Uterine Serous Carcinoma: a rare presentation of an uncommon type of cancer

Introduction: Endometrial adenocarcinoma is the most common type of uterine cancer and is divided into two types; type 1 includes 80 percent of the cases while type 2 comprises 10 to 20 percent, with latter being more aggressive. Type 2 endometrial cancer is of serous or clear cell histology and abnormal uterine bleeding is the most common clinical presentation. This case portrays an infrequent presentation of uterine cancer. Case Presentation: A 73-year-old woman with past medical history of hypertension and diabetes mellitus type 2 presents to the emergency room with chief complaint of nausea and abdominal bloating for 2 months, associated with early satiety, decreased appetite, and weight loss of 30 pounds in over 6 months. On arrival, vitals showed T 98.2, HR 103, BP 129/72, and RR 17. Further labs demonstrated sodium 115, alkaline phosphatase 165, albumin 2.9, WBC 13.15, hemoglobin 11.7, and hematocrit 34.7. Abdominal CT scan revealed diffuse metastatic mesenteric implants. Pelvic ultrasound demonstrated multiple uterine nodules with calcifications and the presence of complex fluid within uterine cavity. Subsequently CA 125 was measured at 396 and CEA was found to be Conclusion: Physicians rely on clinical presentation and physical exam to formulate a diagnosis. However, not every patient presents with the most common clinical symptoms. It is of utmost importance for clinicians to have a high index of suspicion, particularly in the outpatient setting and when malignancy is a potential diagnosis. The goal is to use a comprehensive clinical judgement to provide competent care to the patients and make an early diagnosis. In this manner, we hope to decrease physical, mental, and emotional burden on the patients while providing a better quality of life

A case of Metastatic Lung Adenocarcinoma: A call for importance of preventive medicine

Introduction: Lung cancer is the second most common cancer and the leading cause of death by cancer in both men and women in United States. There is an estimation of over 200 thousand new cases and over 100 thousand deaths due to lung cancer in 2021. Case Presentation: A 67-year-old male with a history of COPD and smoking presents with complaint of progressive cough and exertional shortness of breath. Chest x-ray demonstrated right sided pleural effusion which was exudative in nature upon pleural fluid analysis. Samples were sent for cytology however patient left against medical advice. Two months later, the patient, now undergoing chemotherapy for metastatic lung adenocarcinoma, was readmitted for management of SOB and right sided pleural effusion. During his extensive hospital course, patient received IV antibiotics for right sided empyema and subsequently underwent VATS of right lung with Talc pleurodesis and chest tube placement in right lung for further drainage. Subsequently patient was discharged home in hemodynamically stable condition. Conclusion: Early diagnosis and treatment of lung cancer can increase the survival rate and provide a better prognosis. USPSTF recommends cancer screening in adults aged 50 to 80 years with a 20-pack year smoking history, current smokers, and those quitted within the 15 years. However, due to lack of access to healthcare, lack of awareness and education, and insufficient practice of preventive medicine many qualified individuals do not get screened for lung cancer. A focus on lung cancer screening can decrease patients’ physical, emotional, and financial burden and lessen the immense cost of lung cancer diagnosis and treatment for the healthcare system

Gangrenous Appendicitis in an Elderly Male

Background: Appendicitis is one of the most common causes of acute abdomen with 250,000 cases reported annually in the U.S. Clinical manifestations include right lower quadrant abdominal pain, nausea, vomiting, and low grade fever. However, in the elderly population they may present with atypical or non-specific symptoms of appendicitis. Case Presentation: An 82-year-old Hispanic gentleman presents to the emergency department with chief complaint of epigastric pain, dizziness and vomiting after eating breakfast in the morning. He reports the epigastric pain is sharp, 4/10, radiating to the left arm with no alleviating or aggravating factors. Vitas on presentation showed a temperature of 98.6F, BP 108/50, heart rate 87, SpO2 94%. Labs revealed an elevated white cell count of 13.68, creatinine of 1.6, high sensitivity troponin of 105. An abdominal ultrasound was ordered which was unremarkable and CT abdomen and pelvis without contrast showing fluid filled distended loops of small bowel likely the result of an abdominal ileus. The patient continued to have worsening abdominal pain in the following days with physical exam now revealing rebound tenderness, guarding and signs of peritonitis. Leukocytosis worsened to 15.58 and surgery was consulted. The patient was taken for an exploratory laparotomy and was found to have a perforated gangrenous appendix. Conclusion: One in every 2000 adults over the age of 65 will develop appendicitis annually, making it an important cause of abdominal pain in this age group. The elderly have a higher rate of perforation at the time of presentation with one study stating that the mortality rate from perforated appendicitis in patients over the age of 80 was 21%. Elderly patient’s may not present with the classic presentation of appendicitis as seen in this case and thus, a high degree of suspicion is needed to make a prompt diagnosis. Although it is a condition we mostly see in the younger population, it is important to keep appendicitis as a differential diagnosis in the elderly

