HIV-Associated Burkitt Lymphoma: More than a starry sky appearance

Introduction: •People with HIV infection are at least 50 times more likely to get lymphoma as compared to the general population. •25-40% of these lymphomas will be Burkitt Lymphoma (BL) – an aggressive B cell malignancy with a high proliferative rate and potentially fatal within months if not diagnosed and treated in a timely manner. •This translates to a 10-20% individual life-time risk of BL for an HIV infected person. •The incidence of BL declined after the introduction of highly active antiretroviral therapy (HAART), but to a lesser extent than other HIV-associated malignancies. •Epidemiologic studies suggest the incidence of BL will increase as the HIV-infected population ages Case Presentation: A 24 yo woman with known HIV presented with 1 month of intermittent fevers, chills, nausea and diffuse abdominal pain most notable in the epigastric region. Her symptoms acutely worsened in the last week, prompting her visit to the Emergency Department. Past Medical History: •HIV- diagnosed in 2014. Last on ART Feb-May 2019 while in jail. CD4 count 596 (low at 26%) and HIV RNA viral count 26,400 prior to ART initiation. CD4 count improved to 33% with an undetectable viral load in April. •Chronic hepatitis C •Active IVDU – heroin, methamphetamines •Tobacco dependence Exam: •Vitals: HR 135, RR 22, Temp 102.8 F, normotensive,SpO2\u3e95% on room air •Profuse sweating, notably uncomfortable •New 2/6 holosystolic heart murmur in LUSB with no radiation •Left lower quadrant and epigastric tenderness, negative Murphy’s sign Labs on admission: •Hgb 9 (baseline: 11) •Normal complete metabolic panel •HIV RNA viral load 55,800 •CD4 count 596, 32% Hospital Course: •Started on broad spectrum antibiotics for presumed endocarditis in the setting of active IVDU •TTE revealed no vegetations, blood cultures negative •CT abdomen pelvis obtained the night of admission demonstrated diffuse gastric thickening with evidence of omental seeding with nodularity and splenomegaly •Endoscopy completed the following day found a large nonbleeding gastric ulcer and diffuse gastric inflammation. •Pathology of endoscopic biopsies of the gastric antrum identified Diffuse Large B-cell Lymphoma (DLBCL) and H.pylori. •Immunohistochemistry test positive for Epstein Barr Virus. •The patient was started on Biktarvy (last use 1-3 months prior) •PET scan was done for staging revealed advanced disease with a diffuse tumor burden •MYC rearrangement detected on FISH analysis, consistent with high grade Burkitt lymphoma •She completed 1 cycle of Short Course EPOCH-RR with a guarded prognosis. There was high concern for TLS and gastric perforation due to the extensive abdominal tumor burden. Fortunately, neither happened. •Thus far, she has tolerated 3 of the anticipated 6 chemo cycles with relatively minor complications by comparison including bradycardia, frequent NSVT and neutropenia necessitating adjustments to her chemotherapy regimen and schedule delays. •Her pain control has remained a challenge in light of her ongoing IV substance use. Discussion: •Lymphoma in the leading cause of cancer-related deaths among HIV-infected patients in the anti-retroviral therapy era. •Burkitt lymphoma (BL) is a highly proliferative NHL deriving from B cells and with characteristic oncogenic pathways, including translocation in the MYC gene-- a gene that normally plays a role in controlling cell proliferation, differentiation and apoptosis. •The WHO classifies 3 different clinical variants of BL: endemic, sporadic and immunodeficiency-associated. •Unlike other HIV-associated lymphomas, BL is frequently noted in patients with CD4 cell counts \u3e200 and viral loads suppressed by ART •HIV-associated BL typically presents with extra-nodal disease, mostly commonly the stomach •Intra-abdominal BL may present with abdominal pain, nausea, vomiting, GI bleeding, bowel obstruction; fever, night sweats, weight loss (B symptoms), fatigue and malaise are also common. •Approximately 70% will present with wide spread disease (stage III or IV), in addition to elevated LDH and uric acid levels •The classic “starry sky appearance” is not often seen in the histological examination of HIV-associated BL. Most are positive for Epstein Barr Virus (EBV). •Recent studies suggest the pathobiology of HIV-associated lymphomas is distinct from non-HIV lymphomas. HIV may directly induce B-cell activation. Further oncogenic viruses, as EBV, are more prevalent in HIV-associated lymphomas. •Survival with HIV-associated BL is approaching that of HIV-negative BL thanks to the development of short duration, dose intensive combination chemotherapy with aggressive CNS prophylaxis, the availability of rituximab and the implementation of effective ART •Rare cases of IRIS- associated Burkitt Lymphoma have been reported, typically within 6 months after the initiation of HAART. It is unclear if that was the case with our patient.https://digitalcommons.psjhealth.org/ppmc_internal/1016/thumbnail.jp

