Prolonged Hemodialysis: An Antidote for Metformin-Associated Lactic Acidosis.

Lactic acidosis is a rare and potentially lethal complication of metformin therapy. We present a case of a middle-aged diabetic man with metformin-induced acute lactic acidosis successfully managed with timely hemodialysis.

Hyperammonemia: A Silent Killer.

Hyperammonemia is most commonly associated with liver disease. Nonhepatic causes of hyperammonemia are uncommon. We present a case of nonhepatic hyperammonemia that turned fatal within a short period of time and discuss the possible treatment modalities for the same.

Stroke in a Young Woman as a Presenting Manifestation of Membranous Nephropathy.

Stroke is one of the most severe complications of nephrotic syndrome (NS), only a few cases have been reported in previous literature. Some of those cases are not clear about whether the stroke was purely caused by NS because they also had other risk factors for stroke, such as old age, hypertension. A recent study showed that serum albumin less than 2.8 g/dL is a risk factor for thromboembolic events (venous thromboembolic events). Anticoagulation is suggested for patients with NS with low albumin by KIDIGO guideline 2012. Here, we describe a case in which a young patient presented with stroke as an initial symptom of membranous nephropathy (MN). A 36-year-old woman with no medical history came to the emergency room for left side weakness. Computed tomography of head showed right middle cerebral artery infarct. She was healthy and had no history of hypertension or peripheral vascular disease. She was not taking any medication before admission and did not have any toxic habits. She had nephrotic range of proteinuria with no active sediment in urine analysis, serum albumin of 1.7 g/dL, normal renal function, elevated blood pressure on admission, and no signs of left ventricular hypertrophy. All coagulopathy workup was negative. The renal biopsy showed MN. She was started on Coumadin and treated with steroids and cyclophosphamide. Four months after the stroke, she still could not perform daily activity independently. This case illustrates that stroke can be an initial symptom of MN, and it is important we detect and anticoagulate this high-risk group of patients before their developing stroke. Urine analysis is an inexpensive screening tool for NS and should be considered as an initial workup for a young patient who presents with stroke.

A case of phosphaturic mesenchymal tumor.

Phosphaturic mesenchymal tumors (PMTs) are rare and found to be commonly associated with phosphaturia and oncogenic osteomalacia. They commonly affect middle-aged adults and are located mostly in the extremities. Most of them are benign with only a few metastatic cases described in the literature. PMT-mixed connective tissue (PMTMCT) type is the most common PMT. Though most cases of PMTMCT have been associated with oncogenic osteomalacia and phosphaturia, there have been many reports of nonphosphaturic variants of this tumor with no clinical or laboratory evidence of tumor-induced osteomalacia. However, most of these nonphosphaturic variants previously described were not metastatic. We describe an unusual case of PMTMCT with widespread osseous metastases and without evidence of tumor-induced osteomalacia or phosphaturia.

Cutaneous basal cell carcinoma mimicking small cell carcinoma.

Neuroendocrine differentiation seen in basal cell carcinomas (BCC) is not generally appreciated by oncologists and can introduce a component of confusion when diagnosing a tumor and developing a management plan. Understanding that BCC commonly have this feature can assist the treating oncologist.

More than meets the eye: the 'pink salmon patch'.

Ocular adnexal lymphomas account for 1-2% of all non-Hodgkin's lymphomas. Conjunctiva is the primary site of involvement in one-third of cases. We present a case of a 47-year-old Hispanic woman who presented with left eye itching and irritation associated with a painless pink mass. Physical examination revealed the presence of a 'pink salmon-patch' involving her left medial conjunctiva. Orbital CT showed a subcentimeter left preseptal soft tissue density. Biopsy revealed a dense subepithelial lymphoid infiltrate comprised predominantly of B cells that did not coexpress CD5 or CD43. These findings were consistent with B-cell marginal zone lymphoma. Further staging assessment did not reveal disseminated disease. She had stage 1E extranodal marginal zone lymphoma as per Ann Arbor staging system. She received external beam radiotherapy to her left eye with complete resolution of the lymphoma in 2 months and continues to remain tumour free at 8-month follow-up. She will be followed up closely for development of any local (unilateral or contralateral eye) or systemic recurrence in the long run.