Patient: Female, 30Final Diagnosis: Thoracic endometriosis syndromeSymptoms: Abdominal painMedication: —Clinical Procedure: Videothoracoscopic pleurodesisSpecialty: PulmonologyObjective:Rare co-existance of disease or pathologyBackground:Catamenial pneumothorax (CP) is a spontaneous pneumothorax commonly associated with menstrual periods. Endometrial tissues most commonly involve the pelvic region. However, after the pelvis, the lungs are most frequently involved. Thoracic endometriosis should always be suspected in young women presenting with CP.Case Report:A 30-year-old woman with history of endometriosis presented with chief complaint of umbilical pain. A computerized tomography (CT) scan of the abdomen and pelvis was performed, which showed an incidental finding of a large right-sided pneumothorax. Chest X-ray imaging showed 50% pneumothorax. A right-sided chest tube was placed, and after the procedure, a chest X-ray image showed expansion of the right lung. The patient was readmitted for elective resection of an umbilical mass and was again incidentally found to have a recurrent pneumothorax on the right side. She underwent videothoracoscopic pleurodesis with pathology, establishing the diagnosis of catamenial pneumothorax.Conclusions:Thoracic endometriosis resulting in catamenial pneumothorax should be suspected in young women of child-bearing age. Treatment options still under debate include endoscopic resection and videothoracoscopic pleurodesis followed by gonadotrophin-releasing hormone (GnRH) therapy to reduce the rate of postoperative recurrence.
Patient: Female, 68Final Diagnosis: Light chain monoclonal gammopathy of undetermined significanceSymptoms: Abdominal painMedication: —Clinical Procedure: —Specialty: OncologyObjective:Rare co-existance of disease or pathologyBackground:Amyloidosis is the extracellular tissue deposition of plasma proteins, which after conformational changes, forms antiparallel beta pleated sheets of fibrils. Amyloid light-chain (AL) is a type of amyloidosis that is due to deposition of proteins derived from immunoglobulin (Ig) light chains. Gastrointestinal tract (GIT) involvement most often found in amyloid A (AA) amyloidosis type. There have been no reports of obstructive GIT AL amyloid patients having monoclonal gammopathy of undetermined significance (MGUS). Our case is the first case to show two coinciding conditions; one is the association of GIT AL amyloidosis with the incidental finding of a rare type of MGUS (LC-MGUS) and the other is the radiologic presentation of GIT amyloidosis with omental calcification mimicking the GIT malignancy.Case Report:A 68-year-old female presented with symptoms of partial bowel obstruction, including intermittent diffuse abdominal pain and constipation. After computed tomography (CT) abdomen and pelvis, an exploratory laparotomy was needed because of suspicion of abdominal carcinomatosis due to diffuse omental calcification. The tissue sent for biopsy surprisingly showed AL amyloidosis. The patient did not report any systemic symptoms. Further workup was advised to inquire about the plasma cell dyscrasia which eventually turned into a very rare version of MGUS knows as light chain MGUS (LC-MGUS). Following adequate resection of the involved structures, the patient was then placed on chemotherapy and successfully went into remission.Conclusions:This case report illustrates that in an era of evidence based medicine, it is important to show through case reports the association of GIT AL amyloidosis with LC-MGUS, as the literature on this topic is lacking. It also points to the importance of timely intervention that can greatly enhance, not only the only the chances of remission but also prevention of further complications such as malignant transformation.
Patient: Male, 64Final Diagnosis: Cystic pheochromocytomaSymptoms: Abdominal painMedication: —Clinical Procedure: —Specialty: Endocrinology and MetabolicObjective:Rare diseaseBackground:Pheochromocytoma is a rare catecholamine-producing tumor with an estimated incidence of less than 0.1% in the global population. We present a case of cystic pheochromocytoma that was diagnosed as an incidental finding. The patient presented with abdominal pain and had a history of hypertension.Case Report:A 64-year-old man with hypertension presented with a clinical history of intermittent abdominal pain for one year. He denied sweating, palpitations, headache or back pain. He was found to have an elevated blood pressure of 170/90 and no palpable abdominal mass. Contrast-enhanced computed tomography (CT) imaging of the abdomen and pelvis were performed that showed cystic mass measuring 9 cm in diameter arising from the left adrenal gland with contrast-enhancing mural nodules. Magnetic resonance imaging (MRI) confirmed the cystic nature of the mass. Laboratory analysis showed an elevated plasma normetanephrine (NMN) of 1,087 pg/ml and metanephrine (MN) of 372 pg/ml; 24-hour urine showed elevated levels of NMN and MN, 3,002 mg/24 h and 1,596 mg/24 h, respectively. Given the laboratory and radiologic findings, a diagnosis of cystic pheochromocytoma was made. After controlling blood pressure with the alpha-blocker, doxazosin, the patient was hydrated and scheduled for an elective adrenalectomy. The histopathology of the excised adrenal gland was consistent with a cystic pheochromocytoma.Conclusions:Cystic pheochromocytoma is a very rare tumor that may present without symptoms. The clinical course of cystic pheochromocytoma is similar to that of solid pheochromocytoma. Early surgical intervention is recommended, following blood pressure control with an alpha-blocker, and adequate hydration.
