Disseminated Histoplasmosis in a Patient With Acquired Immunodeficiency Syndrome in a Non-Endemic Region (California).

Histoplasmosis is caused by infection with Histoplasma capsulatum (H. capsulatum). Progressive disseminated histoplasmosis is a more severe form of histoplasmosis and is seldom diagnosed in non-endemic regions of the world owing to the fungus's geographical distribution. In the United States (USA), Histoplasma capsulatum is classically known to be endemic to the Mississippi and Ohio River valleys, and cases in non-endemic areas, such as the southwest USA, are exceedingly rare. Patients with acquired immunodeficiency syndrome (AIDS) are at risk for infection with H. capsulatum, and failure to recognize and treat histoplasmosis may be devastating to patients. In non-endemic regions, the proposed mechanism for disseminated histoplasmosis in AIDS patients is reactivation of a previous infection. Here, we present the case of a young male patient who presented to a southern California hospital with diarrhea, was diagnosed with AIDS, and developed acute hypoxic respiratory failure. Chest imaging revealed diffuse reticulonodular opacities, and histoplasmosis was confirmed by urine and serologic examination. He was subsequently treated with liposomal amphotericin B and safely discharged from the hospital with oral itraconazole therapy. This case contributes to the current limited body of literature citing histoplasmosis infections in California, and clinicians should consider histoplasmosis as a differential diagnosis in non-endemic regions.

A Rare Case of Coccidioidomycosis Meningitis.

Disseminated coccidioidomycosis is a fungal disease endemic to the Southwest United States as well as South and Central America. This dimorphic fungus typically manifests as pulmonary infection; however, there are very rare instances of extrapulmonary disseminated disease especially in immunocompromised hosts. Here, we present a 46-year-old immunocompromised patient with a recent diagnosis of pulmonary coccidioidomycosis that initially presented with acute respiratory failure and was found to have coccidioidomycosis meningitis. This case highlights that despite early and adequate treatment of a known pulmonary coccidioidomycosis infection, dissemination of the disease can still ensue and should be considered in cases of acute encephalopathy.

Sclerosing epithelioid fibrosarcoma associated with WRN gene variant presenting as chronic dyspnea and pathologic cervical fracture: a case report and review of the literature.

BACKGROUND: Sclerosing epithelioid fibrosarcoma is an aggressive sarcoma subtype with poor prognosis and limited response to conventional chemotherapy regimens. Diagnosis can be difficult owing to its variable presentation, and cases of sclerosing epithelioid fibrosarcoma are rare. Sclerosing epithelioid fibrosarcoma typically affects middle-aged individuals, with studies inconsistently citing gender predominance. Sclerosing epithelioid fibrosarcoma typically arises from the bones and soft tissues and often has local recurrence after resection and late metastases. Immunohistochemical staining typically is positive for mucin-4. Werner syndrome is due to an autosomal recessive mutation in the WRN gene and predisposes patients to malignancy. CASE PRESENTATION: A 37-year-old Caucasian female presented to the emergency department with 4 months of dyspnea and back pain. She had been treated for pneumonia but had persistent symptoms. A chest, abdomen, and pelvis computed tomography showed near-complete right upper lobe collapse and consolidation, mediastinal lymphadenopathy, lytic spinal lesions, and a single 15-mm hypodense liver nodule. The patient underwent a transthoracic right upper lobe biopsy, bronchoscopy, endobronchial ultrasound with transbronchial lymph node sampling, and bronchoalveolar lavage of the right upper lobe. The bronchoalveolar lavage cytology was positive for malignant cells compatible with poorly differentiated non-small cell carcinoma; however, the cell block materials were insufficient to run immunostains for further investigation of the bronchoalveolar lavage results. Consequently, the patient also underwent a liver biopsy of the liver nodule, which later confirmed a diagnosis of sclerosing epithelioid fibrosarcoma. Next-generation sequencing revealed a variant of unknown significance in the WRN gene. She was subsequently started on doxorubicin. CONCLUSION: Sclerosing epithelioid fibrosarcoma is a very rare entity, only cited approximately 100 times in literature to date. Physicians should be aware of this disease entity and consider it in their differential diagnosis. Though pulmonary involvement has been described in the context of sclerosing epithelioid fibrosarcoma, this malignancy may affect many organ systems, warranting extensive investigation. Through our diagnostic workup, we suggest a possible link between sclerosing epithelioid fibrosarcoma and the WRN gene. Further study is needed to advance our understanding of sclerosing epithelioid fibrosarcoma and its clinical associations as it is an exceedingly rare diagnosis.

A Rare Presentation of Severe Organophosphate Poisoning: A Case Report and Review of Literature.

Organophosphates are chemicals commonly used as pesticides and work to inhibit acetylcholinesterase, leading to acetylcholine build up at muscarinic and nicotinic receptors throughout the body. Poisonings are often seen as small volume, chronic cases due to agricultural exposures, but can present as suicide attempts via organophosphate ingestion. Organophosphate poisonings, particularly when large volumes are ingested, require rapid and robust initiation of treatment. We present a case highlighting the appropriate management of profound organophosphate toxicity. We present a case of a 40-year-old female brought in by ambulance after purposefully ingesting two bottles of 100mL dichlorvos (DDVP), one of the largest volume organophosphate ingestions documented in the literature. She presented with severe salivation, diaphoresis and encephalopathy and was then intubated, requiring mechanical ventilation. She received multiple days of intensive care as she was treated with atropine, pralidoxime, intravenous fluids and vasopressors.