. In cases of severe obesity, we consider EUS-BD, rather than PTBD, as the second drainage method of choice for distal malignant biliary obstruction when ERCP fails. Takashi Obana and Shuuji Yamasaki Copyright © 2016 Takashi Obana and Shuuji Yamasaki. All rights reserved. A Giant Renal Vein Aneurysm in a Patient with Liver Cirrhosis Tue, 06 Sep 2016 07:37:38 +0000 We present an unusual case of a 40-year-old female patient with liver cirrhosis and diffuse abdominal pain. The imaging studies revealed a huge renal vein aneurysm. The patient refused any interventional management, despite the risk of possible rupture, and after a week of mild pain therapy, she was discharged. She was followed up closely, and after one year, she remains asymptomatic. Conservative management of such patients has been described before with success. However, open repair or percutaneous thrombosis of the aneurysm remains the indicated therapy, when vein patency is an issue for organ viability. Konstantinos Filis, George Galyfos, and Ioannis Ketikoglou Copyright © 2016 Konstantinos Filis et al. All rights reserved. Successful Tocilizumab Therapy for Macrophage Activation Syndrome Associated with Adult-Onset Still’s Disease: A Case-Based Review Mon, 05 Sep 2016 14:06:51 +0000 We report the case of a 71-year-old Japanese woman with adult-onset Still’s disease (AOSD) in whom macrophage activation syndrome (MAS) developed despite therapy with oral high-dose prednisolone and intravenous methylprednisolone pulse therapy twice. She was successfully treated with tocilizumab (TCZ). Soon afterward, her fever ceased and high levels of both ferritin and C-reactive protein levels decreased. Her course was complicated by disseminated intravascular coagulation, cytomegalovirus infection, and Pneumocystis jirovecii pneumonia. After these were resolved, AOSD-associated MAS was well controlled. She was discharged on hospital day 87. Although biologics such as TCZ are becoming established for the treatment of AOSD, there is no recommended therapy for AOSD-associated MAS. Several biologics have been tried for this complication, but their efficacy and safety remain controversial. We reviewed reported cases of AOSD-associated MAS successfully treated with various biologics. TCZ initiation after adequate nonselective immunosuppressive therapy, such as methylprednisolone pulse therapy or a prednisolone-based combination of immunosuppressants, can be an effective treatment for AOSD-associated MAS. On the other hand, biologics given after insufficient immunosuppressive therapy may cause MAS. A strategy combining adequate immunosuppression and a biologic could be safe if special attention is given to adverse events such as opportunistic infections or biologic-associated MAS. Eri Watanabe, Hitoshi Sugawara, Takeshi Yamashita, Akira Ishii, Aya Oda, and Chihiro Terai Copyright © 2016 Eri Watanabe et al. All rights reserved. Supine Frequent Ventricular Extrasystoles in a Pregnant Woman without Structural Heart Disease Thu, 25 Aug 2016 16:52:23 +0000 Arrhythmias are the most common cardiac complication during gestational period and may occur in women with or without known structural heart disease. Premature extra beats and sustained tachyarrhythmias are the most common arrhythmias in pregnancy. Symptomatic episodes occur in 20–44% of pregnant women, usually as palpitations, dizziness, or syncope. We searched on Pubmed for ventricular premature complexes (VPC) in pregnant women and found no case reporting increased incidence of this arrhythmia while supine. The aim of this study is to report a case of a pregnant woman without previous structural heart disease that presented a great number of VPC when supine. The arrhythmogenesis increase during pregnancy is multifactorial. In the reported case, we believe that augmented venous return was the most important pathophysiologic process. When the patient changes to left lateral decubitus, there could be a sudden release of the inferior vena cava, causing an abrupt augmentation of venous return to the right heart chambers and increasing the risk of arrhythmias. Obstetricians and primary care physicians should be aware of palpitations and related patient complains while they are asleep or supine. Natália Stela Sandes Ferreira, Tatiana La Croix Barros, and Ronaldo Altenburg Gismondi Copyright © 2016 Natália Stela Sandes Ferreira et al. All rights reserved. Idiopathic Sclerosing Encapsulating Peritonitis: A Rare Cause of Subacute Intestinal Obstruction Thu, 25 Aug 2016 16:28:19 +0000 We present a case of a previously healthy 50-year-old