An Unusual Case of Dual Pancreatic Tumors.

We report a simultaneous occurrence of pancreatic adenocarcinoma and pancreatic neuroendocrine tumor. A 64-year-old woman presented with abdominal pain and weight loss. Abdominal computed tomography revealed a pancreatic head mass with a mesenteric artery encasement. Endoscopic ultrasound revealed a second mass in the tail of the pancreas. Pathology reported adenocarcinoma of the head of the pancreas and a neuroendocrine tumor in the tail of the pancreas. The neuroendocrine tumor was nonfunctional, with no symptoms or signs present on assessment. The patient had advanced unresectable carcinoma, so she was treated with chemotherapy.

Mycobacterium avium complex: An unusual cause of hypercalcemia.

Mycobacterium avium-complex (MAC) is an infectious granulomatous disease which is associated with hypercalcemia especially in immunocompromised patients. We present an unusual case of MAC infection in an immunocompetent patient presenting as hypercalcemia.A 76-year-old immunocompetent male was admitted for hypercalcemia of 12.6 mg/dl found on outpatient evaluation for fatigue. PTH level was low 8 pmol/L, Vitamin D 25hydroxy was 29 ng/ml, 1,25 dihydroxy vitamin D (1,25(OH)2 vitamin D) levels was low at 11 pg/ml, PTH related peptide was 1.1 pmol/L. Hypercalcemia resolved with intravenous hydration and bisphosphonate administration. CT chest identified a nodule with central cavity in the right upper lobe. Pathology from percutaneous biopsy of thenodule demonstrated granulomatous inflammation. AFB culture came positive for MAC. Patient was treated with Azithromycin, Rifabutin and Ethambutol for twelve months.Granulomatous diseases like MAC cause hypercalcemia via activation of macrophages which express extrarenal 1- alpha -hydroxylase. It converts vitamin D to its active form 1,25(OH)2 vitamin D causing its excess, leading to hypercalcemia. Interestingly, in our patient calcium level was elevated with appropriately low PTH but 1,25(OH)2 vitamin D level was also low. There are few reported cases of hypercalcemia in granulomatous disease with normal levels of 1,25(OH)2 vitamin D levels, and our case is the first one to have MAC associated hypercalcemia with low 1,25(OH)2 vitamin D levels, suggesting an alternative mechanism for hypercalcemia in these patients.

Cytomegalovirus Proctitis in a Patient with Chronic Lymphocytic Leukemia on Ibrutinib Therapy: A Case Report.

Ibrutinib is a Bruton tyrosine kinase (BTK) inhibitor that has shown significant efficacy in patients with lymphoid carcinomas, mostly chronic lymphocytic leukemia (CLL). Cytomegalovirus (CMV) infection is not a common infectious complication associated with ibrutinib. To increase the clinical awareness about this rare entity, we present the first case of CMV proctitis in an immunocompromised host who was being treated with ibrutinib. An 88-year old female with a history of CLL treated with ibrutinib presented with two days of painless hematochezia. Physical examination revealed cachexia and temporal wasting; bright red blood was observed on the digital rectal examination. A complete blood count demonstrated a significant decrease in hemoglobin from her baseline. Subsequent colonoscopy revealed a circumferential rectal ulcer; biopsy of the rectal ulcer was positive for CMV immunostain. The patient was treated with intravenous ganciclovir and later transitioned to valganciclovir for a total of 21 days of treatment. Her condition resolved, and she was found doing well at the follow-up visit.