Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. A Complicated Course of Acute Viral Induced Pharyngitis, Icteric Hepatitis, Acalculous Cholecystitis, and Skin Rash Wed, 26 Oct 2016 08:44:29 +0000 This case reveals the complexities and challenges in the diagnosis of acute Epstein-Barr virus (EBV) infection, indicating the potential relationship between EBV infection and severe icteric hepatitis, acalculous cholecystitis, and lymphocytic vasculitis. We suggest including EBV infectious mononucleosis in the list of differential diagnoses when any of these clinical syndromes (or a combination thereof) occurs without apparent cause, especially in the presence of lymphocytosis. To our knowledge, this is the first report to suggest the possible role of EBV in the pathogenesis of cutaneous lymphocytic vasculitis. Also it is possible that EBV infection triggered the flare-up of the underlying rheumatologic disease. Therefore, it could be assumed that a part of the clinical syndrome (e.g., dermatologic manifestations) might be related to the flare-up of the underlying rheumatologic disease. Fereshte Sheybani, HamidReza Naderi, Seddigheh Sadat Erfani, and Masoumeh Gharib Copyright © 2016 Fereshte Sheybani et al. All rights reserved. Adult Onset Still’s Disease Associated with Mycoplasma pneumoniae Infection and Hemophagocytic Lymphohistiocytosis Wed, 26 Oct 2016 07:06:04 +0000 Adult Onset Still’s Disease (AOSD) is a systemic inflammatory disorder that can be associated with hemophagocytic lymphohistiocytosis (HLH), a rare but potentially fatal disease of overactive histiocytes and lymphocytes. We present a unique case of AOSD complicated by Mycoplasma pneumonia infection and HLH. A 28-year-old female developed joint pains followed by a diffuse, erythematous, pruritic skin rash that quickly spread throughout the body. The patient deteriorated and developed fever, chills, cough, and dyspnea and had to be intubated. She had hypoalbuminemia, elevated liver enzymes, a very high serum ferritin level, positive anti-Mycoplasma pneumonia IgG and IgM antibodies, and normal rheumatoid factor and anti-nuclear antibodies. The chest X-ray showed diffuse bilateral infiltrates. Bone marrow biopsy revealed hemophagocytosis. The patient was treated with azithromycin, methylprednisolone, and anakinra and was discharged home on cyclosporine and prednisone. This case highlights that patients can develop features of both AOSD and HLH at the beginning of the disease and early diagnosis and treatment increase the likelihood of recovery. Abhishek Agnihotri, Allison Ruff, Lauren Gotterer, Addie Walker, Amy H. McKenney, and Andrei Brateanu Copyright © 2016 Abhishek Agnihotri et al. All rights reserved. Severe Hyponatremia due to Levofloxacin Treatment for Pseudomonas aeruginosa Community-Acquired Pneumonia in a Patient with Oropharyngeal Cancer Tue, 25 Oct 2016 15:19:16 +0000 Hyponatremia (serum Na levels of <135 mEq/L) is the most common electrolyte imbalance encountered in clinical practice, affecting up to 15–28% of hospitalized patients. This case report refers to a middle-aged man with severe hyponatremia due to Syndrome of Inappropriate Antidiuretic Hormone Secretion related to four possible etiological factors: glossopharyngeal squamous cell carcinoma, cisplatin treatment, right basal pneumonia with Pseudomonas aeruginosa, and the treatment with Levofloxacin. This case report discusses a rare complication of common conditions and of a common treatment. To our knowledge this is the first case of hyponatremia related to Levofloxacin and the second related to fluoroquinolones. Mihaela Mocan and Sorin Nicu Blaga Copyright © 2016 Mihaela Mocan and Sorin Nicu Blaga. All rights reserved. Pasteurella multocida Bacteremia in an Immunocompromised Patient Tue, 25 Oct 2016 15:09:10 +0000 We present the case of a 61-year-old Caucasian gentleman who presented with a one-day history of fever, chills, and altered mental status. His symptoms were initially thought to be secondary to cellulitis. Blood cultures grew Pasteurella multocida, a rare pathogen to cause bacteremia. Our patient was treated with ciprofloxacin for two weeks and made a complete and uneventful recovery. Our patient’s uncontrolled diabetes mellitus and chronic kidney disease put him at a higher risk for developing serious P. multocida infection. The patient’s dog licking the wounds on his legs was considered as the possible source of infection. As