Primary small cell neuroendocrine cancer of adrenal gland: a rare extrapulmonary small cell cancer.

Small cell cancer is an aggressive neoplasm of neuroendocrine origin that is most commonly found in the lungs. However, up to 5% of cases can be extrapulmonary. These have been reported to be located in the gastrointestinal and genitourinary systems and rarely in other locations. Only five prior cases of small cell cancer have been reported where the primary lesion is at the adrenal gland. Here we present the case of a female patient in her mid-50s who presented with right upper quadrant pain and was diagnosed with metastatic small cell carcinoma of the adrenal gland. The patient received palliative chemotherapy for her metastatic cancer and was ultimately admitted to hospice after progression of her disease. This case and the accompanying literature review highlight a rare manifestation of extrapulmonary small cell cancer.

Acute Non-Traumatic Sub-Arachnoid Hemorrhage in a Young Female With Diabetic Ketoacidosis.

Diabetic ketoacidosis (DKA) is one of the most common causes of morbidity and mortality in patients with type 1 DM. Due to severe acidosis, ketonemia and electrolyte disturbances it can lead to various complications in the body, which can be fatal in some cases. Neurological complications related to DKA include cerebral edema, cerebral infarction, brain herniation, cortical venous thrombosis. It is very rare for DKA to cause subarachnoid hemorrhage (SAH). We present a case 19-year-old female with severe DKA, who developed SAH without any pre-existing aneurysm or other common risk factors. The patient did not have any neurologic deficits and was managed conservatively with the resolution of her symptoms. We have also summarized the existing literature regarding the association of DKA with subarachnoid hemorrhage.

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma Presenting as Chronic Diarrhea; An Unusual Presentation of a Common Lymphoproliferative Disorder.

Chronic lymphocytic leukemia (CLL) is the most common lymphoproliferative disorder in the United States. It has a variable presentation with most patients having asymptomatic lymphocytosis. Many other patients present with lymphadenopathy or enlargement of other organs of the reticuloendothelial system. However, CLL can present with extramedullary involvement. Most commonly, this is in the form of skin or central nervous system involvement, though rarely it can present with gastrointestinal involvement. Here, we present the case of a 70-year-old Caucasian male who presented with chronic diarrhea for over 4 months. After failing conservative treatment, a colonoscopy was performed which showed diffuse mucosal nodularities with a biopsy revealing CLL. The patient was treated successfully with chemotherapy and his diarrhea improved. This is a differential to keep in mind in patients with chronic diarrhea, once the more common causes have been ruled out.

Meningeal rheumatoid nodules in a 55-year-old man presenting with chronic headaches and oculomotor nerve palsy: an uncommon extra-articular manifestation of rheumatoid arthritis.

Rheumatoid arthritis (RA) is a multisystem inflammatory disease which can involve many organ systems including the central nervous system (CNS). Though not very common, the results can be severely debilitating. The spectrum of the CNS involvement includes meningitis, encephalitis and occasionally rheumatoid nodules. Its presentation is variable, though very rarely it can present as focal neurological deficits. Imaging can be suggestive, but diagnosis usually requires tissue biopsy. Treatment consists of high-dose steroids and immunosuppressants. We describe the case of a 55-year-old male patient with a history of RA presenting with a third nerve palsy and headache who was found to have rheumatoid nodules on biopsy. CNS involvement in RA should be considered in anyone with rheumatoid arthritis who presents with focal neurological deficits, though infections and space-occupying lesions should also be ruled out.

The role of echocardiography in diagnostic evaluation of patients with syncope-a retrospective analysis.

BACKGROUND: Syncope is a symptom complex comprising of a brief loss of consciousness leading to a transient decrease in cerebral blood flow that resolves completely. 2D-transthoracic echocardiography (TTE) is a useful tool to detect underlying structural heart disease, which can lead to syncope, e.g., aortic stenosis, atrial masses. This study aimed to find the subgroups of patients with syncope who would benefit the most from a TEE. METHODS: We did a retrospective chart review of all patients aged 18 years or older, admitted to our hospital with a primary diagnosis of syncope between January 2015 and January 2017 to determine the frequency and findings of echo in all these patients. The baseline characteristics, demographics were taken into account for the inclusion of these patients into the study. RESULTS: A total of 369 patients were initially studied, but only 139 patients were included in the final analysis based on inclusion criteria. Among the high-risk patients (i.e., abnormal Physical exam and/or abnormal EKG, population), 43.75% had significant echocardiographic finding. While among low-risk patients (i.e., normal EKG and exam), 10% (9/91) had a significant finding. Patients with abnormal EKG or examination findings were 7.08 times (95% CI = 2.89-17.3) more likely to have an abnormal echocardiogram (P < 0.001). CONCLUSION: Our study suggests that the diagnostic yield of 2D-TTE in the absence of abnormal physical exam and/or abnormal EKG is very limited and may add an extra burden on the finances and resources of both the patient and the hospital.

