Primary Pulmonary Diffuse Large B Cell Lymphoma (PPDLBCL) is an extremely rare entity, which exhibits an aggressive behavior by compressing local blood vessels. It represents only 0.04% of all lymphoma cases and is extremely rare in young age. We present a case of a primary pulmonary lymphoma with superior vena cava syndrome (SVCS) in a young female. 27-year-old African American female presented with fever, cough, and facial puffiness for 2 weeks and unintentional weight loss. Chest examination showed decreased breath sounds and dullness on percussion on right side. Labs were normal except for mild leukocytosis, high lactate, and lactate dehydrogenase. Chest X-ray showed a large right side infiltrate with pleural effusion but chest CT showed 10 × 14 × 16 cm mass in the right lung without hilar and mediastinal lymphadenopathy. CT guided biopsy of the right lung mass was done and large B cell lymphoma was diagnosed. She received “involved field radiation” because of the bulky tumor size and superior vena cava involvement prior to R-CHOP to which she responded well. PPDLBCL should be considered as one of the differentials in a young patient with a large lung mass, which needs timely diagnosis and management.
Myxedema coma is a decompensated hypothyroidism which occurs due to long-standing, undiagnosed, or untreated hypothyroidism. Untreated hypothyroidism is known to affect almost all organs including the heart. It is associated with a decrease in cardiac output, stroke volume due to decreased myocardial contractility, and an increase in systemic vascular resistance. It can cause cardiac arrhythmias and the most commonly seen conduction abnormalities are sinus bradycardia, heart block, ventricular tachycardia, and torsade de pointes. The authors report a case of an elderly man who presented with sudden cardiac arrest and myxedema coma and who was successfully revived.
INTRODUCTION: Hepatic portal venous gas (HPVG) and gastric emphysema is an ominous finding with high mortality and is usually associated with intestinal necrosis. It is an indication for urgent surgery. We report a case of Clostridium difficile (C.diff) enteritis presenting as HPVG and gastric emphysema without the evidence of intestinal ischemia. CASE PRESENTATION: 76-year-old Male presented with vomiting, severe abdominal pain and constipation for 2-3 days. Other review of systems was comprehensively negative. Other medical problems were Human Immunodeficiency Virus (on treatment), Hypertension and colonic diverticulosis. He was tachycardic 107 and hypotensive 99/50. Physical examination revealed distended and diffusely tender abdomen but no guarding or rigidity. Initial labs showed leukocytosis of 15 thousand and lactic acidosis. CT abdomen showed marked diffuse portal venous gas in liver and multiple gas collections surrounding the stomach. Small bowel was moderately dilated at proximal and midlevel. Because of high suspicion of small bowel obstruction (SBO) and perforation patient underwent urgent exploratory laparotomy but surprisingly only internal hernia of jejunum was noted,which was reduced, without evident SBO or intestinal necrosis. Stool was positive for C diff toxin and gene. Patient was treated for C diff with intravenous metronidazole. He clinically improved and came out of septic shock. CT abdomen after 1 week showed complete resolution of HPVG and gastric gas. Vasculitis work up was negative. DISCUSSION: HPVG and gastric emphysema is considered an ominous radiological finding. More recently, it has been associated with various benign causes like superior mesenteric syndrome.However ischemia remains the most common cause and concern, as mortality rate is 75-90%. Few Cases have been reported with C.diif induced bowel ischemia leading to HPVG. However our patient had C.diff enteritis but no evidence of ischemic necrosis. Possible explanation of HPVG is the escape of the C.diff induced gas formation in jejunum from internal hernia, which then circulated to liver and stomach. CONCLUSIONS: We illustrate a rare case of C diff presenting as HPVG and gastric emphysema without any evidence of intestinal ischemia. Although uncommon but C.diff infection should be considered as a nonfatal etiology of HPVG.
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