gentleman who had recurrent vomiting and abdominal pain of two-month duration. The patient was subsequently diagnosed with abdominal cocoon on computed tomography. Idiopathic sclerosing encapsulating peritonitis, also known as abdominal cocoon, is a rare cause of small bowel obstruction. Visualization of variable encasement of the small bowel loops by a characteristic membranous sac, either preoperatively with cross-sectional imaging or intraoperatively, is the key to diagnosis. This is a highly treatable condition; surgical excision of the sac with adhesiolysis facilitates a full recovery in affected patients. Mei Chin Lim, Niketa Chandrakant Chotai, and Danilo Medina Giron Copyright © 2016 Mei Chin Lim et al. All rights reserved. Myocardial Infarction and Aortic Root Mycotic Aneurysm Complicating Aortic Valve Endocarditis: Utility of Cardiac CT Thu, 25 Aug 2016 13:43:20 +0000 Aortic mycotic aneurysms are a rare but life-threatening potential complication of infective endocarditis. Rapid deterioration of the vascular wall in highly focal areas makes these pseudoaneurysms particularly prone to rupture, resulting in uncontrolled aortic hemorrhage. While computed tomography angiography (CTA) is the imaging modality of choice for the evaluation of mycotic aneurysms, it is not routinely performed in patients with known or suspected infective endocarditis (IE). However, current valvular heart disease guidelines support the use of cardiac CTA in cases of IE and suspected perivalvular extension when there is inadequate or ambiguous visualization on echocardiography. Here, we describe a case of IE in which cardiac CTA was used for two purposes: to assess perivalvular complications and to define coronary anatomy in a patient with a suspected embolic myocardial infarction. Subsequent detection of an aortic root mycotic aneurysm not previously demonstrated on transthoracic or transesophageal echocardiography allowed for timely and uncomplicated surgical intervention, while avoiding invasive coronary angiography. Aimee E. Moores, Michael S. Cahill, and Todd C. Villines Copyright © 2016 Aimee E. Moores et al. All rights reserved. Effectiveness of a Short-Term Treatment of Oxygen-Ozone Therapy into Healing in a Posttraumatic Wound Mon, 22 Aug 2016 16:47:38 +0000 Introduction. A number of studies suggest that oxygen-ozone therapy may have a role in the treatment of chronic, nonhealing, or ischemic wounds for its disinfectant and antibacterial properties. Nonhealing wounds are a significant cause of morbidity. Here we present a case of subcutaneous oxygen-ozone therapy used to treat a nonhealing postoperative wound in a young man during a period of 5 weeks. Case Presentation. A 46-year-old man had a motorcycle accident and underwent amputation of the right tibia and fibula. At the discharge he came to our attention to start rehabilitation treatment. At that time the wound was ulcerated but it was afebrile with no signs of inflammation and negativity to blood tests. At 2 months from the trauma despite appropriate treatment and dressing, the wound was slowly improving and the patient complained of pain. For this reason in addition to standard dressing he underwent oxygen-ozone therapy. After 5 weeks of treatment the wound had healed. Conclusion. In patients with nonhealing wounds, oxygen-ozone therapy could be helpful in speeding the healing and reducing the pain thanks to its disinfectant property and by the increase of endogenous oxygen free radicals’ scavenging properties. Compared to standard dressing and other treatments reported in the literature it showed a shorter time of action. Irene Degli Agosti, Elena Ginelli, Bruno Mazzacane, Gabriella Peroni, Sandra Bianco, Fabio Guerriero, Giovanni Ricevuti, Simone Perna, and Mariangela Rondanelli Copyright © 2016 Irene Degli Agosti et al. All rights reserved. An Unexpected Interaction between Sofosbuvir/Ledipasvir and Atorvastatin and Colchicine Causing Rhabdomyolysis in a Patient with Impaired Renal Function Mon, 22 Aug 2016 16:45:51 +0000 Hepatitis C virus (HCV) infection affects roughly 170 million people worldwide. Sofosbuvir/Ledipasvir (Sof/Led) is a new once daily direct acting antiviral combination pill that was approved in October 2014 for use in patients with HCV genotype 1 infection. Coadministration of Sof/Led is studied only with rosuvastatin which shows significantly increased level of drug and is associated with increased risk of myopathy, including rhabdomyolysis. There is no mention of such HMG-CoA reductase inhibitor interaction as a class, as pravastatin did not