Internal Jugular Venous Thrombosis With Superior Vena Cava Syndrome: A Rare First Presentation of Gray Zone Lymphoma.

Gray zone lymphoma (GZL) is defined as a B-cell lymphoma with intermediate features between both diffuse large B-cell lymphoma (DLBCL) and classical Hodgkin lymphoma (CHL). GZL is an aggressive disease, which in addition to the B-symptoms, can present as shortness of breath and neck swelling from underlying superior vena cava (SVC) syndrome. Thrombosis of the internal jugular vein (IJVT) is rare and usually associated with head and neck infection, intravenous (IV) drug abuse, and central venous catheter placement. GZL's initial presentation as IJVT with SVC syndrome is very uncommon. We report the case of a 47-year-old female presenting with neck swelling and shortness of breath. Initial investigations were oriented at the thyroid gland. A computerized tomography (CT) scan of the chest, neck, and head showed a large anterior/superior mediastinal soft tissue mass with left IJVT. An excisional biopsy of the left axillary lymph node confirmed the diagnosis of GZL. The mediastinal lymphoma can compress the internal jugular vein and also release thrombogenic substances that can cause IJVT. The compression of the SVC by the lymphoma and the IJVT formation can cause SVC syndrome. Both of these conditions can be life-threatening and should be identified in the early stages to prevent complications.

Anaplastic Large-Cell Lymphoma (ALCL) First Manifested as a Rapidly Progressive Acute Respiratory Failure (RF): Lymph Node Biopsy Negative Presentation Posing a Diagnostic Challenge.

Anaplastic large-cell lymphoma (ALCL) is an aggressive subtype of non-Hodgkin lymphoma. There are two forms of ALCL: primary and secondary. Primary can be systemic, affecting multiple organs, or cutaneous, affecting mainly the skin. A secondary form occurs when another lymphoma undergoes an anaplastic transformation. ALCL rarely presents as initial symptoms of respiratory failure. In most of these situations, the trachea or bronchial involved with an obstruction was present. We present an unusual case of ALCL where the patient rapidly progressed to acute hypoxic respiratory failure with a patent bronchus and trachea. Unfortunately, the patient rapidly deteriorated and died before diagnosis. Only upon at autopsy, it was found that his lung parenchyma was diffusely involved with ALCL. The autopsy report showed that the patient had CD-30 anaplastic lymphoma kinase (ALK)-negative ALCL diffusely involving all lung fields.

Synchronous Liver Abscess With Cholecystitis: A Rare Case of Initial Presentation of Gallbladder Cancer Posing a Diagnosis Challenge.

Gallbladder carcinoma (GBC) is the most common of all biliary tract cancers. GBC is a multifactorial disease. Gallbladder dysplasia from any gallbladder inflammatory condition is one of the main risk factors for GBC. The late diagnosis of GBC is a major problem in its treatment. It is treated by radical resection and the prognosis is improved by adjuvant chemoradiation. We present a rare case of gall bladder cancer presenting as hepatic abscesses with severe sepsis. An 83-year-old male presented with progressive symptoms of shakiness, general weakness, vomiting, and profuse diarrhea. Lab work revealed deranged liver enzymes. Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) abdomen revealed intrahepatic abscesses contiguous with the gallbladder lumen through a gallbladder wall defect and cholecystitis of unknown chronicity. Subsequently, he underwent central hepatectomy and the pathology report of the sample as well as endoscopic retrograde cholangiopancreatography (ERCP) brushings revealed gallbladder adenocarcinoma. The case was complicated by biloma, acute renal failure, and the development of malignant ascites, and the patient died almost four months after the diagnosis of gallbladder cancer.

Case Report of Painless Obstructive Jaundice: A Rare First Presentation of Small-Cell Lung Cancer.

Small-cell lung cancer (SCLC) is a very aggressive type of lung cancer that is of neuroendocrine origin. Because of the high levels of circulating tumor cells, it has a very high rate of metastasis. Obstructive jaundice as the initial manifestation of small cell lung carcinoma is rare. Most of the cases are due to extrahepatic cholestasis by biliary duct obstruction. The biliary duct obstruction may be secondary to metastasis to lymph nodes or pancreatic head metastasis. Obstructive jaundice secondary to intrahepatic cholestasis is even rarer. A 75-year-old male presented to the emergency department (ED) with a complaint of new-onset painless jaundice that his dentist incidentally detected. Examination revealed a mass in the right upper quadrant (RUQ) of the abdomen. Computed tomography (CT) angiography of the abdomen, pancreas, and pelvis shows innumerable hepatic hypodensities highly suspicious for metastatic disease. However, there was no extrahepatic dilatation or pancreatic mass. He was diagnosed with diffuse metastasis of small cell lung carcinoma (SCLC) by needle biopsy of the liver. He developed acute kidney injury and liver damage and thus compromised chemotherapy for SCLC. Later, the patient chose comfort care and passed away the next day. To our knowledge, this is the second reported case of SCLC initially presenting as obstructive jaundice secondary intrahepatic cholestasis by diffuse liver metastases.

Dropped Gallstone Mimicking Retroperitoneal Tumor 5 Years After Laparoscopic Cholecystectomy Posing a Diagnostic Challenge.

Laparoscopic cholecystectomy is the standard treatment for cholecystitis. The major complications associated with laparoscopic cholecystectomy include bleeding, abscess formation, biliary injury with bile leakage, and bowel injury. Gallbladder perforation and subsequent stone spillage are not uncommon in laparoscopic cholecystectomy. The majority of these spilled stones remain clinically silent. But sometimes they can cause abscesses and make diagnosis challenging especially when it occurs years after the procedure and when the abscess form in uncommon sites. A 66-year-old female with a history of laparoscopic cholecystectomy presented with aggravating abdominal pain in the right upper quadrant (RUQ). The CT abdomen revealed a mass in the retroperitoneum behind the hepatic flexure. Upon further examination, follow-up CT scans, and biopsy repeatedly failed to exclude malignancy, so it was suggested that the patient undergo surgical removal of the mass. The pathological analysis of the excised mass revealed that it was a dropped gallstone from the procedure that triggered an inflammatory reaction. Dropped gallstones should be considered as a differential diagnosis in a patient with a history of laparoscopic cholecystectomy presenting with an abdominal or retroperitoneal abscess, as a failure of early recognition puts the patient at risk of undergoing unnecessary and invasive procedures.

A Rare Case of Acute Liver Failure Secondary to Miliary Liver Metastasis.

Acute liver failure (ALF) is a potentially fatal condition that adversely affects multiple organs and has a high mortality rate. ALF due to hepatic infiltration is rare even though it is a common place for cancer to metastasize. Patients with ALF usually present with abdominal pain and elevated liver function tests. We report a case of a 65-year-old male that developed ALF due to miliary liver metastasis of non-small cell carcinoma from an unknown primary origin. The patient initially presented with a couple of episodes of coffee-ground emesis and epigastric pain. Upon further evaluation, along with computed tomography (CT) scans and liver biopsy, the diagnosis was established. The patient passed away on the 12th day of hospitalization.