Disseminated Mucormycosis from Marijuana Use in a Renal Transplant Patient.

Mucormycosis is a serious fungal infection that typically affects immunocompromised patients. We present a case of disseminated mucormycosis infection in a 34-year-old male with a history of marijuana use and focal segmental glomerulosclerosis who underwent living unrelated kidney transplant. After his transplant, he developed recurrent focal segmental glomerulosclerosis. Two months later, he developed pleuritic chest pain and imaging revealed a ground glass opacity with a surrounding dense consolidation within the right upper lobe, concerning for an angioinvasive fungal infection. During the hospitalization, his creatinine increased, and a biopsy of the allograft kidney demonstrated acute tubulointerstitial nephritis, acute vasculitis, and glomerular intracapillary fibrin thrombi with angioinvasive Mucorales fungal infection. The patient subsequently underwent transplant nephrectomy. Grossly, the allograft was pale white to dusky tan-red with poorly delineated cortical medullary junctions. Microscopic examination revealed necrotic tubules with a dense neutrophilic infiltrate, multinucleated giant cells, and ribbon-like, aseptate hyphae. A Gomori's methenamine silver stain highlighted the fungal elements, which were morphologically consistent with Mucorales. Review of the literature revealed that the incidence of mucormycosis within the first year is low at approximately 0.07% for renal transplant patients with an estimated overall mortality of 40-50%. Additionally, few case reports have been published demonstrating marijuana use as a cause of pulmonary mucormycosis or even disseminated disease. The purpose of our case report is to add knowledge to the presenting symptoms and investigate the association of marijuana use with pulmonary and disseminated mucormycosis.

Nasopharyngeal Lipoma: A Rare Presentation of a Common Lesion.

Lipomas are common slow-growing benign tumors composed of mature adipose tissue. They can grow in any location where fat is present. They are well encapsulated and are generally of little clinical concern. Lipomas are typically located in the subcutaneous fat of the neck and trunk. The presence of a lipoma in the nasopharynx is rare. These lesions may produce clinical symptoms or be found incidentally. Here, we present the case of a 34-year-old male who was found to have an incidental pharyngeal lipoma following a nasopharyngoscopy for unrelated tympanostomy tube placement. This case illustrates a rare presentation of an otherwise common lesion.

Osteochondrolipoma of the Hand.

Lipoma is the most common type of benign soft tissue tumor and is composed of mature adipose tissue. A neoplasm of adipose tissue with admixed mature bone and cartilage, or osteochondrolipoma, is an extremely rare histologic variant. Most documented osteochondrolipomas have occurred in the soft tissues of the head and neck related to the oral cavity, and the tumor is seen involving the extremities. A fatty mass with nonlipomatous elements can present a diagnostic challenge. We present a rare case of osteochondrolipoma involving the wrist. The clinical presentation, radiographic images, histologic findings, and treatment are discussed in this case report.

Syringomatous Adenoma of the Nipple with Associated Invasive Carcinoma: A Case Report.

Syringomatous adenoma of the nipple is a rare benign infiltrative neoplasm that was first described in 1983. At the time of this writing, a literature search revealed no cases of syringomatous adenoma of the nipple in association with invasive carcinoma of the breast. We report a case of syringomatous adenoma of the nipple in a 40-year old female who also had bilateral invasive ductal carcinoma and ductal carcinoma in situ of the breasts. Syringomatous adenomas of the nipple have been postulated to originate from eccrine structures of the nipple due to their microscopic similarity to other tumors of eccrine origin, such as syringomatous carcinoma. However, their exact origin is uncertain. Despite their benign behavior, they usually demonstrate an infiltrative and expansile proliferation into adjacent nipple and breast tissue. They have been confused with tubular carcinoma and low-grade adenosquamous carcinoma of the breast, both clinically and histologically. Complete excision is the therapy of choice, and only incompletely excised lesions have shown recurrence. We present this case to raise awareness that syringomatous adenoma of the nipple may present in patients with a simultaneous invasive carcinoma of the breast.

Granular Cell Tumor - An Important Entity to Consider on Upper Gastrointestinal Endoscopy.

Granular cell tumors (GCT) are benign, submucosal tumors derived from neural or Schwann cells. They are commonly found in the oral cavity, skin, breast and tongue. Less commonly, they can also occur in the gastrointestinal tract, usually in the esophagus. We describe two cases of esophageal GCT which were discovered by upper endoscopy (EGD). Case one underwent endoscopic ultrasound (EUS) guided fine needle aspiration and biopsy and case two underwent biopsy of a submucosal nodule. Both biopsies were histologically diagnosed as GCT with supportive S100 positive immunostaining. GCTs are an important diagnosis for physicians to consider in their differential of esophageal nodule or lesion. Though benign, they may rarely show malignant transformation. Therefore, it is essential to have surveillance with EGD/EUS every two to three years if they are not surgically resected.

Acute Hemolytic Transfusion Reaction Due to Anti-Kpa Antibody.