A Case Of Multifactorial Orthostatic Hypotension Complicated By Chemotherapy Associated Autonomic Toxicity

A Case Of Multifactorial Orthostatic Hypotension Complicated By Chemotherapy Associated Autonomic Toxicity Christopher Bender, MD Providence Portland Medical Center – Portland, OR Additional Authors: Amy Dechet, MD Introduction: Autonomic neuropathy is known to occur as a side effect of some chemotherapy drugs, including cisplatin. This reports presents a patient with new onset of autonomic instability and orthostatic hypotension after receiving multiple rounds of cisplatin and gemcitabine chemotherapy. Case Presentation: An 81-year-old man with history of stage III lung cancer presented after a fall at home that occurred while getting out of bed in the middle of the night in the setting of recent malaise and poor oral fluid intake. His cancer was treated with surgical lobectomy and thoracic lymphadenectomy five months prior to his admission, and three rounds of chemotherapy with cisplatin and gemcitiabine. He had been admitted to the same hospital three days prior for weakness and back pain and was empirically started on tamsulosin for urinary retention and was discharged with a foley catheter in place. On presentation he was noted to have marked orthostatic hypotension, and during the first night of admission he had high blood pressures while sleeping, with systolic blood pressure greater than two hundred mmHg. Postural hypotension did not improve over the first twenty-four hours after multiple intravenous fluid boluses. He was managed by discontinuing exacerbating medications including tamsulosin and benadryl, as well as treatment with physical therapy, an abdominal binder, and minimizing the amount of time spent supine. He was discharged on the fifth day of hospitalization after clearance by physical therapy. Discussion: Although this case initially appeared to be a straightforward case of orthostatic hypotension related to hypovolemia, it became more complicated when the patient continued to display orthostatic hypotension after initial fluid resuscitation and discontinuation of associated medications. Further suggesting autonomic dysfunction was an inconsistent response of heart rate in relation to hypotension, as well as markedly elevated systolic blood pressure readings at night while the patient was supine. While not a common side effect, there are prior documented cases of autonomic neuropathy in association with cisplatin, which was determined to be the most likely etiology in this case, given the timeline of presentation. An additional factor complicating this case was the issue of addressing orthostatic hypotension in a patient with autonomic instability causing intermittent severe hypertension such that the use of midodrine was not an option. This required creative problem solving including the use of an abdominal binder and compression stockings in order to get the patient stable for discharge from the hospital.https://digitalcommons.psjhealth.org/ppmc_internal/1000/thumbnail.jp

Formation en anglais de spécialité dans les départements informatiques des IUT : choix des matériaux linguistiques et didactisation

En Institut Universitaire Technologique, notre mission première est de préparer nos étudiants à un métier, de les rendre opérationnels sur leur premier emploi et de les aider à rester évolutifs face aux opportunités qu’ils sauront déceler ou qui leur seront proposées. Dans notre domaine d’enseignement de l’anglais nous devons privilégier la formation à la langue de métier : elle assure la crédibilité de l’étudiant à une embauche ; elle conforte ses compétences techniques ; elle lui donne de f..

