Bronchial myeloid sarcoma with concurrent Aspergillus fumigatus infection in a patient presenting with hemoptysis.

Myeloid sarcoma (MS) is an extramedullary myeloid neoplasm characterized by proliferation of myeloblasts which can occur in any organ or site. Bronchial and pulmonary involvement, however, is uncommon. We describe a case of bronchial MS in an 81-year-old female with a history of high-grade myelodysplastic syndrome; she was started on treatment few months before, and she presented with fever, cough and profuse hemoptysis. She was found to be pancytopenic with bilateral airspace consolidations, most notably in the right upper and lower lobes, on imaging studies. She was treated with broad-spectrum antibiotics and antifungals without much improvement in her clinical or radiological status. Ultimately, biopsy of the lung lesions showed myeloid sarcoma with concurrent Aspergillus fumigatus infection. Bronchial/pulmonary MS should be considered in the list of differential diagnoses in a patient with a history of myeloid neoplasm and presenting with respiratory related symptoms, as early administration of chemotherapy may help to improve survival rates.

Fibroid degeneration in a postmenopausal woman presenting as an acute abdomen.

Uterine fibroid, one of the most common tumors in women, is estrogen dependent, which commonly regresses after menopause. Fibroid degeneration after menopause, therefore, is rare. Here the authors report a case of 56-year-old postmenopausal woman who presented with acute abdominal pain, low grade fever, and leukocytosis as a result of fibroid degeneration.

Perforation in a patient with stercoral colitis and diverticulosis: who did it?

Stercoral colitis with perforation of the colon is an uncommon, yet life-threatening cause of the acute abdomen. No one defining symptom exists for stercoral colitis; it may present asymptomatically or with vague symptoms. Diagnostic delay may result in perforation of the colon resulting in complications, even death. Moreover, stercoral perforation of the colon can also present with localized left lower quadrant abdominal pain masquerading as diverticulitis. Diverticular diseases and stercoral colitis share similar pathophysiology; furthermore, they may coexist, further complicating the diagnostic dilemma. The ability to decide the cause of perforation in a patient with both stercoral colitis and diverticulosis has not been discussed. We, therefore, report this case of stercoral perforation in a patient with diverticulosis and include a discussion of the epidemiology, clinical presentation, and a review of helpful diagnostic clues for a rapid differentiation to allow for accurate diagnosis and treatment.

Acute mesenteric ischemia: a sequela of abdominal aortography.

The use of abdominal angiography and transcatheter embolization has increased rapidly in the last few decades. Although improvement in angiographic techniques has made the procedure safe, ischemic colitis is a rare but potentially dreadful complication. We report a case of a 51-year-old woman who developed ischemic colitis following aortography, demonstrating that such angiographic studies may produce substantial morbidity.

IgM Myeloma or Waldenstrom's Macroglobulinemia Is the Big Question?

ABSTRACT: Although critical from therapeutic and prognostic perspectives, differentiating IgM Myeloma (MM) from Waldenstrom's macroglobulinemia (WM) is fraught with failure. WM can usually be distinguished from IgM MM by the lymphoplasmacytic versus pure plasmacytic morphology, absent versus present lytic bone lesions, and immunophenotypic findings. However, all these features have their own limitations; hence, it requires constant vigilance and periodic re-evaluation. Here we describe a case of a 70-year-old woman initially diagnosed as smoldering IgM MM, who eventually turned out to have WM.

Concurrent Acute Monoblastic Leukemia and Multiple Myeloma in a 66-Year-Old Chemotherapy-Naive Woman.

Concurrent acute myeloid leukemia (AML) and multiple myeloma (MM) is rare, more so in chemotherapy-naive patients. Concurrent occurrence of these two malignancies portends poor prognosis. Although anthracycline-based AML regimen, allogeneic hematopoietic stem cell transplantation, tipifarnib and bortezomib have shown promising results in small number of patients, there is a lack of established therapy. We describe a case of concurrent AML and MM in a 66-year-old woman and review previously published literature.

A 20-year-old Chinese man with recurrent hypokalemic periodic paralysis and delayed diagnosis.

Periodic paralysis in the setting of hypokalemia can be the result of several underlying conditions, requiring systematic evaluation. Thyrotoxic periodic paralysis (TPP), a curable cause of hypokalemic periodic paralysis, can often be the first manifestation of thyrotoxicosis. Because the signs and symptoms of thyrotoxicosis can be subtle and clouded by the clinical distress of the patient, the diagnosis of the underlying metabolic disorder can be overlooked. The authors report a case of TPP in a young Chinese man in whom the diagnosis of thyrotoxicosis was initially missed. This case illustrates the lack of awareness of TPP among many physicians, delay in the diagnosis of TPP and the importance of performing thyroid function testing in all cases of periodic paralysis.

