Spontaneous Tumor Lysis Syndrome Secondary to Metastatic Small Cell Lung Cancer.

Tumor lysis syndrome (TLS) is an oncology emergency caused by the lysis of tumor cells that releases cell contents into the blood. TLS is typically associated with leukemia following the initiation of chemotherapy. Spontaneous TLS has been seen in hematologic malignancies, but the incidence of spontaneous TLS in solid tumors is rare, and only nine cases have been reported in small cell lung carcinoma. We present a case of a patient who presented with severe metabolic acidosis and electrolyte abnormalities consistent with TLS. At presentation, our patient was found to have small cell lung carcinoma with metastasis to the liver. This patient was managed with bicarbonate, rasburicase, allopurinol, and calcium replacement and started on continuous renal replacement therapy, but unfortunately was transitioned to comfort care and passed away. Risk factors for spontaneous TLS include bulky disease, elevated lactate dehydrogenase, elevated white blood cell counts, renal compromise, and abdominal organ involvement. The most common laboratory findings for TLS include metabolic acidosis and hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia. Cases of spontaneous TLS, however, have been noted to have smaller elevations in phosphate levels. Spontaneous TLS is a rare but potentially fatal complication that can be seen in small cell lung carcinoma.

Evaluation of Electromagnetic Navigational Bronchoscopy Using Tomosynthesis-Assisted Visualization, Intraprocedural Positional Correction and Continuous Guidance for Evaluation of Peripheral Pulmonary Nodules.

BACKGROUND: Electromagnetic navigational bronchoscopy (ENB) has been shown to have variable diagnostic accuracy for the assessment of peripheral pulmonary nodules. This may be because of discrepancies between the preplanned computed tomography of chest target lesion location versus actual target location (computed tomography-to-body divergence), and the lack of a continuous navigational image. The ILLUMISITE (Medtronic, Minneapolis, MN) is a newly developed ENB platform that utilizes tomosynthesis, an imaging technology that can visualize the target location using fluoroscopy (F-ENB). This new system also allows for intraprocedural positional correction and continuous navigation guidance during sampling to overcome these limitations and improve diagnostic yield. We report our first experience in a single center, single proceduralist using this new technology. METHODS: We conducted a retrospective, single center, single operator study reviewing 72 consecutive patients (78 nodules) over a 3-month period. We investigated the overall diagnostic yield and diagnostic yield by nodule location, size, and sedation type using this new F-ENB system. RESULTS: The overall diagnostic yield was 87% and pnemothoraces occurred in 2/78 procedures. We did not find any statistically significant difference when comparing pulmonary nodule location, size or sedation method utilized ( P =0.231, 0.338, and 0.112, respectively). Sixty-nine percent of the pulmonary nodules biopsied were 2 to 3 cm in size. The average distance corrected after tomosynthesis visualization was 15.4 mm (0.4 to 29.8 mm). CONCLUSION: We report our initial experience with the ILLUMISITE system using fluoroscopic tomosynthesis-assisted visualization with continuous navigational guidance at our institution. This new technology allows the operator to correct for better target lesion alignment and real time positional correction and may improve diagnostic yields with minimal complications for evaluation of peripheral pulmonary nodules.

Fatal Wernicke's Encephalopathy with Cardiovascular Involvement in a Young Psychiatric Patient.

Wernicke's encephalopathy (WE) is an acute neurological disorder caused by thiamine deficiency that is frequently missed in non-alcoholic patients. Coma and cardiomyopathy are uncommon presentations of WE that have been rarely reported in the literature. We report the case of a 36-year-old male with a known history of schizophrenia who presented with coma and vasopressor refractory hypotension. Initial computed tomography (CT) of the head at admission was unremarkable. Transthoracic echocardiogram showed diffuse myocardial hypokinesia with a left ventricular ejection fraction of 40-45%. Due to persistent encephalopathy, a repeat non-enhanced CT head was obtained on the second day of hospital admission followed by magnetic resonance imaging (MRI) of brain that showed findings suggestive of WE. The patient was immediately started on high-dose intravenous (IV) thiamine therapy. Although his hemodynamic parameters significantly improved following thiamine replacement, he did not show signs of neurological recovery and resulted in a dismal outcome. This case illustrates the importance of early recognition of thiamine deficiency in critically ill patients to prevent fatal outcomes. Immediate parenteral thiamine administration should be considered in all patients presenting with coma, cardiomyopathy, and refractory hypotension regardless of their body mass index, and alcohol use status.