A Case of Multiple Myeloma Presenting with Gastrointestinal Bleeding and Evans Syndrome.

Autoimmune events are rare in multiple myeloma (MM). Herein, we report a rare case of a patient presenting with recurrent gastrointestinal (GI) bleeding of unknown origin, also having pancytopenia eventually diagnosed as MM with Evans syndrome. This is an uncommon disorder presenting as autoimmune hemolytic anemia (AIHA) with immune thrombocytopenia purpura (ITP). A 56-year-old African American male presenting with recurrent GI bleeds and pancytopenia of unknown origin developed acute colonic diverticulitis on recurrent admissions, and sigmoid colectomy with primary anastomosis was performed. Flow cytometry with serum protein electrophoresis eventually revealed IgG MM with elevated Kappa/Lambda ratio. Bone marrow biopsy revealed 80% to 90% Kappa clonal plasma cells confirming MM. Direct antiglobulin test (DAT) was positive with pancytopenia. The patient initially showed a good response to chemotherapy with thrombocytopenia improving with intravenous (I/V) dexamethasone. DAT done after completion of initial chemotherapy was negative. However, his disease relapsed after three months with pancytopenia and DAT becoming positive again. The patient was restarted on chemotherapy for debulking, which resulted in a negative DAT again after two months, but pancytopenia did not improve. The patient eventually passed away due to subarachnoid hemorrhage. We highlight only this fourth reported case because of its unique presentation. In elderly patients with unknown cause of GI bleeding with pancytopenia, blood dyscrasias, especially MM, should be considered. Autoimmune workup if positive might warrant the use of steroids for pancytopenia, which can improve thrombocytopenia in MM with Evans syndrome but not anemia.

Sweet hydrothorax: a common presentation of a rare condition.

Sweet hydrothorax is a known, yet rare, complication of peritoneal dialysis. It can be life-threatening. This case is about a 70-year-old lady who presented with acute respiratory failure due to massive right-sided hydrothorax that developed insidiously over 3 months of starting peritoneal dialysis. Thoracentesis and technetium scan confirmed the diagnosis. Treatment was successful with hemodialysis.

Minimal change disease associated with MALT lymphoma.

Low-grade Extranodal Marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue, a subtype of non-Hodgkin's Lymphoma, involving the kidney is a rare clinical entity. Association of Minimal change disease nephrotic range proteinuria with Hodgkin's lymphoma is well described, however is extremely uncommon with non-Hodgkin's lymphoma. We describe a patient who presented with nephrotic syndrome and a kidney biopsy revealed marginal zone lymphoma and diffuse epithelial foot process effacement. He showed dramatic response to a combination therapy with cyclophosphamide, corticosteroids, and Rituximab.

Metal fume-induced diffuse alveolar damage.

Metal fume fever is a well-defined clinical entity characterized by a self-limited influenza-like illness. Severe and protracted illness related to metal fume exposure is rare. We describe 2 related cases of serious metal fume fever in a 29- and a 51-year-old male precipitated by the use of an acetylene torch to dismantle galvanized steel in a poorly ventilated area. Each case was unusual in both severity and duration of symptoms for metal fume exposure. High-resolution computed tomography scans revealed diffuse alveolar damage in both patients. The 29-year-old male was started on steroids 1-day after exposure and experienced a significantly attenuated course of symptoms compared with the 58-year-old male, who received treatment 3 days after exposure.

Guillain-Barré syndrome as a paraneoplastic manifestation of small-cell carcinoma of lung.

Guillain-Barré syndrome (GBS) encompasses the variants of acute immune-mediated polyneuropathies usually preceded by an infection. A few case reports have associated GBS to neoplastic diseases. It remains unclear whether these are merely coincidental or represent paraneoplastic phenomena. The clinical features of GBS associated with oncological cases do not appear to differ from post-infectious GBS. We report a 74-year-old man in whom small cell carcinoma of lung (SCLC) was diagnosed during a presentation with GBS. Treatment with chemotherapy for SCLC and intravenous immunoglobulins led to complete neurological recovery and tumor regression.