P. multicoda bacteremia is rare, but severe with a high mortality rate, it is imperative to have a high index of suspicion for this infection especially in the vulnerable immunocompromised population. Shweta Kukrety, Jai Parekh, and Theresa Townley Copyright © 2016 Shweta Kukrety et al. All rights reserved. Corrigendum to “Recurrent Syncope Associated with Lung Cancer” Mon, 24 Oct 2016 12:49:16 +0000 Dingguo Zhang, Liansheng Wang, and Zhijian Yang Copyright © 2016 Dingguo Zhang et al. All rights reserved. A Huge Cystic Retroperitoneal Lymphangioma Presenting with Back Pain Sun, 23 Oct 2016 14:29:46 +0000 Retroperitoneal lymphangioma is a rare location and type of benign abdominal tumors. The clinical presentation of this rare disease is nonspecific, ranging from abdominal distention to sepsis. Here we present a 73-year-old female patient with 3-month history of back pain. USG and CT revealed a huge cystic mass which was surgically excised and appeared to be lymphangioma on histopathology. Mahir Gachabayov, Kubach Kubachev, Elbrus Abdullaev, Valentin Babyshin, Dmitriy Neronov, and Abakar Abdullaev Copyright © 2016 Mahir Gachabayov et al. All rights reserved. Inconceivable Hypokalemia: A Case Report of Acute Severe Barium Chloride Poisoning Thu, 20 Oct 2016 10:19:07 +0000 Barium is a heavy divalent alkaline earth metal that has been known as a muscle poison. Barium can cause human toxicity, which may lead to significant hypokalemia and have serious consequences. This paper reports a case of unprecedented barium intoxication in which the patient, who suffered from depression, swallowed at least 3.0 g barium chloride to commit suicide. On admission, the patient presented with nausea, vomiting, stomach burning feeling, dizziness, and weakness. Emergency biochemical testing showed that the patient was suffering from severe hypokalemia (K+ 1.7 mmol/L). His electrocardiogram (ECG) prompted atrioventricular blocking, ventricular tachycardia, prolongation of PR interval, ST segment depression with U waves, and T wave inversion. Intravenous potassium supplements were given immediately to correct hypokalemia and regular monitoring of vital signs and fluid balance was arranged. After all-out rescue of our hospital personnel, the condition of the patient is currently stable and he is gradually recovering. This case exemplifies the weaknesses of the management of toxic substances and the lack of mental health education for young people. We hope to get more attention for the supervision of toxic substances and the healthy development of young people. Haibo Tao, Yanru Man, Xiaoyuan Shi, Jun Zhu, Hang Pan, Qin Qin, and Shanrong Liu Copyright © 2016 Haibo Tao et al. All rights reserved. A Rare Case of an Irreducible Patella Dislocation Thu, 20 Oct 2016 09:05:39 +0000 Reports of irreducible patellar dislocations are exceedingly sparse throughout the literature. Obvious radiographic or physical exam findings including fracture or inversion of the patella are often present to explain the block to reduction. Not described previously in the literature is the instance of an irreducible patella dislocation in the setting of innocuous appearing injury imaging. We present a case of a healthy thirty-two-year-old female who sustained an irreducible lateral patella dislocation while participating in a dance aerobics class. Closed means of reduction were unsuccessful, necessitating open reduction. Intraoperative findings suggest incarceration of a nondisplaced fracture and a chondral defect as the block to reduction. Following open reduction, the patient has had no further episodes of pain or instability related to the patella at one-year follow-up. Irreducible patellar dislocations are exceedingly rare injuries, where associated osseous or chondral lesions may necessitate open reduction despite innocuous appearing initial imaging. A high index of suspicion to proceed with open reduction may limit repeated attempts at closed reduction and further injury. Dimitri E. Delagrammaticas and Scott D. Cordes Copyright © 2016 Dimitri E. Delagrammaticas and Scott D. Cordes. All rights reserved. Adalimumab Induced or Provoked MS in Patient with Autoimmune Uveitis: A Case Report and Review of the Literature Thu, 20 Oct 2016 09:01:35 +0000 Anti-tumor necrosis factor α (anti-TNF-α) agents have been widely used in the field of autoimmune diseases and have proved decisive efficacy and relative safety. Data