Duration of in-hospital cardiopulmonary resuscitation and its effect on survival.

OBJECTIVE: This study aims to determine the correlation between the duration of cardiopulmonary resuscitation (CPR) and the return of spontaneous circulation (ROSC) in an in-hospital cardiac arrest cohort. METHODS: All patients (age ≥ 17 years) who underwent CPR at our institution from 2015 to 2017 were included. The primary endpoint was ROSC or death. A total of 88 patients were included in the study. The Pearson correlation of CPR duration with the establishment of ROSC was calculated using the IBM SPSS, version 25. RESULTS: In all, 88 patients who received CPR, 55% (n = 48) experienced ROSC and survived. The remaining 45% (n = 40) of the total and 56% (n = 27) of those with ROSC died during the same hospitalization (Fig. 1). Among the 48 patients with ROSC, the documented duration of their CPR was about 10 min on average in comparison with 27.5 min CPR for patients who did not achieve ROSC (Fig. 2). Among all the patients, there was a negative correlation between the duration of the CPR and the establishment of ROSC. This is shown in Fig. 3. CONCLUSION: Our study shows that CPR duration is inversely associated with the establishment rates of ROSC. Most of the benefits of CPR can be achieved in the first 15 min, and a further increase in the duration of CPR provides a minimal gain. Still, survival was achievable till 38 min in some cases, and the ideal duration of resuscitation should remain a bedside decision taking into consideration the whole clinical picture.

Anastrozole-induced liver injury after a prolonged latency: a very rare complication of a commonly prescribed medication.

Anastrozole is an aromatase inhibitor that has been used more frequently over the last decade especially for oestrogen receptor-positive breast cancer. It has a relatively safe side effect profile. However, occasionally it has been associated with serious adverse events. Here, we present the case of a 58-year-old woman who presented with significantly elevated liver enzymes 4 years after starting anastrozole. She was not taking any other medications and an extensive workup did not reveal any other cause for her liver injury. The patient's liver enzymes normalised after discounting the anastrozole. She scored 4 on the updated Roussel Uclaf Causality Assessment Method grading system which was possible for drug-induced liver injury. A review of the literature revealed six prior cases of anastrozole-related liver injury. Anastrozole should be considered as a possible culprit in patients who develop an unexplained acute liver injury.

Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia: An Updated Review of Diagnosis and Management.

Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a condition caused by the replacement of the normal right ventricular myocardium with fibrofatty tissue. ARVC/D can present with a variety of clinical conditions including right ventricular dysfunction, ventricular tachyarrhythmias, sudden cardiac arrest, and sudden cardiac death (SCD). Since the first report of ARVC/D in 1982, many advances have been made in the diagnosis, genetic findings for pathology, and treatment. The 2010 International Task Force diagnostic criteria distinguish between major and minor criteria and focus on gross structural changes, microscopic changes, repolarization defects, conduction defects, arrhythmias, and family history. Implantable cardiac defibrillators and catheter ablation of the endocardium and epicardium with electromagnetic mapping have emerged as successful tools in the treatment and prevention of ventricular tachyarrhythmias and SCD. This review discusses the pathophysiology, genetics, diagnosis, and treatment advances in ARVC/D.

Amiodarone-induced diffuse alveolar haemorrhage: a rare but potentially life-threatening complication of a commonly prescribed medication.

Amiodarone is an antiarrhythmic agent that is used commonly in clinical practice. It is associated with many side effects, the most common being pulmonary manifestations. Interstitial pneumonitis is one of the most common complications, however rarely amiodarone can cause diffuse alveolar haemorrhage (DAH) too. We describe the case of a 73-year-old woman who presented with shortness of breath and haemoptysis 4 days after starting amiodarone. She was diagnosed with amiodarone-induced DAH based on imaging and bronchoalveolar lavage. She was treated with intravenous and then oral steroids, and amiodarone was discontinued. The patient made a significant clinical and radiological recovery. She was discharged 10 days after her presentation. This case highlights a rare but potentially life-threatening complication of a commonly used medication.

Herpes Simplex Esophagitis in Immunocompetent Patients: A Rare But Easily Managed Condition.

