Fatal Hemophagocytic Lymphohistiocytosis Resulting in the Death of a Previously Healthy 49-Year-Old Man in Ten Days.

Hemophagocytic lymphohistiocytosis (HLH) is an aggressive, life-threatening condition with sudden onset of a systemic inflammatory response syndrome. The triggers can be apparently non-specific, and the clinical presentations can be very deceptive during a rapidly deteriorating clinical course. Herein, we report a case of a 49-year-old White/Caucasian male with no known past medical history who presented with multi-organ failure, including liver, kidney, and bone marrow, along with disseminated intravascular coagulation. He had a high probability of HLH. Unfortunately, he died ten days after the initial presentation. At autopsy, the liver was necrotic and immunostains revealed diffuse positivity for HSV-1 & 2. The bone marrow was markedly hypocellular with phagocytes containing intact and fragmented red blood cells. There was also disseminated fungal infection involving almost all tissues. PCR, done on frozen tissue samples, revealed Aspergillus fumigatus. The rapid and fatal course of this patient illustrates the sometimes-aggressive course of HLH and the importance of autopsy examination in revealing the underlying etiology for this patient's death.

Uterine Carcinosarcoma Presenting as Metastatic Osteosarcoma in the Lung: A Case Report and Literature Review.

Uterine carcinosarcomas (UCS) are aggressive tumors characterized by their biphasic nature, consisting of high-grade epithelial and mesenchymal elements. One component may predominate over the other. We present the case of a 59-year-old female who initially received a diagnosis of endometrial serous carcinoma and presented one year later with a malignant neoplasm in the lung featuring osteosarcomatous differentiation. Notably, the bone scan did not reveal any evidence of a primary bone tumor. However, additional sampling from the endometrium demonstrated a UCS with an osteosarcomatous component.Upon reviewing existing literature, it has been observed that metastases in carcinosarcoma cases generally arise from the carcinomatous component. Conversely, the sarcomatous component typically spreads locally to areas such as the vagina, cervix, or fallopian tubes. The presented case stands out as a unique instance of an undiagnosed UCS manifesting as metastatic osteosarcoma in the lung. This case underscores the complexity and diverse presentations of UCS and emphasizes the importance of comprehensive evaluation in understanding its clinical manifestations.

Incidental Colonic Masses, Cytomegalovirus Infection, and Amyloidosis in a Treatment-Naive Chronic Lymphocytic Leukemia (CLL) Patient without GI Symptoms.

Gastrointestinal (GI) involvement by chronic lymphocytic leukemia (CLL) is quite uncommon and generally presents with GI bleeding, abdominal pain, and obstruction. However, presentation of CLL as discrete masses without GI symptoms is very rare. A notable complication for patients with CLL is infection due to immunological dysregulation and is typically caused by encapsulated bacteria involving the respiratory tract while viral infections often happen post treatment. Here we present a 78-years-old female with history of treatment-naïve CLL who was incidentally found to have discrete colonic masses secondary to CLL, as well as cytomegalovirus (CMV) and herpes simplex virus (HSV) infections during endoscopic studies for colostomy reversal. On follow-up computed tomography, she was found to have pulmonary amyloidosis as well. We recommend that gastrointestinal tract evaluation should be a part of the complete assessment of the treatment response and remission status in CLL patients to permit early and appropriate therapeutic intervention.

Premalignant Conditions of Bone.

Development of malignancy is a multifactorial process, and there are multitude of conditions of bone that may predispose patients to malignancy. Etiologies of malignancy include benign osseous conditions, genetic predisposition, and extrinsic conditions. New-onset pain or growth in a previously stable lesion is that should concern for malignant change and should prompt a diagnostic workup for malignancy.

The optimal approach of EBUS-FNA rapid on-site evaluation (ROSE): a five-year experience from a large academic medical center.