Patient: Male, 66Final Diagnosis: Giant cell arteritisSymptoms: Hearing lossMedication: —Clinical Procedure: —Specialty: RheumatologyObjective:Unusual clinical courseBackground:The classical picture of giant cell (temporal) arteritis (GCA) is not always evident. A wide variety of unusual presentations have been increasingly reported. Sensorineural hearing loss (SNHL) as an initial manifestation of GCA is a rare, yet important entity. Similar to blindness, SNHL also deserves serious attention as timely intervention may play a key role in overall prognosis. Only a few cases of SNHL associated with GCA have been reported in the literature, the majority of them were diagnosed early and responded well to glucocorticoid therapy. Our report focuses on a case of persistent audiometry-proven SNHL despite optimal doses and duration of glucocorticoids required in GCA patients with ischemic complications.Case Report:We present the case of a 66-year-old male with severe bi-temporal headache, left jaw claudication, and progressively worsening hearing loss, the latter symptom reported over the preceding year. Examination of his temporal artery remained insignificant, but the laboratory data showed raised erythrocyte sedimentation rate (ESR) of 52 mm/hour. Audiometry performed and the interpretations were coincided with the bilateral high frequency mild to moderately-severe SNHL. Prompt administration of IV methylprednisolone started at high-optimum doses that were gradually tapered over the subsequent six months. On biopsy of the left temporal artery, the findings were consistent with the GCA. The patient responded well in terms of headache and general condition improvement, but results of repeat audiometry at follow-up visits proved disappointing and the interpretations were that there was no change in the audiometry results based on first presentation.Conclusions:This case is purposefully reported to draw the attention of practicing physicians, and encourage them not only to better understand atypical presentations of GCA but also to intervene in a timely fashion. This case should encourage literature to reset recommendations and encourage have high-indexed suspicion when elderly patients present with deafness since early diagnosis and treatment may have profound effects on overall long-term prognosis of other cranial ischemic complications as well.
Patient: Female, 44Final Diagnosis: Cat-scratch diseaseSymptoms: LymfadenopathyMedication: —Clinical Procedure: Lymph node biopsySpecialty: Infectious DiseasesObjective:Unusual clinical courseBackground:Bartonella infection is the causative organism of cat-scratch disease (CSD), which typically presents with self-limited localized lymphadenopathy. In HIV-infected patients, Bartonella infection can cause systemic illnesses with significant morbidity and mortality manifesting as bacillary angiomatosis (BA), hepatic peliosis, splenitis, bacteremic febrile illness, and other organ involvement. To the best of our knowledge, there have been no reports of HIV-infected patients presenting with generalized lymphadenopathy caused by Bartonella infection. We report an unusual case of CSD presenting with generalized lymphadenopathy in an AIDS patient with advanced immunosuppression.Case Report:A 44-year-old woman with AIDS, advanced immunosuppression, and intermittent adherence to antiretroviral therapy and medical care, presented with cough and increased generalized tender lymphadenopathy. A lymph node biopsy 1 year earlier was non-diagnostic for tuberculosis, fungal infection, and lymphoproliferative disorders. She remained with generalized lymphadenopathy. A repeat biopsy with the addition of Warthin-Starry silver staining suggested the diagnosis of cat-scratch lymphadenitis. She responded well to a long course of azithromycin antibiotic therapy, with the resolution of lymphadenopathy.Conclusions:Cat-scratch disease may present with prolonged generalized lymphadenopathy, an unusual presentation in HIV patients with advanced immunosuppression. Awareness of the possibility of CSD in a similar clinical scenario may prompt early recognition and management of this disease.