concerning their adverse effects has been lately describing central nervous system (CNS) demyelination process at escalating basis. Case Presentation. A 23-year-old male with autoimmune uveitis and a family history of multiple sclerosis (MS) developed two neurological attacks, after Adalimumab infusion, simultaneously with several cerebral lesions on magnetic resonance imaging (MRI). Hence the diagnosis of Adalimumab induced MS was suspected. Conclusion. This case is reported to tell physicians to be cautious when using anti-TNF-α in patients with family history of MS and to reconsider the risk of MS in patients with autoimmune diseases. Rana Alnasser Alsukhni, Ziena Jriekh, and Yasmin Aboras Copyright © 2016 Rana Alnasser Alsukhni et al. All rights reserved. Bowel Ischemia from Heat Stroke: A Rare Presentation of an Uncommon Complication Thu, 20 Oct 2016 08:27:14 +0000 A healthy 27-year-old female presented to the hospital after she collapsed an hour into her first marathon run on a hot humid day. On presentation, she was hyperthermic, encephalopathic, tachycardic, and hypotensive. On admission, she was found to have lactic acidosis, rhabdomyolysis, and acute kidney injury and was treated with cold normal saline and cooling blankets. She subsequently started having abdominal pain and bloody bowel movements. Computed tomography of the abdomen revealed ascending colon thickening. Furthermore, her lab findings showed transaminitis and elevated coagulation parameters. Due to the acute hypotensive state from the heat stroke, patient had developed bowel ischemia, ischemic hepatitis, and disseminated intravascular coagulation, all of which are uncommon complications of heat stroke. She was managed aggressively with intravenous fluid hydration with resolution of her symptoms over the course of 4 days. In addition to the uncommon complications, early presentation of this bowel ischemia despite adequate hydration in such a healthy individual is another unique aspect of the case. Umair Masood, Anuj Sharma, Wajihuddin Syed, and Divey Manocha Copyright © 2016 Umair Masood et al. All rights reserved. A Case of De Novo Anterior Condylar Dural Arteriovenous Fistula Long after Curative Transvenous Embolization of Contralateral Anterior Condylar Arteriovenous Fistula Tue, 18 Oct 2016 14:42:37 +0000 We report on a 55-year-old man who developed a de novo DAVF in left ACC 5 years after curative transvenous embolization for DAVF in right ACC. Angiography revealed that the de novo lesion demonstrated more aggressive arteriovenous shunt flow than the initial lesion. Successful transvenous embolization was performed for also the second lesion. The authors describe the possible pathophysiological mechanisms and management strategies for this rare occurrence. Shinya Hagiwara, Takeshi Miyazaki, Masahiro Tsuji, Mizuki Kambara, Tsutomu Yoshikane, Hidemasa Nagai, and Yasuhiko Akiyama Copyright © 2016 Shinya Hagiwara et al. All rights reserved. Severe Agranulocytosis following Simultaneous Administration of Chlorpromazine and Trimethoprim-Sulfamethoxazole in a Patient with Sepsis: A Possible Toxic Combination Tue, 18 Oct 2016 14:28:55 +0000 Background. Chlorpromazine and trimethoprim-sulfamethoxazole (TMP/SMX) are two commonly prescribed medications by physicians. Either of those medications could cause fatal drug-induced agranulocytosis, with an unclear underlying mechanism. The likelihood of simultaneous prescription of both medications is high and could hypothetically result in severe agranulocytosis that is resistant to treatment. Case Presentation. We are presenting a case of a patient with psychosis on chlorpromazine who was prescribed TMP/SMX for a urinary tract infection. Consequently, the patient developed severe agranulocytosis and septicemia. Patient was managed by granulocyte colony-stimulating factor; however, the time to neutrophil recovery was delayed when compared to the average reported time published by previous studies. Conclusions. Simultaneous use of chlorpromazine and TMP/SMX is a possible toxic combination that could induce severe agranulocytosis. Further reports are needed to confirm this observation. Anil Jha, Hassan Ghoz, and Nicholas James Copyright © 2016 Anil Jha et al. All rights reserved. Primary Sjogren’s Syndrome Presenting as Acute Interstitial Pneumonitis/Hamman-Rich Syndrome Thu, 13 Oct 2016 12:59:10 +0000 A previously well, 45-year-old Pakistani lady was admitted to the