have any clinically significant interaction with Sof/Led. Other myotoxic drugs, including colchicine are not studied. We present a case of a serious drug interaction between Sof/Led and atorvastatin, in the background of CKD and colchicine use. Shyam Patel, Jennifer Andres, and Kamran Qureshi Copyright © 2016 Shyam Patel et al. All rights reserved. Clinical Evolution of Central Pontine Myelinolysis in a Patient with Alcohol Withdrawal: A Blurred Clinical Horizon Tue, 16 Aug 2016 11:55:05 +0000 Central pontine myelinolysis (CPM), a potentially fatal and debilitating neurological condition, was first described in 1959 in a study on alcoholic and malnourished patients. It is a condition most frequently related to rapid correction of hyponatremia. Chronic alcoholism associated CPM tends to be benign with a favorable prognosis compared to CPM secondary to rapid correction of hyponatremia. We describe a normonatremic, alcoholic patient who presented with CPM after a rapid rise in his sodium levels. Our case illustrates the fact that CPM can manifest even in patients who are normonatremic at baseline. Rapid rises in sodium levels should be promptly reversed before clinical symptoms manifest in patient with risk factors for CPM irrespective of their baseline sodium levels. Furthermore, clinical evolution of CPM can be difficult to discern from the natural course of alcohol withdrawal delirium, requiring astuteness and maintenance of a high degree of clinical suspicion on the part of the physician. Abdul S. Mohammed, Prajwal Boddu, and Dina F. Yazdani Copyright © 2016 Abdul S. Mohammed et al. All rights reserved. Endobronchial Carcinoid Tumour with Extensive Ossification: An Unusual Case Presentation Tue, 16 Aug 2016 10:37:49 +0000 Carcinoid tumour is a well-known primary endobronchial lung neoplasm. Although calcifications may be seen in up to 30% of pulmonary carcinoid tumours, near complete ossification of these tumours is an unusual finding. Such lesions can prove diagnostically challenging at the time of intraoperative frozen section as the latter technique requires thin sectioning of the lesion for microscopic assessment. We present an unusual case of endobronchial carcinoid tumour with extensive ossification in a 45-year-old male. Preliminary intraoperative diagnosis was achieved through the alternative use of cytology scrape smears. The final diagnosis was confirmed after decalcification of the tumour. The prognostic implications of heavily ossified carcinoid tumours remain elusive. Long-term clinical follow-up of these patients is recommended. Allison Osmond, Emily Filter, Mariamma Joseph, Richard Inculet, Keith Kwan, and David McCormack Copyright © 2016 Allison Osmond et al. All rights reserved. Mounier-Kuhn Syndrome in an Elderly Female with Pulmonary Fibrosis Mon, 15 Aug 2016 08:09:46 +0000 Mounier-Kuhn syndrome (MKS), or tracheobronchomegaly, is a rare clinical and radiologic condition characterized by pronounced tracheobronchial dilation and recurrent lower respiratory tract infections. Tracheobronchomegaly presents when the defect extends to the central bronchi. MKS can be diagnosed in adult women when the transverse and sagittal diameters of the trachea, right mainstem bronchus, and left mainstem bronchus exceed 21, 23, 19.8, and 17.4 mm, respectively. Its diagnosis is based on chest radiograph and chest computed tomography (CT). Patients, usually middle-aged men, may be asymptomatic or present with clinical manifestations ranging from minimal symptoms with preserved lung function to severe respiratory failure. Pulmonary function tests (PFTs) typically reveal a restrictive pattern. This report presents an elderly woman with previously diagnosed pulmonary fibrosis with symptoms of increased sputum production and haemoptysis. High-resolution chest CT showed tracheal and main stem bronchi dilatation along with bronchial diverticulosis. PFTs indicated a restrictive pattern characteristic of the underlying pulmonary fibrosis. The patient is the oldest, referred to the female gender, at presentation of MKS hitherto reported. This case highlights the need to include MKS in the differential diagnosis of recurrent lower respiratory tract infections, even in older subjects. Panagiotis Boglou, Nikolaos Papanas, Anastasia Oikonomou, Stamatia Bakali, and Paschalis Steiropoulos Copyright © 2016 Panagiotis Boglou et al. All rights reserved. Ulipristal Acetate in Myomectomy Optimization in an Infertile Patient with Giant Myomas Wed, 10 Aug 2016 09:07:29 +0000 The use of ulipristal acetate (UPA) has been recently introduced