Brown Tumor From Secondary Hyperparathyroidism Mimicking Metastatic Renal Cell Carcinoma in a Patient With End-Stage Renal Disease.

Brown tumors (also known as osteitis fibrosa cystica) are rare complications of end-stage renal disease (ESRD) and secondary hyperparathyroidism (HPT), characterized by focal bone lesions that resemble neoplasms. They are often misdiagnosed as metastatic bone disease, especially in patients with a history of malignancy. We present a case of a 60-year-old man with a history of renal cell carcinoma (RCC), and ESRD on hemodialysis (HD), who developed diffuse bone lesions on imaging with osteolytic/osteoblastic appearance concerning metastases, but on further workup was found to have brown tumors. We discuss the treatment and outcome and briefly review the relevant medical literature.

Adult Vitamin B12 Deficiency-Associated Pseudo-Thrombotic Microangiopathy: A Systematic Review of Case Reports.

Cobalamin-deficient thrombotic microangiopathy or vitamin B12 deficiency presenting as pseudo-thrombotic microangiopathy is a rare disorder that can be misdiagnosed as thrombotic thrombocytopenic purpura. Patients with this condition are at risk of receiving unnecessary plasmapheresis with a potential delay in appropriate therapy with vitamin B12 supplementation. There are no established diagnostic criteria for this condition in clinical practice. We performed a systematic review of case reports published between January 2018 and January 2023 to analyze the clinical characteristics, risk factors, and patterns of laboratory markers to improve the diagnostic criteria for this condition.

Preoperative Determination of Depth of Invasion in Oral Cavity Squamous Cell Carcinoma by Standard Cross-Sectional Imaging With Computed Tomography and Positron Emission Tomography/Computed Tomography.

Background Depth of invasion (DOI) is a known indicator of metastatic potential in oral cavity squamous cell carcinoma (SCC). Our purpose was to investigate the accuracy of preoperative determination of DOI in oral cavity SCC by computed tomography (CT) and positron emission tomography/computed tomography (PET/CT). Methodology A retrospective study was performed using consecutive patients with histologically proven oral cavity SCC presenting to our otorhinolaryngology department between January 2014 and July 2019 who underwent preoperative contrast-enhanced CT and/or PET/CT. Pathological assessment of DOI was determined by a review of pathology reports. The degree of DOI determined by radiographic studies was correlated to pathology results. Results A total of 79 patients were screened of whom appropriate radiographic studies were available for 63 patients. The mean DOI by pathological assessment was 12.3 ± 9.1 mm. CT and PET/CT determined depth both correlated with pathological DOI (r = 0.710; p < 0.001, r = 0.798; p < 0.001). No significant correlation was seen for CT-determined depth (r = 0.136; p = 0.709) or PET-determined depth (r = 0.234; p = 0.707) with pathologically confirmed superficial tumors (<5 mm). For patients with pathological tumor depth >10 mm, CT and PET determined depth both correlated with pathological depth (r = 0.577; p = 0.002, r = 0.668; p = 0.001). The sensitivity and specificity of CT and PET for the identification of deep invasion were 88.2% and 41.7% and 52.9% and 50%, respectively. Conclusions DOI measurement is feasible with routine preoperative CT and PET/CT images and is comparable to pathological measurement in patients with oral cavity SCC.

Proximal Sessile Serrated Adenomas Are More Prevalent in Caucasians, and Gastroenterologists Are Better Than Nongastroenterologists at Their Detection.

BACKGROUND AND AIM: Proximal sessile serrated adenomas (PSSA) leading to colorectal cancer (CRC) represent an alternate pathway for CRC development. In this study, we aim to determine the prevalence of PSSAs and the impact of patient, colonoscopy, and endoscopist-related factors on PSSA detection. METHODS: Patients ≥ 50 years of age undergoing a screening colonoscopy between 2012 and 2014 were included. Detection rates based on patient gender, race, colonoscopy timing, fellow participation, bowel preparation quality, and specialty of the endoscopist were calculated. t-tests were used to compare detection rates and a multivariate-adjusted analysis was performed. RESULTS: 140 PSSAs were detected from 4151 colonoscopies, with a prevalence of 3.4%. Detection rate was higher in Caucasians compared to African-Americans (AA) (3.7 ± 4.1 versus 0.96 ± 3.5; p < 0.001). Gastroenterologists detected more PSSAs compared to nongastroenterologists (3.9 ± 3.5 versus 2.2 ± 3.0; p = 0.028). These findings were still significant after adjusted multivariate analysis. The rest of the factors did not make significant difference in PSSA detection rate. CONCLUSIONS: PSSAs are more prevalent in Caucasians compared to AAs. Racial difference in prevalence of PSSAs is intriguing and warrants further investigation. Gastroenterologists have a significantly higher PSSADR compared to nongastroenterologists. Educational measures should be implemented in nongastroenterologists to improve their PSSA detection rates.