BACKGROUND: Kpa (KEL3, Penney) is a red blood cell antigen within the Kell system, first described in 1957, that occurs in less than 2 percent of the population. Although anti-Kpa antibodies were identified in 2-5 percent of those with alloantibodies among patients requiring chronic transfusion, only five previously published case reports of anti-Kpa reactions were identified. CASE REPORT: Reported here is a case of an elderly female who experienced an acute hemolytic transfusion reaction due to this antigen. Following initiation of blood transfusion, she experienced a sudden onset of rigorous chills, accompanied by elevated temperature, tachycardia, and hypertension. Laboratory studies showed uremia, elevated creatinine, positive direct Coomb's, and low haptoglobin. Serology revealed anti-Kpa antibody. CONCLUSION: This report is only the sixth, to our knowledge, of a significant reaction attributable to anti-Kpa and only the second of an acute hemolytic reaction associated with it. It serves as a reminder of the potential of low incidence antigens causing severe reactions; this potential should be considered when evaluating acute hemolytic reaction.

A Very Rare Case of Sarcoid-Lymphoma Syndrome Imposing an Intriguing Diagnostic Challenge.

An enigmatic association between sarcoidosis and lymphoma has been proposed in the past. This poses a significant diagnostic challenge, especially when the time interval is less than one year between the two diagnoses. A 54-year-old male patient presented to his primary care physician with worsening acute kidney injury and hypercalcemia. His chest x-ray showed bilateral interstitial nodular thickening and mild bilateral hilar fullness. After a diagnostic workup, the patient was diagnosed with sarcoidosis and started on prednisone. He initially improved, but returned with acute kidney injury, hypercalcemia, and generalized lymphadenopathy. An excisional lymph node biopsy was positive for diffuse large B-cell lymphoma. Our case illustrates the sarcoidosis-lymphoma syndrome. Although there is no recommendation to screen patients with sarcoidosis for malignancy, it is crucial to be aware of this association and to evaluate any new or enlarging lymphadenopathy with a biopsy. It is essential to assess response to prednisone in patients with sarcoidosis.

Catch Me If You Can.

Nocardia is a genus of anaerobic gram-positive bacteria that most commonly infect persons with compromised immunity. Pneumonia and soft tissue infections are seen most frequently; osteomyelitis is an uncommonly reported manifestation of nocardiosis. We report a case of pelvic osteomyelitis due to Nocardia asteroides in a patient with unrecognized acquired immune deficiency syndrome (AIDS) without evidence of concomitant pulmonary or skin infection.

Gastric Zygomycosis in a Previously Healthy 56-Year-Old Male.

Zygomycosis refers to invasive fungal infections caused by fungi belonging to the phylum zygomycota. Infections generally occur in immunocompromised individuals. The following case is of a previously healthy 56 year-oldmale admitted to the hospital following a motor vehicle accident. During his hospitalization, there was a significant drop in hemoglobin with no obvious source of bleeding. This prompted the clinician to insert a nasogastric tube which returned at least 2 liters of black fluid and led to an upper gastrointestinal endoscopy. The endoscopy revealed numerous large crater-like gastric ulcers with adherent clot, up to 30 mm in greatest dimension. Biopsies of the ulcer margins revealed broad pauciseptate, ribbon-like, slightly refractile fungal forms, which were highlighted with periodic acid-Schiff (PAS) stain. A Gomori methanamine silver (GMS) stain was negative. These forms were suggestive of zygomycetes. A subsequent gastrectomy was performed, which revealed similar findings. The patient experienced severe trauma, which may have contributed to the progression of his condition; however, this is an unusual presentation as the patient was previously healthy, and he did not illustrate any conditions that might compromise his immunity. The severity and rarity of this condition makes this a very unique and intriguing case.

Renal Angiomyolipoma With Incidental Oncocytoma: A Case Report and Review of Literature.

We present a 37-year-old female with a history of tuberous sclerosis. She developed flank pain, hypotension, and a sudden drop in hemoglobin levels which prompted a work-up. A computed tomography scan demonstrated enlarged heterogeneous kidneys and a large complex collection in the right kidney, likely hemorrhagic in nature. The findings were suspicious for bilateral angiomyolipomas with retroperitoneal hematoma. She was treated with bilateral transarterial embolization. She subsequently developed recurrent fever and was suspected of having emphysematous pyelonephritis, for which she underwent a right nephrectomy. The entire kidney was replaced by a tan bulging, lobular mass, with scattered tan-yellow nodules. Microscopic examination revealed an angiomyolipoma with an incidental oncocytoma. The association of renal angiomyolipoma and renal oncocytoma is rare and only 16 cases have been previously reported.

Combined Melanocytic Nevus, Superficial Congenital and Deep Penetrating Types with Fibroepithelioma of Pinkus, Collision Tumor - A Case Report.

We present a case of collision tumor composed of a combined melanocytic nevus with superficial congenital and deep penetrating components and a fibroepithelioma of Pinkus on the left lumbar back of a 21-year-old male. He presented to the dermatologist for evaluation of numerous moles, and the lesion in question was described as a brown variegated papule with slightly irregular shape and irregular borders. This case is being reported as it is very unusual to see a fibroepithelioma of Pinkus in conjunction with a melanocytic lesion.