The contemporary role of renal mass biopsy in the management of small renal tumors

The selective use of percutaneous biopsy for diagnosis in renal masses is a relatively uncommon approach when compared to the management of other solid neoplasms. With recent advancements in imaging techniques and their widespread use, the incidental discovery of asymptomatic, small renal masses (SRM) is on the rise and a substantial percentage of these SRM are benign. Recent advances in diagnostics have significantly improved accuracy rates of renal mass biopsy (RMB), making it a potentially powerful tool in the management of SRM. In this review, we will discuss the current management of SRM, problems with the traditional view of RMB, improvements in the diagnostic power of RMB, cost-effectiveness of RMB, and risks associated with RMB. RMB may offer important information enabling treating clinicians to better risk-stratify patients and ultimately provide a more personalized treatment approach for SRM

Incidental giant renal oncocytoma: a case report

<p>Abstract</p> <p>Introduction</p> <p>Large renal oncocytomas are not very rare entities. To the best of our knowledge, we report one of the largest oncocytomas in the English literature. The tumor was incidentally diagnosed and, based on the preoperative clinical and radiographic findings, was therefore considered to be a renal cell carcinoma.</p> <p>Case presentation</p> <p>A 48-year-old Caucasian diabetic man had an abdominal ultrasound for chronic abdominal discomfort, which revealed a large mass on the left kidney. An abdominal computed tomography scan revealed a contrast enhancing, well defined, heterogenous large mass (16.5 × 13.9 cm) originating from the left lower pole with cystic and solid areas. A magnetic resonance imaging scan was performed with no evidence of renal vein or caval thrombus or embolus. A radical nephrectomy was performed through a left flank intercostal incision and the pathology diagnosed renal oncocytoma. The postoperative course was uneventful and the patient was discharged six days later.</p> <p>Conclusion</p> <p>Several reports have characterised this essentially benign renal histiotype, which represents 5% to 7% of all solid renal masses. Unfortunately, most renal oncocytomas cannot be differentiated from malignant renal cell carcinomas by clinical or radiographic criteria. Central stellate scar and a spoke-wheel pattern of feeding arteries are unreliable diagnostic signs and are of poor predictive value. These tumors are treated operatively with radical or partial nephrectomy or thermal ablation, depending on the clinical circumstances. We report on, to the best of our knowledge, the fourth largest lesion of this type of renal pathology.</p

Grain Structure Evolution of Al−Cu Alloys in Powder Bed Fusion with Laser Beam for Excellent Mechanical Properties

Powder Bed Fusion with Laser Beam of Metals (PBF-LB/M) is one of the fastest growing technology branches. More and more metallic alloys are being qualified, but processing of aluminum wrought alloys without cracks and defects is still challenging. It has already been shown that small parts with low residual porosity can be produced. However, suffering from microscopic hot cracks, the fracture behavior has been rather brittle. In this paper different combinations of temperature gradients and solidification rates are used to achieve specific solidification conditions in order to influence the resulting microstructure, as well as internal stresses. By this approach it could be shown that EN AW-2024, an aluminum-copper wrought alloy, is processable via PBF-LB/M fully dense and crack-free with outstanding material properties, exceeding those reported for commonly manufactured EN AW-2024 after T4 heat treatment

Bilateral synchronous occurrence of three different histological types of renal tumor: a case report

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A Multi-institutional Study on Histopathological Characteristics of Surgically Treated Renal Tumors: the Importance of Tumor Size

PURPOSE: The incidence of accidentally detected small renal tumors is increasing throughout the world. In this multi-institutional study performed in Korea, histopathological characteristics of contemporarily surgically removed renal tumors were reviewed with emphasis on tumor size. MATERIALS and METHODS: Between January 1995 and May 2005, 1,702 patients with a mean age of 55 years underwent surgical treatment at 14 training hospitals in Korea for radiologically suspected malignant renal tumors. Clinicopathological factors and patient survival were analyzed. RESULTS: Of the 1,702 tumors, 91.7% were malignant and 8.3% were benign. The percentage of benign tumors was significantly greater among those 4cm (4.5%) (p or = T3 was significantly less among tumors 4cm (26.8%) (p or = 3 was also significantly less among tumors 4cm (50.9%) (p < 0.001). The 5-year cancer-specific survival rate was 82.7%, and T stage (p < 0.001), N stage (p < 0.001), M stage (p = 0.025), and Fuhrman's nuclear (p < 0.001) grade were the only independent predictors of cancer-specific survival. CONCLUSION: In renal tumors, small tumor size is prognostic for favorable postsurgical histopathologies such as benign tumors, low T stages, and low Fuhrman's nuclear grades. Our observations are expected to facilitate urologists to adopt function-preserving approach in the planning of surgery for small renal tumors with favorable predicted outcomes.ope