Both Ultrasound Features and Nuclear Atypia are Associated with Malignancy in Thyroid Nodules with Atypia of Undetermined Significance.

BACKGROUND: The optimal management of thyroid nodules that undergo fine-needle aspiration (FNA) with findings of atypia of undetermined significance (AUS) is unclear. Categorizing nodules by AUS subtype and ultrasound characteristics may improve risk stratification. Therefore, the purpose of this study is to evaluate the association between AUS subtype and ultrasound features on risk of malignancy (ROM). METHODS: We performed a review of all patients with a thyroid nodule who underwent an FNA at our institution between January 2010 and November 2015. Patients with AUS were divided into groups with (1) nuclear atypia, (2) architectural atypia, or (3) Hurthle cell atypia. Their ultrasound features were assessed using the American Thyroid Association (ATA) thyroid nodule sonographic patterns. We conducted a univariate and multivariable analysis to determine the association between AUS subtype and other variables of interest with ROM. RESULTS: Of the 3428 thyroid nodules that underwent FNA, 237 (6.9%) had AUS. Of the 97 surgically resected nodules, 67 (69%) were benign and 30 (31%) were malignant. On univariate analysis nuclear atypia (p < 0.01) was associated with a thyroid malignancy. On multivariable analysis, both ATA high-risk ultrasound features (p = 0.04, odds ratio [OR] 3.68) and nuclear atypia (p < 0.01, OR 11.8) were independently associated with a final diagnosis of thyroid carcinoma. CONCLUSIONS: Nuclear atypia and ATA high-risk ultrasound features are useful in identifying patients with AUS that are at a higher risk of thyroid malignancy. Surgeons should take these factors into consideration when evaluating patients with AUS.

Spontaneous epidural air entrapment.

BACKGROUND: Epidural pneumorrhachis (EPR), an extension of pneumomediastinum, results from air that leaks from the mediastinum and accumulates in the epidural space of the spine. It is an uncommon, benign condition; most cases are asymptomatic, are recognized only on computed tomography scans, and require no treatment. CASE REPORT: We present a case of EPR, pneumomediastinum, pneumothorax, and subcutaneous emphysema in a young male who was managed conservatively with supportive care. CONCLUSIONS: EPR is a rare yet benign condition that can be found incidentally while working up lung or spine pathology. Although radiography can define the presence of a pneumomediastinum and subcutaneous emphysema, the diagnosis of EPR can only be made using computed tomography. The management of EPR is usually conservative, and the focus should be on underlying disease.

Abdominal pain as initial presentation of lung cancer.

Isolated spleen metastasis (ISM) in general is very rare with a reported incidence of 2.3-7.1% for all solid cancers. Lung cancers rarely metastasise to the spleen. It is very atypical for ISM to be the initial presentation of lung cancer as well. In our case, a 55-year-old woman presented with a 3-week history of left-sided abdominal fullness and dull pain. Workup was remarkable for splenic mass that turns out to be adenocarcinoma with unknown primary tumour. Biopsy of the mass with immunohistochemistry and whole body position emission tomography scan was able to identify lung cancer as the primary tumour. The patient underwent splenectomy, wedge resection of the lung mass along with short-course of chemotherapy. She never had any recurrences since then.

Loeffler's endocarditis with biventricular mural thrombi.

A 42-year-old man presented to clinic with 1-week history of cough, malaise, loss of appetite and fever. Symptoms started acutely with cough and generalised weakness followed by fever, chills, nausea, vomiting and diarrhoea. He has been healthy before with no chronic illnesses. Further workup disclosed, leucocytosis with 87% eosinophilia, bilateral lung infiltrate, deep venous thrombosis, pulmonary embolism and both right and left biventricular mural thrombi. Extensive workup was done and was consistent with hypereosinophilic syndrome, which explained all his clinical findings. The patient was started on high-dose steroids and responded very well with a complete resolution of symptoms over the course of a few weeks.

Cocaine-induced leg ulceration.

A 48-year-old woman presented with a red, pruritic and painful skin rash on her legs bilaterally after she snorted cocaine. This was associated with fever and cough. Physical examination showed large violaceous plaques and large flaccid bullae, involving bilateral lower extremities. Blood work showed neutropoenia with absolute neutrophil count of 0.64×10(9) cells/L. Antinuclear antibody, perinuclear antineutrophil cytoplasmic antibody and anti-double-stranded DNA were positive. Biopsy showed thrombogenic vasculopathy which is consistent mainly with levamisole ingestion that was reported with levamisole ingestion. The patient was counselled to stop cocaine misuse and treated with skin emollients and antibiotics for the pneumonia that was discovered on the chest X-ray. Skin ulcers improved and she was discharged in stable condition. Ten days after discharge, she was readmitted with new lesions and worsening necrotic ulcers from the old lesions. The patient admitted to snorting cocaine again a few days after being discharged.

A skin nodule in a 66-year-old man as sign of an ominous prognosis.

Skin metastases are common in lung cancer but are rarely noted as the presenting complaint. As evidence of dissemination, they, of course, carry an ominous prognosis. We present a case of metastatic adenocarcinoma of the lung in an otherwise healthy man, whose only symptom was a painless skin nodule.

Telescoping intestine in an adult.

