Calcitriol induced hypercalcemia - a rare phenomenon in lung cancer: A case report.

BACKGROUND: Calcitriol-induced hypercalcemia has been rarely reported in cases of lung cancer; however, it is frequently reported in cases of lymphoid malignancy and granulomatous disease. We present a rare case of hypercalcemia associated with squamous cell cancer of the lung with elevated calcitriol level. CASE SUMMARY: A 61-year-old Caucasian female with severe hypercalcemia of 15 mg/dL, which led to a new diagnosis of metastatic lung cancer. Since the parathyroid hormone-related peptide (PTHrP) level was minimally elevated at 2.1 pmol/L, we believe excessive calcitriol production by tumor cells was the underlying mechanism for hypercalcemia. Calcitriol was significantly elevated at 130 pg/mL with a low 25-hydroxyvitamin D level of 25.9 ng/mL and suppressed PTH level of 8 pg/mL. Corticosteroids are generally used to treat calcitriol-induced hypercalcemia, but we successfully treated our patient with bisphosphonate, highlighting the further utility of bisphosphonates in hypercalcemia treatment. CONCLUSION: We believe that the underlying cause of hypercalcemia, in this case of metastatic squamous cell lung carcinoma, was elevated calcitriol, which was likely produced by the tumor cells. In addition to PTHrP, calcitriol levels should be included in the workup for hypercalcemia in cases of lung cancer. However, the pathophysiology and prognostic significance of dysregulated calcitriol production in solid tumors remain unclear and warrant further research. Bisphosphonate may be used as a steroid-sparing therapy even in cases of calcitriol-induced hypercalcemia and warrants further investigation.

The Perspective of a Breast Cancer Patient: A Survey Study Assessing Needs and Expectations.

Background Patient satisfaction is one of the key indicators of health care quality. We aim to identify patient's needs and expectations in a breast cancer clinic to provide patient-centered care and better overall satisfaction.  Methods A 17-item survey was administered to 110 patients at a breast cancer clinic. The survey was designed after a thorough literature review and approved by an oncologist and a palliative care physician.  Results Self-reported knowledge about the disease was reported adequate by 90.9% of our patients yet only 55.45% of our patients could identify the stage of their cancer. More education was desired by 32.7% of patients including various treatment options (29%), common complications (24.5%), prognosis (26.3%) and risk factors (11.8%). The majority of our patients were having some form of cancer-related emotional stress and physical symptoms. The majority of our patients (57.27%) wanted their oncologist to address social/emotional issues and 25.45% felt the need for more focus on physical symptoms in their subsequent visits. End-of-life (EoL) care discussions were considered an integral component of overall care by 29% of our patients. Components of EoL care discussions that patients stated they could benefit from included prognosis (27.27%), life expectancy (29%), the treatment effect on the quality of life (22.7%), palliative care (9%), hospice (10.9%), advance directives (11.8%), and family involvement in medical decision-making (13.6%). There was a difference noted regarding their EoL care discussion based on the stage of cancer. Patients with early-stage disease wanted their oncologists to decide on the frequency of this discussion (72.7%). Patients with advanced disease wanted EoL care discussion to be done more frequently as initiated by them or their oncologist or if there's a change in the treatment plan.  Conclusions A discrepancy between self-reported and actual knowledge in breast cancer patients emphasizes the need for patient education. Most patients rely on their oncologists for their diagnosis-related emotional and social issues. Surprisingly, more than a quarter of our patients consider EoL care discussions important even though the majority of our patients were healthy and having stage I and II disease.

Multiple Myeloma Relapse as Intracranial Plasmacytoma: A Rare Presentation.

Multiple myeloma (MM) infrequently involves the central nervous system (CNS). The usual sites of involvement are skull and meninges; however, intracranial tumors are exceedingly rare. We report the case of a 60-year-old female who presented to our center for the complaint of recurrent syncope. The patient was diagnosed with MM approximately one and a half years ago and had received chemotherapy followed by an allogeneic bone marrow transplant and was in remission afterward. We initiated workup for syncope and a brain MRI revealed an intracranial mass. Histopathological studies of the intracranial mass confirm the diagnosis of plasmacytoma and further testing shows relapse of MM. This is a unique case of MM relapse with isolated intracranial plasmacytoma. It usually carries a poor prognosis. Early diagnosis and management are imperative to improve survival.

