Rationale: Fibrinolysis shutdown associated with severe thrombotic complications is a recently recognized syndrome that was previously seldom investigated in patients with severe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. It presents a unique therapeutic dilemma, as anticoagulation with heparin alone is insufficient to address the imbalance in fibrinolysis. And while the use of fibrinolytic agents could limit the disease severity, it is often associated with bleeding complications. There is a need for biomarkers that will guide the timely stratification of patients into those who may benefit from both anticoagulant and fibrinolytic therapies. Patient concerns: All 3 patients presented with shortness of breath along with comorbidities predisposing them to severe SARS-CoV-2 infection. One patient (Patient 3) also suffered from bilateral deep venous thrombosis. Diagnoses: All 3 patients tested positive for SARS-CoV-2 RNA by reverse transcription polymerase chain reaction (RT-PCR) and were eventually diagnosed with respiratory failure necessitating intubation. Interventions: All 3 patients required mechanical ventilation support, 2 of which also required renal replacement therapy. All 3 patients were also placed on anticoagulation therapy. Outcomes: In Patients 1 and 2, the initial D-dimer levels of 0.97 μg/ml fibrinogen equivalent units (FEU) and 0.83 μg/ml FEU were only slightly elevated (normal <0.50 μg/ml FEU). They developed rising D-dimer levels to a peak of 13.21 μg/ml FEU and >20.0 μg/ml FEU, respectively, which dropped to 1.34 μg/ml FEU 8 days later in Patient 1 and to 2.94 μg/ml on hospital day 13 in Patient 2. In Patient 3, the D-dimer level on admission was found to be elevated to >20.00 μg/ml FEU together with imaging evidence of thrombosis. And although he received therapeutic heparin infusion, he still developed pulmonary embolism (PE) and his D-dimer level declined to 5.91 μg/ml FEU. Despite “improvement” in their D-dimer levels, all 3 patients succumbed to multi-system organ failure. On postmortem examination, numerous arterial and venous thromboses of varying ages, many consisting primarily of fibrin, were identified in the lungs of all patients. Lessons: High D-dimer levels, with subsequent downtrend correlating with clinical deterioration, seems to be an indicator of fibrinolysis suppression. These findings can help form a hypothesis, as larger cohorts are necessary to demonstrate their reproducibility.
Background: The inverted and oncocytic subtypes of sinonasal Schneiderian papillomas are benign tumors with possible rare malignant transformation and are typically managed with complete surgical resection and close follow-up. While computed tomography (CT) and magnetic resonance imaging (MRI) are mainstays in preoperative evaluation of bony invasion and soft tissue extension of the lesion, their imaging characteristics by 18F-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) is less well characterized. Objective: To describe the clinical presentation and management of a PET positive sinonasal lesion. To conduct a literature review of FDG uptake in benign sinonasal papillomas. Methods: Case report (n = 1) and literature review of similar cases (n = 32). Results: We report the case of a 69-year-old man presenting with an isolated left maxillary sinus mass with avid FDG uptake, discovered on PET/CT imaging. An endoscopic left maxillary mega-antrostomy provided successful definitive treatment for final pathologic diagnosis of oncocytic papilloma. Literature review of cases of sinonasal papillomas with avid FDG uptake found that oncocytic papillomas, on average, exhibit greater uptake than inverted papillomas and both may be mistaken as malignancies on PET. Conclusion: While PET imaging demonstrating avid FDG uptake is associated with an increased risk of malignancy, it does not rule out the possibility of a benign sinonasal papilloma nor other benign inflammatory lesions. Particularly, oncocytic papillomas may have very high FDG uptake and mimic malignant lesions.
Introduction: Primary graft dysfunction (PGD) is a major cause of mortality following heart transplant (HT). Pathological characteristics of PGD have not been well characterized. We sought to describe the clinical and pathological characteristics of patients who died or were re-transplanted due to PGD. Methods: We identified a cohort of 161 HT recipients between 3/7/2012 to 12/31/17 who developed PGD. Of these, 40 patients had severe PGD, and 16 died in the first month post-transplant. Autopsy or explant pathology was available in 6 patients, which was compared to pathology from the first endomyocardial biopsy in 24 patients with severe PGD that survived. Results: Of the 6 patients for whom pathology was available, mean age was 54, four were male and five were white. Half had non-ischemic dilated cardiomyopathy. Two were sensitized. Five patients had severe PGD and one patient had moderate PGD. There were five deaths and one re-transplant. On pathologic examination, most patients (4/6) had broad areas of myocardial necrosis with diffuse vascular thrombosis. Two patients had focal areas of myocardial necrosis. In no cases was there evidence of cellular rejection (ACR) or antibody-mediated rejection (AMR). In the 24 survivors of severe PGD, median age was 54 , twenty were male and half were white. Five were sensitized. On pathologic examination, ischemic changes were found in 10 patients (42%). While there was no significant ACR, 7/24 (30%) of cases showed evidence of either AMR 1 or AMR 2. Conclusions: In patients succumbing to moderate or severe PGD, PGD was associated with diffuse myocardial necrosis and vascular thrombi. In survivors of severe PGD, the most prominent finding was diffuse ischemic changes on routine heart biopsy. In both, there was no evidence of cellular rejection, however there was significant incidence of AMR, possibly induced by ischemic changes. These findings suggest that severe PGD may have an ischemic component characterized by vascular thrombosis.
Ghost cell odontogenic carcinoma (GCOC) is an exceptionally rare malignant odontogenic neoplasm with a significant potential for aggressive growth. Although the literature on this tumor is limited, its high recurrence rates suggest that early and multimodal intervention may be beneficial. This study reports a case of GCOC of the mandible that was successfully treated with surgical resection, reconstruction, and radiation. A comprehensive literature review was performed, and the relevant genomic and histopathological characteristics of this malignancy were determined.
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