Background: The incidence of mucinous appendiceal adenocarcinomas (MAA) has increased over the past three decades. Advanced stage tumor diagnosis is likely attributable to non-specific findings. Here we describe advanced stage appendiceal MAA presenting as inguinal ulcers, scrotal abscesses, and other nonspecific symptoms. To our knowledge, this is the first report of MAA presenting as inguinal pain with inflamed phlegmonous tissue and scrotal abscess. Case presentation: A 67-year-old male presented to a rural facility complaining of weight-loss, fatigue, hematuria, dysuria, painful right inguinal ulceration, and right scrotal abscess drainage. Computed tomography of the abdomen and pelvis revealed a distended appendix (> 1.3 cm) and a fistula between the appendix, urinary bladder, right scrotum, and right groin. Laparoscopic appendectomy was performed and diagnosed as MAA. After a right hemicolectomy, the MAA was staged as pT3b pN0 M0 G2. Conclusion: This case highlights a unique presentation of late stage appendiceal MAA. Due to the increased incidence of appendiceal MAAs, reports of unique clinical features are needed to facilitate early diagnosis and intervention, especially in rural settings with limited access to specialists.
While PD-1 inhibitors have revolutionized the treatment of metastatic NSCLC and the drugs are overall well tolerated, a small percentage of patients develop immune mediated liver injury due to reactive cytotoxic T lymphocytes as the reactivated T cells attack other tissues, including the liver. Generally, this has been seen consistently across the entire drug class, not specific to single agents. We present a rare case of immune mediated liver toxicity specific to Pembrolizumab that was subsequently not observed with Nivolumab, despite both drugs having identical mechanisms of actions. Patient has had multiple serial labs and imaging studies showing no progression of her disease, stable on Nivolumab. This case highlights the need for further investigation regarding the mechanism of Immune mediated liver toxicity/ injury that may be specific to single agents and not necessarily a drug class.
surgical evaluation as the case was not amenable to endovascular intervention. General surgery, surgical oncology, and vascular teams concluded that intraoperative mortality associated with reconstruction would approach 100%. The patient was then evaluated by palliative and hospice teams, and she was discharged with home hospice services two days after admission. (Figure ) Discussion: Our case emphasizes that in patients presenting with FBRBR and sepsis, clinicians should have a high suspicion of DCFs, especially in the setting of a history of PUD, abdominal surgery and radiotherapy, and recent excessive NSAID use.[2683] Figure 1. Axial (A) and coronal (B) views of an enhanced abdominal CTA scan demonstrating locules of gas within the inferior vena cava (yellow asterixis) with communication with the duodenal lumen (yellow arrow) suggestive of a duodenocaval fistula.
Upper gastrointestinal hemorrhage is an uncommon but can be a lethal presentation of a pseudoaneurysm because a rupture is associated with a 40%-80% mortality rate. We report a rare case of left gastric artery pseudoaneurysm secondary to peptic ulcer disease presenting as an upper gastrointestinal hemorrhage.
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