Steroid resistant hypereosinophilic syndrome found to be Hodgkin’s Lymphoma

Hyperoeosinophilic syndrome (HES) is rare, and clinicians may not recognize its potential association with malignancy. Red flag signs of HES include steroid resistance, older age, and significant lymphadenopathy that can be indicative of malignancy. In this case, an elderly male presenting with right chest wall erythema and axillary lymphadenopathy was initially diagnosed with and treated for cellulitis. Labs were significant for hypereosinophilia. Evidence of end organ damage raised concern for HES. Over the course of three hospitalizations, he was found to have a rising eosinophil count despite high-dose corticosteroid treatment. Further investigation eventually revealed a diagnosis of Hodgkin’s Lymphoma. This case highlights steroid-resistant HES as a presenting sign of malignancy and allows for discussion of potential investigative approaches for HES therapy. Though corticosteroids are first-line treatment for hypereosinophilia and HES, they are well known to have many adverse effects. Biologics, such as mepolizumab and benralizumab, have more acceptable side effect profiles and are effective in treating non-myeloid HES. The use of biologics as first-line treatment for HES has yet to be investigated.

Disseminated Mycobacterium avium infection in a young woman with sickle cell disease and iatrogenic iron overload

A 29-year-old woman with known sickle cell disease (SCD) and iatrogenic iron overload presented to the emergency department with a recurrent pain crisis and fever. Blood cultures obtained at a recent prior admission for the same complaints grew M avium. Bone marrow biopsy revealed non-caseating granulomas, but stains for mycobacteria and fungi were negative. Disseminated non-tuberculous mycobacterial infections (NTMIs) occur almost exclusively in immunosuppressed patients. SCD is not considered a risk factor for the development of disseminated NTMIs, making diagnosis challenging in this population. However, a number of case reports describing disseminated NTMIs in patients with SCD have been published. This case adds to the current literature, suggesting SCD with iatrogenic iron overload is a possible risk factor for disseminated NTMIs. Potential mechanisms for this increased risk include 1) functional asplenia, 2) iatrogenic iron overload, 3) chronic indwelling central venous catheters, and 4) hydroxyurea use. Further investigation is required to describe the strength and mechanism of the relationship between SCD and disseminated NTMIs.

Hepatosplenic T cell lymphoma and hemophagocytic lymphohistiocytosis in an adult patient with Crohn’s disease on immunosuppressive therapy

Hepatosplenic T cell lymphoma (HSTCL) is an exceedingly uncommon, aggressive peripheral T cell lymphoma comprising < 1% non-Hodgkin’s lymphomas (NHL). Despite treatments including allogeneic stem cell transplantation, median survival is < 2 years. In the majority of patients, the etiology of HSTCL is undetermined; although it has been associated with chronic immunosuppression which accounts for 20% of cases. HSTCL presents as a systemic illness, and sometimes in association with hemophagocytic lymphohistiocytosis syndrome (HLH). Our patient is a young male with a long-standing history of Crohn’s disease on immunosuppressive medications, who presented with progressive bicytopenia. He was diagnosed with HSTCL on a bone marrow biopsy and met clinical diagnostic criteria for HLH. He was started on chemotherapy and dexamethasone per HLH treatment protocol and underwent allogeneic hematopoietic stem cell transplantation (HSCT).

Acute ischemic stroke on the setting of left atrial myxoma: optimal time for cardiac surgery

The surgical resection timing of left atrial (LA) myxoma is still controversial in concern for the risk of further embolic phenomena if delayed surgery versus hemorrhagic transformation during early surgery. We describe a case of 60-year-old man without significant past medical history admitted with two-day of double vision and found to have LA myxoma. Multiple factors including clinical aspects and comorbidities should be evaluated to decide the favorable management.

Significant bradycardia in patient with COVID-19 sepsis: Full management review

Cardiovascular manifestations of COVID-19 infection remain an ongoing study. We present a case of significant bradycardia in the patient with COVID-19 sepsis. We discuss about the possible mechanism, pathophysiology, and management in this pathology.

