Coccidioidomycosis causes significant morbidity in endemic areas. In the absence of sensitive diagnostic serologic testing, clinicians have increasingly relied on lung and lymph node biopsies for diagnosis. Recently, endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has been shown to be an excellent sampling method for the diagnosis and staging of lung cancers, especially when combined with endoscopic ultrasound guided fine needle aspiration (EUS-FNA). We present 13 consecutive cases where EBUS-TBNA and/or EUS-FNA of pulmonary lymph nodes were performed as part of the workup for pulmonary coccidioidomycosis. EBUS-TBNA+EUS-FNA led to diagnosis in all nine cases in which they were performed concurrently, and in the remaining 4 in which either was performed individually. BAL was performed in all cases with positive results in 5 (38%). The mean time to diagnose by EBUS/EUS (1.6 d) was significantly shorter than by bronchoalveolar lavage (6.3 d) (P=0.003). The findings indicate that combined EBUS-TBNA+EUS-FNA for lymph node biopsy facilitates early and accurate diagnosis of pulmonary coccidioidomycosis.
Spontaneous renal artery dissection is a rare cause of renal infarction and can be a diagnostic challenge at times, necessitating high index of suspicion. Other common underlying causes, especially thromboembolic phenomena, need to be considered and investigated first before making this uncommon diagnosis with vascular imaging studies. Very few cases did report strenuous exercise as a predisposing factor for the development of spontaneous renal artery dissection, but we believe that sexual intercourse has not been reported before as an underlying precipitating etiology. We report a case of a young male who presented with renal infarction that started during sexual intercourse and was found to have an angiographically proven renal artery dissection.
INTRODUCTION: Meigs' Syndrome has been described as the development of ovarian fibroma or fibroma-like mass with pleural effusion and ascitic fluid. It is present in approximately 1% of all ovarian fibroma, thecoma and granulosa cell tumors. Pseudo-Meigs' Syndrome is secondary to benign etiologies and reported to be more uncommon. These syndromes should be considered in women with the clinical triad of pleural effusion, ascites and a pelvic mass and can mimic more serious malignant tumors [1]. A thorough evaluation including biopsy and peritoneal and pleural fluid analyses need to be performed. CASE PRESENTATION:A G0P0 29-year-old female presents with chills and fatigue since the start of her menstrual cycle. She was found to be tachycardic, tachypneic and hypoxemic to 85% with moderate abdominal distention. CT of the chest, abdomen and pelvis showed a large left-sided pleural effusion, multiple abdominal masses with compressive effect and large-volume abdominal ascites. CA-125 level was elevated at 295 U/ml. Biopsy showed small muscle proliferation with bland spindle cells and no malignant features. Thoracentesis was consistent with exudative effusion and negative cytology. Left-sided pleural effusion continued to reaccumulate requiring multiple thoracenteses. Patient underwent left pleuroscopy with pleural biopsies showing fibrotic pleura and reactive mesothelial proliferation, negative for malignancy. There was an active ascitic fluid leak into the left hemithorax through a small, thinned-out region in the dome of the left hemidiaphragm. She underwent abdominal myomectomy several months later with resolution of symptoms. Final pathology was consistent with leiomyomata.DISCUSSION: We describe a case of abdominal leiomyomatosis resulting in ascites and leak into the left hemithorax with recurrent exudative pleural effusions and resolution after surgical myomectomy, consistent with Pseudo-Meigs' Syndrome [2]. Right-sided pleural effusions are most common as pleural fluid collects due to fluid leakage from edematous tumor resulting in translocation via diaphragmatic pores into the right hemidiaphragm [3]. Effusions are exudative in nature, although in previous studies only 1.6% of patients underwent pleural fluid analysis [4]. CA-125 are typically found to be elevated, with normalization post-surgery [5]. CA-125 levels were not re-checked post-myomectomy in our case. Surgical tumor removal results in resolution of ascites and pleural effusion [5]. Therefore, in patients presenting with pleural effusion and ascites in the setting of abdominal leiomyomata, Pseudo-Meigs' Syndrome should be suspected, and pleural fluid analysis and cytology play an important role in aiding diagnosis and further management. CONCLUSIONS:The prompt evaluation of patients with leiomyomatosis presenting with ascites and large pleural effusion can be vital in guiding future interventional management.
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