Association of microalbuminuria with ischemic heart disease in non-diabetic Asian-Indians: A case control study.

CONTEXT: Microalbuminuria is a known indicator of atherosclerosis and its association with ischemic heart disease (IHD) has been extensively studied in the diabetic population. The significance of urine microalbumin in non-diabetics, however, is yet to be elucidated. AIM: To determine whether an independent association exists between microalbuminuria and IHD in non-diabetic Asian-Indians, and the level of microalbuminuria predictive of concomitant IHD. MATERIALS AND METHODS: A cross-sectional case-control study was conducted between July 2009 and June 2011. Non-diabetic patients undergoing evaluation for IHD were divided into cases and controls, based on the presence or absence of IHD, respectively. Fifty cases and 50 controls were included, and matched by age, sex, smoking habit, hypertension and body-mass index (BMI). Fasting blood glucose (FBG), fasting lipid profile, and urine microalbumin were recorded for all patients. RESULTS: Mean fasting glucose, mean low density lipoprotein (LDL)-cholesterol and mean urine microalbumin were all significantly higher in cases compared to controls. Urine microalbumin was independently associated with IHD, and microalbumin greater than 12.6 mg/g was predictive of IHD (OR: 13.5; 95% CI, 4.6-39.9; P < 0.001). CONCLUSION: Urine microalbumin is independently associated with IHD in non-diabetics and levels greater than 12.6 mg/g are predictive of IHD.

A simple score to predict fetal outcomes in gestational diabetes mellitus.

BACKGROUND: Strict glycemic control is critical in preventing adverse maternal and fetal outcomes with gestational diabetes mellitus (GDM), but frequently results in recurrent maternal hypoglycemia and is often impracticable. This study was done to determine whether a more lenient strategy might provide satisfactory outcomes and to formulate a glycemic score for prognostication of fetal outcomes. METHODS: A prospective non-interventional study was conducted on consecutive patients admitted with GDM between May 2007 and August 2009. Patients with pre-gestational diabetes were excluded. All patients received treatment at the discretion of treating consultants. Glycemic control was estimated by recording mean values of all glucose profiles performed. Fasting and postprandial blood glucose levels below 95 mg/dl and 120 mg/dl, respectively, were considered controlled. A glycemic score was calculated based on the number of mean blood glucose values controlled. Fetal outcomes were noted. RESULTS: Ninety-four patients with GDM were included. The glycemic score was significantly predictive of adverse fetal outcomes (p < 0.001). Analysis by receiver operating characteristic (ROC) curve showed good sensitivity and specificity for macrosomia (78.3% and 81.8%, respectively) and congenital anomalies (73.9% and 66.7%, respectively) with a glycemic score of 2 or less [area under curve (AUC) 0.768; odds ratio (OR), 11.17; 95% Confidence Interval (CI), 2.58-48.35; p < 0.001; and AUC 0.765; OR, 2.22; 95% CI, 0.71-6.92; p = 0.055, respectively]. Binomial logistic regression confirmed the glycemic score to be independently predictive of fetal outcome (p = 0.015). CONCLUSION: The glycemic score is a sensitive and specific prognostic marker. Tight control of three of four values of blood glucose within the glucose profile appears sufficient to prevent adverse fetal outcomes.

AS, DISH or something else?

A 68-year-old farmer presented with progressively worsening pain in multiple joints associated with stiffening for 9 months. Locomotor examination revealed grossly restricted movement of the axial skeleton. There were no neurological deficits. Radiological evaluation demonstrated diffuse bone densification and extraspinal calcification with bony ankylosis reminiscent of ankylosing spondylitis. Laboratory tests subsequently yielded the true diagnosis. The patient was counselled accordingly and started on appropriate therapy.

Community-acquired multidrug-resistant Gram-negative bacterial infective endocarditis.

