Non-insidious Large Joint Manifestation of Severe Cachectic Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is an autoimmune disorder in which constitutional symptoms typically occur before joint swelling becomes a true clinical phenomenon. Weight loss, although common, is generally mild in nature and occurs after long standing inflammation. While large joints do become inflamed, RA has a much stronger predilection for the small joints. Our case is a rarity in the fact that there was initial large joint swelling without long standing inflammation. Additionally, the weight loss was cachectic in nature and extreme. Furthermore, while extra-articular manifestations do commonly occur, spontaneous pneumothorax is certainly atypical. The content of this manuscript serves to enlighten hospitalist physicians and residents, as to the odd way in which a case like this may present

Gastrointestinal Bleeding Secondary to Metastatic Duodenal Choriocarcinoma in a Patient with Concomitant Peptic Ulcer Disease

Testicular tumors are one of the most common solid tumors in young males. Choriocarcinoma usually presents as metastatic disease. Gastrointestinal tract involvement is rare. We report a case of a 40-year-old male presenting to our hospital with a three-day history of dyspnea on exertion and black stool after recent diagnosis of testicular choriocarcinoma. Urgent EGD performed revealed small clean-based fundal ulcer and an antral ulcer without the stigma of recent bleeding. Capsule endoscopy was performed and revealed a bleeding ill-defined mass in the proximal duodenum. A subsequent push enteroscopy showed an ulcerated bleeding mass in the third part of the duodenum that was treated with a hemospray with adequate hemostasis. Pathology was consistent with pure choriocarcinoma. The patient received a cisplatin-based chemotherapy regimen. The patient tolerated the chemotherapy regimen well and was discharged for outpatient follow-up. At the three-month follow-up, the patient did not show evidence of recurrent gastrointestinal bleeding