medical unit on-call of Khyber Teaching Hospital (KTH) Peshawar with a 5-day history of fever, productive cough with copious mucoid sputum, dyspnea, and pleuritic chest pain. She also complained of dry eyes, mouth, and vagina. Her chest X-ray showed diffuse alveolar shadowing and arterial gas analysis confirmed type 1 respiratory failure. Over the next few days, she deteriorated rapidly making an urgent transfer to the medical intensive care unit (MICU) necessary, where she was mechanically ventilated. An HRCT followed by bronchoscopic biopsies made a diagnosis of acute interstitial pneumonitis (AIP), formerly known as Hamman-Rich syndrome. She also turned out to be positive for both anti-SS-A/Ro and anti-SS-B/La antibodies along with a positive Schirmer’s test and lower lip biopsy. She received intravenous steroids and supportive care. The patient had a complete recovery after approximately three weeks’ stay in the hospital with lung function returning back to normal. This is most probably the first ever case of primary Sjogren syndrome (pSjS) presenting as AIP, recovering completely in less than a month time. Abidullah Khan, Mohammad Humayun, Iqbal Haider, Maimoona Ayub, Zakir Shah, and Fahad Ajmal Copyright © 2016 Abidullah Khan et al. All rights reserved. A Case Report of X-Linked Hyperimmunoglobulin M Syndrome with Lipoma Arborescens of Knees Wed, 12 Oct 2016 07:01:32 +0000 The X-linked hyperimmunoglobulin M syndrome (HIGM), caused by mutations in the CD40LG gene, is a kind of primary immunodeficiency disease (PID). Patients with X-linked HIGM are susceptible to infection as well as autoimmune diseases. Lipoma arborescens (LA) is a rare benign tumor, of which the pathogenesis mechanism has not been clearly understood. We report a case of HIGM combined with LA in a 22-year-old male patient. A new deletion mutation of CD40LG gene was detected in this case. The possible relationship between HIGM and LA was also discussed. Qiuting Dong, Jinxia Zhao, Zhongqiang Yao, Xiangyuan Liu, and Huiying He Copyright © 2016 Qiuting Dong et al. All rights reserved. Pericardial Tamponade in an Adult Suffering from Acute Mumps Infection Wed, 12 Oct 2016 06:48:29 +0000 Here, we report a case of a 51-year-old man with acute pericardial tamponade requiring emergency pericardiocentesis after he suffered from sore throat, headache, malaise, and sweats for two weeks. Serological analyses revealed increased mumps IgM and IgG indicating an acute mumps infection whereas other bacterial and viral infections were excluded. In addition, MRI revealed atypical swelling of the left submandibular gland. Whereas mumps has become a rare entity in children due to comprehensive vaccination regimens in western civilizations, our case highlights mumps as an important differential diagnosis also in adults, where the virus can induce life-threatening complications such as pericardial tamponade. Sascha Kahlfuss, Robert Rainer Flieger, Annette Mankertz, Kadir Yilmaz, and Torsten Kai Roepke Copyright © 2016 Sascha Kahlfuss et al. All rights reserved. Splenic Involvement in Hereditary Hemorrhagic Telangiectasia Tue, 11 Oct 2016 12:48:07 +0000 A 33-year-old man who presented with prolonged epigastric pain was referred to our hospital. He had experienced recurrent epistaxis and had a family history of hereditary hemorrhagic telangiectasia. Computed tomography and magnetic resonance imaging revealed splenomegaly and a 9 cm hypervascular mass in his spleen. Computed tomography also showed a pulmonary arteriovenous malformation and heterogeneous enhancement of the liver parenchyma, suggesting the presence of arteriosystemic shunts and telangiectases. Based on these findings, the patient was definitely diagnosed with hereditary hemorrhagic telangiectasia according to Curaçao criteria. He underwent splenectomy, and his symptoms disappeared after surgery. Pathological examination of the resected specimen revealed that the hypervascular lesion of the spleen was not a tumor but was composed of abnormal vessels associated with hereditary hemorrhagic telangiectasia. Symptomatic splenic involvement may be a rare manifestation of hereditary hemorrhagic telangiectasia but can be revealed by imaging modalities. Susumu Takamatsu, Kota Sato, Shunsuke Kato, Hiroto Nagano, Shunro Ohtsukasa, and Yasuyuki Kawachi Copyright © 2016 Susumu Takamatsu et al. All rights reserved. Trazodone Addition to Paroxetine and Mirtazapine in a Patient