Background: Sarcoidosis is a systemic disorder of unknown etiology. It affects the organ systems in the body, and is characterized by the presence of noncaseating granulomas in the involved organs. The most common manifestation is bilateral hilar adenopathy along with skin, joint, and eye lesions. Here, we discuss an unusual manifestation of sarcoidosis along with autoimmune hepatitis (AIH). Case report: We report the case of a 33-year-old African American female presented with two-day history of progressive jaundice and deranged Liver function test (LFTs) the autoimmune work up was positive for anti-nuclear antibody (ANA) 1:640 and anti-smooth muscle antibody (SMA) 1:160, The serum Angiotensin converting enzyme (ACE) level was elevated 299 U/L; a right upper quadrant ultrasound revealed a mildly enlarged liver, subsequent CT chest and CT abdomen enlarged paratracheal and subcarinal adenopathy periportal edema in the liver and numerous small hypodense nodules in the spleen. Subsequent liver biopsy showed chronic, non-granulomatous, portal and parenchymal inflammation that was compatible with Autoimmune Hepatitis. Bronchoscopy with transbroncial biopsy revealed chronic, non-caseating granulomatous inflammation that was consistence with sarcoidosis. Thus the patient was diagnosed with sarcoidosis and AIH. The patient was started on Prednisone 60 mg daily, with subsequent reduction to 15 mg. The serum transaminase levels returned to normal level within three months. Conclusion: This case underscores the significance of association of Sarcoidosis that presented with Autoimmune Hepatitis. Physicians should be aware of this possibility so they may efficiently pick up the diagnosis after relevant investigations and start appropriate management. Timely intervention is key to treat the acute presentation and to prevent the further complications.
Objective: To determine the cardiac manifestations in patients with pulmonarytuberculosis. Study Design: Case series study. Period: Jan 2014 to June 2014. Setting:Liaquat University Hospital Hyderabad. Methods: All the patients presented with shortness ofbreath, cough with sputum, fever, haemoptysis, anorexia and weight loss were recruited andthen the subjects with early morning sputum positive for acid fast bacilli and radiological lesionssuggestive of pulmonary tuberculosis, of ≥20 years of age and either gender were enrolled andentered in the study. The data was analyzed in SPSS 16 and the frequency and percentage wascalculated. Results: Total one hundred patients with pulmonary tuberculosis were evaluatedfor cardiac manifestation during six months study period. The mean ±SD for age of patientswith pulmonary tuberculosis was 45.21±8.95. The mean age ±SD of patient with cardiacmanifestations was 48.95±5.53. The majority of the subjects were in 30-49 years age groupwith male predominance (p<0.01). The electrocardiographic findings were observed in 72/100(72%) patients whereas echocardiographic changes were observed in 50/72 (69.4%) patientswith pulmonary tuberculosis. The common ECG findings identified were tachycardia 30.5%,P-pulmonale 12.5% and PR prolonged in 9.7% patients with tuberculosis whereas the commonechocardiographic findings noticed were pericardial effusion 42% and multiple abnormalitiesin 24% subjects with tuberculosis. Conclusions: The sinus tachycardia, cor-pulmonale andlow voltage QRS complexes were predominant abnormalities on electrocardiograph whereaspericardial effusion was the common abnormality on echocardiography in patients withpulmonary tuberculosis.
Introduction Male sex is a risk factor for obstructive sleep apnea (OSA). However, because men have been historically described as more vulnerable towards developing OSA, definitions of severity have been based mostly on male-specific pathophysiology. This study aimed to describe sex differences in referral patterns of diagnostic sleep study modalities (in-lab polysomnography [PSG], home sleep apnea tests [HST]) and their results as they related to OSA severity. Methods We defined a clinical cohort of individuals that underwent diagnostic sleep testing at the University of Kansas Health System Sleep Disorders Center between 2012-2021. We determined the association between sex and moderate-severe OSA (as compared to no or mild OSA) separately for individuals that underwent HST and PSG, in logistic regression models adjusted for age, body mass index (BMI) and Epworth sleepiness scale (ESS) scores. A complementary analysis stratified by age groups (< 35, 35-50, 50-65, ≥65 years) was also conducted. Results A total of 10,357 participants were included in this analysis (5,428 women [52.4%]; 53.0 [14.4] years; BMI=34.0 [16.1] kg/m2). Individuals that underwent HST were younger, more likely to be men, had higher BMI, lower ESS scores, and more severe OSA. Men were more likely to be diagnosed with moderate-severe OSA in both modalities, however higher odds were observed in those diagnosed using HST (ORHST [95%CI] = 2.86 [2.52-3.25]) than in those diagnosed using PSG (ORPSG [95%CI] = 2.48 [2.09-2.95]). Further disparities were observed among those with < 35 years, where men had a 4-fold increase in the odds of a moderate-severe OSA diagnosis than women in a HST (ORHST [95%CI] = 4.10 [2.59-6.50]) and only a 2.5-fold increase in the odds in a PSG (ORPSG [95%CI] = 2.48 [1.13-5.45]). Conclusion As expected, men are more likely than women to receive a diagnosis of moderate-severe OSA, however the effects were stronger in those diagnosed with HSTs as compared to PSGs, particularly at younger ages. These results suggest that potential sex inequalities in diagnosis and determination of OSA severity may be influenced by the choice of diagnostic sleep study modality, particular in younger women. Support (if any) NCATS (UL1TR002366), AHA (20CDA35310360).
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