A 47-year-old stem cell transplant recipient with fever, cough and chest pain.

Infections and malignancies are among the most serious complications that follow organ or stem cell transplantation. They may have a mild course, and nonspecific and overlapping manifestations. The present article describes a case of symptomatic nodular pulmonary disease that complicated hematopoietic stem cell transplantation. It was diagnosed to be post-transplant lymphoproliferative disorder, a potential sequela of immunosuppression and a very difficult entity to treat in profoundly immunosuppressed patients.

A 29-year-old man with hospital-acquired cavitary pneumonia.

Cavitary lung processes pose a formidable diagnostic challenge. Causes vary widely and include cavitary pneumonia, vasculitis and malignancy. In some cases, patient history and basic work-up may yield a diagnosis, but in others, an extensive work-up, including tissue biopsy, may be necessary to establish the cause. The authors present a case of cavitary pneumonia that complicated an open lung biopsy. It developed in the hospital and was caused by mucormycosis, a potential emerging infection causing health care-associated infections.

A pneumonia that will not go away.

Pneumonia is a common diagnosis with significant morbidity and mortality. However, pneumonia is a commonly overdiagnosed entity, with many similar-appearing conditions. A young, previously healthy woman was misdiagnosed with a variety of respiratory tract infections over the course of five months before establishing the correct diagnosis - chronic eosinophilic pneumonia.

Mucormycosis in two community hospitals and the role of infectious disease consultation: a case series.

BACKGROUND: Mucorales are ubiquitous filamentous fungi that can cause a devastating, invasive infection. This order has become an increasingly important pathogen during the last two decades, due to the dramatic increase in patients with predisposing factors. The aim of this retrospective study was to report the clinical characteristics, therapeutic options, and outcomes of patients diagnosed with mucormycosis in community hospitals in Amarillo, Texas, and to reflect on the role of infectious disease (ID) physicians in managing this potentially life-threatening problem. PATIENTS AND METHODS: This was a retrospective chart review of patients hospitalized with mucormycosis in two community hospitals in Amarillo between January 1, 2001 and December 31, 2011. RESULTS: Ten patients were diagnosed with mucormycosis during the study period, with a mean age of 58.8 years. There were five cases of pulmonary infection, two cases of cutaneous infection, two cases of rhinocerebral infection, and one case of gastrointestinal infection. Poorly controlled diabetes was the most common risk factor, identified in six patients, followed by hematological malignancy, immunosuppression, and trauma. ID physicians were consulted in all cases, albeit late in some cases. Nine patients received antifungal therapy, and five patients received surgical debridement. Lipid formulations of amphotericin B were prescribed for eight patients, used alone in two cases, and combined with caspofungin and posaconazole in one and five cases, respectively. One patient was treated with posaconazole alone. Eight patients were discharged from the hospital alive. The mortality rate at 6-month follow-up was 40%. CONCLUSION: Mucormycosis is an emerging fungal infection that continues to carry significant morbidity and mortality. At-risk patient populations are on the rise, and include those with poorly controlled diabetes mellitus. Early diagnosis, in consultation with an ID physician, and an aggressive combined approach with surgical debridement and combined antifungal therapy is pivotal in improving patients' outcomes.

Progressive disseminated histoplasmosis presenting with cachexia and hypercalcemia.

Histoplasmosis is a common endemic mycosis. The majority of infections involving this dimorphic fungus are asymptomatic. Manifestations in symptomatic patients are diverse, ranging from flu-like illness to a more serious disseminated disease. We present here a case of chronic disseminated histoplasmosis mimicking a metastatic cancer. We reviewed the literature for cases of disseminated histoplasmosis presenting with hypercalcemia, focusing particularly on clinical presentation, risk factors predisposing for fungal infection, and outcome. We report a case of a 65-year-old diabetic male who presented with unexplained weight loss and hypercalcemia. Multiple brain space-occupying lesions and bilateral adrenal enlargement were evident on imaging studies. Biopsies showed caseating granulomas with budding yeast, consistent with histoplasmosis. The patient's symptoms resolved after liposomal amphotericin B and itraconazole therapy. Granulomatous diseases, including fungal infections, should be considered alongside malignancies, in patients with similar presentation.