in the treatment of uterine leiomyomas. This drug has proven useful to control menometrorrhagia and to reduce myoma size. In the case presented here, we show the benefits of UPA treatment in facilitating surgical removal of giant myomas in an infertile patient. In addition to myoma reduction and a better control of preoperative bleeding, the treatment with UPA reduced the duration and complexity of the surgery, as well as the area of uterine wall involved and the resulting scar. No side effects were observed and the patient became pregnant 6 months after the surgery and had a normal pregnancy and delivery. This case report shows the beneficial effects of UPA in the preoperative treatment of myomas which affect uterus function. Elena de la Fuente, María Dolores Borrás, Miriam Rubio, and Nuria Abril Copyright © 2016 Elena de la Fuente et al. All rights reserved. Tracheobronchial Amyloidosis Mimicking Tracheal Tumor Tue, 09 Aug 2016 07:49:23 +0000 Tracheobronchial amyloidosis is a rare presentation and accounts for about 1% of benign tumors in this area. The diagnosis of disease is delayed due to nonspecific pulmonary symptoms. Therapeutic approaches are required to control progressive pulmonary symptoms for most of the patients. Herein, we report a case of a 68-year-old man admitted with progressive dyspnea to our institution for further evaluation and management. He was initially diagnosed with and underwent management for bronchial asthma for two years but had persistent symptoms despite optimal medical therapy. Pulmonary computed tomography scan revealed severe endotracheal stenosis. Bronchoscopy was performed and showed endotracheal mass obstructing 70% of the distal trachea and mimicking a neoplastic lesion. The mass was successfully resected by mechanical resection, argon plasma coagulation (APC), and Nd-YAG laser during rigid bronchoscopy. Biopsy materials showed deposits of amorphous material by hematoxylin and eosin staining and these deposits were selectively stained with Congo Red. Although this is a rare clinical condition, this case indicated that carrying out a bronchoscopy in any patient complaining of atypical bronchial symptoms or with uncontrolled asthma is very important. Elif Tanrıverdi, Mehmet Akif Özgül, Oğuz Uzun, Şule Gül, Mustafa Çörtük, Zehra Yaşar, Murat Acat, Naciye Arda, and Erdoğan Çetinkaya Copyright © 2016 Elif Tanrıverdi et al. All rights reserved. Hyperemesis Gravidarum in Undiagnosed Gitelman’s Syndrome Sun, 07 Aug 2016 12:46:54 +0000 Introduction. Gitelman’s syndrome (GS) is an autosomal recessive inherited defect in the thiazide-sensitive sodium-chloride cotransporter (NCCT) in the renal distal convoluted tubule. Physiologic changes of pregnancy promote renal potassium wasting, but serum potassium levels are kept in the physiologic range by increased levels of progesterone, which resist kaliuresis. In the presence of GS, this compensatory mechanism is easily overwhelmed, resulting in profound hypokalemia. We present a case of an 18-year-old primigravida with undiagnosed GS who presented with hyperemesis gravidarum in her 7th week of pregnancy. This report adds to the limited experience with GS in pregnancy as reported in literature and provides additional information on medical management that leads to successful maternal and fetal outcomes. Maria Czarina Acelajado, R. Michael Culpepper, and Wilburn D. Bolton III Copyright © 2016 Maria Czarina Acelajado et al. All rights reserved. IL-6-Producing, Noncatecholamines Secreting Pheochromocytoma Presenting as Fever of Unknown Origin Sun, 07 Aug 2016 07:28:10 +0000 Fever of unknown origin (FUO) can be an unusual first clinical manifestation of pheochromocytoma. Pheochromocytomas are tumors that may produce a variety of substances in addition to catecholamines. To date, several cases of IL-6-producing pheochromocytomas have been reported. This report describes a 45-year-old woman with pheochromocytoma who was admitted with FUO, normal blood pressure levels, microcytic and hypochromic anemia, thrombocytosis, hyperfibrinogenemia, hypoalbuminemia, and normal levels of urine and plasma metanephrines. After adrenalectomy, fever and all inflammatory findings disappeared. Marco Ciacciarelli, Davide Bellini, Andrea Laghi, Alessandro Polidoro, Antonio Pacelli, Anna Giulia Bottaccioli, Giuseppina Palmaccio, Federica Stefanelli, Piera Clemenzi, Luisa Carini, Luigi Iuliano, and Cesare Alessandri Copyright © 2016 Marco Ciacciarelli et al. All rights reserved. Amelioration of Sickle Cell Pain after Parathyroidectomy in Two Patients with Concurrent