Late-stage diagnosis of carcinoid heart disease due to lack of access to health care.

Carcinoid syndrome (CS) is a unique constellation of symptoms caused by release of vasoactive substances from neuroendocrine tumors (Pandit et al., StatPearls, 2022). Neuroendocrine tumors are rare with an annual incidence of 2 in 100,000 people (Ram et al., 46:21-27, 2019). Up to 50% of patients with these tumors will develop carcinoid syndrome, which is characterized by symptoms caused by elevated levels of serotonin and most commonly include fatigue, flushing, wheezing, and non-specific gastrointestinal symptoms such as diarrhea and malabsorption (Pandit et al., StatPearls, 2022) (Fox et.al., 90:1224-1228, 2004). Over time, patients with carcinoid syndrome can develop carcinoid heart disease (CHD). CHD refers to the cardiac complications that occur when the vasoactive substances, such as serotonin, tachykinins, and prostaglandins, secreted from the carcinoid tumors. These complications most commonly include valvular abnormalities, but can also present as coronary artery damage, arrhythmias or direct myocardial injury (Ram et al., 46:21-27, 2019). While CHD is not typically an initial feature of carcinoid syndrome, it does eventually occur in up to 70% of patients with carcinoid tumors (Ram et al., 46:21-27, 2019) (Jin et.al., 146:65-73, 2021) (Macfie et.al., 224:665-669, 2022). CHD is associated with significant morbidity and mortality due to the risk of progressive heart failure (Bober et.al., 14:1179546820968101, 2020). In this case, we describe a 35-year-old Hispanic woman in South Texas with undiagnosed carcinoid syndrome for over 10 years that eventually progressed to severe CHD. In this patient's case, we emphasize how lack of access to healthcare resulted in delay of diagnosis, appropriate treatment, and worsened prognosis in this young patient.

Flea-Borne Typhus Causing Hemophagocytic Lymphohistiocytosis: An Autopsy Case.

Infection with members of the order Rickettsiales (the genera Rickettsia, Anaplasma, Orientia, and Ehrlichia) is known to cause hemophagocytic lymphohistiocytosis (HLH). The literature is scant on flea-borne typhus (FBT) being implicated in this process. We present a case of autopsy-proven HLH caused by FBT in a 71-year-old diabetic female who was initially suspected of having diabetic ketoacidosis who rapidly suffered decompensated multi-organ failure. Although she was suspected of having FBT and HLH pre-mortem, due to her rapid progression to multi-organ failure, she was transitioned to comfort care by her family five days after admission. A literature search yielded five other cases of HLH secondary to FBT, which are analyzed in this review. The literature on HLH occurring with infection due to other members of the order Rickettsiales is also surveyed.

Retropharyngeal abscess- An unusual complication in a COVID-19 patient.

The coronavirus disease 2019 (COVID-19) pandemic has generated many challenges for physicians, including multiple long-term effects that are still being studied. We report a CASE of patient who developed a retropharyngeal abscess post-COVID19 infection. We report a CASE of a female who was diagnosed with COVID19 pneumonia and hospitalized for a week at an outside institute. Approximately 3 weeks post discharge she developed neck pain, dysphagia, voice change and odynophagia for which she went to an outside emergency department. A soft tissue neck CT was performed and was concerning for retropharyngeal abscess. The patient was then transferred to our institution. On arrival, a CT scan of the neck and nasopharyngoscopy were performed and biopsies of the epiglottis and right inferior tonsillar pole were taken. Biopsies of the epiglottis and tonsil showed acute inflammation, spongiosis, edema and marked dilation of the lymphatics. Her clinical course was complicated by persistent infection requiring multiple washouts, hyperglycemia, tube feed intolerance, dysphagia and deconditioning. A multi-disciplinary approach was instituted for appropriate management. This case report highlights the necessity for close follow up after recovery from COVID-19 infection, particularly in patients with multiple comorbidities.

A Rare Case of a Solitary Fibrous Tumor of the Spermatic Cord.

Solitary fibrous tumors (SFTs) are rare mesenchymal tumors, originally identified in the pleura. Even though they have subsequently been described in several extrapleural sites, the incidence of SFTs in the spermatic cord is particularly rare. Here, we report a case of a 27-year-old male that presented with a 3-year history of left scrotal swelling. Computed tomography (CT) and ultrasound demonstrated multiple solid, hypoechoic well-circumscribed masses that were separate from the testis. Surgical excision of the mass led to pathologic diagnosis of a solitary fibrous tumor involving the spermatic cord. Solitary fibrous tumors, although rare, are an important differential diagnosis for urogenital tumors.

Stereotactic body radiation therapy (SBRT) in the management of pulmonary spindle cell carcinoma.

A 69-year-old woman underwent routine screening with CT scan of the chest, which showed a new right upper lobe lesion. Interval increase in size of the right upper lobe nodule over 3 months, prompted a CT-guided biopsy of the lung that confirmed a diagnosis of malignant pulmonary spindle cell carcinoma (PSCC) with 90% programmed death ligand 1 expression. Positron emission tomography CT demonstrated localised stage IIA disease. Given histologically proven PSCC and the rapid growth of her tumour, curative radiation with stereotactic body radiation therapy (SBRT) to the right upper lobe primary tumour was planned as patient was deemed not to be a surgical candidate. Repeat imaging with a CT chest 2 months after SBRT demonstrated good local control of the primary disease in the right upper lobe despite rapidly advancing distant metastasis. The patient continues systemic therapy with pembrolizumab, to which she has shown good response.