Diagnosis and typing of systemic amyloidosis: The role of abdominal fat pad fine needle aspiration biopsy.

INTRODUCTION: Systemic amyloidosis (SA) has a broad nonspecific clinical presentation. Its diagnosis depends on identifying amyloid in tissues. Abdominal fat pad fine needle aspiration (FPFNA) has been suggested as a sensitive and specific test for diagnosing SA. MATERIALS AND METHODS: Thirty-nine FPFNA from 38 patients (16 women and 20 men, age range 40-88 years) during a 15-year period were reviewed. Smears and cell blocks were stained with Congo red (CR). A panel of antibodies (serum amyloid protein, serum amyloid A, albumin, transthyretin, kappa light chain and lambda light chain) was used on six cell blocks from five patients. The FNA findings were correlated with clinical and histological follow-up. RESULTS: FPFNAs were positive, confirmed by CR in 5/39 (13%), suspicious in 1/39 (3%), negative in 28/39 (72%), and insufficient for diagnosis in 5/39 (13%) of cases. In all the positive cases, SA was confirmed within 2-16 weeks. Among the 28 negative cases, SA was diagnosed in 21, the rest were lost to follow-up. Among the insufficient cases, SA was diagnosed in four and one was lost to follow-up. Specificity was 100%, whereas sensitivity was 19%. SA typing using cell block sections was successful in three, un-interpretable in one, and negative in two cases. CONCLUSION: FPFNA for SA is not as good as previously reported. This may be due to different practice setting, level of experience, diagnostic technique, or absence of abdominal soft tissue involvement. A negative result of FPFNA does not exclude SA. Immune phenotyping of amyloid is possible on cell block.

Comparison of ProEx C with p16INK4a and Ki-67 immunohistochemical staining of cell blocks prepared from residual liquid-based cervicovaginal material: a pilot study.

BACKGROUND: Although liquid-based cervicovaginal cytology has high sensitivity for detecting dysplastic/malignant lesions, many pitfalls exist. Cell blocks can be prepared from residual liquid-based cervicovaginal material and used for immunohistochemistry. The aim of this study was to evaluate a new marker, ProEx C, on cell blocks and its ability to distinguish dysplastic/malignant lesions from morphologically abnormal but benign cells. The results of this study were compared with previously reported results for p16 and Ki-67 on the same material. METHODS: ProEx C is a cocktail of monoclonal antibodies against proteins associated with aberrant S phase cell cycle induction (topoisomerase IIA, minichromosome maintenance protein 2). ThinPrep (CytycCorp., Boxborough, Mass) cervicovaginal specimens from 79 patients were selected. Four cases had no residual abnormal cells in the cell block. On the basis of the cell block diagnosis, 29 cases were negative for intraepithelial lesion or malignancy (NILM), 27 had low-grade squamous intraepithelial lesions (LSIL), 16 had high-grade squamous intraepithelial lesions (HSIL), and 3 had squamous cell carcinomas (SCC). Cell block sections were immunostained with ProEx C. RESULTS: Thirteen of 16 (81%) cases of HSIL stained positively with ProEx C. Two of 27 (7%) LSIL stained positively, and 2 (7%) cases of NILM stained positively. All 3 cases of SCC were strongly positive (100%). Staining for ProEx C showed a higher positive predictive value compared with p16. CONCLUSIONS: ProEx C can be used on cell blocks prepared from residual liquid-based cervicovaginal cytologic specimens. Being a nuclear only stain, it is cleaner and easier to interpret even in scant specimens.

Primary testicular non-Hodgkin's lymphoma with atrial mass as an initial presentation of acquired immunodeficiency syndrome.

The association between human immunodeficiency virus HIV infection and the increased incidence of testicular tumors is a recent well-recognized phenomenon. Testicular tumors in the setting of HIV infection are most frequently of germ cell origin, less commonly lymphomas. We are presenting a unique case of testicular non-Hodgkin's B-cell lymphoma with associated atrial mass and mediastinal lymphadenopathy. The patient was not known to be HIV positive at the time of presentation. The initial clinical, radiological, and gross pathologic impression was that of seminoma. Discussion of the differential diagnosis and appropriate work up is presented.