Positive acute viral infection markers, autoimmune disease and type II mixed cryoglobulinemia: a rare concurrence.

Cryoglobulins are abnormal serum immunoglobulins that tend to precipitate in intravascular compartments at temperatures lower than 37°C causing blood flow restriction to vital organs. They are divided into type I, II and III based on the immunoglobulin subtypes of the cryoprecipitates. Type II cryoglobulinemia is most commonly associated with viral infections, autoimmune diseases and lymphoproliferative disorders. Here, we reported an 80-year-old man who presented with fatigue, acute kidney injury, palpable purpura, anaemia and altered mental status. He was diagnosed with type II cryoglobulinemia with concomitant positive autoimmune markers, varicella IgM antibody and IgM hepatitis B core antibody. The patient responded well to intravenous and oral steroid treatment.

Granulomatous Myositis Associated with Myasthenia Gravis: A Rare Case.

Myasthenia gravis (MG) is an immune-mediated disease of the neuromuscular junction mediated by anti-acetylcholine receptor (AChR) antibodies (Ab). Granulomatous Myositis (GrM) is a histological diagnosis characterized by the presence of epithelioid granuloma in striated muscles. Few cases describing the presence of concomitant thymoma and non-thymoma-related MG with GrM have been reported. This present case is an addition to the literature describing the presence of concomitant thymoma and non-thymoma-related MG with GrM. The patient described is a 77-year-old male who started developing weakness and atrophy involving the musculature of the bilateral lower and upper extremities. Initial laboratory workup showed an elevated level of serum creatine phosphokinase (CPK) of 1,231 U/ L (reference range: 22 to 198 U/L). The right quadriceps muscle biopsy performed showed inflammatory infiltrates containing eosinophils, plasma cells, and lymphocytes forming multinucleate giant cells consistent with a diagnosis of GrM. Detailed laboratory and imaging work conducted to rule out an underlying cause of GrM showed elevated titers of AChR Ab (79.50 nmol/L, reference range: <0.02 nmol/L) and striational Ab (titer: 1:320, reference range < 1:120). A positive repetitive nerve stimulation test for the left ulnar nerve (decrement in the amplitude of muscle action potential by 13%) further confirmed the diagnosis of MG concomitant with GrM. Computed tomography of the chest was negative for the presence of a thymoma. The patient was started on treatment with oral prednisone and mycophenolate mofetil, which resulted in an improvement of symptoms and the downward trending of serum CPK level.

Tension Pneumocephalus: A Rare Complication of Transsphenoidal Resection of a Pituitary Macroadenoma.

Tension pneumocephalus (TP) is described as the presence of a large amount of air in the cranial cavity, compressing the parenchyma and ventricles. It is a rare neurosurgical emergency and has been reported in only a handful of cases as a complication of transsphenoidal resection of a pituitary adenoma. Our reported case is an addition to the series of those cases. A 60-year-old male patient underwent transsphenoidal resection of a pituitary macroadenoma. Computed tomography (CT) of the head performed post-procedure showed post-surgical changes with no identification of any acute intracerebral processes. On postoperative Day 2, the patient had a bout of sneezing and since that time, he was noted to be more altered in terms of his mentation and lethargic with no focal neurological deficits. A repeat CT of the head showed a large amount of air in the intracranial cavity compressing the brain parenchyma with slit-like appearances of the cerebral ventricles. The patient underwent emergent bifrontal air evacuation through burr holes. A cerebrospinal fluid leak was also noted while reconstructing the skull base. A postoperative CT scan showed marked resolution of TP. The patient improved clinically, was discharged home five days later, and was monitored closely by the surgical team on an outpatient basis.

A Case of Rapidly Deteriorating Lymphangitic Carcinomatosis in a Patient with Stage IV Pancreatic Cancer.

Pulmonary lymphangitic carcinomatosis (PLC) is defined as a tumor in the lung lymphatic vessels. It is rarely seen as a result of malignancy and generally carries a poor prognosis. Proper knowledge of the clinical presentation is important for physicians to be aware of in order to consider a diagnosis of PLC. We present the case of a 52-year-old Caucasian gentleman who initially came to the hospital with a three-week history of dyspnea. In the hospital, a diagnosis of Stage 4 pancreatic cancer with a lymphangitic spread of the tumor to the lungs was made. Despite optimal treatment, the patient required mechanical ventilation for acute hypoxic respiratory failure. PLC is a relatively rare manifestation of malignancy; yet, it generally carries a poor prognosis. It may occur during the course of malignancy or may represent as the first findings in malignancy. It is important for physicians to be aware of the clinical presentations of PLC in order to ensure timely treatment. Oftentimes, PLC can be diagnosed through clinical judgment alone without the need for radiological support and other invasive measures.

Gastropleural Fistula: A Rare Complication of a Common Procedure.

Weight loss surgeries are evident to be highly beneficial in patients with morbid obesity (body mass index (BMI) ≥40.0 kg/m2) and severe obesity (BMI between 35.0 and 39.9 kg/m2 with co-morbidities). While this results in significant mortality benefit, there is always the possible risk of postsurgical complications. Gastrobronchial and gastropleural fistulas are two rare, post-operative pulmonary complications associated with these surgeries. Our patient is a 54-year-old female who underwent a biliopancreatic diversion with a duodenal switch. A few weeks later, she started developing a cough, fever, and shortness of breath. Computed tomography (CT) chest showed the presence of a loculated right sided hydropneumothorax. A gastrointestinal fluoroscopic contrast study performed showed a large fistula originating from the distal end of the stomach and ending towards the right pleural cavity. The fistula was successfully closed with the endoscopic fulguration of fistulous opening with argon beam coagulation and orthoscopic clipping, resulting in complete obliteration of the fistula tract. The right-sided hydropneumothorax was initially treated conservatively with antibiotics and chest tube drains followed by video-assisted thoracoscopic decortication with chest tube placement. Gastropleural fistula formation is rare but is nonetheless a serious postoperative complication of bariatric procedures and mimics pneumonia clinically. It is, therefore, essential to obtain detailed imaging work-up to rule out fistula formation, which, in turn, can be timely treated without causing further devastating results to the patient.

Role of Bisphosphonate Therapy in Patients with Osteopenia: A Systemic Review.

By contrast to clinical trials exploring osteoporosis, clinical trials specifically designed for the osteopenic population are limited. Thus, less clinical data are available regarding treatment benefits and cost-effectiveness of treating a patient population with a bone mass density in the osteopenic range (T-score between -1 and -2.5). In this article, we aimed to highlight this high-risk population with a low bone mass density (BMD) susceptible to high fracture risk by reviewing different national and international guidelines for treating osteopenia. The cost-effectiveness of the therapy for the above-mentioned patient population is also discussed. By reviewing different clinical trials, we have specifically highlighted the role of bisphosphonate therapy for fracture risk reduction and increment in bone mineral density (BMD) in patients with osteopenia.

Tumor Lysis Syndrome: A Rare Complication of Chemotherapy for Metastatic Breast Cancer.

Tumor lysis syndrome (TLS) is a fatal complication of chemotherapy treatment. It is rarely seen in the treatment of solid tumors particularly in breast cancer. We presented the case of a chemo-naïve 58-year-old Caucasian woman who developed tumor lysis syndrome (TLS) after a single treatment dose of gemcitabine for metastatic breast cancer. Despite optimal management, the patient clinically deteriorates and is referred to inpatient hospice. Although targeted chemotherapy options have become increasingly effective, physicians should be aware of the rare, yet often fatal complications of TLS. Similarly, physicians should be able to quickly recognize the development of TLS to ensure swift and effective prophylaxis or treatment.