Non-Hodgkin lymphoma of the thyroid in a patient with hyperthyroidism.

Primary thyroid lymphoma is incredibly rare with an annual incidence of approximately 2.1 per million persons, accounting for 2% of thyroid malignancies. One of the only known risk factors is autoimmune thyroid disease, specifically Hashimoto's, although there have been a few cases of thyroid lymphoma associated with Graves' disease. Here, we present one such case of a patient with pre-existing hyperthyroidism who developed non-Hodgkin's lymphoma of the thyroid. The patient initially presented with rapidly progressing right-sided neck swelling. He was clinically and biochemically euthyroid with negative thyroid stimulating immunoglobulin, maintained on methimazole. Biopsy of the thyroid nodule with flow cytometry revealed non-Hodgkin lymphoma. Intervention included radiation therapy.

Bird Fancier's lung: An underdiagnosed etiology of dyspnea.

Bird Fancier's Lung is a type of hypersensitivity pneumonitis, an immunologically mediated lung disease due to repetitive exposure of air-borne avian antigen. This was first described in 1965 and is known as one of the most common causes of hypersensitivity pneumonitis. This case highlights this underdiagnosed etiology of dyspnea, disease presentation and exposure variability, and methods of diagnosis.

Urine in the lung: An uncommon cause of transudative pleural effusion.

Urinothorax [UT], the accumulation of urine in the pleural space, is an uncommon cause of pleural effusions resulting from trauma, obstruction, or iatrogenic causes. Thoracentesis with pleural fluid analysis and evaluation of biochemical characteristics, such as pleural fluid creatinine (PCr) to serum creatinine ratio (Scr), is necessary to establish this diagnosis. This case illustrates a 93 year old man with a complicated past medical history including chronic kidney disease stage 4, adenocarcinoma of the prostate status post brachytherapy complicated by proctitis, high grade transitional cell carcinoma of the right kidney with right hydronephrosis, and recurrent hematuria who was hospitalized for worsening hematuria and suprapubic pain. The patients CXR showed a large right pleural effusion. A repeat thoracentesis was performed removing 1.85L clear yellow fluid. PCr and SCr were 4.1 mg/dl and 3.94 mg/dL respectively. This confirmed the diagnosis of UT with a PCr to SCr ratio of 1.04. Again, diagnosis requires pleural fluid analysis and is associated with a paucicellular, transudative effusion with an ammonia-like odor, acidotic pH less than 7.4, and a PCr to SCr ratio greater than 1.0. Management is dependent on correcting the underlying pathology, such as repairing traumatic GU injury or obstruction.

Pneumocystis jirovecii Pneumonia in a HIV-Infected Patient with a CD4 Count Greater Than 400 Cells/µL and Atovaquone Prophylaxis.

We describe a rare case of Pneumocystis jirovecii pneumonia (PCP) in a heterosexual man with a pertinent medical history of well-controlled human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART) and PCP prophylaxis with atovaquone. The patient presented with recurrent shortness of breath, worsening malaise, and fever, following treatment for hypersensitivity pneumonitis one month prior, including a twenty-four-day course of 40 milligrams daily glucocorticoid with taper. However, transbronchial biopsies, lavage, and cytology from prior admission were inconclusive. The patient refused video-assisted thoracic surgery (VATS) at that time. Upon readmission, bronchoscopy with right VATS and lung biopsy were performed. Grocott's methenamine silver stain of right lung biopsy was positive for Pneumocystis jirovecii. This case is a rare example of PCP in a patient with a normal CD4 count (>487 cells/µL) and a low viral load (<20 copies/mL) despite PCP prophylactic antibiotics in the setting of recent iatrogenic immunosuppression.

A rare case of parental iron-induced persistent hypophosphatemia.

We report a case of an African American woman who presented with fatigue, generalized weakness, and hypophosphatemia in the setting of a recent hospitalization for severe, symptomatic iron deficiency anemia requiring ferric carboxymaltose infusions. Parental iron is indicated in numerous clinical settings including chronic kidney disease, inflammatory bowel disease, and iron deficiency anemia. Ferric carboxymaltose is one of the most common forms of parental iron infusions used due to administration procedure and minimal reported side effects. The most common side effect reported is a transient decrease in serum phosphate. This case highlights the necessity of monitoring serum phosphate in the setting of parental iron infusions, especially ferric carboxymaltose, and when severe hypophosphatemia occurs management includes intravenous phosphorous and calcitriol.

Spontaneous Coronary Artery Dissection Treated with Direct Coronary Stenting.

BACKGROUND Spontaneous coronary artery dissection (SCAD) is a rare medical emergency characterized by non-traumatic and non-iatrogenic tearing of the intima of a coronary artery, with an estimated incidence of 1-4%. CASE REPORT A 39-year-old woman with no known cardiac risk factors or recent trauma presented with acute chest pain, electrocardiographic (ECG) changes consistent with ST-elevation acute coronary syndrome, and elevated cardiac enzymes. Coronary angiography revealed near-complete stenosis of the distal left anterior descending (LAD) coronary artery with findings consistent with coronary artery dissection. Due to ongoing chest pain refractory to medical therapy, she underwent successful complex intervention on the distal LAD lesion with a 2.0×30 mm Onyx drug-eluting stent that was post-dilated to high pressure with a 2.5 noncompliant balloon, reducing the 99% stenosis to a 0% residual. She recovered fully and was discharged on aggressive risk factor modification with dual antiplatelet therapy (aspirin and clopidogrel) and high-intensity statin. CONCLUSIONS Spontaneous coronary artery dissection (SCAD) is a rare condition that can present with ECG changes and ischemic symptoms identical to ST-elevation transmural myocardial infarction secondary to plaque rupture. Coronary angiography is required to evaluate patients, and, depending on the catheterization findings, the patient's hemodynamic profile, and severity of ischemic symptoms, complex interventions such as direct coronary stenting can best treat patients such as ours, while medical management might be considered for others.

Strangulation-Induced Thyrotoxicosis in a Patient with Undiagnosed Underlying Graves' Disease.

Thyrotoxicosis is a constellation of symptoms including palpitations, tremors, agitation, and heat intolerance, caused by excess thyroid hormone. It can be life-threatening in its most serious form. We present a rare case of thyrotoxicosis provoked by mechanical trauma to the neck via strangulation in a young female with a history of self-resolving postpartum symptoms of hyperthyroidism one year prior, but no formal diagnosis of thyroid dysfunction. Although hyperthyroidism and posttraumatic stress have many similar features, thyroid storm is a life-threatening disorder that needs immediate intervention.