Incidental Colonic Masses, Cytomegalovirus Infection, and Amyloidosis in a Treatment-Naive Chronic Lymphocytic Leukemia (CLL) Patient without GI Symptoms.

Gastrointestinal (GI) involvement by chronic lymphocytic leukemia (CLL) is quite uncommon and generally presents with GI bleeding, abdominal pain, and obstruction. However, presentation of CLL as discrete masses without GI symptoms is very rare. A notable complication for patients with CLL is infection due to immunological dysregulation and is typically caused by encapsulated bacteria involving the respiratory tract while viral infections often happen post treatment. Here we present a 78-years-old female with history of treatment-naïve CLL who was incidentally found to have discrete colonic masses secondary to CLL, as well as cytomegalovirus (CMV) and herpes simplex virus (HSV) infections during endoscopic studies for colostomy reversal. On follow-up computed tomography, she was found to have pulmonary amyloidosis as well. We recommend that gastrointestinal tract evaluation should be a part of the complete assessment of the treatment response and remission status in CLL patients to permit early and appropriate therapeutic intervention.

Perceptions of the professional and personal impact of hybrid fellowship training: a qualitative study.

OBJECTIVES: This study aimed to elucidate graduate perceptions of how fellowship training impacted their post-training professional and personal lives. METHODS: Interviews were conducted with 13 graduates of a hybrid (e.g. blended-learning) fellowship program. All participants were at least 1 year post completion of fellowship to limit recall bias and allow for post-training personal and professional development. Qualitative analysis was performed on interview transcriptions using directed content analysis with two coders other than the interviewers, followed by discussion until agreement was reached if there were disputes related to coding analysis. If needed, arbitration was provided from one of two interviewers. RESULTS: Analysis revealed three primary constructs of post-fellowship impact: practical, social, and personal. Practical subthemes were centric to care delivery. Social subthemes extended to intra, inter, and non-professional connections. Personal subthemes noted professional and cognitive evolution. DISCUSSION: Participants clearly described impact extending well beyond day-to-day practice suggesting that fellowship impacted the whole person versus sole practitioner. This study may impact program structure and content inclusion for fellowship programs as well as providing support for fellows in training.

Pancreatic Acinar Metaplasia in Distal Esophageal Biopsies Is Associated With Chronic Nonsteroidal Anti-inflammatory Drug Use.

CONTEXT.­: The cause of pancreatic acinar metaplasia (PAM) at the distal esophagus/esophagogastric junction is still controversial. Whereas some authors believe it is congenital, others believe it is acquired because of inflammation of the gastric cardia, and more recently it was proposed to be due to chronic proton pump inhibitor use based on a study in rats. OBJECTIVE.­: To determine whether there is correlation between chronic proton pump inhibitor use and PAM in humans. We also investigated the correlation between several clinical and pathologic factors and PAM. DESIGN.­: Four hundred forty-four consecutive biopsies from the distal esophagus/esophagogastric junction were reviewed for the presence of PAM, which was then correlated with several clinical and pathologic findings. RESULTS.­: Pancreatic acinar metaplasia was found in 71 patients (16%). Pancreatic acinar metaplasia was significantly associated with patient age younger than 51 years ( P < .001), chronic carditis ( P = .01), and chronic proton pump inhibitor use ( P = .008). Surprisingly, we also found significant association between PAM and chronic nonsteroidal anti-inflammatory drug use ( P < .001). These associations, including that with chronic nonsteroidal anti-inflammatory drug use, remained significant in multivariate analysis. CONCLUSIONS.­: Our findings confirm the previous reports of significant association between PAM and chronic carditis and the findings from animal studies of association with chronic proton pump inhibitor use. The strong association with chronic nonsteroidal anti-inflammatory drug use has not been previously reported and warrants further studies.

Right Ventricular Outflow Obstruction Due to Metastatic Neuroendocrine Tumor.

