Fusobacterium nucleatum is a gram-negative bacillius commonly found in oropharynx and is traditionally associated with Lemierre syndrome, which is characterized by history of recent oropharyngeal infection, internal jugular vein thrombosis, and isolation of anaerobic pathogens, mainly Fuosobacterium necrophorum. However, recent evidence indicated that F. nucleatum is also a normal resident of human gut. Less than a dozen of case reports had linked F. nucleatum to gastrointestinal variant of Lemierre syndrome with portal vein thrombosis. However, F. nucleatum bacteremia-associated hepatic vein thrombosis is very rare. We report a case of a 73-year-old man who had hepatic vein thrombosis associated with F. nucleatum bacteremia, most likely from subclinical primary infection affecting the lower gastrointestinal tract. The underlying pathophysiology and treatment options are discussed here. With rapid increase in reporting of Lemierre syndrome, this case deserves particular attention from clinicians.
ImportanceThe usefulness of computed tomography of the head (CTH) in patients with acute-onset atraumatic altered mental status (AMS) is poorly understood, but use in these patients remains high.ObjectiveTo evaluate the use of CTH (event rate) in patients with AMS and the positive outcome event rate of the performed CTH studies.Data SourcesThe PubMed/MEDLINE, PubMed Central, Embase, and CINAHL databases were searched using predefined Boolean parameters. All studies that met inclusion criteria until January 31, 2022, were included.Study SelectionRandomized clinical trials and observational, cohort, and case-control studies were included. Conference abstracts, reviews, letters, case reports, case series, systematic literature, and meta-analyses were excluded.Data Extraction and SynthesisThe systematic literature review was performed per Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data were independently extracted by 2 authors. Data were pooled using a random-effects method.Main Outcomes and MeasuresEvent rate of CTH use in patients with acute atraumatic AMS. The CTH event rates and positive CTH event rates were calculated with 95% CIs.ResultsOf 9338 studies identified, 26 qualified for the systematic review and 25 for the meta-analysis. The 25 studies in the meta-analysis included a total of 79 201 patients. The CTH event rate was 94% (proportion, 0.94; 95% CI, 0.76-1.00), and the positive CTH event rate was 11% (proportion, 0.11; 95% CI, 0.07-0.15). There was significant heterogeneity among the studies included (I2 > 50%, P < .001), for which a random-effects model was used. There was significant publication bias, as evident by an asymmetric funnel plot. There was no fluctuation of the results during the sensitivity analysis, which reassured the reliability of the data.Conclusions and RelevanceIn this meta-analysis, CTH use among patients with acute-onset atraumatic AMS was very high with a low yield. Large-scale studies are needed to guide clinical decision-making in such a situation.
Interstitial pneumonia with autoimmune features (IPAF) is a new diagnostic classification initially proposed by the European Respiratory Society/American Thoracic Society Task Force for undifferentiated connective tissue related interstitial lung disease. Currently, choice of therapy is left to the individual provider and consists of corticosteroids and/or immunosuppressants. Rituximab is not a well-established medication to treat IPAF. In this report we present a case of significant response to rituximab in a patient with IPAF who couldn't tolerate prednisone and Azathioprine. CASE PRESENTATION:A 74 year old female with a past medical history of CAD, hypertension, and hyperlipidemia was referred to pulmonary clinic for persistent pulmonary infiltrates on chest X-Ray. She complained of fatigue, dyspnea on exertion, and cough. She denied fever. She was a former smoker with 5 pack-years smoking history. She was treated with PO antibiotics for suspected pneumonia by her PCP without improvement in symptoms. Her vitals were stable, physical exam revealed bilateral inspiratory crackles. CXR prior to clinic showed bibasilar airspace disease. CT Chest displayed multilobar pulmonary opacities with several reverse halo signs. CBC, CMP, and CRP were normal. ESR was mildly elevated. To rule out any connective tissuerelated lung disease, autoimmune work up was sent which showed strong positive ANA (>1:1280) but negative dsDNA, CCP, ANCA