Hyperparathyroidism: An Interesting Finding Thu, 04 Aug 2016 09:16:24 +0000 Patients with sickle cell disease have high morbidity and healthcare utilization due to repeated painful crises. Some coexisting conditions which cause pain similar to sickle cell disease may go undiagnosed in these patients. We report two adults with concurrent hyperparathyroidism who experienced significant improvement in sickle cell pain following parathyroidectomy thereby pointing to hyperparathyroidism as the principal causative factor for their pain. Meticulous evaluation for parathyroid disorders can be rewarding in sickle cell disease. John Muthu and Mir Ali Copyright © 2016 John Muthu and Mir Ali. All rights reserved. Needle Fracture during Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Suspicious Thoracic Lymph Nodes Sun, 31 Jul 2016 08:52:29 +0000 Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is used to make a cytopathologic diagnosis of suspicious lesions located around the gastrointestinal tract. It is a safe technique with few complications. The most common complications of EUS-FNA are related to pancreatic lesions (pancreatitis, bleeding, and abdominal pain). Rare complications have been noted such as stent malfunction, air embolism, infection, neural and vascular injuries, and tumor cell seeding. There are very few studies examining equipment malfunctions. We report a case of needle fracture during the EUS-FNA of suspicious thoracic lymph nodes in a 79-year-old man investigated for unexplained weight loss. Bartosz Adamowicz, Thibaut Manière, Vincent Déry, and Étienne Désilets Copyright © 2016 Bartosz Adamowicz et al. All rights reserved. Simultaneous Two-Vessel Subacute Stent Thrombosis Caused by Clopidogrel Resistance from CYP2C19 Polymorphism Sun, 31 Jul 2016 08:50:49 +0000 Clopidogrel resistance from CYP2C19 polymorphism has been associated with stent thrombosis in patients undergoing percutaneous coronary intervention with drug-eluting stents. We present a case of a 76-year-old male who received drug-eluting stents to the right coronary artery and left anterior descending artery for non-ST elevation myocardial infarction and was discharged on dual antiplatelet therapy with aspirin and clopidogrel. He subsequently presented with chest pain from anterior, anteroseptal, and inferior ST segment elevation myocardial infarction. An emergent coronary angiogram revealed acute stent thrombosis with 100% occlusion of RCA and LAD that was successfully treated with thrombus aspiration and angioplasty. Although he was compliant with his dual antiplatelet therapy, he developed stent thrombosis, which was confirmed as clopidogrel resistance from homozygous CYP2C19 polymorphism. Ashwad Afzal, Bimal Patel, Neel Patel, Sudhakar Sattur, and Vinod Patel Copyright © 2016 Ashwad Afzal et al. All rights reserved. Systemic Sarcoidosis Unmasked by Cushing’s Disease Surgical Treatment Mon, 25 Jul 2016 09:41:34 +0000 Diseases responsive to glucocorticoids, like sarcoidosis, are rarely masked by Cushing’s syndrome. An ACTH secreting pituitary adenoma is a possible cause of Cushing’s syndrome and its resection can make a subclinical sarcoidosis clear. Only few cases of sarcoidosis following the treatment of hypercortisolism are reported in literature. We report a case of sarcoidosis after the resection of an ACTH secreting pituitary adenoma. Daniele Bongetta, Cesare Zoia, Francesco Lombardi, Elisabetta Lovati, Pietro Lucotti, and Paolo Gaetani Copyright © 2016 Daniele Bongetta et al. All rights reserved. Multiple Small Coronary Artery Fistulas Emptying into the Left Ventricle: A Rare but Challenging Problem Mon, 25 Jul 2016 08:35:24 +0000 A coronary artery fistula (CAF) is an abnormal communication between a coronary artery and a cardiac chamber or a great vessel. CAFs are rare based on coronary arteriography and when found they most often empty into the right ventricle and atrium and less often into the high pressure, low compliance left ventricle (LV). A patient who presented with atypical chest pain and was found to have multiple small CAFs originating from the ramus intermedius coronary artery and emptying into the LV is presented. This case highlights the challenges in providing an appropriate therapy for multiple small CAFs emptying into the LV. Omar Kahaly and Konstantinos Dean Boudoulas Copyright © 2016 Omar Kahaly and Konstantinos Dean Boudoulas. All rights reserved. Ulcerative Colitis Activity Presenting as Fever of Unknown Origin, in a Patient with Longstanding Disease under Continuous Treatment with Mesalazine Mon, 18 Jul 2016 