Neuroendocrine tumors (NETs) are rare malignant tumors that arise from neuroendocrine cells of the gastrointestinal tract and often metastasize to the liver, lung, and bone. Cardiac metastasis of NETs is uncommon. We report a patient with a past medical history of a neuroendocrine tumor of the left femur presenting with signs and symptoms of new onset heart failure. Transthoracic echocardiogram and cardiac magnetic resonance showed a large mass within the right ventricle causing right ventricular outflow obstruction. A positron emission tomographic/computed tomographic scan (PET-CT) revealed increased uptake of fluorodeoxyglucose (FDG) activity within the right ventricle consistent with metastasis. Cardiac biopsy of the right ventricular mass revealed metastatic nonfunctioning neuroendocrine tumor. In view of the fact that it was a tumor that caused the right ventricular obstruction, the patient was started on chemotherapy with improvement of symptoms. This case highlights that in patients with a history of neuroendocrine tumor presenting with heart failure, cardiac metastasis should be included in the differential.

Cholangiocarcinoma: classification, diagnosis, staging, imaging features, and management.

Cholangiocarcinoma is a relatively uncommon malignant neoplasm with poor prognosis. The distinction between extrahepatic and intrahepatic subtypes is important as epidemiological features, biologic and pathologic characteristics, and clinical course are different for both entities. This review study focuses on the role imaging plays in the diagnosis, classification, staging, and post-treatment assessment of cholangiocarcinoma.

Lanthanum deposition from oral lanthanum carbonate in the upper gastrointestinal tract.

AIMS: Lanthanum carbonate is used as an alternative to calcium-based phosphate binders to manage hyperphosphataemia in patients with renal failure. The deposition of lanthanum within gastroduodenal mucosa of patients treated with the medication has been described, but given the relative novelty of this entity, the histiocytic deposits in the gastroduodenal mucosa can be confused with a variety of other processes, including infections and other drug-induced forms of injury. METHODS AND RESULTS: We describe five cases of lanthanum phosphate deposition in upper gastrointestinal (GI) tract biopsies. Three cases were confirmed with scanning electron microscopy and energy dispersive X-ray analysis, including one unique patient, status post-renal transplant for polycystic kidney disease, who had last taken lanthanum 7 years prior to biopsy. CONCLUSION: Lanthanum deposition in the upper GI tract is a mimic of other drug-related forms of GI injury, including iron pill-related gastropathy. The key to making this diagnosis is a thorough drug history and awareness of the histological features.

Fibrin Ring Granulomas in Checkpoint Inhibitor-induced Hepatitis.

Fibrin ring granulomas are an uncommon finding in liver biopsies although they have been described in liver injury secondary to several infectious and noninfectious entities, most notably Q fever. Immune checkpoint inhibitors are recent advances in cancer therapy, and stimulate the immune system to cause antitumoral effects but may also lead to adverse immune events such as hepatitis and colitis. We report 2 patients on combination ipilimumab/nivolumab who developed hepatitis and had fibrin ring granulomas in their liver biopsies.

Coccidioidomycosis Presented as a Pelvic Mass in an Otherwise Healthy Female.

We present a case of a 32 year old female with a past medical history of hypertension who presented with several years of chronic back pain and was ultimately diagnosed with isolated pelvic coccidioidomycosis. She was initially seen by gynecologic oncology for assessment of possible metastatic cancer by image study, but a cytopathologic diagnosis of coccidioidomycosis lead to a cancellation of the planned surgery and extensive antifungal treatment managed by the infectious disease team. She had no known previous pulmonary disease or immunodeficiency. Pelvic coccidioidomycosis without known pulmonary disease is very rare, and disseminated infection typically only occurs in those who are severely immunocompromised. Our case presented with several years of back pain and a pelvic mass mistaken for possible malignancy by image study.

The iDigoxin Assay is More Sensitive than LOCI Digoxin Assay for Rapid Detection of Convallatoxin, the Active Cardiac Glycoside of Lily of The Valley.

