HighlightsPatients with secondary hyper-parathyroidism experience severe and prolonged hypocalcemia following parathyroidectomy.Pre/postoperative management for HBS helps to minimize long-term effects.No clear set outline for management of HBS, treatment is on case-by-case bases.
Ignatzschineria spp. bacteremia associated with maggot infestation is extremely rare in humans. There are only a few cases worldwide ever reported in the literature. We described a clinical case with a male patient who presented with maggot manifestation at his lower extremity, was found with bacteremia, and subsequently identified as Ignatzschineria spp by 16S rRNA sequencing.
INTRODUCTION:Gemcitabine is used for treatment of pancreatic cancer. Pulmonary toxicity is uncommon side effect of gemcitabine. We are presenting a case of gemcitabine induced pneumonitis. CASE PRESENTATION: A 73 year-old-female with history of pancreatic cancer, hypertension, chronic kidney disease and anemia presented to emergency department with complain of shortness of breath (SOB) for five days which got progressively worse after her 6th chemotherapy cycle. She was diagnosed with adenocarcinoma of pancreases with metastasis to liver about one and half year prior to presentation. She received treatment with gemcitabine and Nab-paclitaxel for a year and was only on gemcitabine for last six month. She was tachypneic and hypoxic requiring 2 L oxygen via nasal cannula (NC). Physical examination was notable for wheeze and rhonchi on both lung auscultation. Blood tests resulted troponin 10pg/mL, brain natriuretic peptide 370pg/mL, serum creatinine 1.69mg/dL, D-dimer 4.45mg/dL, hemoglobin 7.1g/dL, white blood cell count 6600 cells/microliter, platelet 86/microliter. Infectious work up including urine culture, blood culture and PCR from nasal swab for atypical pneumonia panel and MRSA were resulted negative. Chest radiograph showed bilateral interstitial and airspace opacities in the mid and lowers lung fields with small pleural effusion (fig 1). She had lung VQ scan without ventilation scan given which showed area of segmental perfusion defect (fig. 2) . Imaging of lower extremities was negative for deep venous thrombus. Echocardiogram was negative for cardiac cause. Arterial blood gas showed respiratory acidosis with pH 7.15 when oxygen requirement increased to 15 L via mask which required high flow nasal cannula then ultimately noninvasive positive pressure ventilation (NIPPV). Heparin infusion was started which later discontinued as perfusion defect correlated with opacities on chest x-ray and respiratory acidosis. She was stated on intravenous methyl prednisolone succinate as other potential causes were unlikely. Her symptoms improved dramatically in one day requiring 2L oxygen via NC. She was discharged on steroid taper dose. DISCUSSION: Gemcitabine induced pneumonitis is diagnosis of exclusion. Our patient received both paclitaxel and gemcitabine for a year but she was only on gemcitabine for six month prior to presentation. SOB was progressive correlating with chemotherapy. Life threatening as well as infectious causes were ruled out before starting treatment for drug toxicity. SOB improved dramatically from NIPPV to NC within 24 hour of treatment with steroid. This case emphasis on early detection of gemcitabine induced lung toxicity help to improve quality of life and choosing alternative therapy. CONCLUSIONS:Gemcitabine induced pneumonitis should be on differential diagnosis of hypoxia in patients on chemotherapy with gemcitabine. Physician should be aware of this uncommon but fatal side effect.
Subacute invasive pulmonary aspergillosis is a locally invasive subacute form of chronic pulmonary aspergillosis (CPA) which typically involves the upper lobes of individuals with pre-existing lung disease or immunodeficiency. Patients with chronic fibrocystic sarcoidosis are prone to CPA. We described a case of sarcoidosis complicated with CPA which was diagnosed concomitantly. CASE PRESENTATION:A 34 year old male with no past medical history presented with hemoptysis for 3 days, associated with chronic productive cough, exertional dyspnea and skin rashes over his arms and face for the past year. Physical examination revealed multiple violaceous plaque over bilateral upper arms and face; reduced breath sounds over bilateral upper zones. CT Chest revealed bilateral upper lobes cavitations, left upper lobe mass-like consolidation, approximately 2.9 cm with air crescent sign. Laboratory tests were notable for lymphopenia, ESR 43 mm/h, CD4þ count 244, Aspergillus Ag 0.6, Aspergillus IgG positive, serum ACE 178 U/L, fungal culture from bronchial alveolar lavage (BAL) isolated Aspergillus species. ANCA, Histoplasma Ag, Cryptococcal Ag, HIV Ag-Ab, Quantiferon TB, Sputum acid fast smear were negative. Endobronchial ultrasound with fine needle aspiration (FNA) of subcarinal lymph nodes showed non-caseating granuloma. Skin biopsies of upper extremities skin lesions showed non-caseating granulomas without microorganisms seen. The patient was started on Voriconazole for 3 months duration and scheduled for outpatient follow up.DISCUSSION: Patients with sarcoidosis are predisposed to CPA due to underlying pulmonary involvement especially with fibrocystic sarcoidosis in addition to the mildly immunocompromised state, as evidenced by low CD4 count. The diagnosis of CPA was made based on symptomatology (chronic productive cough, dyspnea and hemoptysis), bilateral upper lobe cavitations on CT Chest, positive Aspergillus IgG and positive BAL culture for Aspergillus species. It was a challenge in making concomitant diagnosis of Sarcoidosis as it is a diagnosis of exclusion. Diagnosis of sarcoidosis cannot be made based on the non-caseating granulomas resulted from the FNA of the lymph nodes as aspergillosis can present with similar picture. The skin rash which appeared to be plaque sarcoidosis ultimately leads us to the diagnosis of sarcoidosis after confirmation of non-caseating granuloma on skin biopsy. CONCLUSIONS:Patients with CPA typically present with background risk factors of underlying lung disease. It is essential to have a high clinical suspicion for underlying undiagnosed disease processes especially when individuals presented with CPA without any obvious risk factors. CPA is a serious complication of sarcoidosis and is associated with high mortality and morbidity. Unfortunately, there is no consensus currently on how to best treat patients diagnosed with sarcoidosis and CPA.
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