Cardiac Tamponade as First Manifestation of Multiple Myeloma: a Case Report With Literature Review

Background: Multiple myeloma is a hematologic malignancy characterized by clonal proliferation of plasma cells, mainly in bone marrow. Extramedullary disease is reported in many cases and may occur at diagnosis, at progression, or during relapse phase. Pericardial involvement is a rare condition that usually occurs with advanced-stage disease. We report a rare case of plasma cell-based pericardial effusion with cardiac tamponade as a form of presentation of multiple myeloma.Case presentation: A 76-year-old woman was admitted to the emergency department for worsening shortness of breath, on segmental examination, she had dyspnea, engorged jugulars, muffled heart sounds and lower limb edema. A Chest X-ray demonstrated cardiomegaly with a mild left pleural effusion, laboratory data showed immunoglobulin G lambda, diagnosis of plasma cell-based pericardial effusion was established by pericardial fluid cytology. The patient received systemic chemotherapy, according to Melphalan-Prednisone and thalidomid protocol. Conclusion: Multiple myeloma with cardiac effusion should be considered for differential diagnosis of patients with recurrent and unexplained pericardial effusions.

Diagnosis particularities of lung cancer in a young patient without external risk factors – A case report

Lung cancer is the most common type of cancer worldwide, smoking being the strongest risk factor. We present the case of a non-smoker, a 23-year-old patient, without environmental exposure or personal pathological history, who was hospitalised for dry cough, a unique episode of haemoptysis and low-graded fever. He was admitted with a left basal diminished vesicular murmur, without detectable rales, and normal oxygen saturation. The chest X-ray highlighted left pleural effusion in a medium amount. A chest ultrasound revealed also an adjacent pulmonary consolidation. The cytological examination of the pleural fluid detected the presence of lymphocytes 36%, eosinophils 25%, polymorphonuclear 39% and frequent red blood cells. Angio-computer tomography confirmed the existence of a left hilar tumour formation with a mass effect on the hilar structures, possibly a few tumoral emboli in the lateral and posterior basal segmentary arteries, a lower left lobe consolidation, a left pleural effusion with hydroaeric level, and a left pneumothorax. The patient required a fibre bronchoscopy that showed us a proliferative infiltrative process, stenosis of the left lower bronchia, and extrinsic compression of the left lower lobe and the 6th segment. Infiltration of mucosa at the left basal pyramid was also detected. The histological examination argued for pulmonary adenocarcinoma. The particularities of the case consist of the lack of exposure to known risk factors for bronchopulmonary neoplasm and the early appearance of lung cancer and its complications in a young patient.

Frequency of Left Plueral Effusion in Acute Necrotizing Pancreatitis

Objective: The aim of this study is to calculate the prevalence of left plueral effusion in acute necrotizing pancreatitis. Study Design: Observational/ case series Place and Duration: Conducted at surgery department of Saidu Teaching Hospital, Swat and Ibne Sina Hospital and Research Institute, Multan for duration of six months from January 2021 to June 2021. Methods: A total of 95 patients, both males and females, ranging in age from 15 to 65 years, were presented. After receiving informed written consent, the baseline comprehensive demographics of the patients presented were recorded, including age, gender, and body mass index. Patients with acute pancreatitis and serum amylase levels greater than 300U/dL were eligible to participate. Patients were subjected to X-ray and CT scans in their entirety. Prevalence of necrotizing pancreatitis was calculated by CT scan and for left plueral effusion X-ray of chest was taken. SPSS 24.0 version was used to analyze complete data. Results: Majority of the patients 65 (68.4%) were females and 30 (31.6%) were males with mean age 39.14+5.67 years. 26 (27.4%) cases had BMI less than 20kg/m2 and the majority were >20kg/m2. Gallstone was the most common cause of acute pancreatitis found in 45 (47.4%) cases, followed by alcoholism 25 (26.3%) and medications 12 (12.6%). Among 95 cases, prevalence of necrotizing pancreatitis was 42 (44.2%) in which 40 cases had left plueral effusion. Mortality rate among necrotizing pancreatitis was 13 (33.3%). Conclusion: We found that the majority of individuals with necrotizing pancreatitis experienced pleural effusion on the left side. Thus, patients with acute pancreatitis who have a high serum amylase level must be treated earlier if they have a left pleural effusion because of severity. Keywords: Plueral Effusion, Acute Necrotizing Pancreatitis, Mortality

Pleural Metastasis of High-Grade Endometrial Stromal Sarcoma With YWHAE Gene (17p13.3) Rearrangement, A Rare Case Report