INTRODUCTION: Rapid on-site evaluation (ROSE) performed during endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) has shown significant value. However, ROSE may not be available for some pulmonary centers. Performing ROSE can be challenging and stressful due to time constrains for preparing, staining and reviewing the cytology slides between passes. MATERIALS AND METHODS: A retrospective cytology report review of EBUS-FNA procedures performed between October 2014 and May 2019 revealed 516 cases that were included in the study. The number of passes for each procedure was documented. The adequacy rates were assessed at 4 different study points; ≤3 passes, ≤5 passes, at odd passes only, and the even passes only. The study groups results were compared to the overall ROSE and the final cytology adequacy. RESULTS: The overall ROSE interpretation was adequate in 370 (71.7%) and inadequate in 146 (28.3%). After reviewing the Papanicolaou stained slides and cell blocks, the final cytology results were adequate in 473 (91.7%) and inadequate in 43 (8.3%) of the cases. The number of passes per procedure ranged from 1 to 17. Our results showed that ROSE evaluation of the first 5 passes during the EBUS-FNA procedure could achieve the similar adequacy rate compared to the overall ROSE evaluation of all the passes. CONCLUSIONS: To achieve the most benefits of ROSE and to reduce the procedure time for EBUS-FNA, we recommend performing ROSE for ≤5 passes depending on the adequacy, and save all additional passes for cell blocks preparation if more than 5 passes are attempted.

Obesity Is a Risk Factor Associated with H. pylori-negative MALT Lymphoma of Stomach.

OBJECTIVE: More than 90% of gastric mucosa-associated lymphoid tissue (MALT) lymphomas are attributed to Helicobacter pylori infections. However, the pathogenesis of H. pylori-negative MALT lymphomas is controversial, and additional etiologies need to be investigated. MATERIALS: A retrospective study of gastric MALT lymphoma cases over a 15-year period revealed 56 cases. The H. pylori status, clinical information, and body mass index (BMI) data were collected. The results of the urea breath test, serology, stool antigen, and previous biopsy results were documented. RESULTS: The 56 cases had an average height of 166.57 cm (range, 147.3-190.5), weight of 83.98 kg (range 55-153.1), and body mass index (BMI) of 30.34 kg/m2 (range, 17.96-49.77). Twenty-one cases were H. pylori-positive (37.5%), with a mean BMI of 27.36 kg/m2 (range, 17.96-47.25), and BMI>30 kg/m2 in 5 (23.8%) patients. Thirty-five cases were H. pylori-negative, with a mean BMI of 31.90 kg/m2 (range, 18.17-49.77), and 20 (57.1%) having BMI>30 kg/m2. A Fisher's exact test and two-tailed test showed a statistically significant difference between the two groups. CONCLUSION: Obesity leads to a baseline state of chronic inflammation and increased production of pro-inflammatory cytokines that can stimulate the lymphocytes, leading to lymphomatous proliferation. Our study suggests a potential correlation between obesity and the risk of development of primary gastric MALT lymphoma.

Spindle Cell Squamous Cell Carcinoma of the Larynx with Malignant Osteoid Differentiation: A Case Report and Review of Literature.

Spindle cell squamous cell carcinoma of the larynx is a rare, aggressive variant of squamous cell carcinoma. It comprises 0.6-1.5% of all laryngeal cancers. Heterologous mesenchymal differentiation as bone, cartilage, and muscle is uncommon, especially malignant osteoid differentiation, as a handful of cases reported in the literature. We present the case of a 66-year-old male active smoker who presented with dysphonia and acute stridor. On examination, a 2.0 cm pedunculated, broad-base, glottic mass involving the left true vocal cord and ventricle was noted, with extension to the anterior commissure causing a narrowing of the airway. The patient underwent localized left vocal cordectomy. The histopathologic and immunohistochemical findings were consistent with spindle cell carcinoma with malignant osteoid differentiation. The patient is alive, status-post adjuvant five cycles of cisplatin therapy, with no recurrence at 18 months of follow-up. We discuss a literature review of this rare entity with either malignant osteoid or osteocartilaginous differentiation.

Deadly combination of Vaping-lnduced lung injury and Influenza: case report.

BACKGROUND: E-cigarette and vaping use-associated acute lung injury (EVALI) has been recently recognized as a complication in individuals who use vaping devices. Another consideration is that EVALI may have an adverse influence on the outcome of intercurrent respiratory infections. We document this deadly combination in the case of a young man who had EVALI and simultaneous 41 Influenza-A infection leading to severe Acute Respiratory Distress Syndrome (ARDS). CASE PRESENTATION: A 27-year-old male with a history of tobacco and vaping use was admitted to hospital after two weeks of flu-like symptoms, diarrhea and vomiting. A chest x-ray was consistent with multifocal pneumonia, and microbiological tests were positive for Influenza-A and methicillin-sensitive Staphalacoccus aureus (MSSA). Bronchoscopy provided evidence of acute inhalational injury. After admission, he acutely decompensated with severe hypoxia and hypotension; he required intubation, sedation and vasopressors. He developed sepsis with acute kidney failure, liver failure, biventricular systolic dysfunction and severe rhabdomyolysis. He was placed on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) initially and later changed to Veno-Arterial (VA) ECMO. Nevertheless, the patient continued to deteriorate, and he expired two weeks after admission. CONCLUSION: This case documents that EVALI can act as a major factor leading a respiratory infection to progress into severe ARDS with a fatal outcome.