Discovery of esophageal stricture following femoral neck fracture: a case of adenosquamous carcinoma of the esophagus in a young female

Adenosquamous carcinoma (ASC) of the esophagus is a rare malignancy of the esophagus with histopathologic features of both adenocarcinoma and squamous cell carcinoma. Given the rarity of this disease, there is scant literature on ASC. We report a unique case of a 29-year-old African American female with advanced ASC manifesting as a pathologic fracture. Magnetic resonance imaging (MRI) confirmed femoral fracture, and femoral biopsy demonstrated metastatic ASC. Upper endoscopy revealed a distal esophageal stricture, and histopathology confirmed ASC. To our knowledge this is the youngest case of ASC to be reported. We discuss ASC epidemiology, clinical findings, diagnosis, and current treatments.

A case of INR elevation with remdesivir and warfarin in a hospitalized patient with COVID-19

Treatments for COVID-19 infection have varied widely within the past year. Remdesivir is the only direct-acting antiviral approved by the Food and Drug Administration with demonstrated efficacy in the management of patients with COVID-19.[1] Commonly reported adverse effects include hepatotoxicity and gastrointestinal symptoms such as nausea and diarrhea. Less common adverse effects include respiratory toxicity, cardiovascular toxicity and nephrotoxicity.[2] We report a case of international normalized ratio (INR) prolongation in a COVID-19 patient receiving concomitant warfarin and remdesivir therapy.

Pegfilgrastim-induced leukocytosis and hyperleukocytosis

Objective: To report a case of leukocytosis (LCT) and hyperleukocytosis (HLCT) episodes post Pegfilgrastim (Neulasta) administration.Case Summary: A 74-year-old female presented with several episodes of LCT and HLCT following administration of Pegfilgrastim while undergoing adjunct dose dependent chemotherapy for adenocarcinoma of the gallbladder. The patient had completed cycle 6, day 8 of chemotherapy and subsequently received Neulasta 48 hours later. Two days later, she presented to the ER with white blood cell (WBC) count of 110K. Prior to Neulasta administration, her WBC counts were within normal range and after each episode of leukocytosis, the patient’s WBC count trended downward. Upon consultation, hematology considered Pegfilgrastim as a likely cause for this patient’s WBC cycling and HLCT.Discussion: Pegfilgrastim-induced HLCT occurs in less than 1% of patient cases. Dose-dependent chemotherapy combined with Pegfilgrastim treatment is an optimal treatment option to reduce the length of chemotherapy schedules and risk of febrile neutropenia. Following the dosing of Pegfilgrastim, the drug clearance is mediated by neutrophil receptors which results in a reduction of ANC values.Conclusions: Further studies are needed to determine the optimum timing and dosage of Pegfilgrastim to offer maximum myeloprotective benefit while also minimizing the risks of adverse events such as leukocytosis and hyperleukocytosis experienced by our patient.

Bilateral thalamic infarction secondary to artery of Percheron occlusion: A rare cause of acute coma

An occlusion of the artery of Percheron (AOP) is a rare clinical condition that remains a diagnostic challenge for physicians given its variable presentation. This infarction is a result of an anatomical variant of a single vessel arising from the posterior cerebral artery. Occlusion of the AOP results in variable levels of alteration of consciousness, vertical gaze palsy, and memory impairment. Unfortunately, due to this variable presentation these strokes are often missed. We report a case of a 71 year-old-female who presented with sudden onset of unresponsiveness who was subsequently diagnosed with bilateral thalamic infarction with midbrain involvement secondary to AOP occlusion. Delayed diagnosis can result in poor neurologic outcomes as demonstrated in this case making it imperative to bring further awareness to this clinical syndrome.

A case of multiple pulmonary nodules diagnosed as pulmonary melanoma without extra-pulmonary site

A 67-year-old patient visited the hospital for the evaluation of pulmonary nodular lesions detected in his chest radiograph duringan annual screening. He was asymptomatic and transbronchial tumor biopsy of the nodule in the right upper lobe revealed features of pulmonary sarcoma, which did not resemble any of the histolopathological categories of primary lung cancer. A positive immunological staining for both HMB-45 and Melan-A resulted in the final diagnosis of melanoma. It is important for a respiratory clinician to remind the possibility of a melanoma, when tumors cannot be histopathologically classified under any of the categories of primary lung cancer.