Pantoea agglomerans Bacteremia: Is It Dangerous?

Introduction. Pantoea agglomerans, an anaerobic Gram-negative bacillus, is a rare cause of opportunistic infections affecting premature infants to seniors. We present a 34-year-old man who was presented for the management of diabetic ketoacidosis and developed Pantoea agglomerans bacteremia after one week of hospitalization. Case Presentation. A 34-year-old African-American male with uncontrolled diabetes mellitus type I and recurrent skin infections was admitted with diabetic ketoacidosis. He had left upper extremity abscess, preliminary wound cultures were positive for Gram-positive cocci, and an initial set of blood cultures were negative. He was started empirically on vancomycin. One week after admission, he started having chills followed by a recurrent increase in body temperature to 102 degrees Fahrenheit. The wound was healing, without active infection. Chest X-ray and CT scan of abdomen and pelvis to rule out infection were negative. Repeat blood cultures showed P. agglomerans in both the tubes. The patient was successfully treated with intravenous ceftriaxone, and he recovered fully without any complication. Discussion. Pantoea agglomerans is a bacteria associated with plants; however, it can infect humans and vertebrate animals. The outcome seems favourable with the institution of appropriate antibiotics even in immunocompromised patients.

Pressure Ulcer Associated with Testicular Prosthesis as a Rare Cause of Spinal Epidural Abscess.

Spinal epidural abscess is a neurologic emergency with a potential complication to the spinal cord such as paralysis. Frequently, it has a nonspecific initial presentation such as neck or back pain, and hence there is a delay in diagnosis. We present the case of a 60-year-old Caucasian male who presented to emergency room with one week of numbness and weakness of all four extremities. Neurological examination showed variable quadriparesis. Urgent MRI of spine with contrast revealed epidural abscess in the cervical region C4-C6 with resultant cord compression, the underlying etiology for hematogenous spread of infection being pressure ulcer associated with testicular prosthesis. Urgent neurosurgical intervention was done to achieve spinal cord decompression. Both blood and pus cultures were positive for Streptococcus intermedius, requiring prolonged administration of intravenous antibiotics. Clinical outcome was encouraging with progressive gain in motor and sensory function. Spinal epidural abscess is a rare diagnosis; hence, clinicians should have a high index of suspicion for timely diagnosis.

Periaortic Abscess following DeBakey Type-1 Aortic Dissection Repair with Dacron Graft-Early Diagnosis and Management.

A 71-year-old male with history of DeBakey type-1 aortic dissection and repair with dacron graft three months prior to presentation was brought to the emergency room with complaints of high-grade fevers, chills, and shortness of breath. Chest X-ray revealed right lower lobe infiltrates and widened superior mediastinum. A follow-up CT chest with contrast showed fluid collection around the aortic graft. He was started on intravenous broad-spectrum antibiotics, and a TEE was done for further evaluation of periaortic fluid collection which showed findings to suggest periaortic abscess. The patient underwent surgical drainage of the abscess and was found to have an abscess around the surgical aortic graft which was drained followed by two weeks of antibiotic treatment. The patient was discharged to a rehabilitation facility and remained asymptomatic at three-month follow-up appointment. Type-1 aortic dissection is a medical emergency requiring acute surgical intervention, and despite significant advancements in diagnosis and management, the immediate and long-term complications remain high leading to increased risk of mortality. Our patient developed spontaneous periaortic abscess three months postoperatively requiring intensive antibiotic therapy along with surgical drainage. Our case emphasizes the importance of early diagnosis and management of late complications of periaortic abscess in patients with aortic dissection repair.

Back Pain: An Ominous Harbinger of Aortitis.

Isolated aortitis is a rare entity and was recently included in the 2012 Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides under the single organ vasculitis group. Isolated aortitis represents a challenging situation due to the lack of reliable diagnostic methodology. Here, we describe the case of a 46-year-old woman who presented with severe upper back pain. She tested negative for pulmonary embolism, myocardial infarction, and other usual causes of back pain. The case highlights the clinical presentation of a rare disease with a usual symptom.