Rate control is the key-Tachycardia induced Cardiomyopathy

Introduction: Tachycardia-induced cardiomyopathy is the systolic dysfunction that results from tachyarrhythmias. It presents symptoms of heart failure and can be reversed with rate control or normalization to sinus rhythm. The aim of presenting this case report is to the awareness of tachycardia-induced cardiomyopathy, which if recognized early can be reversed by the treatment. Case Presentation: A 62-year-old male with a history of tobacco use presented with orthopnea, palpitations, and exertional dyspnea. A month ago, he was seen by his primary care physician for palpitations and was diagnosed with new-onset atrial fibrillation. There was a gradual progression of his exertional symptoms to NYHA class IV that prompted him to come to the emergency room. Upon admission, he was noted to have atrial fibrillation with the rapid ventricular response at 140 bpm. An echocardiogram revealed an LV ejection fraction of 20 % with dilated LV and RV chambers. His heart rate was controlled with metoprolol and digoxin. He was started on a heart failure regimen. Ischemic cardiac workup was unremarkable. He was subsequently followed up in the clinic. The repeat cardiac echocardiogram was noted for marked improvement of LV systolic function and of the patient\u27s symptoms. He was continued on rate control and heart failure medications. Conclusion: Tachycardia-induced cardiomyopathy can result from various tachyarrhythmias including atrial fibrillation with a rapid ventricular response. In such cases, cardiomyopathy may develop over a few weeks to over a few years. Once tachycardia-induced cardiomyopathy is suspected, treatment should focus on rate control in addition to the management of heart failure. Our case demonstrates how increased awareness of tachycardia-induced cardiomyopathy helps in timely diagnosis and can be reversible

A Case of Disseminated Cryptococcosis

Background: Cryptococcus is an invasive fungal infection, typically acquired through inhalation. It is found in soil contaminated with bird droppings and it can disseminate to the lungs, meninges, and skin. In the United States, the incidence of cryptococcosis is estimated to be about 0.4-1.3 cases per 100,000 population with the most common species being Cryptococcus Neoformans and Cryptococcus Gatti. Cryptococcosis is commonly seen in HIV patients, however, immunocompromised individuals with cancer, solid organ transplants, or chronic glucocorticoid therapy are also at high risk. Case Presentation: A 69-year-old male with history of polymyositis and granulomatosis polyangiitis on chronic steroids presents to the ER with chief complaint of progressively worsening shortness of breath and confusion of three days duration, as per patient’s wife. Patient had been noted to be more lethargic and confused with increased productive cough. Chest x-ray and high-resolution CT demonstrated bilateral dense multilobar infiltrates and he was started on Ceftriaxone, Azithromycin and Solu-Medrol for multilobar pneumonia. A serum cryptococcal antigen was ordered by infectious disease which came back positive with titers of 1:2560 and thus, he was started on Amphotericin B and Flucytosine. A lumbar puncture was then performed which showed Cryptococcal Neoformans and Cryptococcus Gatti positive in CSF. Unfortunately, the patient’s condition deteriorated, and he expired. Conclusion: Cryptococcosis predominantly occurs in HIV patients. We need to have a high index of suspicion in immunosuppressed patients including patients on chronic steroids that are at high risk of developing cryptococcosis. Prompt recognition and treatment is critical as there is a high mortality rate

Hepatic chylothorax, a rare finding in a patient with subacute hepatic hydrothorax

Background: The presence of chyle in the pleural space is termed chylothorax. Etiologies include traumatic (iatrogenic, blunt, or penetrating injury) and non-traumatic (non-malignant and malignant). Liver cirrhosis is a rare cause of non-traumatic, nonmalignant chylothorax. We describe a case of a transudative chylothorax in a patient with cirrhosis and hepatic hydrothorax. Case presentation: A 72-year-old woman presents with complaints of shortness of breath for 7 days, altered mental status, and abdominal distention. Patient has past medical history of diabetes, hypertension, and liver cirrhosis. On arrival, vital signs demonstrated T 96.2 F°, HR 75, RR 16, BP 143/68, and SO2 97%. On physical exam, was found on 2 liters of oxygen, had decreased right-sided breath sounds, ascites, and lower extremity edema. Laboratory analysis showed, WBC 3.49, Hb 7.5, Hct 23.3, Platelets 57, AST 23, ALT 12, ALP 137, Cr 1.6, BUN 24, Albumin 2.3, Ammonia 19, INR 1.13, PT 12.2. Chest X-ray and CT showed complete opacification of the right hemithorax. Thoracentesis revealed transudative fluid, compatible with hepatic hydrothorax. A second thoracentesis revealed a cloudy appearance, PH 8, WBC 105, RBC 57, PMN 11%, lymphocytes 56%, glucose 329, LDH 39, protein,confirming transudative chylothorax. Conclusion: Chylomicrons in pleural fluid confirm the diagnosis of chylothorax. Transudative chylothorax has been associated with cirrhosis. These effusions occur after therapeutic thoracocentesis due to reaccumulation of pleural fluid from chylous ascites. Elevated intraperitoneal pressures, atrophy in splanchnic lymphatics, and diaphragmatic anatomical defects allow fluid to cross compartments, driven by lower pressures in the pleural cavity. In our patient, malignancy and major lymphatic lesions were ruled out by imaging. Chylothorax is a rare condition with high morbidity and mortality, therefore a prompt diagnosis and treatment are of utmost importance

