Consideration of alternative causes of lactic acidosis: Thiamine deficiency in malignancy.

Lactic acidosis is a common metabolic acidosis characterized by increased serum lactate and is usually associated with a decreased blood pH. Lactic acidosis has many different causes but has been differentiated into type A, hypoxic causes, and type B, non-hypoxic causes. Tissue hypoxia, type A, is the most common cause, usually secondary to processes such as sepsis and multi-organ failure. Type A must be differentiated from type B in the correct clinical setting as treatments are vastly different. Type B causes may include drug side-effects, toxins, enzymatic defects, inherited or acquired, any of which may lead to overproduction or underutilization of lactate. However, as most clinicians are more familiar, and likely more initially concerned with hypoxic etiologies, evaluation is directed toward finding the source of hypoperfusion or hypoxia, and thus generally leading to a delay in discovering a type B cause (or mixed type A and type B). Here we describe a case of lactic acidosis in the setting of thiamine deficiency thought to be secondary to advanced lung cancer. The purpose of this paper is to bring awareness to the clinician to consider other causes of lactic acidosis when evaluating a patient.

Rectal Hematoma Mimicking as a Gastrointestinal Stromal Tumor: An Atypical Endoscopic Ultrasound Finding.

Acute gastrointestinal bleeding (GIB) represents a frequently encountered condition that prompts individuals to seek urgent medical attention at the emergency department, often leading to subsequent hospitalization. GIB can range from self-limited bleeding to hemorrhagic shock. Multiple etiologies contribute to the occurrence of GIB. In this report, we present the case of an 84-year-old male with multiple medical comorbidities admitted with hemodynamically stable lower GIB. Colonoscopy demonstrated a submucosal mass without evidence of bleeding. He subsequently underwent an endoscopic ultrasound (EUS) with sonographic findings concerning for a gastrointestinal stromal tumor. However, pathological analysis from both colonoscopy and EUS indicated the presence of blood, but no evidence of malignancy. A follow-up EUS performed two months later showed a complete resolution of the previously observed submucosal mass, suggesting that the initial evaluation was likely a hematoma that has resolved completely.

A Rare Presentation of Appendiceal Carcinoma.

Appendiceal cancer is a rare malignancy. Our patient presented initially to her primary care physician due to symptoms of lightheadedness and dizziness and was found to have severe anemia requiring hospital admission. She underwent a colonoscopy and was found to have mucosal ulceration in the appendiceal orifice. She underwent a biopsy of the ulceration, which was remarkable for moderately differentiated adenocarcinoma. The patient then underwent a right hemicolectomy. The usual presentation for appendiceal carcinoma is acute appendicitis; however, our patient presented with the microcytic anemia.

A Case of Angioimmunoblastic T-cell Lymphoma That Mimics As Autoimmune Diseases and Infections.

Angioimmunoblastic T-cell lymphoma (AITL) is an aggressive malignancy with a presentation like either autoimmune diseases, drug reactions, or infections. We hereby present a unique case of AITL. A 61-year-old Caucasian male with a past medical history of chronic obstructive pulmonary disease (COPD) presented to the emergency department with a rash over his bilateral knees, shortness of breath, and productive cough of few days. He was managed for suspected COPD exacerbation associated with community-acquired pneumonia. On the day of admission patient was having an itchy maculopapular rash, ecchymosis on the left flank, and generalized lymphadenopathy. Physical exam showed generalized lymphadenopathy. Laboratory tests revealed leukocytosis, thrombocytopenia and were positive for multiple autoantibodies. Epstein-Barr virus polymerase chain reaction and hepatitis B virus core antibody were positive. Skin biopsy revealed findings suggestive of a small vessel vasculitis. Inguinal lymph node biopsy showed AITL. The patient recovered with chemotherapy. The case illustrates that clinical presentation of AITL mimics rheumatologic disorders and infections. This complexity could arise from the follicular T helper cell, which is an important checkpoint for B cell activation and differentiation. Additionally, skin involvement is one of the important findings of AITL and a variety of lesions have been reported as skin manifestations.

Reactive Perforating Collagenosis; An Uncontrolled Pruritus That Left You Scratching Your Head.

Acquired perforating collagenosis is a rare disease of altered collagen formation that is extruded through the epidermis. It is most commonly seen in patients with microvascular disease including longstanding diabetes and chronic kidney disease (CKD). Due to the rarity of the disease, no large randomized clinical studies have been performed to determine the most efficacious method of treatment. Therefore, most of the knowledge available for treatment is secondary to the information collected through case reports, case series, and retrospective analyses. In this report, we present the case of a 68-year-old male with history of stage IV CKD who presented with a severe skin rash that was present over his body, including the chest, arms, back, neck, and buttocks. It did not involve the mouth, legs, palms or soles of the feet. He did not have a significant history of diabetes and had been placed on steroids with the concern that this rash may have been secondary to a drug reaction, erythema multiforme, or bullous pemphigoid. Two skin biopsies were performed as the patient was not responding to systemic and topical steroid or oral antibiotic therapy. The final biopsy ultimately revealed a diagnosis of acquired perforating collagenosis. This is unusual in our case because although our patient had advanced CKD, he was not on dialysis, and had no significant longstanding history of diabetes. Additionally, as the prevalence of CKD is increasing in the population, it becomes more pertinent for providers to be aware of dermatological conditions associated with advanced CKD. This case report seeks to raise awareness of this disease. Furthermore, as the initial skin biopsy was unrevealing, this case also emphasizes the importance of repeating a biopsy to reduce the chance of sampling error.

A rare cause of exercise induced ventricular tachycardia.

Coronary fistulas are anomalous shunts from a coronary artery to a cardiac chamber or great vessel, bypassing the myocardial circulation. A 42-year-old Asian man with no significant history of cardiac disease presented with exertional chest discomfort in the form of chest tightness over the precordial area. The patient had no cardiac risk factors, but given the duration and persistence of symptoms, we did a stress echocardiogram. The exercise led to a 'coronary artery steal phenomenon' caused by the coronary fistula, which diverted the blood from the left anterior descending artery to the pulmonary artery thereby producing the ischemic symptoms and ventricular tachycardia. Transcatheter coil embolization was unsuccessful, but the fistula was eventually closed surgically. A repeat stress echocardiogram before discharge was completely normal. We emphasize the need to individualize treatment, taking into consideration all factors in a particular patient.

The most common cause of hemoptysis worldwide: a fluke?

Global travel is associated with an increasing incidence of helminthic infections in nonendemic regions. We describe a patient with recurrent hemoptysis from a chronic infection not commonly found in the USA.

Celiac artery disease and fatal rupture of a hepatic artery aneurysm in the Ehlers-Danlos syndrome.

Isolated visceral arteriopathies of the celiac and hepatic artery are rare. We present a case of a Caucasian man who presented with abdominal pain and was found to have a spontaneous celiac artery dissection. Genetic analysis revealed a mutation consistent with Ehlers-Danlos syndrome type IV. The patient died 2 months later from a spontaneous rupture of his hepatic artery.