Herpes simplex (HS) is an opportunistic infection, primarily in immunocompromised patients, caused by herpes simplex virus. Oral and genital mucosa are the most commonly involved sites; it is rare for HSV to invade the esophagus and cause esophagitis, especially in immunocompetent patients. Here, we present a case where an immunocompetent patient presented with HS esophagitis, which had evolved into esophageal ulcers. He was successfully treated with acyclovir. Subsequently, we did a comprehensive literature search and tabulated all the possible complications and management plans of previously reported cases of HS in immunocompetent patients.

Rapid onset type-1 diabetes and diabetic ketoacidosis secondary to nivolumab immunotherapy: a review of existing literature.

Nivolumab is a programmed cell death receptor (PD-1) inhibitor that is increasingly used for various malignancies, both as a first line agent and as salvage therapy. Being a PD-1/PD-1 ligand checkpoint inhibitor, it is known to cause autoimmune inflammation of various organs and has been associated with thyroiditis, insulitis, colitis, hepatitis and encephalitis to name a few. There are increasing reports of nivolumab leading to acute onset fulminant type 1 diabetes and diabetic ketoacidosis (DKA). We present a case of a 68-year-old man who developed DKA after 2 doses of nivolumab for metastatic melanoma. He was found to have type 1 diabetes, but no diabetes related antibodies were positive. He recovered from diabetes and continues to use insulin 1 year after his diagnosis. This case and associated review illustrates the importance of educating and monitoring patients who start nivolumab therapy regarding this potentially life threatening complication.

Human cytomegalovirus pneumonia in an immunocompetent patient: a very uncommon but treatable condition.

Human cytomegalovirus (CMV) is a double-stranded DNA virus that can cause widespread severe infection in immunocompromised individuals but is more typically a subclinical infection in immunocompetent individuals. Rarely, it can cause a serious infection in immunocompetent individuals. Here, we describe a 36-year-old otherwise healthy male who presented with fever, cough and malaise who was diagnosed with CMV pneumonia. He made a rapid recovery after initiation of ganciclovir and has been doing well on follow-up visits. We performed a comprehensive review of CMV pneumonia in immunocompetent individuals and have summarised the prior 16 reported cases of CMV pneumonia in immunocompetent patients. This article highlights the importance of considering CMV as a cause of pneumonia even in immunocompetent individuals, especially when the more common causes have been excluded. Early diagnosis allows prompt treatment and potentially complete recovery.

Hypercalcaemia, renal dysfunction, anaemia and bone lesions (CRAB) do not always represent multiple myeloma: diffuse large B cell lymphoma presenting with CRAB symptoms in a 69-year-old man.

Hypercalcaemia, renal dysfunction, anaemia and bone lesions (CRAB) are a constellation of signs and symptoms that are collectively referred to as the CRAB features. When present together, multiple myeloma (MM) should be at the top of the differential diagnosis. We present a 69-year-old man who presented with severe body aches and bone pain in his ribs and pelvis, associated with fatigue and constipation. He was found to have hypercalcaemia, acute kidney injury, anaemia and numerous lytic lesion on chest imaging. Physical examination and imaging were unremarkable for any enlarged lymph nodes. The patient was initially suspected to have multiple myeloma, however, serum and urine protein electrophoresis, and serum free light chain assays were negative. The patient was ultimately diagnosed with diffuse large B cell lymphoma based on a bone marrow biopsy. This case highlights the fact that presence of hypercalcaemia, renal dysfunction, anaemia and bone lesions are not usually specific for MM.

Importance of Basal Metabolic Index in the Diagnosis of Heart Failure With B-Type Natriuretic Peptide.

BACKGROUND: Increased basal metabolic index (BMI) is associated with decreased levels of B-type natriuretic peptide (BNP). This makes the diagnosis of the congestive heart failure challenging in the obese population. We sought to determine the association and strength of the relationship between the two variables. METHODS: The association between BMI and BNP was examined in 405 patients utilizing a retrospective chart review in a single center study. Pearson correlation and regression analyses were performed to identify trends. BNP trends were also correlated with age. RESULTS: The mean age of patients was 77 years with 45% men and 55% women. Mean BNP level was 1,158 standard deviation (SD) ± 1,537. Mean BMI was 33 SD ± 28. BNP levels were found to be inversely related to increasing BMI (P value < 0.001). Using a cut-off of 3,500 pg/mL, there was a linear negative correlation on the dotted graph. In regression analysis the measure of effect of BMI on BNP levels was -0.90 pg/mL. There was no significant association between age and BNP levels (P = 0.90). CONCLUSIONS: Irrespective of age, obese patients have lower BNP levels, complicating the diagnosis of heart failure exacerbation in such patients. Our results suggest that BNP levels in patients with BMI greater than 33 should be adjusted 9 pg/mL per unit increase in BMI.