Fascial bundles of the infraspinatus fascia: anatomy, function, and clinical considerations.

The infraspinatus fascia is a tough sheet of connective tissue that covers the infraspinatus fossa of the scapula and the muscle within. Muscle fibers originate from the fossa and fascia and then travel laterally to insert on the greater tubercle of the humerus. Frequently the infraspinatus fascia is quickly removed to appreciate the underlying muscle, but the fascia is an interesting and complex structure in its own right. Despite having a characteristic set of fascial bundles, no contemporary anatomy texts or atlases describe the fascia in detail. The infraspinatus fascia was dissected in detail in 11 shoulders, to characterize the fascial bundles and connections that contribute to it. Thereafter, 70 shoulders were dissected to tabulate the variability of the fascial bundles and connections. Six characteristic features of the infraspinatus fascia were noted: a medial band, an inferior-lateral band, and superior-lateral band of fascia, insertion of the posterior deltoid into the infraspinatus fascia, a transverse connection from the posterior deltoid muscle to the infraspinatus fascia, and a retinacular sheet deep to the deltoid and superficial to the infraspinatus and teres minor muscles. Although other structures of the shoulder are more frequently injured, the infraspinatus fascia is involved in compartment syndromes and the fascial bundles of this structure are certain to impact the biomechanical function of the muscles of the posterior shoulder.

An uncommon unilateral primary T cell adrenal lymphoma: A case report.

Primary adrenal lymphoma (PAL) is a rare disease with rapid progression. We present a case of PAL with T cell lymphoma in an 81-year-old male who initially presented with altered mental status and extreme weight loss. It is important to consider PAL in patients found to have adrenal masses to allow for prompt diagnosis and initiation of treatment.

Acute Plasma Cell Leukemia Presenting as Primary Hyperammonemic Encephalopathy.

Primary plasma cell leukemia (PPCL) is a rare form of multiple myeloma (MM) and is a rare aggressive disease with a median overall survival of 6 - 11 months. We present a case of acute hyperammonemic encephalopathy as the initial presentation of PPCL in a 78-year-old woman to highlight an atypical presentation of this disorder.

Metastatic Small-Cell Lung Cancer Presenting as Primary Adrenal Insufficiency.

A 40-year-old male smoker with HIV was admitted for cough, hypotension, and abdominal pain for 5 days. Chest radiography showed a right lower lobe consolidation. CT of the chest, abdomen, and pelvis revealed paratracheal adenopathy, a 5.8 × 4.5 cm mass invading the right bronchus intermedius, and dense bilateral adrenal masses, measuring 5.4 × 4.0 cm on the right and 4.8 × 2.0 cm on the left. Laboratory studies showed white blood cell count of 18.5 K/mm3, sodium of 131 mmol/L, creatinine of 1.6 mg/dL, and CD4 count of 567 cells/mm3. The random morning cortisol level was 7.0 µg/dL, the ACTH stimulation test yielded inappropriate response, and a random serum ACTH was elevated at 83.4 pg/mL. MRI brain revealed no pituitary adenoma confirming primary adrenal insufficiency. The adrenal CT washout study was consistent with solid mass content, concerning for metastasis. Bronchoscopy with endobronchial mass and paratracheal lymph node biopsy confirmed small-cell lung cancer (SCLC). Intravenous steroids, 100 mg hydrocortisone every 8 hours, improved his hypotension and abdominal pain. PET scan revealed metabolically active right paratracheal mass, right hilar mass, and bilateral adrenal masses. Treatment included palliative chemotherapy consisting of carboplatin/etoposide/atezolizumab and chest radiation. We present this novel case to demonstrate SCLC's ability to cause primary adrenal insufficiency, as well as evaluate clinical response to chemotherapeutics.