with Treatment-Resistant Depression: The Pros and Cons of Combining Three Antidepressants Tue, 11 Oct 2016 09:20:50 +0000 Dual antidepressant combination for treatment-resistant depression is a strategy well supported by literature and accepted in clinical practice. Rather, the usefulness of the combination of more than two antidepressants is controversial. This may be related to the possibility of higher side-effect burden and to doubts about its pharmacological effectiveness and therapeutic advantage compared to other standard treatment options. We report a relapse of moderate-to-severe depressive symptoms with insomnia that successfully remitted after the addition of trazodone to a dual combination of paroxetine and mirtazapine (in standard effective doses) in a patient with treatment-resistant depression. We also review the literature and discuss the utility of triple antidepressant combination in treatment-resistant depression. This clinical case highlights the utility of combining trazodone as a third antidepressant for the relapse of depressive symptoms after the failure of a dual antidepressant combination. Trazodone may be advantageous in patients presenting recurrence of moderate-to-severe depressive symptoms that include sleep problems and/or insomnia and may be particularly useful when benzodiazepines are not recommended. Although its use may be controversial and associated with higher risk of side-effects, more investigation is needed to determine the efficacy and safety for triple antidepressant combinations as reliable strategies for treatment-resistant depression in clinical practice. Rui Lopes, José Carlos Alves, and Raquel Garcia Rego Copyright © 2016 Rui Lopes et al. All rights reserved. Stent Thrombosis Patients with Hyporesponsiveness to Clopidogrel, Prasugrel, and Ticagrelor: A Case Series Using Short Thromboelastography Sun, 09 Oct 2016 14:04:29 +0000 Patients after percutaneous coronary intervention (PCI) with stent implantation and functional hyporesponsiveness to P2Y12 inhibitors are at higher risk of ischaemic events, particularly stent thrombosis (ST). It is currently not routine practice to assess the functional response to these agents. However, concern over functional hyporesponsiveness to clopidogrel has led to widespread uptake of prasugrel and ticagrelor as the default P2Y12 inhibitor after stent implantation in patients with acute coronary syndrome. Here we report, for the first time, 3 cases in which patients who have had ST exhibit hyporesponsiveness to clopidogrel, prasugrel, and ticagrelor. Bartosz Olechowski, Alexander Ashby, Nalyaka Sambu, Michael Mahmoudi, and Nick Curzen Copyright © 2016 Bartosz Olechowski et al. All rights reserved. Diffuse Arterial Thrombosis as a First Manifestation of Occult Malignancy Wed, 05 Oct 2016 09:05:53 +0000 Aim. To raise the awareness of a hypercoagulability state as it is often associated with the different types of malignancies. Venous thromboembolism is a frequent complication in these patients, and usually it happens after the diagnosis of cancer is confirmed. However, hypercoagulability disorders presenting as the first symptoms or signs in the cancer patients have rarely been reported. Furthermore, arterial thrombosis is extremely rare even in cancer patients. Method. Review of the case characteristics and literature review. Results. We present a case of 39-year-old woman who was admitted to our hospital because of intermittent claudication in the right lower extremity. CT angiography revealed multiple thrombi in the arterial system starting from the left ventricle, followed by a thrombus in the distal part of the descending aorta, in the superior mesenteric artery, and in the right popliteal artery. Further investigation of this young patient with no risk factors for hypercoagulable state and no other comorbidities led to complete work-up including diagnostic evaluation for malignancy. The suspicion was confirmed after performing upper endoscopy with biopsy, which revealed malignant neoplasm of the stomach. Conclusion. Whenever a patient suffers hypercoagulability disorders, even arterial thrombosis, we should always consider the possibility of a cancer. Marija Vavlukis, Irina Kotlar, Emilija Chaparoska, Emilija Antova, and Sasko Kedev Copyright © 2016 Marija Vavlukis et al. All rights reserved. Treatment of Snoring with a Nasopharyngeal Airway Tube Tue, 04 Oct 2016 11:49:56 +0000 Objective. To