Protrusion of a bowel segment into another (intussusception) produces severe abdominal pain and culminates in intestinal obstruction. In adults, intestinal obstruction due to intussusception is relatively rare phenomenon, as it accounts for minority of intestinal obstructions in this population demographic. Organic lesion is usually identifiable as the cause of adult intussusceptions, neoplasms account for the majority. Therefore, surgical resection without reduction is almost always necessary and is advocated as the best treatment of adult intussusception. Here, we describe a rare case of a 44-year-old male with a diffuse large B-cell lymphoma involving the terminal ileum, which had caused ileocolic intussusception and subsequently developed intestinal obstruction requiring surgical intervention. This case emphasizes the importance of recognizing intussusception as the initial presentation for bowel malignancy.

Chronic hepatitis C therapy: a rare complication revisited.

The combined regimen of peg-interferon α2a plus ribavirin along with protease inhibitors (boceprevir or telaprevir) is considered as a very portent and effective therapy for hepatitis C infections. However, this combined therapy has been associated with a side effect that can make the course of the disease more complicated. In this case, a 50-year-old man developed insulin-dependent diabetes soon after initiating triple hepatitis C therapy. The treatment had to be stopped and the course of his hepatitis C infection has been challenged with this rare side effect.

Right coronary artery aneurysm: an unusual cause of chest pain.

Giant coronary artery aneurysm is an uncommon but well-recognised entity in infants and children with Kawasaki disease. We describe an unusual case of ischaemic cardiomyopathy in an 86-year-old woman owing to giant aneurysm in a dominant right coronary artery discovered with left heart catheterisation and was missed on ECG and nuclear studies. This case highlights the importance of early diagnosis which allows appropriate management. Transcatheter therapy is the main treatment option in this case; however, medical therapy can be used alone with variable results and outcome.

Leukocytosis of unknown origin: gangrenous cholecystitis.

There have been case reports where patients admitted with acute cholecystitis, who were managed conservatively, had subsequently developed GC (gangrenous cholecystitis). The current case is unique, since our patient denied any prior episodes of abdominal pain and the only tip off was leukocytosis. A high index of suspicion is essential for the early diagnosis and treatment of GC. GC has a mortality rate of up to 22% and a complication rate of 16-25%. Complications associated with GC include perforation, which has been reported to occur in as many as 10% of cases of acute cholecystitis. The radiological investigations may not be conclusive. Ultrasonography usually serves as the first-line imaging modality for the evaluation of patients with clinically suspected acute cholecystitis. However, CT can play an important role in the evaluation of these patients if sonography is inconclusive. There is a need for an early (if not urgent) surgical intervention in acute cholecystitis (whether laparoscopic or open surgery) in order to decrease the time elapsed from the start of symptoms to admission and treatment.

Hyponatremia associated with unilateral hand weakness and numbness: a case report.

CONTEXT: The key clinical features in this case are to make the diagnosis apical lung cancer (Pancoast tumor) in a patient with brachial plexopathy and to recognize the association between syndrome of inappropriate secretion of antidiuretic hormone (SIADH) as a paraneoplastic syndrome and non-small cell lung cancer (NSCLC). CASE REPORT: We herein describe a rare case of NSCLC presented as pancoast tumor complicated by brachial plexopathy and associated with SIADH as a paraneoplastic phenomena. There were no renal insufficiency, congestive cardiac failure, liver insufficiency, volume depletion, diuretic use, hypoadrenalism, and hypothyroidism in our patient. Furthermore, the findings of serum hyponatraemia and hypo-osmolality associated with an inappropriate high urinary osmolality indicate that the SIADH was present in our patient due to the NSCLC. CONCLUSION: Our case also emphasizes that early recognition and appropriate applied management may significantly improve symptoms and prevent complications of hyponatremia which may enhance quality of life in patients with paraneoplastic SIADH.

Gastrointestinal Kaposi's Sarcoma Presenting as Ileocolic Intussusception.

CONTEXT: Kaposi's sarcoma (KS) is the most common neoplasm in patients with acquired immune deficiency syndrome (AIDS). Gastrointestinal (GI) involvement with KS commonly occurs in association with cutaneous lesions or lymph node involvement, with GI tract involvement alone occurring in only 3.5% of cases. There are several case reports described in the literature about asymptomatic intestinal KS with skin manifestations. Although GI KS is usually asymptomatic, hemorrhages from the oral cavity, esophagus, stomach, and large bowel have been reported in this disease. CASE REPORT: Our case is unique, in a way that the patient does not have skin manifestation, and also is that the first manifestation presented as acute intestinal intussusception and obstruction with nodular mass lesions of the stomach and GI tract due to GI KS. CONCLUSION: As a differential diagnosis of KS, nonHodgkin lymphomas frequently involve the gut in AIDS patients. Furthermore, tumors of the gut with spindle-shaped cells such as leiomyomas, rhabdomyosarcomas, high-grade pleomorphic sarcomas, or GI stromal tumors have to be considered in the differential diagnosis. Overall, the visceral involvement of the KS is usually associated with poor prognosis. Our case illustrates the importance of physicians to recognize GI KS as a differential diagnosis for HIV positive patients with recurrent abdominal pain. It is commonly occurs in association with cutaneous lesions or lymph node involvement and rarely presents with GI involvement alone, which is makes it a challenge to the physician.