12:42:15 +0000 Background. The presence of ulcerative colitis (UC) with no bowel symptoms, as fever of unknown origin (FUO), is uncommon. Objective. To describe the case of an 80-year-old woman who presented with fever, with a history of UC under treatment with mesalazine. Case Presentation. She was admitted due to fever lasting for 12 days with no associated symptoms. Seven years earlier, she was diagnosed with UC. After an extended workup for FUO that failed to reach the diagnosis, she underwent a gallium-67 scintigraphy. This revealed a persistent diffuse concentration of gallium-67 in the ascending colon at 24-hour imaging that remained stable at 48- and 72-hour imaging without any topographic change after the use of laxatives. Considering the results and in the absence of another diagnosis, the patient was treated with 30 mg prednisone daily and mesalazine, as treatment of active UC. Subsequently, the patient’s condition improved markedly and the fever retreated. One month later, she was reevaluated with a gallium-67 scintigraphy with total absence of gallium-67 concentration in the ascending colon. Conclusion. UC activity must be included in the differential diagnosis of FUO in patients with longstanding disease, since fever may present alone, with no other manifestations. Panagiota Voukelatou, Elissavet Sfendouraki, Theodoros Karianos, Sofia Saranti, Dimitrios Tsitsimelis, Ioannis Vrettos, and Andreas Kalliakmanis Copyright © 2016 Panagiota Voukelatou et al. All rights reserved. Diversification of Antitumour Immunity in a Patient with Metastatic Melanoma Treated with Ipilimumab and an IDO-Silenced Dendritic Cell Vaccine Mon, 18 Jul 2016 08:19:14 +0000 Indoleamine 2,3-dioxygenase (IDO) expression in dendritic cells (DCs) inhibits T-cell activation and promotes T-cell differentiation into regulatory T-cells. Moreover, IDO expression promotes resistance to immunotherapies targeting immune checkpoints such as the cytotoxic T lymphocyte antigen-4 (CTLA-4). Here, a patient with metastatic melanoma pretreated with ipilimumab, an anti-CTLA-4 blocking antibody, was vaccinated with IDO-silenced DCs cotransfected with mRNA for survivin or hTERT tumour antigens. During vaccination, T-cell responses to survivin and hTERT tumour antigens were generated, and a certain degree of clinical benefit was achieved, with a significant reduction in lung, liver, and skin metastases, along with a better performance status. T-cell responses against MART-1 and NY-ESO-1 tumour antigens were also detected in the peripheral blood. The patient also mounted an antibody response to several melanoma proteins, indicating diversification of the antitumour immunity in this patient. The identification of such serum antibody-reacting proteins could facilitate the discovery of tumour neoantigens. Mouldy Sioud, Marta Nyakas, Stein Sæbøe-Larssen, Anne Mobergslien, Steinar Aamdal, and Gunnar Kvalheim Copyright © 2016 Mouldy Sioud et al. All rights reserved. Pulmonary Talcosis in an Immunocompromised Patient Thu, 30 Jun 2016 15:41:16 +0000 The first case of pulmonary talcosis or talc pneumoconiosis related to inhalation of talc during its extraction and processing in mines was described by Thorel in 1896. Pulmonary talcosis is most commonly seen secondary to occupational exposure or intravenous (IV) drug abuse and, occasionally, in excessive use of cosmetic talc. Based on literature review, there has been an increase in reported incidents of pulmonary talcosis due to various forms of exposure to the mineral. We report an 82-year-old man who is diagnosed with Philadelphia chromosome positive pre-B cell acute lymphoblastic leukemia (ALL) treated with palliative imatinib who presented with chronic hemoptysis and dyspnea shortly after his diagnosis. His symptoms were initially thought to be due to an infectious etiology due to his malignancy, immunocompromised state, and radiographic findings until high-resolution computerized tomographic (HRCT) findings showed a diffuse pulmonary fibrosis picture that prompted further questioning and a more thorough history inquiry on his exposure to causative agents of interstitial lung disease. Very often, patients do not recognize their exposure, especially in those whose exposure is unrelated to their occupation. Our case emphasizes the need for thorough and careful history taking of occupational and nonoccupational exposure to known causative agents of interstitial lung disease. Thanh-Phuong Nguyen, Sowmya Nanjappa, Manjunath Muddaraju, and John N. Greene Copyright © 2016 Thanh-Phuong Nguyen et al. All rights reserved.