Characteristics and distinct prognostic determinants of individuals with hepatosplenic T-cell lymphoma over the past two decades.

BACKGROUND: Hepatosplenic T-cell lymphoma (HSTCL) is a rare and aggressive peripheral T-cell lymphoma with historically dismal outcomes, representing less than one percent of non-Hodgkin lymphomas. Given its rarity, the true incidence of HSTCL is unknown and most data have been extrapolated through case reports. To the best of our knowledge, the largest and most up to date study addressing the epidemiology and outcomes of patients with HSTCL in the United States covered a period from 1996 to 2014, with a sample size of 122 patients. AIM: To paint the most updated epidemiological picture of HSTCL. METHODS: A total of 186 patients diagnosed with HSTCL, between 2000 and 2017, were ultimately enrolled in our study by retrieving data from the Surveillance, Epidemiology, and End Results database. We analyzed demographics, clinical characteristics, and overall mortality (OM) as well as cancer-specific mortality (CSM) of HSTCL. Variables with a P value < 0.01 in the univariate Cox regression were incorporated into the multivariate Cox model to determine the independent prognostic factors, with a hazard ratio of greater than 1 representing adverse prognostic factors. RESULTS: Male gender was the most represented. HSTCL was most common in middle-aged patients (40-59) and less common in the elderly (80+). Non-Hispanic whites (60.75%) and non-Hispanic blacks (20.97%) were the most represented racial groups. Univariate Cox proportional hazard regression analysis of factors influencing all-cause mortality showed a higher OM among non-Hispanic black patients. CSM was also higher among non-Hispanic blacks and patients with distant metastasis. Multivariate Cox proportional hazard regression analysis of factors affecting CSM revealed higher mortality in patients aged 80 or older and non-Hispanic blacks. CONCLUSION: Overall, the outlook for this rare malignancy is very grim. In this retrospective cohort study of the United States population, non-Hispanic blacks and the elderly had a higher CSM. This data highlights the need for larger prospective studies to investigate factors associated with worse prognosis in one ethnic group, such as treatment delays, which have been shown to increase mortality in this racial/ethnic group for other cancers.

A Rare Presentation of Erysipelothrix rhusiopathiae Endocarditis with Acute Heart Failure.

Erysipelothrix rhusiopathiae is an occupation-related infection that can be found in farm animals or marine life. This infection can present with a spectrum of infection ranging from local cellulitis to aortic endocarditis. Developing endocarditis is rare from this organism with only a few case reports in the literature. We presented a case of E. rhusiopathiae bacteremia that led to aortic valve endocarditis with a Gerbode defect within the mitral valve complicated with an acute exacerbation of congestive heart failure, necessitating emergent valve replacement surgery, with eventual permanent pacemaker due to complete heart block. We intend to highlight some unusual characteristics of this infection including thrombocytopenia and hyponatremia. It is important to identify this infection in early stages to prevent the late disseminating complications including endocarditis.

A Rare Case of Dose-Dependent Losartan-Induced Angioedema.

Angiotensin converting enzyme inhibitors (ACE-Is) have long been associated with angioedema and cough. These complications are thought to be related to an increase in bradykinin levels. Angiotensin receptor blockers (ARBs) such as losartan, however, are not known to increase bradykinin levels and, therefore, this complication is not as widely recognized. However, there is a significant proportion of patients who develop angioedema on ARB medications after previous episodes of angioedema on ACE-I. Though there is increasing literature to support that the patients may develop angioedema while taking ARBs such as losartan, a dose-dependent nature has not been well documented. We present a patient with a 20-year history of losartan use who developed angioedema suddenly after an increase in dosage. A dose-dependent relationship between ARBs and angioedema has not been well documented and this is the first documented case of angioedema presenting in a dose-dependent manner with losartan use. We hope that our case will bring awareness to the potential dose-dependent relationship between losartan and angioedema in order to aid clinicians when titrating ARB medications in order to expediently diagnose the fatal side-effect of angioedema and to encourage further research.

Management of Newly Diagnosed Chronic Myeloid Leukemia During COVID-19 Hospitalization: A Teaching Case.

Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm characterized by the dysregulated production and uncontrolled proliferation of mature and maturing granulocytes. CML has the potential to cause secondary immunodeficiency in affected patients. COVID-19 infection has been associated with worse outcomes in immunocompromised patients, including patients with hematologic cancers, requiring hospitalization. Herein we present a 61-year-old male with known COVID-19 infection who presented for the evaluation of acute hypoxic respiratory failure and was found to have marked leukocytosis of 125,000. The patient was eventually diagnosed with CML, and his respiratory failure resolved with conventional COVID-19 pneumonia treatment. With this case report, we hope to assist clinicians in the workup of marked leukocytosis in the setting of COVID-19 pneumonia and aim to help clinicians in the management of patients admitted with COVID-19 pneumonia and concomitant CML.

