A Study of Artificial Sweeteners and Thyroid Cancer Risk.

BACKGROUND: In recent decades, data from certain observational studies have stirred controversy over artificial sweeteners by linking them with certain malignancies. As the incidences of artificial sweetener consumption and thyroid cancer are both increasing, our study aimed to determine any possible association between them. METHODS: This retrospective observational study enrolled 50 patients (group 1) with proven diagnosis of well-differentiated thyroid cancer (WDTC) and 50 control subjects (group 2) diagnosed as having benign thyroid nodule by fine-needle aspiration. The survey questionnaire included the total amount and duration of intake of artificial sweeteners. RESULTS: Increased consumption of artificial sweeteners was noted in group 1 as compared to group 2, which was statistically significant (76% vs. 24%, P < 0.01). This study suggested that the use of an average of four packets (4 g) per day of artificial sweetener for an average duration of 5 years is associated with WDTC. CONCLUSIONS: Our study emphasizes the significance of artificial sweetener consumption as a potential risk factor for WDTC and increase in public awareness regarding this association if other studies in future report similar findings.

Leukostasis in Chronic Lymphocytic Leukemia.

BACKGROUND Chronic lymphocytic leukemia (CLL) is a mature B cell lymphocytic neoplasm that has an indolent clinical course. Therefore, not all patients with CLL require treatment at the time of diagnosis. Hyperleukocytosis (white blood cell count, >100×109/L) is present in a large proportion of patients with CLL. However, symptomatic hyperleukocytosis (leukostasis) is an extremely uncommon presentation of CLL. Leukostasis frequently presents with the clinical manifestation of respiratory, neurological, or renal system problems. This is secondary to the decreased tissue perfusion due to the intravascular accumulation of large aggregates of leukemic cells. Leukostasis is a medical emergency requiring intensive care unit (ICU) admission and its management includes aggressive hydration, prevention and treatment of tumor lysis syndrome, cytoreduction, and leukapheresis. CASE REPORT We report a case of a 77-year-old woman with a long history of untreated CLL who presented with respiratory symptoms with hyperleukocytosis. Her condition rapidly deteriorated, requiring intubation. She required induction chemotherapy with chlorambucil as well as 2 sessions of leukapheresis, to which she responded well. In most reported leukostasis cases in the literature, the white blood cell (WBC) count was >1000×109/L. We present a case of a patient with leukostasis with WBC count 524×109/L who responded to chlorambucil and leukapheresis, with good recovery. CONCLUSIONS Leukostasis, although extremely rare, is a life-threatening complication in patients with CLL. It should be strongly considered in the differential diagnosis of patients with CLL who present with hyperleukocytosis and acute pulmonary symptoms. Clinicians should be aware of this medical emergency, as delayed treatment can increase morbidity and mortality.

Acquired Hemophilia A: A Potentially Fatal Bleeding Disorder.

Acquired hemophilia A (AHA) is a rare autoimmune hematological disorder that has an incidence of about 1.5 cases per million people per year. It occurs in the elderly with the median age of 75 years, and most of the cases are idiopathic. It occurs due to the development of factor VIII inhibitor, which is an autoantibody against factor VIII leading to potentially life-threatening bleeding episodes. The diagnosis of AHA is often delayed and challenging. We report a case of an 86-year-old male who initially presented with signs and symptoms of a stroke. He was found to have oral mucosal bleeding and swelling of the floor of the mouth. He later developed epistaxis, hematuria, and melena. He had an isolated elevation of activated partial thromboplastin time (APTT) with very high levels of factor VIII inhibitor (1152 Bethesda units) and very low levels of Factor VIII (<1%). He was managed with supportive transfusion, bypass agents, and immunosuppressive therapy. AHA is a rare autoimmune bleeding disorder and is more commonly seen in the elderly population. Bleeding in AHA is usually sudden and sometimes life-threatening. Hence early hemostasis with bypassing agents and treatment with immunosuppressive agents should be initiated. Due to the rarity of the disorder, it is crucial to report AHA cases to create awareness and increase the index of suspicion of the clinicians for early diagnosis and treatment to prevent morbidity and mortality.

Myocardial Infarction with Limb Arterial and Venous Thrombosis in a Patient with Enoxaparin-Induced Thrombocytopenia.

