Primary lymphoma of the liver is extremely rare, and is more common among immunocompromised patients. It typically occurs after the fifth decade of life and has a male predominance. It often presents with diagnostic difficulties to both clinicians and pathologists as most cases have a solitary or multiple mass lesions in the liver with normal alpha-fetoprotein levels. Chemotherapy is the standard of therapy. Here, we describe a unique case of primary hepatic lymphoma in an elderly immunocompetent female who presented with symptomatic hypercalcemia.
Simultaneous liver abscesses are rarely seen and reported. We are reporting a case of two simultaneous, complex liver abscesses in a patient who had no evidence of liver abscess on cross-sectional imaging close to three months prior to this presentation. These abscesses were 7-8 cm in size, large, and septated. Microbiological studies were positive for Streptococcus constellatus, which is a known cause of pyogenic liver abscess. In our patient, pyogenic liver abscesses were associated with bacteremia and sepsis. This patient was managed with broad spectrum parenteral antibiotics and percutaneous drainage with improvement in clinical condition. This patient was discharged home with a peripherally inserted central catheter (PICC) line in place to complete a six-week course of parenteral antibiotics. A complete history and physical with pertinent examination findings are key to diagnosis of liver abscess. S. constellatus should be considered in the differential diagnosis of patients with liver abscess and sepsis.
INTRODUCTION: Primary mediastinal large B-cell lymphoma (PMLBCL) is a unique type of B-cell lymphoma probably arising from a putative thymic medulla B-cell. PMLBCL comprises seven percent of diffuse large B cell lymphomas (2.4 percent of all non-Hodgkin lymphomas). There is a female predominance and a median age at diagnosis in the third to fourth decade. In some cases, the presentation can be an oncological emergency with locally invasive anterior mediastinal mass arising from thymus causing external pressure on the heart and the surrounding structures. PMLBCL presenting as brachial plexopathy with cardiac tamponade is an uncommon presentation.CASE PRESENTATION: 37-year-old female, who presented to the ED with a 3-week history of left-sided neck pain and progressive swelling with associated 2 weeks history of numbness in the left wrist, tingling sensation in her 4th and 5th finger with weakness on the same side. She endorsed exertional dyspnea and palpitation that worsened over the last 4 days prior to presentation.On examination she was noted to have left sided neck mass about 6 x 8cm, firm, nontender, non-mobile with extension below the clavicle. Tachycardic with Muffled heart sounds and grade 3/6 Systolic Ejection Murmur at right upper sternal border. Flexion deformity with reduced sensation of the left 4th and 5th finger. Chest X-ray shows cardiomegaly with widened mediastinum. Computed Tomography scan was suggestive of anterior mediastinal mass. Echocardiogram done showed large pericardial effusion with Echocardiographic findings consistent with tamponade physiology.She underwent pericardiocentesis with 700 cc of serosanguinous fluid drained and subsequently had CT guided biopsy of the anterior mediastinal mass. Biopsy report showed high grade B-cell lymphoma with Immunostain showing lymphoma cells positive for CD20, BCL6 and negative for BCL2, CD5. She was diagnosed to be High grade stage IIB, commenced on chemotherapy and completed 6 cycles of DA-EPOCH-R.Left hand weakness and neuropathy resolved following chemotherapy. Repeat CT chest and Echocardiogram showed near resolution of the anterior mediastinal mass and pericardial effusion respectively. DISCUSSION: The majority of patients with primary diffuse large B-cell mediastinal lymphoma are symptomaticat the time of diagnosis. Patients present with a locally invasive anterior mediastinal massoriginating in the thymus, with frequent airway compromise and superior vena cava (SVC)syndrome. Symptoms related to the compression or invasion of local structures (i.e., cough, dyspnea, dysphagia, hoarseness) are common, systemic B-symptoms occurs in about 47% ofpatients, brachial plexopathy is an uncommon presentation.CONCLUSIONS: PMBL is a tumor of young adults who present with a rapidly proliferating tumor. At diagnosis, the tumor is usually limited to the mediastinum, therefore high index of suspicion is required in making the diagnosis.
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