A Rare Cause of Acute Abdomen in a 59-Year-Old Male.

Celiac artery dissection is often an inconspicuous cause of acute abdomen. Spontaneous celiac artery dissection is most often associated with aortic dissection, and thus isolated spontaneous celiac artery dissection is rare. Herein, we present a case of celiac artery dissection with no aortic involvement. This case emphasizes the importance of including such a condition in the differential diagnosis of patients presenting with acute abdomen.

Pericardial Tamponade and Elevated Serum CA-125 Level in Inadequately Treated Hypothyroidism.

Cardiac tamponade is a medical emergency and must be managed promptly, and reaching a diagnosis is imperative to prevent recurrence. Herein, we present a case of a young female patient that presented with progressive shortness of breath and abdominal distension and was found to have cardiac tamponade with the finding of elevation of a blood tumor marker, CA-125, in the setting of nonadherence to thyroid replacement therapy. She was managed by surgical pericardial window and abdominal paracentesis, with replacement of thyroid hormones leading to resolution of the tamponade and ascites. CA-125 elevation associated with cardiac tamponade and myxedema ascites due to hypothyroidism is very rare, and we aim to shed light on the importance of having a broad differential when approaching cardiac tamponade and understand the association between CA-125 and hypothyroidism.

Transfusion-related acute lung injury in a COVID-19-positive convalescent plasma recipient: a case report.

We present a case of transfusion-related acute lung injury as a complication of convalescent plasma transfusion in a patient who presented with COVID-19-related severe acute respiratory syndrome. Despite treatment with tocilizumab, remdesivir, and intravenous steroids, worsening dyspnea prompted adjunctive treatment with convalescent plasma. Two hours after completion of the plasma transfusion, the patient developed hypoxia-induced cardiac arrest secondary to transfusion-related acute lung injury. This case sheds light on life-threatening transfusion reactions and emphasizes the need to investigate post-transfusion monitoring protocols as well as the possible role of surveillance equipment.

Multisystem thromboembolism in a COVID-19 patient: a case report.

Hypercoagulability has been found in patients diagnosed with the novel coronavirus 19 (COVID-19) and has been identified as a major cause of morbidity and mortality. Herein, we report the challenge in managing a patient presenting with a 5 day history of COVID-19 diagnosis, complicated by deep venous thrombosis, pulmonary embolism and ischemic stroke in the setting of atrial septal aneurysm, presumed patent foramen ovale and paradoxical embolism, identified to have clots in transit on echocardiogram. The application of anticoagulation was felt to be high risk. The patient was transferred to a tertiary facility where the patient underwent thrombus aspiration and was eventually complicated by hemorrhagic conversion of the stroke.

Life-Threatening Diffuse Alveolar Hemorrhage as an Initial Presentation of Microscopic Polyangiitis: COVID-19 as a Likely Culprit.

Microscopic polyangiitis (MPA) is a systemic small vessel vasculitis but it is rare to see life-threatening diffuse alveolar hemorrhage (DAH) in MPA as an initial presentation. MPA more commonly presents with renal involvement and develops pulmonary manifestations later in the disease course. Our patient is a 77-year-old female with a recent history of recovered COVID-19 infection who presented with sudden onset fever, dyspnea, and hemoptysis for three days. She was diagnosed with MPA because of the new-onset DAH, a strongly positive myeloperoxidase (MPO) antibody, and the low likelihood of another etiology. The patient was treated with pulse-dose steroids and plasmapheresis while being on mechanical ventilation. This case highlights the importance of the prompt recognition of DAH as an initial presentation of MPA and illustrates the possible role of COVID-19 in inciting autoimmune conditions.

A rare cause of acute compartment syndrome after gluteal cyst rupture.

Acute Compartment Syndrome (ACS) is a serious medical condition that often results in high morbidity. ACS more commonly presents after substantial trauma in the extremities where compartment pressures can be measured. Here, we present an unusual case of a healthy man who presented with ACS of the thigh secondary to rupture of the gluteal cyst which was formed after multiple unsupervised testosterone injections. Our goal is to encourage a broad differential diagnosis while keeping limb threatening conditions and emergencies on top in patients complaining of leg pain and also to educate the patient population on safety concerns of unsupervised intramuscular injections.

How low can you go? Severe hyponatremia with a sodium of 94 mg/dL corrected with proactive strategy.

We present a case of severe symptomatic hyponatremia (94 mEq/L) in a male patient who presented with nausea, vomiting, and multiple falls. The patient was found with symptomatic hypo-osmolar hypovolemic hyponatremia secondary to volume loss from vomiting, diuretic use, and consumption of solute-free water. To manage such a severely hyponatremic patient, concomitant 3% hypertonic saline and DDAVP were initiated with successful slow and sustained correction of sodium without complications of osmotic demyelination syndrome.