BACKGROUND Heparin, often used as an anticoagulant, acts by binding to antithrombin III. Indeed, heparin binds to a variety of proteins other than antithrombin III. Among them, platelet factor 4 can bind and neutralize the anticoagulant activity of heparin. Upon binding with heparin, platelet factor 4 undergoes a conformational change and expresses immunogenic neo-epitopes that induce the generation of antibodies of the platelet factor 4 heparin complex. This immune reaction may lead to thrombocytopenia and venous, arterial, or microvascular thrombosis. However, the risk of such complications is quite variable, as it is affected not only by the source and dose of heparin and the clinical condition (e.g., cardiovascular surgery and orthopedic surgery) of the patient, but also the molecular size of the heparin formulation. Venous, arterial, and small-vessel thrombosis can lead to leg swelling, pulmonary embolism, stroke, skin necrosis, or gangrene requiring limb amputation or intestinal resection. Myocardial infarction due to coronary thrombosis also occurs, although it is less common and can be readily recognized. CASE REPORT Heparin-induced thrombocytopenia (HIT) is a potentially life-threatening complication of heparin therapy. We report the case of a 67-year-old woman who developed ST-segment elevation myocardial infarction and thrombocytopenia within 10 days of prophylactic enoxaparin therapy after undergoing bilateral total knee replacement surgery. She also had peripheral arterial and venous thrombosis. With thrombolysis and argatroban anticoagulation therapy, she recovered without residual sequelae. CONCLUSIONS Thrombocytopenia with coronary and other vascular thrombosis is a potentially serious complication of heparin therapy. A trend of decreased platelet count, decreased platelet count by 30% or more, and/or occurrence of any type of thrombosis should raise the suspicion of HIT. This case demonstrates that early recognition and prompt treatment of HIT can be life-saving.

Isolated Chronic and Transient Neutropenia.

Neutrophils are a critical part of the body's defense system to prevent serious bacterial and fungal infections. Neutropenia is a term which is defined by the absolute neutrophil counts (ANC) < 1,500 cells/µL, and it becomes clinically significant when the level falls below 500 cells/µL. The risk of morbidity and mortality increases considerably when the levels fall below 200. In some ethnicities, the neutropenia is chronic and is frequently seen on routine outpatient visits. On the other hand, transient neutropenia is associated with a transient drop in the neutrophil count and many of the underlying causes are reversible. Patients and their families, as well as some clinicians, express great concern for neutropenia, leading to a multitude of tests and emergency room visits. In this review, we discuss the causes of both chronic and transient neutropenia. Also, we have given special emphasis on the mechanism of neutropenia and management of transient neutropenia.

A Case of Thoracic Endometriosis Syndrome Presenting with Recurrent Catamenial Pneumothorax.

BACKGROUND Catamenial pneumothorax (CP) is a spontaneous pneumothorax commonly associated with menstrual periods. Endometrial tissues most commonly involve the pelvic region. However, after the pelvis, the lungs are most frequently involved. Thoracic endometriosis should always be suspected in young women presenting with CP. CASE REPORT A 30-year-old woman with history of endometriosis presented with chief complaint of umbilical pain. A computerized tomography (CT) scan of the abdomen and pelvis was performed, which showed an incidental finding of a large right-sided pneumothorax. Chest X-ray imaging showed 50% pneumothorax. A right-sided chest tube was placed, and after the procedure, a chest X-ray image showed expansion of the right lung. The patient was readmitted for elective resection of an umbilical mass and was again incidentally found to have a recurrent pneumothorax on the right side. She underwent videothoracoscopic pleurodesis with pathology, establishing the diagnosis of catamenial pneumothorax. CONCLUSIONS Thoracic endometriosis resulting in catamenial pneumothorax should be suspected in young women of child-bearing age. Treatment options still under debate include endoscopic resection and videothoracoscopic pleurodesis followed by gonadotrophin-releasing hormone (GnRH) therapy to reduce the rate of postoperative recurrence.

Diffuse Peritoneal and Bowel Wall Infiltration by Light Chain-AL Amyloidosis with Omental Calcification Mimicking Abdominal Carcinomatosis - An Elderly Female with Incidental Finding of Light Chain Monoclonal Gammopathy of Undetermined Significance (LC-MGUS).