Sickle Cell Anemia In Hispanic-Americans In South Texas: Two Case Reports

Introduction: Sickle cell anemia and traits are well described in the African-American population. Hispanic Americans are an underappreciated community affected by Sickle cell disease, where it affects about every 1 in 16300 live births compared to 1 in every 365 African-American births.Hence, it is essential to acknowledge the incidence in Latin American origin people to provide competent and specific care to these populations. Case Description: Case 1: A 28-year-old Latin-American lady with sickle cell anemia, multiple transfusions, and exchange transfusion in the past presented with complaints of lower back and lower extremity pain. The patient got admitted with acute sickle cell crisis, secondary to suspected pneumonia. It was managed supportively and received multiple PRBC transfusions, was discharged after five days. Case 2: A 32-year-old Latin-American lady with intellectual disability, familial dysmorphic features, sickle cell disease presented to the emergency department with chest pain and shortness of breath, got admitted with acute chest syndrome secondary to sickle cell crisis for further management. She received one PRBC transfusion, after which her symptoms resolved, and discharged home the same day. Discussion: Although only 10 to 15% of patients with sickle cell disease are of Latin origin, the prevalence is higher in areas with a predominantly Hispanic population, such as South Texas.Many of those affected suffer the consequences of sickle cell crisis.Physicians and all other health care providers should be well-versed in managing the disease to provide competent and comprehensive care, especially in such areas

The Importance of a Broad Differential Diagnosis: Hepatitis C Virus Associated Cryoglobulinemic Vasculitis

Introduction: Mixed cryoglobulinemia syndrome (MCS) is a systemic inflammatory syndrome affecting small-medium sized vessels due to the presence of type II or III cryoglobulins in the serum. MSC can manifest as systemic vasculitis with symptoms varying from weakness, arthralgia, palpable purpura, peripheral neuropathy, and renal involvement. The most common cause of MCS includes lymphoproliferative disorders, autoimmune diseases and viral infections, with hepatitis C virus (HCV) being the most common etiology. Case Presentation: A 60-year-old lady was referred to our office for evaluation of rheumatoid arthritis. She reported history of bilateral thumb pain, bilateral knee pain associated with episodes of swelling, warmth, and erythema, and left shoulder pain resulting in restricted range of motion. Further, she reported new onset of slightly painful and itchy skin lesions on her arms bilaterally for one year associated with onset of chemotherapy for treatment of colorectal cancer. She denied fever, chills, fatigue, weight loss, hearing loss, dry, red or painful eyes, nasal or oral sores, epistaxis, Raynaud phenomenon, shortness of breath, chest pain, hemoptysis, dysphagia, hematemesis, hematochezia, and hematuria. Physical examination was significant for red non-blanchable lesions on bilateral legs and feet without ulceration, bilateral tenderness of carpometacarpal joints, and left shoulder tenderness with restriction of range of motion. Patient had a skin biopsy done which had revealed leukocytoclastic vasculitis. Differential diagnoses included rheumatoid vasculitis, IgA vasculitis, Cryoglobulinemia, and ANCA related vasculitis. The patient was empirically started on Prednisone 40 mg daily to be titered down. Work up revealed elevated liver enzymes, positive cryoglobulins, cryocrit more than one percent, positive ANA with nuclear speckled pattern with a titer of 1:80, and reactive HCV antibody. Based on history, physical examination and lab findings, a diagnosis of HCV induced cryoglobulinemic vasculitis was made. Conclusion: In the context of biopsy proven leukocytoclastic vasculitis, a broad differential diagnosis including systemic causes of vasculitis should be undertaken. MCS associated with HCV is a severe form of the disease with a 5-year mortality rate of 25 percent. Therefore, it is of utmost importance to make an accurate diagnosis and initiate the appropriate treatment to improve the quality of life, reduce complications and the mortality

Granulomatous Mastitis: A rare or an underdiagnosed disease?

