Key Clinical Message
Significant elevations in alpha‐fetoprotein should raise suspicion for hepatocellular carcinoma as malignancies with metastasis to the liver can elevate the alpha‐fetoprotein level but typically <300 ng/mL. Diagnosis should be confirmed with typical characteristics of hepatocellular carcinoma on imaging and or liver biopsy to confirm diagnosis.
Waldenström's macroglobulinemia is a rare hematology malignancy which often presents with "B symptoms," anemia, and thrombocytopenia. A 46-year-old woman presented with 2 months of abdominal distension accompanied by an unintentional 20-lb weight loss. Her abdominal CT scan demonstrated diffuse carcinomatosis with bilateral ovarian lesions and screening labs revealed a markedly elevated CA-125, suggesting a diagnosis of ovarian cancer. Upon admission for workup, patient was found to have a significant protein gap, later attributed to a markedly elevated IgM. Omental and bone marrow biopsy confirmed the diagnosis of Waldenström's macroglobulinemia, with elevation in CA-125 thought to be secondary to peritoneal irritation. This patient has since been successfully treated with six cycles of bendamusine and rituximab with no evidence of disease on staging scans and normalization of both CA-125 and IgM. To our knowledge, this is the first documented case of Waldenström's macroglobulinemia presenting with symptoms classically associated with ovarian cancer and demonstrates the importance of maintaining a broad differential when evaluating patients with abdominal carcinomatosis.
Without transmission electron microscopy cases of amyloidosis-like glomerulopathy may be erroneously considered to be amyloidosis, diabetic or membranous nephropathy. Mesangial widening and increased matrix, and capillary basement membrane thickening are features common to amyloid-like glomerulopathy, amyloidosis, and diabetic renal problems. Amyloid-like immunofluorescence may be positive for IgG, and C3 within the mesangium and capillary walls suggesting possible membranous nephropathy. Some cases appear to represent light chain nephropathy, which is known to result in crystalline-like ultrastructural deposits. Identification of amyloid-like glomerulopathy is made by Congo Red negativity and characteristics of ultrastructural fibrils.The renal biopsies from all patients were fixed in 2.5% glutaraldehyde, rinsed in Millonig’s phosphate buffer, and post fixed in 1% osmium tetroxide. They were then en bloc stained with 1% uranyl acetate, rinsed with Walpole’s non-phosphate buffer, dehydrated with a graded series of ethanols and embedded with Epon 812 epoxy resin. Ultramicrotomy thin sections were post-stained with uranyl acetate and lead citrate and scanned using a JEOL JEM 100C.
In two histologically diagnosed cases of acute pyelonephritis, several ultrastructural features were observed. The transmission electron microscope (TEM) highlights the bacterial adhesion, inflammatory process, phagocytosis and lysosomal release characteristic of pyelonephritis.The renal biopsies from both patients were fixed in 2.5% glutaraldehyde, rinsed with Millonig's buffer, and post fixed with 1% osmium tetroxide. They were then en bloc stained with 0.5% uranyl acetate, rinsed with Walpole's buffer, dehydrated with a graded series of ethanols and embedded with Epon 812 epoxy resin. Ultramicrotomy thin sections were stained with uranyl acetate and lead citrate and scanned using a JEOL - JEM100C.Using the TEM, bacteria are seen in tubular epithelial cells, phagocytized to the basement membrane, within cells of the tubular lumen, and within the polymorphonuclear leukocytes (polys). Bacteria may also be seen phagocytizing within cells in the tubular lumen. The inflammatory response of polys is seen in the tubular lumen and interstitium, and attached and within the tubular basement membrane.
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