Introduction/Objective Endometrial stromal sarcoma (ESS), a rare malignant neoplasm of endometrial stroma, accounts for less than 1% of all uterine tumors. High grade ESS (HGESS) is aggressive and commonly relapses even after surgical and neoadjuvant therapy. Abdominal and pelvic regions are common sites of metastasis, however, distant metastases to the liver, lung, vertebrae, and brain have been reported. Methods/Case Report We encountered a 49-year-old female who presented with shortness of breath, found to have a left pleural effusion and multiple pleural masses. She initially presented three years ago with heavy irregular menses and left pelvic pain for one year. D&C revealed prominent small spindle cells for which a stromal nodule and low-grade or malignant process was probable. CT scan showed an enlarged uterus. Hysterectomy with bilateral salpingo- oophorectomy, bilateral pelvic and para-aortic lymph node dissection, and partial omentectomy were performed. The uterus revealed an intramural 7 cm mass with a serpiginous growth pattern and lymphovascular invasion. Tumor cells were plump to spindled with areas of high cellularity, rounded nuclei, increased atypia and mitosis. Atypical areas were positive for cyclin D1, focally positive for CD10, and negative for ER, PR, SMA, desmin, AE1/3 and CAM5.2. FISH studies showed rearrangement of YWHAE gene (17p13.3) and no rearrangement of JAZF1 or PHF1 gene regions. Findings supported the diagnosis of HGESS. The patient received post-operative chemotherapy. Biopsy of the current pleural lesion revealed a nonspecific malignant spindle cell neoplasm positive for BCL1, CD56, CD117, CD99, TLE1 and INI1, while negative for AE1/3, CAM5.2, EMA, ER, PR, CK5/6, calretinin, SMA, desmin and S100. The CD10 stain was inconclusive. FISH studies showed rearrangement of YWHAE gene (17p13.3) and no rearrangement involving JAZF1 or PHF1 gene regions. No rearrangement of the SS18 gene region was observed and synovial sarcoma was excluded. Overall findings support the diagnosis of metastatic HGESS. Results (if a Case Study enter NA) NA Conclusion HGESS, a rare tumor with a nonspecific immunostain profile, has the ability to metastasize to rare body sites, such as the pleura in our case. Display of spindle cell morphology is a nonspecific finding that raises broad differential diagnoses. In women, with or without a history of uterine neoplasm, HGESS is a clinically worthwhile diagnosis to be mindful of.

Bilateral iliopsoas abscess presenting with abdominal wall cellulitis and left-sided empyema thoracis: a rare presentation

Iliopsoas abscess is common in immunocompromised patients and rarely presents with empyema thoracis. We present a 26-year-old male with no comorbidities who presented with a 3-day history of abdominal pain, fever and dyspnoea. There was no history of tuberculosis or recent contact with a tuberculous patient. On examination, the patient had facial dysmorphism and abdominal wall cellulitis extending bilaterally from flank to the inguinoscrotal region. Chest X-ray showed a left pleural effusion. Ultrasonography and contrast-enhanced CT also showed bilateral iliopsoas abscess with a left massive pleural empyema. The patient underwent bilateral abscess open drainage, thoracostomy for left empyema thoracis and intravenous antibiotic therapy. The patient had an uneventful course postoperatively and was discharged.

Systemic lupus erythematous presenting with hemorrhagic shock caused by gastric penetration of pancreatic pseudocyst: a case report

Background Systemic lupus erythematous that causes various organ damage is rarely associated with pancreatic lesion. To the best of our knowledge, no cases presenting with hemorrhage shock caused by gastric penetration of pancreatic pseudocyst due to lupus pancreatitis have been reported. Herein, we report a case of hemorrhage shock caused by gastric penetration of pancreatic pseudocyst due to lupus pancreatitis. Case presentation A 53-year-old Japanese man with a history of systemic lupus erythematous, pancreatic pseudocyst, and chronic pancreatitis complained of epigastric pain and had hematemesis. He visited our emergency room and was admitted in our hospital. Upper endoscopy showed that hemostasis was obtained; however, computed tomography scan was performed since he was suspected to have gastric penetration into hollow viscera. The computed tomography revealed accumulation of fluid around the pancreas and gastric penetration of pancreatic cyst. Blood test showed increased serum amylase level. These results suggest that the exacerbation of chronic pancreatitis causes the penetration. Surgery was considered; however, we took a wait-and-see approach since hemostasis was obtained. After that, he was in stable condition, although he suffered from fever and accumulation of left pleural effusion was observed by computed tomography. However, he had massive hematemesis and melena 9 days after hospitalization and died in spite of several treatments including blood transfusion. Autopsy revealed that he actually had pleural thickening, which is not caused by accumulation of left pleural effusion but by severe pleural inflammation. We therefore performed additional blood and urinary tests on the same day. The test results showed that he had a high titer of anti-double-stranded deoxyribonucleic acid (DNA) antibody, hypocomplementemia, and erythrocyturia, indicating that he had systemic lupus erythematous with high disease activity considering his fever and pleural inflammation. Conclusions Patients who have systemic lupus erythematous with high disease activity have the potential to develop fatal complications due to pancreatitis, so appropriate treatments are required for such patients.