Introduction:Granulomatous mastitis (GM) is a benign chronic inflammatory breast disease that is poorly understood, with no universal agreement on underlying etiologies and treatment protocol. The proposed etiologies include trauma, metabolic processes, hormonal changes, autoimmune disorders, and infections. This entity commonly presents with unilateral painful firm and erythematous breast mass, and less frequently with areolar retraction, fistula formation and ulceration. The disease is more common in Hispanic and Asian population. Due to its inflammatory nature, the mainstay of treatment includes a tapered course of high-dose corticosteroid, and methotrexate has proven to be effective in some cases. Case Presentation: A 47-year-old Hispanic woman presents to the office with a chief complaint of left tender red breast mass. She reports a similar episode in 2016, after a miscarriage, for which she was diagnosed with mastitis and underwent incision and drainage with subsequent resolution. She also reports one episode of breast mass associated with high fevers that resolved spontaneously. She denied fever, chills, weight loss, or breast discharge. The physical exam was remarkable for a 5 cm indurated tender left breast mass with surrounding erythema. Based on presentation, history, and physical examination the differential diagnosis included infectious mastitis, breast cancer, and granulomatous mastitis. Labs were remarkable for ESR of 51, RF 53. Mammogram demonstrated focal asymmetries of the left breast and ultrasound revealed one focus suspicious of abscess formation and another representing a resolving abscess with granulation tissue formation. A core needle biopsy of the mass was consistent with granulomatous inflammation. Patient was diagnosed with granulomatous mastitis and started on a course of antibiotic therapy with doxycycline and anti-inflammatory with celecoxib. On follow up, she reported significant improvement in her symptoms. Conclusion: The early diagnosis of GM may be challenging due to its clinical presentation and imaging findings mimicking other etiologies such as infectious or neoplastic causes. Therefore, it is important for physicians to keep a high index of clinical suspicion when evaluating a patient with such clinical presentations to make an early accurate diagnosis. The ultimate goal is to avoid unnecessary investigations and procedures which can cause emotional, physical, and financial burdens to the patient

A Very di-Still-ed Diagnosis- Adult-Onset Still’s Disease Presenting in a Middle-Aged Hispanic Patient

Background: Adult-Onset Still’s Disease (AOSD) is a systemic inflammatory disorder characterized by daily high fevers, arthritis, evanescent rash, and leukocytosis (1). Patients can present without typical manifestations and pose a challenging differential. We present a case of a 52-year-old gentleman with a one-year history of recurring fever, lymphadenopathy, and weight loss diagnosed with AOSD. This case highlights the diagnostic challenge that AOSD poses and the strategies to help aid in the diagnosis. Case Presentation: A 52-year-old gentleman presented to the ED for a 2-week history of fever associated with chills and bone pain. He reported that he has been having intermittent fever, weight loss, night sweats, and rash for the past year with prior workup being unrevealing. He endorsed swollen glands and fatigue but denied productive cough, chest pain, gastrointestinal, urinary, or neurological symptoms. On physical examination, the patient was febrile at 101.9 deg F, tachycardic 121 BPM, and RR 21 br/min. He appeared cachexic, with dry oral mucosa, palpable lymphadenopathy, and bilateral knee tenderness. Laboratories were remarkable for WBC 22.3 th/mm3, hemoglobin 11.1 gm/dL, platelet 513 th/mm3, sedimentation rate 120 mm/h, CRP 23 mg/dL, lactic acid 0.89 mmol/L, ferritin level 28,595.9 ng/mL, and LDH 603 IU/L. Peripheral smear revealed reactive neutrophilic leukocytosis. Infectious etiology, including SARS Covid-19PCR, HIV, blood cultures, lumbar puncture with CSF analysis, and QuantiFERON gold were negative. Autoimmune workup was unrevealing. CT Chest/Abdomen demonstrated moderate pleural effusions and reactive bilateral hilar, mediastinal, and retroperitoneal lymphadenopathy, and hepatomegaly. CT-guided biopsy of the left inguinal lymph node showed benign follicles with mixed B and T cells. Flow cytometry showed increased granulocytes and eosinophils without immunophenotypic abnormalities to suggest hematologic malignancy. After excluding infectious and malignant causes, rheumatology was consulted. Based on symptomatology, laboratory, and radiographic findings, a diagnosis of AOSD was entertained. Yamaguchi\u27s criteria supported the diagnosis with four major and four minor criteria met (2). The patient was started on prednisone 1 mg/kg with excellent response. Conclusion: AOSD is a diagnosis of exclusion, and the appropriate clinical scenario should warrant further investigation. AOSD should be in the differential after careful workup and excluding infectious etiology, malignancy, and other connective tissue diseases