A 55-Year-Old Woman With Frequent Pulmonary Exacerbations and Endobronchial Lesions.

CASE PRESENTATION: A 55-year-old woman with COPD, heart failure with preserved ejection fraction (congestive heart failure), diabetes mellitus, and hypertension presented with baseline dyspnea at rest that had worsened over the last week. She reported associated runny nose, congestion, and cough productive of green sputum. She smoked six cigarettes per day and denied alcohol, drugs, or occupational exposure. She was admitted and initiated on treatment for acute exacerbation of COPD; however, her condition did not improve with steroid, ceftriaxone, and nebulized albuterol and budesonide treatments. She had been diagnosed with asthma and COPD without ever undergoing pulmonary function testing. She presented 11 times to the ED with six hospital admissions in the last 1.5 years for worsening dyspnea at rest, wheezing, and lower extremity edema deemed secondary to exacerbation of her COPD or congestive heart failure. She reported medication compliance, which included fluticasone-vilanterol, tiotropium bromide, and furosemide. She repeatedly demonstrated mild vascular congestion on imaging without hyperinflation, a normal to mildly elevated brain natriuretic peptide (<10 to 200 pg/mL), and dyspnea without hypoxia. She was treated normally for both COPD and congestive heart failure exacerbations simultaneously with methylprednisolone, albuterol, and furosemide with rapid improvement over the course of 1 to 2 days. No significant improvement was noted with steroid therapy, despite receiving them as an inpatient and outpatient. At the time of discharge, her symptoms would be at her baseline.

Percutaneous tattoo pigment simulating calcific deposits in axillary lymph nodes.

The isolated finding of calcific deposits within axillary lymph nodes on mammography suggests a broad range of differential diagnoses, from benign causes such as granulomatous reaction secondary to previous histoplasmosis infection to malignancies such as breast cancer and metastatic disease from extramammary primary malignancies. Therefore, the isolated finding of intranodal calcium may warrant biopsy for a definitive diagnosis when a benign etiology is not apparent. We present a patient with isolated axillary lymph node densities on mammography and chest computed tomography, which were subsequently proven to represent deposition of tattoo pigment.

Abdominal apoplexy: two unusual cases of hemoperitoneum.

Abdominal apoplexy, or idiopathic spontaneous intraperitoneal hemorrhage, is a rare and often fatal condition resulting from a variety of disease processes affecting the arterial and venous abdominal vasculature. Preoperative and intraoperative diagnosis and treatment of abdominal apoplexy are challenging. The source of bleeding may remain elusive even after careful autopsy dissection given the absence of intravascular pressure. Despite these challenges, early diagnosis and rapid treatment remain central to a successful outcome, as nonsurgical mortality has approached 100%. Presented here are two fatal cases of abdominal apoplexy, one involving a patient with arterial dissection of the gastroduodenal artery and one involving rupture of the superior mesenteric-portal venous system with perivascular pseudoaneurysm formation.