Primary Adrenal Lymphoma: When B Symptoms Appear Hand in Hand with Adrenal Masses.

Primary adrenal lymphoma (PAL) is a very rare type of non-Hodgkin's lymphoma (NHL). Herein, we report a case of NHL of both adrenal glands in a 69-year-old man. The patient was admitted because of a 1-month history of B symptoms and symptomatic hypotension. Biochemical analysis showed normocytic normochromic anaemia, hyponatraemia, hyperkalaemia, and elevated lactate dehydrogenase, C-reactive protein and D-dimers. A computed tomography scan revealed bilateral enlargement of the adrenal glands. There was no evidence of endocrine adrenal dysfunction. The mass in the right adrenal gland was biopsied and histopathology identified a diffuse large B-cell lymphoma of the activated B-cell subtype. A positron emission tomography 18F-fluorodeoxyglucose scan showed intensive hypermetabolic lesions involving both adrenal glands, as well as other locations, with higher uptake in the adrenal glands. Taken together, these findings suggested the diagnosis of PAL. The patient responded favourably to debulking therapy and is currently undergoing chemotherapy. LEARNING POINTS: Primary adrenal lymphoma is a rare condition presenting with unspecific symptoms; diagnosis requires histopathological confirmation.Adrenal function must be evaluated to rule out insufficiency.Positron emission tomography may reveal hitherto unsuspected extension of disease and should be performed where available.

Multiple complications of a 14-year-old hemodialysis catheter.

INTRODUCTION: Vascular access for hemodialysis is a key factor in every patient dependent on this treatment. Maintaining a central venous catheter can be a good choice when all the other options have been exhausted, but unwanted and rare complications may arise from longer catheter dwell time. CASE REPORT: We describe a case of a 65-year-old woman undergoing hemodialysis treatment since 1986 after a bilateral nephrectomy due to complicated nephrolithiasis. Her last access, two Tesio® tunneled cuffed catheters implanted via the right internal jugular vein functioned correctly for 14 years without complications, and so, was not replaced in the meantime. She was referred to our hospital due to a rupture in a catheter lumen, which was corrected conservatively by creating a more proximal tunnel and excising the affected area. A few weeks later, a new rupture in the same lumen was identified, so the catheter was replaced with angiographic control. The catheter was frail, so upon its removal, the tip fractured and remained in the right ventricle, being swiftly removed by an endovascular snare without complications. DISCUSSION: This case reports two rare complications associated with catheter handling and identifies a possible technique for conservative resolution of a lumen rupture.

Triple POCUS: A New Approach to an Old Problem.

Pulmonary embolism (PE) is the most serious and life-threatening clinical presentation of venous thromboembolism, and difficult to diagnose. Triple point-of-care-ultrasonography (POCUS) of the lung, heart and leg veins is a multiorgan approach that may help to evaluate patients suspected of having PE, in combination with existing protocols and computed tomographic pulmonary angiography (CTPA). We present the case of a 26-year-old man with sudden onset of dyspnoea and swelling of the leg with a Well's score of 9. With CTPA unavailable at the time of presentation, triple POCUS showed subpleural consolidations and a venous thrombus in a popliteal vein. A diagnosis of deep vein thrombosis with PE was made and the appropriate treatment was started immediately. Although triple POCUS has less sensitivity and specificity than CTPA, it could be very useful in some clinical settings. LEARNING POINTS: In a patient with suspected pulmonary embolism, the best diagnostic strategy is to combine clinical assessment, plasma D-dimer measurement and computed tomographic pulmonary angiography (CTPA).Triple point-of-care ultrasonography of the lung, heart and leg veins may improve clinical assessment of pulmonary embolism if CTPA is unavailable or contraindicated.Point-of-care ultrasonography should be incorporated as the fifth pillar of the physical examination.