ABSTRACT
Primary appendiceal carcinomas are rare and often found incidentally when the appendix is surgically removed. Adenocarcinoma predominates the histological types of malignancies, with mucinous adenocarcinoma being the most prevalent of the various subtypes. Pseudomyxoma peritonei (PMP), a complication seen in mucinous adenocarcinoma of the appendix (MAA), is the collection of mucinous ascites in the intra-abdominal cavity and the thickening of the surrounding viscera by mucin-producing tumor cells. PMP initially presents with increased abdominal discomfort and girth and, in later stages, presents with obstructive abdomen symptoms. These symptoms are nonspecific and can be a challenge to pinpoint. Such was the case for our patient, in this case report, who initially presented with dyspepsia and later demonstrated compressive symptoms and weight loss, raising concern for malignancy. An appendiceal pathology was of concern when his right lower quadrant pain acutely worsened during an abdominal ultrasound, and imaging and biopsy confirmed MAA with PMP. The aim of this report is to shed light on the management of recurrent MAA. Our patient's recurrent MAA was managed with debulking procedures and three rounds of hyperthermic intraperitoneal chemotherapy (HIPEC) and was managed postoperatively with folinic acid, fluorouracil, and irinotecan (FOLFIRI) and bevacizumab, which in its totality helped achieve a progression-free survival of more than two years. We believe that cytoreduction and intraoperative chemotherapy prolong survival in patients with recurrent disease, as was the case with our patients. Our patient also demonstrated benefit as his disease stabilized after starting bevacizumab; however, more studies need to be performed at a larger scale to show a consistent relationship.
ABSTRACT
Multiple myeloma (MM) is a hematologic malignancy of plasma cells. It can lead to multiorgan involvement and thus may present with various clinical manifestations, the most common being hypercalcemia, renal impairment, anemia, and bone involvement. Extramedullary multiple myeloma (EM) with soft tissue plasmacytoma (plasma cell tumor of soft tissue outside of the bone marrow) is an uncommon finding in patients with MM, which, when present, is clinically symptomatic based on the location of the tumor. An EM in the retroperitoneum is an infrequent presentation with only a few reported cases. We present a 56-year-old male with a history of retroperitoneal EM near the renal pelvis causing renal failure, presenting with obstructive shock from inferior vena cava (IVC) compression. Perirenal retroperitoneal plasmacytoma causing acute renal failure has been previously reported. A retroperitoneal EM plasmacytoma compressing the IVC precipitating obstructive shock is a unique finding that has yet to be mentioned in the literature. This report hopes to highlight the consideration of EM in patients with MM with obstructive symptoms, particularly in patients such as ours, who had a history of EM in the past. In addition, it shows the utility of bedside point-of-care ultrasound (POCUS) in the intensive care unit. After seeing persistently collapsed IVC on POCUS despite aggressive fluid management with worsening lower extremity edema and ascites, a presumptive diagnosis was made and later confirmed with magnetic resonance imaging (MRI). Although IVC stenting was planned initially, it was deferred due to fear of stent migration after chemotherapy. He was initially stabilized with vasopressors and treated with chemotherapy with cyclophosphamide and dexamethasone, which resolved hypotension. Timely intervention allowed vasopressors to be tapered, and he was subsequently discharged with outpatient chemotherapy.
ABSTRACT
End-stage renal disease requiring chronic dialysis is an immunocompromised state which increases the risk of tuberculosis development and its spread. Due to the high frequency of non-specific or "decoy" symptoms at presentation and frequent extrapulmonary involvement, diagnosis of tuberculosis is a significant challenge. Therefore, it is correctly labeled as 'Tuberculosis; the great imitator' as it can mimic various other disease processes, causing confusion and testing of subsystems involved in the disease process, which come back as abnormal, leading to a vicious cycle. Missing the diagnosis leads to grave consequences, especially in a patient with a miliary form of tuberculosis, as the prognosis with any delay in treatment is poor. High diagnostic suspicion is required to promptly diagnose and treat the condition, especially in a resource-rich setting where tuberculosis is uncommon. Here, we report a patient with miliary tuberculosis who presented with a chief complaint of chronic diarrhea and fecal continence, with prior recent negative interferon-gamma release assay testing. Due to every organ system involved, multiple subspecialties were on board, with a broad differential in mind, including malabsorption syndromes, neoplasia, infections, amyloidosis, and autoimmune disorders, and therefore, numerous tests were performed. However, despite all efforts, the diagnosis was delayed significantly, leading to the unfortunate demise of the patient. The case report sheds light on unique clinical features of miliary tuberculosis, diagnostic findings, and a reminder to always keep tuberculosis high in the differential in an appropriate clinical setting.
