Acute Recreational Cannabis-Induced Hypersensitivity Pneumonitis: A Case Report.

Hypersensitivity pneumonitis (HP) is a lung disease in which foreign matter is inhaled and exposed to lung parenchymal and interstitial tissue. Such matter may include pollen, molds, chemicals, and smoke. HP leads to widespread inflammation and even fibrosis in chronic forms; the main route of treatment usually involves corticosteroids and antifibrotics as needed. We describe a patient case in which HP was diagnosed after using recreational marijuana, and her chest x-ray had a complete resolution after one day of a corticosteroid regimen. As recreational marijuana use increases, clinicians need to keep HP on the differential diagnosis in patients that frequently utilize recreational marijuana obtained through illicit business.

Lemmel's Syndrome: A Rare Complication of Periampullary Diverticula.

Periampullary diverticula are outpouches in the mucosa in the duodenum surrounding the ampulla of Vater. Most cases of periampullary diverticuli are asymptomatic, but complications can arise, increasing a patient's mortality. Diagnosis of periampullary diverticuli is often incidental during endoscopy or imaging studies for abdominal pain. When a patient with periampullary diverticuli is symptomatic, imaging modalities such as CT scan and MRI can help make the diagnosis, but a side-viewing endoscope provides direct visualization of the diverticuli and also allows for the potential treatment of the disease. Lemmel's syndrome is a complication of periampullary diverticuli where the diverticuli causes mechanical obstruction of the bile duct leading to obstructive jaundice without choledocholithiasis. These patients are at risk for further complications such as sepsis and perforation. Early diagnosis and treatment of these patients can help to prevent further complications from arising. We are presenting a case of Lemmel's syndrome with obstructive jaundice from a periampullary diverticuli, further complicated by cholangitis without dilation of the biliary tree.

Inflammatory Myofibroblastic Tumor: A Rare Case Report.

Inflammatory myofibroblastic tumors (IMTs) are rare benign tumors that can occur anywhere in the body, most commonly in the pediatric and young adult populations. The gold standard treatment is surgical resection, possibly along with chemotherapy and/or radiotherapy. IMTs have a high recurrence rate and may present with secondary symptoms, such as hemoptysis, fever, and stridor. We present a 13-year-old male patient with hemoptysis for one month who was subsequently diagnosed with an obstructing IMT of the trachea. The preoperative assessment showed the patient was not in acute distress and could protect his airway, even when lying flat. The treatment plan was discussed with the otolaryngologist, to keep the patient spontaneously breathing throughout the case. Anesthesia was induced with boluses of midazolam, remifentanil, propofol, and dexmedetomidine. Doses were adjusted as needed. Glycopyrrolate was also given to limit the patient's secretions before initiating the surgical procedure. The FiO2 was kept under 30% as tolerated to reduce the risk of airway fire. During surgical resection, the patient was kept spontaneously breathing, and paralytics were avoided. Due to high tumor vascularity and inability to obtain hemostasis, the patient was kept intubated and on ventilation post-operatively until definitive treatment could be performed. On postoperative day 3, the patient returned to the operating room due to a worsening condition. He was found to have a partial obstruction of the right mainstem bronchus by the tumor. More of the tumor was debulked, and he remained intubated above the level of the debulked mass. The patient was then transferred to a higher acuity institution for advanced care. After the transfer, the patient underwent a carinal resection on cardiopulmonary bypass. This case provides insight into successfully sharing the airway during tracheal tumor resection, emphasizing minimizing the risk of airway fire and constant communication with the surgeon.

Lung Cancer Presenting as Upper Extremity Musculoskeletal Pain: A Case Report.

Adenocarcinoma is a tragically common iteration of lung cancer. Risk factors included primary or secondary exposure to tobacco smoke, family history of the disease, and occupationally related hazards, among others. Metastasis to various distant organs may present quite late and in unusual ways, providing a challenge to healthcare providers. A combination of imaging, biopsy, and histochemical analysis can be used to clinch the diagnosis and guide management. Effective treatment relies on a prompt diagnosis, from surgery to radiation and chemotherapy. Our case illustrates how an advanced metastatic lung cancer clinically manifested as something as seemingly benign as shoulder pain.