We describe two cases of bacterial endocarditis secondary to multidrug-resistant Gram-negative organisms. In both cases, the diagnosis was made in accordance with the modified Duke's criteria and confirmed by histopathological analysis. Furthermore, in both instances there were no identifiable sources of bacteraemia and no history of contact with hospital or other medical services prior to the onset of symptoms. The patients were managed in similar fashion with prolonged broad-spectrum antibiotic therapy and surgical intervention and made complete recoveries. These cases highlight Gram-negative organisms as potential agents for endocarditis, as well as expose the dissemination of such multidrug-resistant bacteria into the community. The application of an integrated medical and surgical approach and therapeutic dilemmas encountered in managing these cases are described.

Amlodipine poisoning revisited: Acidosis, acute kidney injury and acute respiratory distress syndrome.

We report the case of an 18-year-old girl presenting with shock following ingestion of 85 mg of amlodipine and 850 mg of atenolol with suicidal intent. Subsequently, the patient developed severe metabolic acidosis, acute kidney injury, and acute respiratory distress syndrome, which were managed conservatively. The patient ultimately made a full recovery. Given the popularity of amlodipine and atenolol as antihypertensive drugs in this part of the world, it is likely that more such cases will be encountered in the future. Physicians should be aware of the severe complications that can develop with amlodipine overdose.

A young woman with seizures and psychosis.

We present a case of a 24-year-old woman with abnormal behaviour of recent onset. She had been diagnosed previously with epilepsy and had been started on antiepileptic medication. Clinical examination confirmed features of psychosis including paranoid delusions and auditory hallucination. Neurological examination showed nystagmus and dysmetria. Further evaluation revealed the underlying cause for her symptoms. She responded promptly to appropriate therapy with complete resolution of psychosis.

Hot and cold: coexistent Graves' disease and Hashimoto's thyroiditis in a patient with Schmidt's syndrome.

A 37-year-old housewife presented with generalised fatigue, palpitations and weight loss over the past 3 months. Physical examination revealed signs of hyperthyroidism. Thyroid function tests confirmed the presence of thyrotoxicosis. Pertechnetate radionuclide imaging of the thyroid showed diffusely increased radiotracer uptake consistent with Graves' disease and a cold nodule in the right lobe. Needle aspiration from the nodule yielded evidence of Hashimoto's thyroiditis. The patient also tested strongly positive for antithyroid peroxidase antibodies. Simultaneous laboratory evaluation revealed primary adrenal failure and probable pernicious anaemia, thus producing a diagnosis of Schmidt's syndrome. The patient was initiated on appropriate medical therapy for endocrinopathy. Graves' disease was treated with radioablation.

Colonization or spontaneous resolution: expanding the role for Burkholderia pseudomallei.

A 19-year-old Asian Indian female presented with productive cough since the past one month and low grade fever since the past two weeks. She was diagnosed with pulmonary tuberculosis and treated with antitubercular drugs. Subsequently, delayed cultures of bronchoalveolar lavage fluid grew Burkholderia pseudomallei (B. pseudomallei). On follow up the patient reported significant subjective improvement and ESR progressively returned to normal. In summary, this case report raises two distinct and equally intriguing roles for B. pseudomallei, i.e. respiratory colonization and spontaneously resolving pulmonary infection. The pathogenic potential of B. pseudomallei, the etiologic agent of melioidosis, is well known. Confirmation of either colonization or spontaneous resolution, would potentially spare many patients unnecessary and expensive therapy with broad-spectrum antibiotics, and contribute to more rational usage of antibiotics, especially in co-infection with Mycobacterium tuberculosis and B. pseudomallei-two bacterial diseases with closely similar clinical, radiologic and histopathologic features.

Phenytoin induced Stevens-Johnson syndrome exacerbated by cefepime.

Steven Johnson syndrome (SJS) is a rare drug induced mucocutaneous reaction. Here, we present an elaborate report of a 28-year-old female patient who developed Phenytoin induced SJS, which was exacerbated by cefepime.

A cardiac cause for deafness.

We describe a case of a 49-year-old diabetic man with a history of myocardial infarction, presenting with deafness for 2 weeks. Initial assessment by otorhinolaryngologists was suggestive of sensorineural hearing loss. Subsequently, the cardiac evaluation showed an apical clot in the left ventricle. Careful neurological reassessment and a cranial MRI yielded a diagnosis of cortical deafness with auditory agnosia secondary to bilateral temporal infarcts. Doppler and MRI ruled out carotid artery thrombosis. The temporal infarcts were therefore considered to be cardioembolic in origin. Cardioembolic stroke is an important differential diagnosis for patients presenting with neurological symptoms on a background of cardiac disease.