BACKGROUND Amyloidosis is the extracellular tissue deposition of plasma proteins, which after conformational changes, forms antiparallel beta pleated sheets of fibrils. Amyloid light-chain (AL) is a type of amyloidosis that is due to deposition of proteins derived from immunoglobulin (Ig) light chains. Gastrointestinal tract (GIT) involvement most often found in amyloid A (AA) amyloidosis type. There have been no reports of obstructive GIT AL amyloid patients having monoclonal gammopathy of undetermined significance (MGUS). Our case is the first case to show two coinciding conditions; one is the association of GIT AL amyloidosis with the incidental finding of a rare type of MGUS (LC-MGUS) and the other is the radiologic presentation of GIT amyloidosis with omental calcification mimicking the GIT malignancy. CASE REPORT A 68-year-old female presented with symptoms of partial bowel obstruction, including intermittent diffuse abdominal pain and constipation. After computed tomography (CT) abdomen and pelvis, an exploratory laparotomy was needed because of suspicion of abdominal carcinomatosis due to diffuse omental calcification. The tissue sent for biopsy surprisingly showed AL amyloidosis. The patient did not report any systemic symptoms. Further workup was advised to inquire about the plasma cell dyscrasia which eventually turned into a very rare version of MGUS knows as light chain MGUS (LC-MGUS). Following adequate resection of the involved structures, the patient was then placed on chemotherapy and successfully went into remission. CONCLUSIONS This case report illustrates that in an era of evidence based medicine, it is important to show through case reports the association of GIT AL amyloidosis with LC-MGUS, as the literature on this topic is lacking. It also points to the importance of timely intervention that can greatly enhance, not only the only the chances of remission but also prevention of further complications such as malignant transformation.

Adrenal Metastasis from Uterine Papillary Serous Carcinoma.

BACKGROUND: Uterine papillary serous carcinoma (UPSC) is a highly malignant form of endometrial cancer with a high propensity for metastases and recurrences even when there is minimal or no myometrial invasion. It usually metastasizes to the pelvis, retroperitoneal lymph nodes, upper abdomen, and peritoneum. However, adrenal metastases from UPSC is extremely rare. Here, we present a case of UPSC with adrenal metastasis that occurred 6 years after the initial diagnosis. CASE REPORT: A 60-year-old woman previously diagnosed with uterine papillary serous carcinoma at an outside facility presented in September of 2006 with postmenopausal bleeding. She underwent comprehensive surgical staging with FIGO (International Federation of Gynecology and Obstetrics) stage 2. Post-operatively, the patient was treated with radiation and chemotherapy. The treatment was completed in April of 2007. The patient had no evidence of disease until July 2009 when she was found to have a mass highly suspicious for malignancy. Subsequently, she underwent right upper lobectomy. The morphology of the carcinoma was consistent with UPSC. She refused chemotherapy due to a previous history of chemotherapy-induced neuropathy. The patient was followed up with regular computed tomography (CT) scans. In October 2012 a new right adrenal nodule was seen on CT, which showed intense metabolic uptake on positron emission tomography (PET)/CT scan. The patient underwent right adrenalectomy. Pathology of the surgical specimen was consistent with UPSC. CONCLUSIONS: UPSC is an aggressive variant of endometrial cancer associated with high recurrence rate and poor prognoses. Long-term follow-up is needed because there is a possibility of late metastases, as in this case.

First Reported Case of Methicillin-Resistant Staphylococcus aureus Vertebral Osteomyelitis with Multiple Spinal and Paraspinal Abscesses Associated with Acupuncture.

Acupuncture is one of the oldest medical procedures in the world and originated in China about 2,000 years ago. Acupuncture is a form of complementary medicine and has gained popularity worldwide in the last few decades. It is mainly used for the treatment of chronic pain. Acupuncture is usually considered a safe procedure but has been reported to cause serious complications including death. It has been associated with transmission of many viruses and bacteria. Two cases of Methicillin-Resistant Staphylococcus aureus have been reported recently following acupuncture therapy. We are reporting a case of a 57-year-old Korean female who developed vertebral osteomyelitis and intraspinal and paraspinal abscesses as a complication of acupuncture. Blood cultures, skin lesion culture, and body fluid culture yielded Methicillin-Resistant Staphylococcus aureus (MRSA). Good anatomical and medical knowledge, good hygiene standards, and proper acupuncture techniques should be followed to prevent the complications. Acupuncturists should consistently review the infection control guidelines to acupuncture. This case should raise awareness of such condition and hazards of presumably benign procedures such as acupuncture.