Another One Bites the Joint: A Case of Reactive Arthritis in an Otherwise Healthy Hispanic Male

Reactive Arthritis is a spondyloarthritis following gastrointestinal or genitourinary infections, traditionally described as a triad of conjunctivitis, urethritis, and arthritis. It is important to identify patients with reactive arthritis as certain disease features portend a poorer prognosis. We present a case of reactive arthritis in a 36-year-old gentleman after a self-limited episode of gastroenteritis. A 36-year-old man presented to the Rheumatology clinic for a 2-week history of multiple arthralgias. The patient reported that one week before the onset of arthritis he experienced a self-limited episode of gastroenteritis. Succeeding, the patient noticed pain and swelling to right wrist, left elbow, and pain and swelling to left wrist. Patient was found to have an elevated ESR and he was prescribed Medrol dose pack and indomethacin which did not resolve symptoms. Patient denied rashes, oral ulcers, conjunctivitis, or constitutional symptoms. Examination was remarkable for swelling of right elbow, bilateral wrists, left knee, and ankles. There was no conjunctivitis, oral ulcers, or keratoderma blenhorragicum. Labs showed negative ANA and rheumatoid factor, sedimentation rate of 107, CRP 8.9, positive HLA-B27. Patient was diagnosed with reactive Arthritis. He was started on Prednisone and Sulfasalazine. Reactive arthritis is a spondyloarthritis that typically affects middle-aged men and is self-limited with remission being achieved by 6-18 months, while recurrence occurs in 25-50% of cases, especially in HLA-B27 positive patients. These patients could potentially develop long term disease resulting in enthesitis and destructive arthritis

Challenge of Diagnosing and Treating a Mediastinal Mass in a Young Patient

Background: Germ cell tumors (GCT) are neoplasms arising in the testicles (1). Rarely these tumors can grow outside of the reproductive organs without involving them, acquiring the name of extragonadal GCT (2). Mediastinal extragonadal GCT is further divided into seminomatous, non-seminomatous (yolk sac tumor, choriocarcinoma and/or embryonal cell tumor), mature teratoma, and immature teratoma according to the histological pattern (2). Case Presentation: 24-year-old-male patient presented to the ER with complaints of a persistent cough of one-month duration accompanied by orthopnea, pleuritic chest pain, and worsening shortness of breath. The patient denied weight loss, testicular pain, night sweats, fever, or hemoptysis. Vital signs on admission were stable. CXR showed a large mass-like density overlying the right hilum. CT chest with contrast showed a 13 cm anterior mediastinal mass with a right loculated pleural effusion. Biopsy was performed with immunohistology compatible with nonseminatomous germ cell tumor. Serological tumor markers including Alpha-fetoprotein, LDH and Beta HCG were significantly elevated. AFP 1,680.4, LDH 399, Beta HCG 113 and CEA 1.3 supported this diagnosis. Conclusion: Nonseminomatous extragonadal GCT is a rare but aggressive neoplasm that arises in the anterior mediastinum. Statistically, they occur more often in men than in women, commonly between the ages of 20 and 40 years old. Treatment with chemotherapy followed by surgical resection of the mass is recommended and should be initiated as soon as the diagnosis is made. Our patient opted to be transferred to MD Anderson Cancer Center for a higher level of care

My Achy-Breaky Heart: A Case of Diffuse Large B-Cell Lymphoma Presenting as Impending Cardiac Tamponade in a Hispanic Woman