study the feasibility of a standard nasopharyngeal airway tube (NPAT) as treatment for snoring. Methods. An obese 35-year-old man, who is a chronic, heroic snorer, used NPATs while (1) the patient’s bedpartner scored the snoring and (2) the patient recorded himself with the smartphone snoring app “Quit Snoring.” Baseline snoring was 8–10/10 (10 = snoring that could be heard through a closed door and interrupted the bedpartner’s sleep to the point where they would sometimes have to sleep separately) and 60–200 snores/hr. Several standard NPATs were tested, consisting of soft polyvinyl chloride material raging between 24- and 36-French (Fr) tubes. Results. The 24 Fr tube did not abate snoring. The 26 Fr tube was able to abate the snoring sound most of the night (smartphone app: 11.4 snores/hr, bedpartner VAS = 2/10). The 28 and 30 Fr tubes abated the snoring sound the entire time worn (smartphone app: 0 snores, bedpartner VAS 0/10) but could not be tolerated more than 2.5 hours. The tube of 36 Fr size could not be inserted, despite several attempts bilaterally. Conclusion. Appropriately sized nasopharyngeal airway tubes may abate the snoring sound; however, as in this patient, they may be too painful and intolerable for daily use. Macario Camacho, Edward T. Chang, Camilo Fernandez-Salvador, and Robson Capasso Copyright © 2016 Macario Camacho et al. All rights reserved. Reversible Posterior Leukoencephalopathy Syndrome Developing After Restart of Sunitinib Therapy for Metastatic Renal Cell Carcinoma Tue, 04 Oct 2016 09:23:21 +0000 A 64-year-old Japanese man had started molecular-targeted therapy with sunitinib for lymph node metastasis 5 years after nephrectomy for left renal cell carcinoma (clear cell carcinoma, G2, pT2N0M0). He was transported to our emergency department because of generalized tonic-clonic seizure, vision loss, and impaired consciousness with acute hypertension after 8 cycles of treatment (2 years after the initiation of sunitinib therapy, including a drug withdrawal period for one year). MRI of the brain (FLAIR images) showed multiple high-intensity lesions in the white matter of the occipital and cerebellar lobes, dorsal brain stem, and left thalamus. Reversible posterior leukoencephalopathy syndrome caused by sunitinib was suspected. In addition to the immediate discontinuation of sunitinib therapy, the administration of antihypertensive agents and anticonvulsants improved the clinical symptoms without neurological damage. Physicians should be aware that sunitinib causes reversible posterior leukoencephalopathy syndrome. The early recognition of reversible posterior leukoencephalopathy syndrome is critical to avoid irreversible neurological damage. Shinji Fukui, Yuta Toyoshima, Takeshi Inoue, Yoriaki Kagebayashi, and Shoji Samma Copyright © 2016 Shinji Fukui et al. All rights reserved. Pulmonary Hilar Tumor: An Unusual Presentation of Sclerosing Hemangioma Tue, 27 Sep 2016 15:42:18 +0000 Pulmonary sclerosing hemangioma is an uncommon benign tumor of the lung; however, on rare occasions it can arise from the pulmonary hilar region. Herein, we report a 53-year-old female patient who presented with a round opacity in the right upper lung field on a radiograph. Chest computed tomography scanning revealed a 3.1 cm mass in the right pulmonary hilum. Thoracoscopic tumor excision was subsequently performed. On pathohistologic study, the tumor was well defined and composed of round stromal cells and surface cells arranged in a papillary, sclerotic, solid, and hemorrhagic pattern. In immunochemical study, the round cells were positive for thyroid transcription factor-1 (TTF-1) and epithelial membrane antigen (EMA) and negative for cytokeratin. The surface cells were positive for TTF-1, EMA, and cytokeratin. Therefore, a final diagnosis of sclerosing hemangioma was confirmed. In conclusion, pulmonary sclerosing hemangioma is uncommon and rare in the pulmonary hilar region. CT scanning is useful to determine its benignity, although imaging features are not specific for a definite differential diagnosis from other pulmonary tumors. Therefore, tissue diagnosis is usually necessary, and pulmonary sclerosing hemangioma should be listed in the differential diagnoses of pulmonary hilar tumors. Jui-Hung Hung, Ching Hsueh, Chiung-Ying Liao, Shang-Yun Ho, and Yuan-Chun Huang Copyright © 2016 Jui-Hung Hung et al. 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.