A 5-month-old boy who had previously undergone a modified Norwood procedure for hypoplastic left heart syndrome presented for elective cardiac catheterization before undergoing the next stage of repair. The catheterization demonstrated mild stenosis of the right ventricle-to-pulmonary artery Sano conduit. The patient became hypoxic and febrile at the end of the procedure and died in the intensive care unit the next day. Postmortem examination demonstrated a vegetation containing Gram-positive cocci in the conduit and a right upper lobe lung abscess also containing Gram-positive cocci. The authors report the first case of Sano shunt endocarditis further complicated by septic pulmonary embolus and review similar infections in this population. Shunt infection may be an underrecognized cause of interstage mortality among patients undergoing a modified Norwood procedure.
Less than 1% of breast cancers occur in men. Of these cases, >90% are infiltrating ductal carcinomas (1). Male breast tissue is rudimentary; it does not differentiate and undergo lobule formation without exposure to increased concentrations of exogenous or endogenous estrogen. Lobular carcinomas of the male breast are therefore very rare, but nonetheless have been reported in settings both with and without documented increased estrogenic exposure (2).The overall incidence of breast cancer is increasing among both women and men. Breast cancer tends to present at an older age in men, and often at a more advanced stage (1). Many of the risk factors for breast cancer in men are similar to those in women, including increased exposure to androgens and estrogens-whether through exogenous administration, liver dysfunction, obesity, testicular anomalies or genetic causes such as Klinefelter's syndrome. Ionizing radiation and alcohol consumption have also been purported to play a role (3). Germline mutations of the BRCA2 gene, however, carry the highest known risk for male breast cancer, accounting for as many as 15% of cases (4).BRCA2 is a tumor suppressor gene responsible for DNA double-strand breakage repair by homologous recombination (5). It has been established that carrying a BRCA2 germline mutation confers susceptibility to a variety of malignancies other than breast cancer, namely, melanoma and cancer of the pancreas and prostate. The Breast Cancer Linkage Consortium has estimated the relative risk of prostate cancer amongst carriers of a BRCA2 mutation to be 4.6 (4). The role of BRCA2 in prostate cancer pathogenesis has been inconsistent across studies, with some suggesting that a BRCA2 gene mutation may not be associated with prostate cancer in high-risk families (6).We report the case of a male BRCA2 carrier in whom invasive pleomorphic lobular carcinoma of the breast and high-grade prostatic adenocarcinoma were discovered concomitantly. An 80-year-old Caucasian male with multiple chronic medical problems presented to his primary care physician for a routine health maintenance examination. The patient was a known carrier of the BRCA2 mutation, discovered after his daughter developed fallopian tube carcinoma at the age of 45 and breast cancer 8 years later. Family history also included pancreatic cancer. A second, younger daughter was tested and was also found to have the BRCA2 mutation.Physical examination was unremarkable with the exception of a palpable 2 · 2 cm mass in the left breast. Mammography revealed a focal area of asymmetry in the left retroareolar region measuring up to 2.5 cm without associated microcalcifications. Several core biopsies of the mass were obtained and showed infiltrating mammary carcinoma. A staging work-up consisting of computed tomography of the chest, abdomen, and pelvis, and positron emission tomography was negative for sites of metastatic disease.The patient underwent bilateral mastectomies with a left axillary sentinel lymph node biopsy, and was begun on hormonal therapy with t...
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