OBJECTIVE: Lily of the valley is a poisonous plant due to the presence of the cardiac glycoside convallatoxin. We compared two immunoassays (LOCI digoxin assay and iDigoxin assay) for rapid detection of convallatoxin if present in human serum. MATERIALS AND METHODS: Aliquots of a drug free serum pool and a digoxin serum pool were supplemented with microliter amounts of lily of the valley extract or nanogram to microgram quantities of convallatoxin, followed by measurement of apparent digoxin concentrations using the LOCI and iDigxoin assays. RESULTS: Apparent digoxin concentrations were observed when aliquots of a drug free serum pool were supplemented with convallatoxin or lily of the valley extract using both assays but apparent digoxin concentrations were significantly higher using the iDigoxin assay. In addition, the interference of convallatoxin in serum digoxin measurement was also significantly higher using iDigxoin assay compared to the LOCI digoxin assay. CONCLUSIONS: The iDigxoin assay is more sensitive in detecting convallatoxin in human serum.

Carcinosarcoma of the parotid: investigating its biology with morphoproteomics.

Carcinosarcoma of the parotid is a rare biphasic malignant neoplasm comprised of both carcinomatous and sarcomatous components representing approximately 0.4% of all malignant salivary gland neoplasms. We report a case of a 55-year-old Caucasian man who presented with a progressively enlarging left facial mass. Histopathological evaluation of the tumoral tissue revealed a high grade, mixed epithelial and mesenchymal malignant tumor, most consistent with a carcinosarcoma of the parotid. Morphoproteomic analysis was performed and revealed expression of secreted protein acidic and rich in cysteine (SPARC); glioma-associated oncogen protein 2 (Gli2); and phosphorylated signal transducer and activator of transcription (p-STAT3 [Tyr705]) in the carcinomatous and malignant mesenchymal components. These aforementioned markers have been linked to the epithelial-mesenchymal transition in which epithelial cells lose their characteristics and phenotypically become mesenchymal cells. This finding allows us to further understand the biology of the 2 cellular components of the carcinosarcoma as having a monoclonal origin.

PETINIA total phenytoin assay on the vista 1500 analyzer is not suitable for monitoring free phenytoin concentration if ultrafiltration is performed at room temperature.

BACKGROUND: Phenytoin is a strongly protein-bound anticonvulsant requiring free drug monitoring for certain patients. Recently, free phenytoin assay on the TDx analyzer was discontinued by the Abbott Laboratories, but Roche Diagnostics has an assay for the determination of free phenytoin. METHODS: Because a clinical laboratory may not have an instrument for using Roche free phenytoin assay, we studied the possibility of determining free phenytoin using particle-enhanced turbidimetric inhibition immunoassay (PETINIA) total phenytoin assay on the Vista 1500 analyzer by comparing free phenytoin values obtained by Roche assay and Hitachi 917 analyzer with values obtained by using PETINIA assay. RESULTS: When protein-free ultrafiltrates were prepared at room temperature from 41 different patients taking phenytoin, using Roche assay (x axis) and PETINIA (y axis) assay, the following regression equation was observed: y = 0.8526x + 0.0661 (r = 0.85, n = 41). The regression equation indicated significant negative bias with the reference method. However, when additional 30 specimens were studied where ultrafiltration was performed at 37°C, lesser negative bias was observed as revealed by the regression equation: y = 0.922x - 0.117 (r = 0.90, n = 30). CONCLUSIONS: We conclude that PETINIA assay on the Vista 1500 analyzer is not suitable for monitoring free phenytoin concentration if ultrafiltration is performed at room temperature but may be used with caution if ultrafiltration is performed at physiological temperature of 37°C, which is the desirable temperature for preparation of ultrafiltrate.

Riding high on cloud 9.

Bath salts have become increasingly popular drugs of abuse. This has led to an increase in emergency department visits for patients with intoxication from these drugs. The literature indicates that bath salt intoxication can have significant physiological and psychiatric sequelae. The purpose of this article is to report data from 10 cases of bath salt intoxication that experienced severe psychiatric symptoms requiring emergency psychiatric detention (i.e. Physician Emergency Certificate). In general, our patients had mild sympathomimetic physiologic responses that resolved quickly. The psychiatric symptoms tended to be short-lived, with staff psychiatrists rescinding the majority of the Physicians Emergency Certificates prior to inpatient admission. Our cases suggest that involuntary admission to psychiatric facilities may be circumvented with additional monitoring in the emergency department. Prospective studies should be done examining the natural course of bath salt-induced psychosis to determine if emergency detention is necessary.