Metastatic Extrapulmonary Small Cell Carcinoma Presenting as Obstructive Jaundice.

Extrapulmonary small cell carcinoma (EPSCC) is a rare cancer with a poor prognosis. It can arise from almost any site and is usually associated with extensive metastasis at the time of diagnosis. Due to the rarity of this cancer, very limited data is available in the literature and most of the recommendations for its evaluation and treatment are based on retrospective studies and expert opinion. This case report shares one such presentation of EPSCC. A 78-year-old male was admitted to the hospital with presenting symptoms of abdominal pain and discoloration of the eyes and urine for 2 months. Initial laboratory investigation revealed obstructive jaundice and leukocytosis. His infectious workup was negative. An ultrasound abdomen was performed, showing multiple liver deposits. He received a computed tomography chest, abdomen, and pelvis with contrast also showing multiple liver deposits highly indicative of metastatic disease. No other obvious abnormality or mass in other visceral organs was reported. He underwent endoscopy and endoscopic retrograde cholangiopancreatography, showing normal pancreatic-biliary ducts. A plastic stent was deployed to help with biliary drainage. A liver biopsy was performed and showed poorly differentiated small cell carcinoma of extrapulmonary origin. His abdominal pain improved after stent placement; however, liver tests continued to worsen. During his hospital stay, he was seen by oncology and given metastatic disease; he was offered palliative chemotherapy. Understanding his poor prognosis, the patient himself opted for comfort care and decided to go home with hospice care. Within days, he became lethargic, likely secondary to hepatic encephalopathy, and expired in the span of the next few days.

Doxycycline-induced acquired haemophilia A.

An 80-year-old man with no personal or family history of bleeding, presented to hospital with extensive haematomas and skin bruising after using doxycycline. His basic lab workup was concerning for a coagulopathy with an elevated activated partial thromboplastin time and significant anaemia. Mixing studies and other factor levels were tested that led to the diagnosis of acquired haemophilia A with low factor VIII levels and high factor VIII antibodies. He was started on steroids, but his haemoglobin level continued to drop. Later, during his treatment, he was given multiple therapeutic agents, including cyclophosphamide, rituximab and recombinant factor VII (NovoSeven-R). Gradually factor VIII levels increased and haemoglobin stabilised. The hospital course was complicated by COVID-19 pneumonia leading to acute respiratory distress syndrome; the patient eventually expired due to respiratory failure.

Epistaxis and gross haematuria with severe thrombocytopaenia associated with influenza vaccination.

Epistaxis may be attributed to many causes during the winter including dry mucous membranes from low indoor humidity from heating. However, epistaxis may also be due to thrombocytopaenia. Immune thrombocytopaenia purpura (ITP) is an autoimmune disorder causing thrombocytopaenia. Viral infections sometimes lead to ITP. Vaccines, predominantly the measles-mumps-rubella vaccine, have been associated with the development of ITP. There are several published case reports regarding influenza vaccine induced ITP. However, an association between ITP and influenza vaccination has not been firmly proven yet. We report the case of an adult with three episodes of epistaxis, each within 1 week of receiving a yearly influenza trivalent inactivated vaccine, the last episode being more severe and also featuring gross haematuria.