Hyperkalemia and cocaine induced dynamic Brugada-type electrocardiogram.

Brugada syndrome is a well-defined clinical entity with the typical electrocardiographic changes in the right precordial leads (V1 and V2), attributed to mutation in SCN5A gene. Brugada-like electrocardiographic pattern can be replicated by sodium channel-blocking drugs and electrolyte abnormalities. We describe a 46-year-old individual, who presented with hyperkalemia secondary to muscle damage and renal insufficiency, after abusing cocaine. The electrocardiogram showed Brugada sign. The electrocardiogram changes disappeared after sodium bicarbonate administration and normalization of serum potassium. The case highlights the importance of recognizing cocaine and hyperkalemia, as potential triggers of the acquired Brugada sign.

Simultaneous ST-segment elevation in inferior and precordial leads following ingestion of a lethal dose of desipramine: a novel Brugada-like EKG pattern.

The typical Brugada electrocardiographic (EKG) pattern includes ST-segment elevation in the right precordial leads (V1-V3) associated with right bundle branch block (rSR') like morphology. Recently, a Brugada-like EKG pattern with ST-segment elevation in inferior leads called the "Brugada variant" has been reported. We report a case of simultaneous typical and variant Brugada EKG patterns with ST-segment elevation in the inferior as well as the precordial leads following ingestion of a lethal dose of desipramine.

An endobronchial lipoma mimicking asthma and malignancy.

Endobronchial lipomas are rare benign tumours of the lung. Bronchial occlusion may lead to a misdiagnosis of asthma or malignancy. We describe a 52-year-old man treated for asthma for several years, who presented with non-resolving right upper lobe pneumonia. Bronchoscopy proved to be diagnostic and therapeutic. Clinical characteristics of this unique entity are discussed.

Microscopic polyangiitis triggered by recurrent methicillin-resistant Staphylococcus aureus bacteremia.

Most of the purported links between microbial agents and primary small-vessel anti-neutrophilic antibody-positive (ANCA) vasculitides remain speculative. There is strong circumstantial evidence for the role of Staphylococcus aureus in the development of Wegener's granulomatosis, but its role in other ANCA-positive vasculitis syndromes is less clear. We describe a patient who developed a non-granulomatous, necrotizing small-vessel vasculitis with a positive anti-neutrophil cytoplasmic antibody of a perinuclear type (p-ANCA), along with anti-myeloperoxidase antibodies after recurrent episodes of methicillin-resistant Staphylococcus aureus bacteremia.

An incidental right atrial mass: cavernous hemangioma.

Cardiac hemangiomas are rare benign tumors of the heart typically diagnosed incidentally. We report a case of a 70-year-old man with a right atrial cavernous hemangioma and a concomitant pulmonary embolism. The possible association, clinical features, operative procedure, and pathologic findings are described.

Divalproex sodium-induced eosinophilic pleural effusion.

Eosinophilic pleural effusion is defined as an effusion in which eosinophils constitute more than 10% of white blood cells. These effusions can be due to multiple causes with drugs being implicated as one of the etiological agents. We report a case of 48-year-old woman with seizure disorder on divalproex sodium (Depakote) who presented with dyspnea. A chest radiograph demonstrated right pleural effusion. Investigations showed peripheral blood eosinophilia with thoracocentesis revealing eosinophilic exudative pleural effusion. An extensive workup for other causes of eosinophilic pleural effusion was unrevealing. Withdrawal of Depakote resulted in resolution of the effusion.

Immune thrombocytopenia associated with Mycoplasma pneumoniae infection: a case report and review of literature.

Although extra-pulmonary manifestations of Mycoplasma pneumoniae are well described, immune thrombocytopenia associated with M. pneumoniae is rarely reported. We describe a woman who developed immune thrombocytopenic purpura during an acute mycoplasma infection. The clinical features and outcomes of all previously reported cases are reviewed, and possible mechanisms underlying this association are discussed. Immune thrombocytopenic purpura should be considered early in patients with thrombocytopenia and mycoplasma infections, with the institution of usual therapy for immune thrombocytopenic purpura.