Epithelial-Mesenchymal Transition Markers in Breast Cancer and Pathological Responseafter Neoadjuvant Chemotherapy.

The association between pathologic complete response (pCR) following to neoadjuvant chemotherapy (NAC) and the improved survival in breast cancer has been previously reported. The aim of this study was is to explore the expression of several biomarkers described during epithelial-mesenchymal transition (EMT) and the achievement of pCR in different molecular subtypes of breast cancer. We identified archived pathology tissue from patients with breast cancer who received NAC during the year 2014. We performed immunohistochemical analysis of vimentin, nuclear factor κB (NF-κB), epidermal growth factor receptor (EGFR), E-cadherin, estrogen receptor (ER), progesterone receptor, and Her2neu and studied the association between the expression of these markers and pCR. A Fisher exact test for categorical cofactors, an unpaired t test and a nonparametric Wilcoxon test for continuous cofactors were used. The results showed a significant expression of vimentin in triple-negative breast cancer (TNBC; P = .023). An inverse correlation between vimentin and the ER expression (P = .032) was observed. No significant association was noted for vimentin, NF-κB, EGFR, and E-cadherin was associated with pCR. This study suggests that the evaluated EMT related biomarkers are not associated with pCR after NAC chemotherapy in an unselected breast cancer population. Vimentin and NF-κB expressions were associated with TNBC and could be further explored as potential therapeutic targets in this subgroup. A prevalence of vimentin and NF-κB among Hispanic patients with breast cancer warrants further investigation as a possibly contributing to the prevalence of TNBC and adverse prognosis in this population.

Acute myeloid leukemia with KMT2A-SEPT5 translocation: A case report and review of the literature.

Chromosomal rearrangement involving the KMT2A gene is one of the most common genetic alteration in acute myeloid leukemia. A total of 135 different KMT2A rearrangements have been identified, where 94 translocation partner genes are now characterized at the molecular level. Of these 94 translocation partner genes, 35 translocation partner genes occur recurrently, but only 9 specific gene fusions account for more than 90% of cases. Translocation of KMT2A with SEPT5 gene at 22q11.2 is rare, with few reported cases in the literature. In this report, we are presenting a case of KMT2A-SEPT5 fusion in de novo acute myeloid leukemia with t(11;22)(q23;q11.2) with a review of the literature.

Integration of VEGF and α-SMA Expression Improves the Prediction Accuracy of Fibrosis in Chronic Hepatitis C Liver Biopsy.

INTRODUCTION: The progression of fibrosis in chronic hepatitis C (CHC) is a multifactorial process. The high adverse effects and the cost of standard health care increase the demand to discover new predictors for the progression of fibrosis in CHC patients. Our study aims to establish the relation between the angiogenic marker [vascular endothelial growth factor (VEGF)] and activated hepatic stellate cells (HSCs) represented by the expression of α-smooth muscle actin (α-SMA) and whether these 2 markers can be used as predictors for the progression of fibrosis in patients with CHC. MATERIALS AND METHODS: Histopathologic and immunohistochemical analyses were used for examining the morphology and the expression of VEGF and α-SMA in 60 CHC biopsies procured from CHC patients. Multivariate analysis was used to correlate the protein expression with staging and grading of liver fibrosis. Cutoff values of α-SMA and VEGF were determined by the receiver operating characteristics curve. RESULTS: There was a positive correlation between VEGF and HSCs expressing α-SMA (ρ=0.287, P=0.026) and both factors were correlated with the stage of fibrosis (P<0.001). Using the receiver operating characteristics curve, both VEGF (area under the curve=0.71, P<0.006) and α-SMA (area under the curve=0.82, P<0.001) were positive predictors for moderate and severe fibrosis. CONCLUSIONS: This study demonstrates the relation between VEGF expression and the activated HSCs denoted by the expression of α-SMA in CHC biopsies and together can be used as a predictor for the progression of fibrosis.