Extreme Reactive Thrombocytosis Caused by Obstructive Nephrolithiasis and Pyelonephritis.

Platelet counts in reactive thrombocytosis rarely exceed 1000 × 109/L. We present the case of a male patient, aged 80 years, with quiescent rheumatoid arthritis who was found to have a platelet count of 1011 × 109/L on routine laboratory testing. The patient was initially asymptomatic but developed leukocytosis to 23.1 × 109/L on hospital day 2. Diagnostic work-up revealed obstructive nephrolithiasis and pyelonephritis, and the thrombocytosis and leukocytosis gradually resolved with empiric antibiotic treatment and ureteral stent placement. Tests for myeloproliferative disorders, including JAK-2V617F mutation, BCR-ABL for chronic myeloid leukemia and acute lymphocytic leukemia, and myeloproliferative neoplasms (MPL/CALR), were negative. Physicians should be aware that in rare cases reactive thrombocytosis can exceed 1000 × 109/L, and that markedly elevated platelet counts in the setting of urinary tract infections may be an early sign of obstructive uropathy.

False-Negative 18F-Fluorodeoxyglucose PET/CT in Malignant Pleural Mesothelioma.

We report a diagnostically challenging case of a 77-year-old man who presented with shortness of breath and was found to have a large right hydropneumothorax with collapse of the right lung. A malignancy was suspected, but pleural fluid cytology and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT imaging were negative. He then underwent video-assisted thoracoscopy with biopsies of the pleura and chest wall which revealed malignant pleural mesothelioma (MPM). Older patients with early stage MPM are more likely to have false-negative FDG PET/CT results. Pleural biopsy is essential when there is clinical suspicion for mesothelioma, even with negative initial FDG PET imaging.

Analysis of Medical Error Contributing to Missed Acute Myeloid Leukemia Diagnosis.

Hospitals and physicians attempt to minimize medical error by putting systems checks and balances in place at multiple levels. The effectiveness of these hospital-specific strategies to thwart error is called into question, as medical error remains a leading cause of death in the United States. This case report outlines the course of a 62-year-old man with a history of non-small cell lung cancer and right tongue squamous cell carcinoma, who had been admitted to an outside hospital for possible pneumonia. On initial presentation, the patient was pancytopenic with an absolute neutrophil count of 598. As his counts continued to downtrend and his conditioned worsened, oncology saw the patient and attributed the pancytopenia to "transient myelosuppression from pneumonia". This statement impacted the trajectory of the patient's care, delaying his ultimate diagnosis and treatment for acute myeloid leukemia. This case emphasizes the power of framing and anchoring biases in medical decision making and the need to evolve practice models from the current method of closed-door inquiry towards a more inclusive system of error reporting and analysis.

Zinc Deficiency-induced Hypogeusia in a Patient with Refractory Iron-deficiency Anemia: A Case Report.

Zinc deficiency is a relatively common condition in various American populations but is frequently unrecognized and under-diagnosed. It typically presents with nonspecific symptoms, including lethargy, immune dysfunction, dermatitis, diarrhea, and decreased taste sensation (hypogeusia). Zinc deficiency often occurs concurrently with iron deficiency and has been linked to more severe clinical manifestations of iron deficiency anemia. We describe a 66-year-old man who presented with weakness and fatigue and was found to have persistent iron-deficiency anemia attributable at least in part to malnutrition caused by zinc deficiency-induced hypogeusia. The hypogeusia rapidly improved and nutritional intake normalized with zinc supplementation.

Herpes Simplex Virus Hepatitis: A Presentation of Multi-Institutional Cases to Promote Early Diagnosis and Management of the Disease.

OBJECTIVE: To compare three cases of Herpes simplex virus (HSV) hepatitis to increase early diagnosis of the disease. Case 1. A 23-year-old man with Crohn's disease and oral HSV. HSV hepatitis was diagnosed clinically and he improved with acyclovir. Case 2. An 18-year-old G1P0 woman with transaminitis. Despite early empiric acyclovir therapy, she died due to fulminant liver failure. Case 3. A 65-year-old woman who developed transaminitis after liver transplant. Diagnosis was confirmed by biopsy and she had resolution of acute liver failure with acyclovir. CONCLUSION: It is imperative that clinicians be aware of patients at high risk for developing HSV hepatitis to increase timely diagnosis and prevent morbidity and fatality.

Trousseau's Syndrome in Cholangiocarcinoma: The Risk of Making the Diagnosis.

We report a case of Trousseau's syndrome with cholangiocarcinoma complicated by a fatal pulmonary embolism after liver biopsy. A 69-year-old man who presented with right upper quadrant pain was found to have portal vein thrombosis and nonspecific liver hypodensities after imaging by computerized tomography. Following four days of anticoagulation, heparin was held for percutaneous liver biopsy. After the biopsy, he developed acute hepatic failure, acute kidney injury, lactic acidemia, and expired. Autopsy revealed intrahepatic cholangiocarcinoma and a pulmonary embolism. Trousseau's syndrome with cholangiocarcinoma is rarely reported and has a poor prognosis. This case highlights a fundamental challenge in the diagnosis and early management of intrahepatic cholangiocarcinoma with hypercoagulability. Diagnostic biopsy creates an imperative to reduce post-operative bleeding risk, but this conflicts with the need to reduce thrombotic risk in a hypercoagulable state. Considering the risk of withholding anticoagulation in patients with proven or suspected cholangiocarcinoma complicated by portal vein thrombosis, physicians should consider biopsy procedures with lesser bleeding risks, such as transjugular liver biopsy or plugged percutaneous liver biopsy, to minimize interruption of anticoagulation.

