No abstract

Rationale: Colorectal neuroendocrine cancer (CRNEC) accounts for < 1% of all colorectal cancers. It presents in advanced stages and carries a risk of poor survival. CRNEC may be diagnosed incidentally on imaging or routine endoscopy. When symptomatic, it may mimic colorectal adenocarcinoma. Syncope and immune thrombocytopenic purpura (ITP) have not previously been reported as clinical presentations. Patient concerns: A 57-year-old man with human immunodeficiency virus infection on treatment, seizure and stroke without residue presented for the evaluation of fall and syncope. Diagnosis: Physical examination revealed tachycardia, swelling, and ecchymosis of his proximal left lower extremity. Laboratory tests showed a new isolated thrombocytopenia of 26,000/mm3. Computed tomography for a trauma survey showed an incidental left posterior rectal wall mass. After hospital admission, his platelet count dropped to 14,000/mm3. A peripheral blood smear revealed low platelet count, no schistocytes or immature cells. ITP at a high risk for bleeding was diagnosed and treated with standard medical therapy but remained refractory. Bone marrow biopsy showed metastatic neuroendocrine carcinoma, likely from the rectum. Interventions: Patient received courses of high-dose dexamethasone and intravenous immunoglobulin. He also receive eleven units of platelet transfusion. A course of rituximab was administered. The platelet count response was suboptimal or short lived with drop to a nadir of 4000/mm3. However, after initiation of Eltrombopag, the thrombocytopenia resolved. Patient was started on etoposide, carboplatin, Atezolizumab. His hospital stay was complicated by neutropenia and sepsis, which was successfully treated. Outcomes: He was discharged to subacute rehab in stable condition. About 4 months later, he was readmitted for severe thrombocytopenia, septic shock, and acute respiratory failure. Despite appropriate treatment, the patient deteriorated and expired. Conclusion: CRNEC is a rare aggressive disease with dismal outcome that lacks standardized treatment. Metastasis to the bone marrow is uncommon and concomitant ITP has not been reported. We report a rare case of rectal neuroendocrine carcinoma metastatic to bone marrow associated with refractory ITP and review the relevant literature.

Hodgkin’s Lymphoma presenting with hypereosinophilia and intractable pruritus is a rare entity. Diagnostic and therapeutic decisions remain a challenge in such patients. Here we report a case of a 25-year-old female with a special case of Hodgkin’s lymphoma. A 25-year-old was admitted to our hospital for intractable pruritus and was found to have significant leukocytosis with eosinophilic predominance. The patient underwent a bone marrow biopsy and mediastinal lymph node biopsy, which confirmed classical Hodgkin’s lymphoma. Furthermore, the patient was given six cycles of adriamycin, bleomycin, vincristine, and doxorubicin (ABVD) chemotherapy and initially showed improvement; however, she relapsed within a short period. Post-treatment positron emission tomography (PET) scan showed interval progression of the disease, and so the patient was referred for a clinical trial with immunotherapy and Brentuximab vedotin.

Colonic mucosal prolapse syndrome is a rare type of non-neoplastic non-inflammatory colorectal polyps that can mimic neoplastic lesions. We present a case of a 65-year-old man with mucosal prolapse syndrome, incidentally, discovered during colorectal cancer screening. The patient was asymptomatic, and his physical exam and laboratory test results were unremarkable. During a colonoscopy, the physician removed three small tubular adenomas and two pedunculated polyps suspicious of neoplasms. Retroflexion revealed small internal hemorrhoids. The histology of the larger polyps revealed mucosal prolapse features, while the smaller polyps displayed features consistent with tubular adenomas. Management involves the removal of associated polyps during colonoscopy, followed by surveillance colonoscopy to detect any recurrent polyps or early signs of colorectal cancer. Accurate diagnosis is crucial to avoid unnecessary interventions and ensure appropriate management.

Pylephlebitis is defined as suppurative thrombophlebitis of the portal venous system. It is a rare condition that can be fatal if left untreated. It is usually caused by polymicrobial bacteria, most commonly Escherichia coli and Streptococcus genus. Klebsiella pneumoniae have been identified but the literature does not suggest a percentage of cases caused by this organism. The presentation includes abdominal pain, signs of sepsis and even septic shock. We present a case of a middle-aged female with K. pneumoniae bacteremia and pylephlebitis, with portal vein thrombosis visualized on an abdominal ultrasound. Although the patient was treated with broad-spectrum antibiotics and anticoagulation, she succumbed to multiorgan failure and septic shock on day two of intensive care.