Appendiceal Adenocarcinoma Presenting as Palpable Breast Masses.

Appendiceal tumors are rare and are most commonly diagnosed incidentally during surgical removal of the appendix for acute appendicitis. Appendiceal adenocarcinomas are the most common appendiceal cancers, and their metastasis to the breast is extremely uncommon. We report a case of mucinous appendiceal adenocarcinoma presenting with breast metastasis. To the best of our knowledge, there has been only one case published in the literature about appendiceal cancer with metastasis to the breast. Interestingly, our patient's initial presentation was palpable breast masses rather than gastrointestinal symptoms.

Migrated Plastic Biliary Stent Causing Cecal Perforation.

Plastic biliary stents can spontaneously dislodge from the common bile duct and migrate distally into the bowels. Most migrated plastic biliary stents get passed with stools without any complication. However, in rare cases, migrated biliary stents can cause bowel perforation requiring urgent intervention. We report a rare case of a 53-year-old woman presenting with severe lower abdominal pain secondary to migrated plastic biliary stent causing cecal perforation. Computed tomography revealed a radiopaque linear foreign body within the cecum. The patient underwent emergent laparoscopy with stent removal and was discharged 2 days later without long-term complications.

Endoscopic Internal Drainage Achieving Successful Closure of Iatrogenic Pharyngoesophageal Fistula.

Endoscopic internal drainage (EID) is a minimally invasive endoscopic technique that effectively closes upper gastrointestinal fistulas. We report the successful closure of an oropharyngeal fistula in a 78-year-old man with a history of supraglottic squamous cell carcinoma. He presented with inspiratory stridor after biopsy of a lateral wall lesion in the piriformis sinus. Imaging showed a fistula tract between the piriformis sinus and the esophagus. EID was performed using a double-pigtail stent inserted inside the fistula. Eventually, repeat imaging showed evidence of fistula closure. To our knowledge, this is the first reported case of using EID for repairing an oropharyngeal fistula.

An Atypical Presentation of Hemosuccus Pancreaticus Manifesting as Hematochezia.

Hemosuccus pancreaticus is a rare cause of upper gastrointestinal bleeding that is often associated with chronic pancreatitis. The bleeding usually manifests as melena because the source originates superior to the ligament of Treitz. We present a patient who was admitted for acute-on-chronic pancreatitis and ultimately developed hematochezia. Endoscopy revealed active oozing at the minor duodenal papilla. Computed tomography angiography identified active contrast extravasation at the gastroduodenal artery, and it was managed successfully with angioembolization. Our case emphasizes clinicians to consider hemosuccus pancreaticus as an alternative differential in a patient with a history of chronic pancreatitis manifesting with hematochezia.

Sjögren-related cardiomyopathy presenting with cardiogenic shock.

Previous reports have described non-ischaemic cardiomyopathy related to a variety of autoimmune diseases. However, very few case reports describe Sjögren disease as a contributing factor to cardiomyopathy. We report the case of a 69-year-old woman with a history of Sjögren disease who presented with cardiogenic shock. Laboratory testing and cardiac MRI revealing apical septal late gadolinium enhancement were consistent with an autoimmune aetiology. After ruling out ischaemic, infectious and other possible causes, the patient's clinical presentation was thought to be related to underlying Sjögren disease. She was treated with intravenous steroids and evidence-based heart failure therapy, but she eventually died after having declined heart transplantation. Given the rarity of Sjögren disease, no diagnostic criteria or standard treatment has been established for cardiomyopathy related to this disease. Diagnosis should be considered in patients who show evidence of autoimmune processes after other possible causes are ruled out.

Unexplained Fatal Hyperammonemia in a Patient With New Diagnosis of Acute Monoblastic Leukemia.

Idiopathic hyperammonemia is a serious condition that can arise after induction of chemotherapy and is characterized by plasma ammonia levels greater than two times the normal upper limit but within the context of normal liver function. While this dangerous complication usually appears several weeks after the start of chemotherapy, we report a fatal case of idiopathic hyperammonemia that was detected only nine days after induction chemotherapy in a 22-year-old man with no liver pathology or other risks for hyperammonemia. The patient's initial emergent presentation was altered mental status. Laboratory workup showed acute monoblastic leukemia and radiological investigation showed cerebral hemorrhagic foci secondary to leukostasis. He received leukoreduction apheresis and he was started on induction chemotherapy with daunorubicin and cytarabine. On the ninth day of induction chemotherapy, it was noted that he developed worsening neurological findings. Investigations showed significant elevation in ammonia level and associated cerebral edema. Although hyperammonemia was mitigated, the patient's cerebral status worsened and he died 15 days after initial presentation. This case shows that critical hyperammonemia can occur quickly after chemotherapy induction and that strategies for preventing a rise in plasma ammonia are necessary.