Type B Lactic Acidosis in a Patient with Gastric Adenocarcinoma and Extensive Hepatic Metastases.

OBJECTIVE: We report the second case of gastric adenocarcinoma associated with type B lactic acidosis. CLINICAL PRESENTATION AND INTERVENTION: An 81-year-old man presenting with upper gastrointestinal bleeding was found to have an advanced gastric adenocarcinoma. He had persistently elevated serum lactate attributed to malignancy-associated type B lactic acidosis as a diagnosis of exclusion. As he remained clinically stable with a near-normal pH, his elevated lactate was not specifically treated. CONCLUSION: This patient had an unusual type B lactic acidosis associated with gastric cancer. In the absence of signs and symptoms of other etiologies of lactic acidosis, physicians should consider malignancy-associated type B lactic acidosis.

Severe romiplostim-induced rebound thrombocytopenia after splenectomy for refractory ITP.

OBJECTIVE: To report a case of severe rebound thrombocytopenia after temporary discontinuation of romiplostim during splenectomy in the context of refractory immune (idiopathic) thrombocytopenic purpura (ITP). CASE SUMMARY: A 65-year-old man with a history of severe refractory ITP failing multiple treatments was considered for romiplostim therapy. He was initiated on 1 µg/kg and titrated upward to 4 µg/kg to elevate and stabilize his platelet levels prior to splenectomy. On day 74 of his clinical course, his platelets increased to 434 × 10(9)/L, and his scheduled dose of romiplostim was withheld on day 75 for fear of romiplostim-induced postsplenectomy rebound thrombocytosis. On day 78, his platelets dropped precipitously to 9 × 10(9)/L, and he experienced multiple episodes of epistaxis. He was reinitiated at 5 µg/kg and soon recovered. He later missed a scheduled dose of romiplostim, and his platelets fell to 23 × 10(9)/L. After resuming romiplostim at 8 µg/kg, his platelets continued to recover. DISCUSSION: Romiplostim, a thrombopoietin mimetic is directly regulated by megakaryocytes and existing circulating platelets via a negative feedback mechanism. This explains the theoretical risk of rapid clearance of romiplostim caused by an increased platelet pool. Clinically, alternative causes of his severe postoperative thrombocytopenia were considered and deemed unlikely. The rebound effect was observed after romiplostim was withdrawn on 2 occasions, and platelet counts improved after restarting romiplostim. The Naranjo Adverse Drug Reaction Probability Score of 7 suggests a probable adverse drug reaction. CONCLUSION: Physicians using romiplostim as a bridge to splenectomy should be cautious about withholding a scheduled dose around the time of surgery.

Acute abdominal pain after intercourse: adrenal hemorrhage as the first sign of metastatic lung cancer.

Although the adrenal glands are a common site of cancer metastases, they are often asymptomatic and discovered incidentally on CT scan or autopsy. Spontaneous adrenal hemorrhage associated with metastatic lung cancer is an exceedingly rare phenomenon, and diagnosis can be difficult due to its nonspecific symptoms and ability to mimic other intra-abdominal pathologies. We report a case of a 65-year-old man with a history of right upper lobectomy seven months earlier for stage IB non-small cell lung cancer who presented with acute abdominal pain after intercourse. CT scan revealed a new right adrenal mass with surrounding hemorrhage, and subsequent FDG-PET scan confirmed new metabolic adrenal metastases. The patient's presentation of abdominal pain and adrenal hemorrhage immediately after sexual intercourse suggests that exertion, straining, or increased intra-abdominal pressure might be risk factors for precipitation of hemorrhage in patients with adrenal metastases. Management includes pain control and supportive treatment in mild cases, with arterial embolization or adrenalectomy being reserved for cases of severe hemorrhage.

Vertebral sarcoidosis mimicking lytic osseous metastases: development 16 years after apparent resolution of thoracic sarcoidosis.

Vertebral sarcoidosis is a rare condition that can present with persistent back pain, often with concurrent lung, lymph node, or skin involvement. It can produce lytic or blastic osseous lesions that are indistinguishable from metastatic cancer on bone scan and magnetic resonance imaging (MRI). It usually occurs at the time of initial diagnosis of sarcoidosis, but may in very rare cases appear many years after presumed resolution of thoracic sarcoidosis. We present the case of a 47-year-old man who developed persistent low back pain 16 years after spontaneous resolution of stage I pulmonary sarcoidosis. MRI of the spine showed lytic thoracic and lumbar vertebral lesions. Computed tomography of the chest showed a pleural-based lung mass, multiple pulmonary nodules, and hilar and mediastinal lymphadenopathy. Positron emission tomography with fluorodeoxyglucose was widely positive, including at the vertebral foci noted on MRI. Metastatic lymphoma was suspected, but mediastinal lymph node and vertebral body biopsies showed noncaseating granulomas with negative stains for acid-fast bacilli and fungi. After 1 month of treatment with prednisone, the angiotensin-converting enzyme level and erythrocyte sedimentation rate had normalized, and the back pain was substantially improved. We found only 1 case report of a longer interval between resolution of initial sarcoidosis and development of vertebral involvement.