panel, SM/RNP, RNP, SM antibody. SSA was positive but not SSb. Rheumatoid factor was positive and Myositis antibody panel was negative except SRP. Fungal panel was negative and PFTs showed only mild reduction in DLCO. Patient had no arthritis, dryness in the mouth, or rash. Based on imaging and positive serologic test, IPAF was diagnosed and immunosuppressive therapy was offered. Patient was started on prednisone and Bactrim. However, due to significant weight gain secondary to prednisone, patient wished to discontinue this therapy. Initially, Mycophenolate Mofetil and later on Azathioprine were started, however, both were stopped due to elevated liver enzymes. Rituximab was prescribed as the primary steroid-sparing agent. Clinically, she responded to treatment well. Repeat CT chest revealed significant improvement of interstitial pneumonia.DISCUSSION: Although evidence-based treatment guidelines for IPAF are yet to be established, there is a significant response to corticosteroids and immunosuppressants such as Azathioprine, Mycophenolate Mofetil and Cyclophosphamide in this cohort of patients. Use of Rituximab for IPAF is not considered a first-line therapy, this case suggests Rituximab can be a viable option as a steroid-sparing agent for those who cannot tolerate other immunosuppressants.CONCLUSIONS: Use of Rituximab for IPAF is not considered a first-line therapy, this case suggests Rituximab can be a viable option as a steroid-sparing agent for those who cannot tolerate other immunosuppressants.
The incidence of recurrence in advanced stage ovarian cancer is 70% with a median interval to first recurrence of 18-24 months after treatment with surgery, chemotherapy, and radiation. Of these, 77.6% of cases reoccur in the abdominal or pelvic cavity. Only 1.8% of recurrent cases present intrathoracic metastases and recurrence 20þ years after treatment has rarely been reported. We present a case of recurrent ERþ ovarian adenocarcinoma presenting with diffuse pleural nodules 29 years post treatment. This is the only reported case in literature where pleural nodules are the primary site of ovarian adenocarcinoma recurrence more than 20 years post-treatment. CASE PRESENTATION:A 72 year old female presented to the emergency department complaining of weakness and increasing shortness of breath over several weeks. On physical exam, she was hypoxic and pale in appearance with diminished breath sounds in the right lower lobe. Labs were remarkable for Hgb of 4. CXR at that time revealed a loculated R pleural effusion and an intact chemotherapy port from prior treatment 30 years ago. Chest CT imaging was obtained, revealing nodular densities throughout the right hemithorax suggestive of pleural neoplasm. CT-guided pleural biopsy was obtained, revealing neoplastic cells demonstrating immunoreactivity with CK7, ER, Pax-8, and CA-125, suggestive of Mullerian Primary Adenocarcinoma. PET-CT demonstrated increased activity in numerous right pleural nodules. The patient was diagnosed with Stage FIGO IVB Ovarian Adenocarcinoma. The 5-year survival rate for distantly metastasized epithelial ovarian cancer is 31%. Treatment options for patients with distant metastases diagnosed with FIGO Stage IVB Ovarian Adenocarcinoma include neoadjuvant chemotherapy followed by surgery, adjuvant therapy, and maintenance therapy. Due to the indolent nature of the disease, and after discussion with the patient regarding goals of care, conservative therapy with frequent imaging and oncologic observation was the selected clinical approach.DISCUSSION: On initial presentation with unilateral pleural nodules and respiratory symptoms, primary tumors of pleural such as malignant mesothelioma was considered highly on the differential, but on further studies including staining with TTF-1, histologic findings were found to be consistent with Mullerian primary, despite the patient having completed treatment 29 years prior and having had no recurrence or symptoms since then. CONCLUSIONS:Although malignant unilateral pleural nodules may raise suspicion for primary lung or pleural neoplasms, recurrence of extra-thoracic malignancy must always be considered when evaluating pleural nodules, regardless of how remote the primary occurrence emerged. This is the only reported case in literature where pleural nodules are the primary site of ovarian adenocarcinoma recurrence more than 20 years post-treatment.
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