Isolated Percutaneous Endoscopic Gastrostomy Site Metastasis From Hypopharyngeal Squamous Cell Carcinoma.

Head and Neck Squamous Cell Carcinoma (HNSCC) is a relatively uncommon malignancy due to the human papillomavirus or environmental factors such as excessive alcohol or tobacco use. Its most common metastatic locations are the lungs, bone, and liver. We are reporting a much more exceedingly rare site, a percutaneous endoscopic gastrostomy (PEG) site. HNSCC metastases and recurrences are commonly seen; however, they present complex challenges to manage successfully. Our presenting patient had an initial diagnosis of hypopharyngeal squamous cell carcinoma and then developed an isolated metachronous metastatic tumor at the site of his gastrostomy tract approximately one year later.

Liposarcoma: A 'Beer Belly' in Disguise.

Liposarcoma is a locally aggressive tumor that may originate in soft tissue sites such as the retroperitoneum or the extremities, or less frequently, from the bone. The fatty tumor may have an insidious growth pattern and be present incidentally on imaging, or it may be present with symptoms such as small bowel or ureter obstruction. The diagnosis can be confirmed post-operatively via fluorescence in situ hybridization (FISH) with the presence of mouse double minute 2 (MDM2) homolog protein and cyclin-dependent kinase 4 (CDK4) gene amplification. The rate of recurrence may be high depending on the subtype of liposarcoma, so it is always recommended to have the patient undergo routine imaging every six months to a year. In this case report, we present a patient who presented with a massive, incidental liposarcoma found on imaging after coming to the emergency department for lower extremity trauma.

Rapid Onset Chylous Ascites Presenting as the Initial Manifestation of Follicular Lymphoma: A Case Report.

Follicular lymphoma is the most common indolent Non-Hodgkin Lymphoma (NHL) with overall survival measured in years for the majority of patients (NHL carries a somewhat positive prognosis). Baseline clinical genetic characteristics appear to be the best predictors of the clinical course. A few cases appear to be familial; however, no consistent environmental or infectious causation has been identified. Our presenting patient has a case of follicular lymphoma that was initially diagnosed in the setting of rapid onset chylous ascites, a highly atypical and rare presentation. Follicular lymphoma typically presents with painless lymphadenopathy in lymph nodes along the torso. The lymphoma cells divide within the nodes and can be palpated as bumps within the axilla or on the neck above the clavicle. Various prognostic indicators and tumor grading can give providers a sense of survival statistics. Once diagnosed, chemotherapy tends to form the backbone of most treatment regimens with various roles for immunotherapy and radiation.

Concealed Uterine Rupture in the Broad Ligament in an Unscarred Uterus With Postpartum Hemorrhage.

Uterine rupture is an obstetric emergency that traditionally occurs during delivery in a mother with previously known risk factors, especially a uterine scar. However, a rupture that occurs in an unscarred uterus is uncommon. We report a case of a low-risk mother who presented for induction of labor for late-term pregnancy, without a history of uterine surgery, required vacuum-assisted vaginal delivery for maternal exhaustion, and one hour later was noted to have postpartum hemorrhage. The postpartum hemorrhage was managed medically but was taken for curettage due to continued hemorrhage and hemodynamic instability, followed by laparotomy which identified an 11 cm vertical uterine rupture parallel to the ascending uterine artery concealed in the broad ligament and extending inferiorly to the lateral cervix, necessitating a total abdominal hysterectomy. The patient tolerated the procedures well and was discharged home on postoperative day 2. Highlighting the importance of a high index of suspicion for uterine rupture, even without risk factors, this report describes an atypical presentation and describes an effective stepwise approach to management.