Liver Cirrhosis and Hepatocellular Carcinoma Diagnosed from Chylothorax: A Case Report

A 71-year-old man visited our hospital with dyspnea and left pleural effusion. Left pleural effusion was diagnosed as chylothorax by thoracentesis. He had no history of trauma or surgery, and there were no findings of malignant lymphoma or thrombosis. Furthermore, he was diagnosed with liver cirrhosis and hepatocellular carcinoma by computed tomography and hematological examinations, and the chylothorax was considered to be caused by liver cirrhosis. We report a review of the literature with this case since it is relatively rare for cirrhosis and hepatocellular carcinoma diagnosed from chylothorax.

Cardiac tamponade and massive pleural effusion in a young COVID-19-positive adult

COVID-19 has a broad spectrum of cardiac manifestations, and cardiac tamponade leading to cardiogenic shock is a rare presentation. A 30-year-old man with a history of COVID-19-positive, reverse transcription polymerase chain reaction (RT-PCR) done 1 week ago and who was home-quarantined, came to the emergency department with palpitations, breathlessness and orthopnoea. His ECG showed sinus tachycardia with low-voltage complexes, chest X-ray showed cardiomegaly and left pleural effusion and two-dimensional echocardiography showed large pericardial effusion with features suggestive of cardiac tamponade. He was taken up for emergency pericardiocentesis which showed haemorrhagic pericardial fluid. Intercostal drainage insertion was done for left-sided large pleural effusion. After ruling out all the other causes for haemorrhagic pericardial effusion, the patient was started on colchicine, steroids, ibuprofen and antibiotics to which he responded. Both pericardial and pleural effusions resolved completely on follow-up.

Splenic injury following endoscopic drainage of a large pancreatic pseudocyst: a case report

Background Many pancreatic pseudocysts spontaneously resolve, but larger or symptomatic pseudocysts may require procedural management. Though endoscopic ultrasound guided approaches are standard of care and have high success rates, complications can include bleeding, infection, and splenic perforation. This patient case report details an unusual series of complications of endoscopic cystogastrostomy that should encourage clinicians to evaluate for anatomic disruptions caused by mass effects of pancreatic pseudocysts prior to endoscopic pseudocyst drainage. Case presentation A 53-year-old African American male with a past medical history notable for alcohol use disorder, chronic pancreatitis, and insulin dependent diabetes presented with a 4-day history of left upper quadrant abdominal pain. Computed tomography imaging with contrast revealed enlargement of a known pancreatic pseudocyst to 15.9 × 10.4 cm. Due to pseudocyst size and the patient’s symptoms, endoscopic cystogastrostomy stent placement was performed. However, postprocedurally, he developed leukocytosis to 19,800 cells/m3 (from 14,100 cells/m3 preoperatively) as well as acute hypoxemic respiratory failure with a large left pleural effusion. Postprocedural computed tomography with contrast demonstrated a new large subcapsular splenic hematoma in communication with a new subdiaphragmatic fluid collection. Due to suspicion of endoscopic procedural complication, he underwent open laparotomy which revealed grade 4 splenic laceration, septic splenic hematoma, and a subdiaphragmatic abscess. Conclusions While endoscopic drainage of pancreatic pseudocyst was technically successful, this case demonstrates complications from mass effect of a large pancreatic pseudocyst which putatively tore the splenorenal ligament, leading to excessive separation of the left kidney and spleen. If anatomic disruptions caused by mass effect from a pancreatic pseudocyst are recognized through preprocedural abdominal imaging, such cases may be considered for early open repair versus cystogastrostomy.

Chest sonography versus chest radiograph in children admitted to paediatric intensive care – A prospective study

There is a paucity of studies on the correlation between chest radiograph and ultrasound (US) in children. Our objective was to study the correlation between bedside chest radiograph and ultrasound findings in 413 children with 1002 episodes of chest radiograph and US enrolled for a prospective, double-blinded observational study in a multidisciplinary paediatric intensive care unit. Weighted κ statistic for agreement was different for right and left lungs and varied from 50% for left pleural effusion to 98% for right pneumothorax. Pulmonary oedema, pneumothorax and pleural effusion were diagnosed by ultrasound alone in a significantly higher number of patients as compared to chest radiograph (P = 0.001). Chest ultrasound is therefore deemed more sensitive than chest radiograph in detection of pleural effusion, pulmonary oedema and pneumothorax.