A Case of Pulmonary Epithelioid Hemangioendothelioma with Literature Review.

Pulmonary epithelioid hemangioendothelioma is a rare vascular tumor and infrequently described in medical literature as case reports and case series. Diagnosis is often incidental with high index of histopathological suspicion from clinical pathologist. The pathological pattern is quite unique with distinct immunohistochemical stains. Up to this day, there is no established standard treatment owing to the scarcity of this tumor. In this case report, we describe a case of pulmonary epithelioid hemangioendothelioma unexpectedly diagnosed with transthoracic needle biopsy, along with a review of the current literature.

Staphylococcal Pericarditis Causing Pericardial Tamponade and Concurrent Empyema.

Bacterial pericarditis is a rare presentation and is usually due to secondary infection from a hematogenous cause or can occur secondary to trauma, intrathoracic surgery, or due to spread of infection from a contiguous focus via ligaments that anchor the pericardium to its surrounding structures. Its course is fulminant characterized by a high mortality rate from sepsis, tamponade, and constriction. We describe a rare case of Staphylococcus aureus pericarditis with concurrent unilateral empyema. The patient rapidly developed tamponade and was successfully treated with antibiotics and urgent percutaneous pericardial drainage with placement of a temporary catheter. Treatment for bacterial pericarditis typically is 4-6 weeks long. Thoracic surgery should be consulted as soon as possible to determine need for surgical intervention, as fibrin deposition may occur, making percutaneous drainage incomplete and leading to complications of persistent purulent pericarditis or constrictive pericarditis.

When it is not just DKA; diabetic ketoacidosis as a first presentation of pancreatic adenocarcinoma.

Pancreatic cancer is the fourth leading cause of cancer related-deaths in the United States. Early symptoms of pancreatic cancer are nonspecific, and most cases are diagnosed at an advanced stage. DKA as a first presentation of pancreatic adenocarcinoma is a seldom reported condition. We present a case of a 59 year old female with type 2 diabetes, who presented to the emergency department with confusion, abdominal pain, polyuria and polydipsia. Laboratory workup showed a high anion gap metabolic acidosis and a blood glucose level of 419 mg/dl with positive serum ketones. She was diagnosed with DKA and admitted to the ICU. A CT abdomen/pelvis was performed to assess for pancreatic pathology as her DKA took longer time to resolve, it showed a pancreatic mass with multiple lesions in the liver. She had biopsies done which were positive for poorly differentiated pancreatic ductal adenocarcinoma. DKA occurs less commonly in patients with type 2 diabetes. Common precipitating factors for DKA in type 2 diabetes include medication noncompliance, infection, or possibly treatment with SGLT2 inhibitors. DKA as a first presentation of pancreatic cancer has been reported more with endocrine islet cell tumors but rarely with adenocarcinoma of the exocrine pancreas. Studies have shown that diabetes is an independent risk factor for development of pancreatic cancer. Other studies suggested that diabetes might be a result of pancreatic cancer or a paraneoplastic effect. One study suggested that diabetes associated with pancreatic cancer occurs at a resectable stage of the disease.

Acute renal infarction: A diagnostic challenge.

Acute renal infarction is a relatively rare and scarcely reported condition. Contrast enhanced CT scan is essential for diagnosing this condition. The most common etiology of this condition is cardioembolic, however up to 59% of cases could be classified as idiopathic acute renal infarction. Here we present a case of a 41 year-old male who was admitted for acute onset right flank pain with fevers and rigors. A CT abdomen with contrast showed findings concerning for right pyelonephritis or renal infarction. Urinalysis was negative for infection. He did not respond to treatment with intravenous antibiotics and was thus diagnosed with acute renal infarction. Work-up for common etiologies was negative and the renal infarction was presumed to be idiopathic. He was discharged home on Enoxaparin. In conclusion, acute renal infarction is a rare condition which should be suspected in patients presenting with acute flank/abdominal pain in whom the more common etiologies have been ruled out.

Unrecognized venous injuries after cardiac implantable electronic device transvenous lead extraction.

BACKGROUND: The major complication rate of transvenous lead extraction (TLE) is estimated to be 1%-2%. Laceration of the central veins can be fatal. OBJECTIVES: To define the incidence and extent of venous injuries on a microscopic level after TLE and compare these data with those of clinically documented events of venous laceration. METHODS: We studied all patients who underwent TLE at our tertiary center within 30 months via a variety of techniques. Extracted leads and tissue around them were fixed in formalin. Pathologic examination was standardized to examine the leads identifying the areas covered by tissue cuffs along the length of the lead. The cuffs were removed and sectioned transversely to their longitudinal axis. Microscopic examination was performed using hematoxylin and eosin stains and Movat stains to identify the presence of vein tissue. RESULTS: In all, 861 leads (585 pacemaker and 272 defibrillator leads) were extracted from 461 patients (median age 63 years, standard deviation 15 years), with an average of 1.9 leads per patient and a median lead age of 2546 days. On microscopic review, 80 leads (9.3%) in 72 of 461 patients (15.6%) showed segments of vein, most of which were transmural (venous tissue including adventitia). Despite this finding, only 5 catastrophic complications (1.1%) occurred that required emergent surgical intervention. Risk factors for venous injury included implantable cardioverter defibrillator lead, age of lead, and the use of laser sheath. CONCLUSIONS: Microscopic venous injuries during lead extraction are common but often not recognized clinically.