The Importance of Excisional Biopsy in Nodular Lymphocyte-Predominant Hodgkin's Lymphoma.

Hodgkin's lymphoma (HL) is a malignancy that is typically B-cell in origin. HL can be further classified into classical HL and nodular lymphocyte-predominant HL (NLPHL). NLPHL is a rare lymphoma. It commonly presents locally with palpable firm lymphadenopathy or mediastinal mass seen on chest imaging. Some patients may have B symptoms (fever, night sweats, and unintentional weight loss), splenomegaly, and hepatomegaly. We describe a case of NLPHL in a 32-year-old male with classical findings of this rare class of HL.

The Prognostic Role of Human Papillomavirus and p16 Status in Penile Squamous Cell Carcinoma-A Systematic Review.

PSCC is a rare cancer, with approximately half of all cases related to HPV. While HPV and p16 IHC testing have proven their prognostic value for oropharyngeal cancer, this is not yet established for PSCC. The current level of evidence exploring the relation between PSCC and HPV is moderate, so we conducted a systematic review following PRISMA guidelines to evaluate the prognostic role of HPV and p16 IHC in PSCC clinical outcomes. We searched the PubMed, Embase, and Cochrane databases and identified 34 relevant studies that met our inclusion criteria. Of these, 33 were retrospective cohort studies, and one was a cross-sectional study. Nine studies reported that HPV-positive and p16-positive PSCC had better overall survival (OS) and disease-free survival (DFS). This study highlights the need for a meta-analysis to determine the role of routine HPV status or p16 staining testing as part of the initial diagnosis and staging of PSCC patients worldwide.

A Case of Intractable Vomiting: Was It the Celiac Artery Compression?

Celiac artery compression syndrome is a rare and poorly understood condition. Compression of the celiac artery by the median arcuate ligament causes intractable nausea, vomiting, and postprandial pain. We present a case of a 55-year-old male with a 50-pound unintentional weight loss and intractable vomiting, whose symptoms persisted despite robotic median arcuate ligament release. He later returned to the emergency department where he was found to have a low gallbladder ejection fraction on imaging indicative of biliary dyskinesia, for which he underwent a cholecystectomy. Eventually, his symptoms improved, and he was able to return to his baseline body weight.

A Case of Recurrent Embolic Strokes in a Young Female With a Patent Foramen Ovale and Presumed Fibroelastoma.

Patent foramen ovale (PFO) occurs in about 25% of the population. PFO closure has been shown to decrease the risk of stroke in patients with recurrent strokes as compared to those treated with medical therapy alone, with more benefit in those with larger PFO sizes. Percutaneous PFO closure, although minimally invasive, does carry surgical risks, which must also be taken into account. We present a case of a 31-year-old female presenting with a left middle cerebellar artery (MCA) stroke and persistent deficits who was found to have both a PFO and presumed fibroelastoma on her aortic valve. She was treated with aspirin and apixaban and advised to follow up with cardiothoracic surgery once she recovered from her stroke for ultimate PFO closure and removal of the fibroelastoma. Unfortunately, she presented again less than one month later with recurrent cerebrovascular accidents (CVA) requiring urgent PFO closure. Our case stresses the importance of tools such as the Risk of Paradoxical Embolism (RoPE) score index when determining treatment plans for patients with PFO, and possible confounding factors such as the presence of an aortic valve fibroelastoma.

Voriconazole Induced Cutaneous Squamous Cell Carcinoma in an Immunocompetent Patient.

Voriconazole therapy can be associated with hair loss, vision changes, and skin phototoxicity, but rarely is it associated with the development of skin cancer. We present a case of an immunocompetent 42-year-old Caucasian male with a past medical history significant for chronic pulmonary aspergillosis (CPA) and prior cutaneous squamous cell carcinoma (cSCC) of the left hand who arrived at our clinic for evaluation of an enlarging, non-tender left preauricular mass over the past six months. He had diffuse actinic changes and appeared older relative to his age. He had a fair complexion but was compliant with sun protection measures and minimized unnecessary ultraviolet (UV) light exposure. His left-sided facial mass was excised, and the final pathology was consistent with cSCC. His only home medication was oral voriconazole 200 mg once daily for six years for pulmonary aspergillosis. He was negative for human immunodeficiency virus (HIV) and had no history of prior transplant operations. This case highlights the importance of recognizing voriconazole as an independent risk factor in the development of cSCC, especially in patients on chronic therapy for aspergillosis.

Occult Perforated Gangrenous Gallbladder Found on Magnetic Resonance Cholangiopancreatography.

Acute gangrenous cholecystitis is a life-threatening disease that is most often diagnosed intraoperatively and can be missed on mildly symptomatic patients without the proper imaging modality. We present a case of a 69-year-old male with a history of hypertension, hyperlipidemia, and type 2 diabetes, and a recent right pontine infarct that arrived with 3 out of 10 right-sided abdominal pain. His liver ultrasound and computed tomography (CT) with contrast demonstrated acute cholecystitis. He was initially worked up conservatively and was scheduled for an elective cholecystectomy per surgery recommendation. However erring on the side of caution, the medical team had ordered a magnetic resonance cholangiopancreatography (MRCP), which demonstrated perforated gangrenous cholecystitis. Of note, the imaging modalities were ordered within a 24-hour window. The patient's antibiotics were promptly broadened, and he was emergently sent to the operating room. Moving forward, we will identify atypical clinical presentations of gangrenous cholecystitis and consider ordering an MRCP when clinical suspicion remains high and initial imaging is inconclusive. Perforated gangrenous cholecystitis is a severe disease and can cause rapid demise if not identified and treated early.

Immunotherapy-Induced Acute Tubulointerstitial Nephritis.

Due to its minimal side-effect profile, immunotherapy has become a popular choice for the treatment of advanced melanoma as compared to conventional chemotherapy. The most common side effects associated with immunotherapy include gastrointestinal, pulmonary, and dermatologic manifestations. However, there have been very few documented occurrences of nephrotoxic side effects. We present a case of a 73-year-old male with a past medical history of chronic kidney disease (CKD) stage 3A, metastatic uveal melanoma, and gastroesophageal reflux disease on pantoprazole who arrived at the intensive care unit with altered mental status and creatinine of 27 gm/dl (baseline creatinine of 3 gm/dl about one year prior), after receiving his first dose of ipilimumab and nivolumab approximately 21 days prior. Kidney biopsy demonstrated acute tubulointerstitial nephritis (ATIN). This case highlights the importance of recognizing acute tubulointerstitial nephritis as a side effect of immunotherapy for prompt diagnosis and early treatment.