Triple negative mixed metaplastic breast carcinoma with squamous and spindle cells in an 84-year-old woman: a rare entity with unclear management strategy and poor prognosis.

Metaplastic carcinoma of the breast, a rare neoplasm, usually presents at an advanced stage, metastasises to distant sites more frequently, has higher Ki-67 expression and is more often triple negative compared with other invasive breast cancers. Here, the authors discuss a case of an 84-year-old woman with triple negative mixed metaplastic breast carcinoma treated with radical modified mastectomy, axillary lymph node dissection and radiation therapy. Because of the rarity of the disease, the pathogenesis and the management remain controversial, thus contributing to overall poor prognosis.

Small cell lung cancer doubling time and its effect on clinical presentation: a concise review.

Small cell lung cancer (SCLC) is one of many types rapidly growing malignant diseases, such as Burkitt's lymphoma and testicular germ cell cancers. At present, there is no reliable way to screen for SCLC, and imaging modalities tend to be delayed in detecting this type of cancer. The clinical presentation of acutely and rapidly growing SCLC can mimic those of pulmonary inflammatory or infectious disorders, and in some instances, this delays appropriate management and negatively affects patient outcome.

T cell acute lymphoblastic leukaemia presenting with sudden onset right oculomotor nerve palsy with normal neuroradiography and cerebrospinal fluid studies.

Leptomeningeal disease presenting with neurological dysfunction is not uncommon in leukaemia. However, it is often accompanied by abnormalities in cerebrospinal fluid (CSF) studies and/or neuroradiography. Here, the authors describe a case of a young patient presenting with sudden onset right oculomotor nerve palsy with normal neuroradiography and CSF studies, who was subsequently diagnosed to have T cell acute lymphoblastic leukaemia (T-ALL). This case highlights that neurological manifestations can be the initial presenting feature of T-ALL and can occur suddenly despite normal neuroradiography and initial CSF studies.

Right upper quadrant pain and mass in a 41-year-old previously healthy man: a presenting feature of HIV-associated extranodal diffuse large B cell lymphoma with cardiac involvement.

With an increasing pandemic of HIV/AIDS, the incidence of HIV-associated lymphoma is expected to rise. Here, the authors report a case of a 41-year-old man who presented with right upper quadrant pain and mass, and was subsequently diagnosed with HIV-associated diffuse large B cell lymphoma (DLBCL) with cardiac involvement. This case illustrates some of the uncommon and interesting aspects of DLBCL: primary extramedullary extranodal stage IV disease as the presenting feature; cardiac involvement at presentation; DLBCL as the only clue to the diagnosis of HIV; and management of HIV-associated DLBCL. This case is also a reminder of the importance of the routine HIV screening for all patients between the ages of 13-64 years, as advocated by centres of disease control and prevention.

Usefulness of the neutrophil-to-lymphocyte ratio in predicting short- and long-term mortality in breast cancer patients.

BACKGROUND: The neutrophil-to-lymphocyte ratio (NLR) is a strong predictor of mortality in patients with colorectal, gastric, hepatocellular, pancreatic, and lung cancer. To date, the utility of NLR to predict mortality in breast cancer patients has not been studied. Therefore, the aim of our study was to determine whether the NLR is predictive of short- and long-term mortality in breast cancer patients. METHODS: Our observational study used an unselected cohort of breast cancer patients treated at the Staten Island University Hospital between January 2004 and December 2006. A total of 316 patients had a differential leukocyte count recorded prior to chemotherapy. Survival status was retrieved from our cancer registry and Social Security death index. Survival analysis, stratified by NLR quartiles, was used to evaluate the predictive value of NLR. RESULTS: Patients in the highest NLR quartile (NLR > 3.3) had higher 1-year (16% vs 0%) and 5-year (44% vs 13%) mortality rates compared with those in the lowest quartile (NLR < 1.8) (P < .0001). Those in the highest NLR quartile were statistically significantly older and had more advanced stages of cancer. After adjusting for the factors affecting the mortality and/or NLR (using two multivariate models), NLR level > 3.3 remained an independent significant predictor of mortality in both models (hazard ratio 3.13, P = .01) (hazard ratio 4.09, P = .002). CONCLUSION: NLR is an independent predictor of short- and long-term mortality in breast cancer patients with NLR > 3.3. We suggest prospective studies to evaluate the NLR as a simple prognostic test for breast cancer.