INTRODUCTION: Diarrheal disease is one of the leading causes of death across the globe. Acute diarrhea in older adults is mostly due to underlying infectious etiology. Patients with underlying systemic lupus erythematosus (SLE) it is important to consider an acute exacerbation of the disease if presenting with diarrhea and abdominal pain. We are presenting a case of 60-yearold female with remote history of SLE, not on immunosuppressive therapy who presented with rash, dyspnea and acute onset of diarrhea.CASE PRESENTATION: A 60-year-old female with medical history of SLE diagnosed 20 years ago, not on immunosuppressive therapy, and other comorbidities who presented to the emergency department with chief complaint of worsening skin rash, dyspnea and diarrhea. She noted a lacy, macular erythematous rash in both the proximal and distal areas of the arms with a marginated appearance with a central clearing that has been ongoing for over one year; it was not alleviated with topicals. Also, she had multiple loose watery and dyspnea that has been ongoing for the past two weeks. She was treated for an asthma exacerbation seven months ago with oral steroids. Upon presentation, she was tachycardic with mild leukocytosis, lactic acidosis with concern of an underlying abdominal infection. She was empirically started on broad spectrum antibiotics and IV fluids. Significantly elevated CRP and presence of a reticular rash prompted starting IV steroids for concern of vasculitis. Skin biopsy showed leukocytoclastic vasculitis. Serological work-up was significant for positive rheumatoid factor, anti-SSA and ANA. After a few doses of IV steroids, her symptoms improved with dissipation of the rash. With clinical improvement with IV steroids and negative stool cultures, it was suspected that the patient suffered from lupus mesenteric vasculitis. DISCUSSION:The prevalence of vasculitis in a patient with SLE ranges between 11-36%, with cutaneous involvement accounting for 82% of vasculitis and visceral 12.3%. Mesenteric vasculitis is the rarest, and most dangerous complication of SLE that is reported in 0.2 -9.7% of all SLE patients. In this patient's case, she did not have significant knowledge regarding her initial diagnosis of SLE. However, she had been receiving oral steroids for management of asthma or skin rashes intermittently that could have helped control potential SLE flares. For the past seven months, she was not any immunosuppressants that could contribute to worsening rash and diarrhea. A typical presentation of acute diarrhea usually warrants an underlying infectious or inflammatory etiology. This patient's case characteristic rash and remote history of SLE prompt us to further evaluate for an underlying autoimmune culprit due to her symptoms. CONCLUSIONS:It is imperative that we evaluate such patients with an underlying autoimmune disease for any exacerbation as a potential cause of presenting symptoms.
Lung cancer is the number one cause of cancer worldwide and is still the most common cause of cancer deaths. Of these, small cell lung carcinoma (SCLC) comprises about 15% of all bronchogenic carcinomas. A rare subset, labeled as combined small-cell lung carcinoma (C-SCLC), is defined as SCLC with histological components of non-small-cell lung carcinoma (NSCLC) and account for only 5% of all SCLC. Here, we present a case of primary pulmonary neoplasm with two distinct underlying histopathologic components.
INTRODUCTION: Hodgkin Lymphoma (HL) is a rare class of malignant B-cell neoplasms which comprises about 10% of all lymphomas in the United States. Classical Hodgkin lymphoma (cHL), hallmarked by malignant Reed-Sternberg cells, represents 90% of all HL. Most patients present with asymptomatic supradiaphragmatic lymphadenopathy while a third may be accompanied by constitutional B symptoms including fevers, drenching night sweats, and significant weight loss. Almost never described are the rare and ominous cutaneous manifestations of cHL. CASE PRESENTATION:A 75 year old female with history of COPD and hypertension presented to the hospital with chief complaint of a progressively worsening, intensely pruritic erythematous papular and nodular-ulcerative rash involving the left upper extremity and chest wall. Symptoms worsened despite being treated for 2 weeks with topical steroids, permethrin cream for suspected scabies and oral antibiotics for possible cellulitis by her dermatologist. Though denied symptoms of cough and shortness of breath, the patient was noted to be hypoxic, requiring 4L nasal cannula. A subsequent CTA chest to evaluate for pulmonary embolism was negative, but revealed bulky mediastinal lymphadenopathy with enlarged lymph nodes in the supraclavicular and left axillary regions. Complete left lung atelectasis with pleural effusion occupying the entire left hemithorax was also noted. Pleural fluid studies from a subsequent thoracentesis demonstrated low LDH and elevated cholesterol levels with cytology negative for malignant cells. Follow up bronchoscopy revealed a fungating endobronchial mass completely occluding the left mainstem bronchus. Pathology of the lesion confirmed cHL and the patient received initiation chemotherapy prior to discharge with immediate improvement in skin rash, pruritus, and oxygenation.DISCUSSION: Cutaneous manifestations of HL are exceedingly rare and occur in 0.5 to 3.4% of patients, usually present in the setting of advanced disease (stage IV). Specific lesions are categorized as ulcerative lesions, papules, nodules or a combination and are often accompanied by pruritus as described in this case. One proposed mechanism is the retrograde lymphatic spread distal to the involved lymph nodes. The anatomic distribution of this patient's lesions, down the left chest wall and arm, follows the retrograde drainage from the adjacent axillary lymph nodes most commonly described. CONCLUSIONS:Recognizing cutaneous Hodgkin's disease is crucial, particularly in those patients with cHL lacking classical B symptoms and other common presentations. Though easily overlooked, raising awareness of this rare manifestation of cHL will prevent the delay in diagnosis and staging while affording the opportunity to initiate timely chemotherapy in this underrepresented subset of patients.
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