Primary presentation of chronic calcific pancreatitis with massive unilateral pleural effusion.

We described a 45-year-old previously healthy man presenting with progressively worsening breathlessness for 10 days. Physical examination was suggestive of a left-sided pleural effusion. A chest X-ray was confirmatory. Analysis of aspirated fluid showed a lymphocytic exudate with grossly elevated amylase and lipase levels. CT revealed chronic calcific pancreatitis as the underlying cause of effusion. Retrospective questioning failed to identify classical symptoms of chronic pancreatitis including abdominal pain and steatorrhoea. The patient was managed with intercostal drainage and supportive care. Although unusual, chronic pancreatitis should be kept as a differential diagnosis in patients with unilateral exudative pleural effusion. Elevated fluid levels of amylase and lipase are useful clues to this uncommon diagnosis.

A novel subtype of myeloproliferative disorder? JAK2V617F-associated hypereosinophilia with hepatic venous thrombosis.

We report the case of a 27-year-old man, presenting with one episode of massive haematemesis and a history of persistent eosinophilia for the past 8 months. An evaluation revealed hepatic cirrhosis with portal hypertension, secondary to chronic Budd-Chiari syndrome. Further investigations confirmed a diagnosis of hypereosinophilic syndrome. Molecular genetic analysis was negative for FIP1L1-PDGFRA gene rearrangement, but positive for JAK2V617F mutation.

Of little yellow men and a fear of the light.

We report the case of a 65-year-old woman presenting with recurrent vomiting for 3 days. She had been previously diagnosed with an atrial septal defect and was on treatment with diuretics and digoxin for paroxysmal supraventricular tachycardia. The clinical examination was consistent with an atrial septal defect with severe pulmonary hypertension. Electrocardiography showed complete heart block with ST-segment changes suggestive of digitalis toxicity. Transthoracic echocardiography confirmed Eisenmengerisation. Serum digoxin levels were elevated. Following hospitalisation, she was diagnosed with photophobia when she persistently asked for ambient lighting to be switched off. Most interestingly, the patient kept reporting seeing little yellow men, which was how she perceived the attending doctors. Cessation of digoxin therapy led to progressive abatement of her symptoms.

Brucellosis and tuberculosis: clinical overlap and pitfalls.

OBJECTIVE: To identify characteristic features of tuberculosis in patients with culture proven brucellosis. METHODS: A retrospective analysis was performed on patients diagnosed with culture proven brucellosis between January and December 2011, based on review of their medical records. Patients with demonstrable co-infection with tuberculosis were excluded. Clinical features, laboratory parameters and tissue histopathology reports where available were noted. RESULTS: Thirty-two patients with brucellosis were included in the study. Twenty-one (65.63%) patients had chronic fever, thirteen (40.63%) had a productive cough, while significant weight loss, evening rise of temperature and night sweats were reported by eight (25.00%), eleven (34.38%) and five (15.63%) patients respectively. Nine (28.13%) patients had at least three of these symptoms. Lymphadenopathy, hepatomegaly and splenomegaly were noted on examination in seven (21.88%), fifteen (46.88%) and twelve (37.50%) patients respectively. Eight (25.00%) patients had hepato-splenomegaly, of these only two had associated significant lymphadenopathy. Respiratory examination was normal in all patients. Elevated ESR greater than 50 mm/hr was seen in eight (25.00%), it was greater than 100 mm/hr in five (15.63%) patients. Hypergammaglobulinemia was seen in eight (25.00%) cases. Bone marrow biopsy showed non-caseating granulomas in three (9.38%) cases, lymph node biopsy showed granulomas in one case. Overall, three (9.38%) patients had known risk factors for tuberculosis, while six (18.75%) had risk factors for brucellosis. CONCLUSIONS: There is a clear overlap between brucellosis and tuberculosis both in terms of clinical presentation and laboratory parameters. It is essential to carefully rule out tuberculosis in all cases of suspected or proven brucellosis before initiating antimicrobial therapy, in order to forestall development of drug-resistant tuberculosis.

Late presentation of TAPVC with multiple cerebral abscesses.

We report the case of a 24-year-old man, presenting with fever, headache, vomiting and seizures, subsequently diagnosed with cyanotic congenital heart disease. Evaluation revealed non-obstructive supracardiac total anomalous pulmonary venous connection (TAPVC) as the underlying disorder. Surprisingly, the patient denied any past cardiac symptoms. Presentation in adulthood is infrequent for TAPVC, and primary manifestation with cerebral abscesses is still more unusual.