Background: Mediastinal masses can arise from typical structures within the mediastinal or they can develop secondary to metastasis from other organ systems [1] Primary mediastinal diffuse large B-Cell lymphomas (PMBCL) are uncommon, accounting for 7% of the cases of diffuse large b cell lymphoma. We describe a case of a 35-year-old woman who presented with atypical chest pain and shortness of breath and was diagnosed with PMBCL in the setting of impending cardiac tamponade. Case Report: A 35-year-old woman with history of cutaneous lupus presented with an 8-month history of chest pain with associated worsening shortness of breath. Upon further questioning, the patient reported having night sweats intermittently with an associated 10-lb weight loss. On examination, patient was tachycardic to 140 BPM, dyspneic with SPO2 99% on room air, with a BP of 137/87 mm/Hg. Results: CXR was performed which showed a widened mediastinum and cardiomegaly. LDH 514 IU/L. Echocardiogram was performed which revealed a large mediastinal tumor, pericardial effusion with suspicion of possible diastolic compromise. Patient was taken to OR for an emergent pericardial window and biopsy of the mass. Pathology along with immunostaining positive for CD45, CD20, Bcl1, Bcl6 correlated with a diagnosis of PMBCL. Conclusions: PMBCL can be aggressive but tend to have similar response rates compared to other types of b cell lymphomas when combination chemotherapy and mediastinum irradiation is initiated [3]. Our patient opted to be transferred to MD Anderson for higher level of care. Patient is scheduled to follow-up with the oncology team soon

Rituximab for steroid-resistant organising pneumonia in a woman with rheumatoid arthritis

Organising pneumonia (OP) is a form of interstitial pneumonia characterised by inflammation and scarring leading to obstruction within the small airways and alveoli. Practice guidelines recommend treatment of moderate to severe OP with glucocorticoids; however, there have been cases of steroid-resistant OP successfully treated with rituximab. We describe a case of a woman in her 20s with rheumatoid arthritis who presented with pleuritic chest pain, haemoptysis and dyspnoea on exertion and was diagnosed with OP after multiple radiographic images and biopsies. The patient failed numerous treatment regimens, including corticosteroids, antibiotics and mycophenolate, but was successfully treated with rituximab. This case highlights the importance of identifying new therapeutic agents that will minimise the use of glucocorticoids in the treatment of OP

Moans, Palpable Groin, and Entrapment of Bone: A Case of Malignant Peripheral Nerve Sheath Tumor in an otherwise Healthy Hispanic Male

Background: Malignant peripheral nerve sheath tumors (MPNTs) are rare malignant soft tissue sarcomas that have an incidence of about 0.001 %. MPNTs typically occur in individuals who have neurofibromatosis or secondary to radiation therapy and rarely occur sporadically. We present a case of a previously healthy 56-year-old gentleman who was diagnosed with MPNTs. Case: A healthy 56-year-old gentleman presented with worsening LLQ abdominal pain for 6 months. Associated symptoms included bloating, LLE swelling, early satiety for the past 2 months, and a 5-10lb unintentional weight loss. Patient denied recent cough, night sweats, dyspnea, fever, chills, melena or hematochezia. Vitals were WNL. Physical examination revealed a palpable mass on LLQ extending into the groin and edema of the left leg with diminished strength 3/5. CBC and CMP were unremarkable. CT abdomen showed a large necrotic mass in the left retroperitoneum infiltrating along the iliopsoas musculature, extending into the left hip and into the left side of L3, L4, L5 vertebral bodies and through L4 transverse process measuring up to 24.6 x 11.5 x 13 cm. Pathology revealed spindle cell sarcoma composed of moderately atypical, elongated spindle cells positive for vimentin, with loss of H3/K27me3, and negative for SMA, S-100 consistent with MPNSTs. Conclusions: The is a rare case of a sporadic presentation of MPNTs. Treatment depends on the extent of tumor burden and metastatic disease is typically treated with chemotherapy. CT chest showed innumerable pulmonary nodules. Patient is currently being treated with Doxorubicin and Ifosfamide with minimal response

It’s Not Always Cellulitis: An Unusual Presentation of Leukocytoclastic Vasculitis

Background: Leukocytoclastic vasculitis (LCV) is a histopathologic term for isolated cutaneous small vessel vasculitis (CSVV) without systemic involvement. LCV can be idiopathic or caused by medications, infections, vascular disorders or malignancies. The annual incidence of biopsy-proven leukocytoclastic vasculitis is approximately 45/million individuals. It presents as erythematous macules with palpable purpura bilaterally on dependent areas of the body. Unilateral and localized presentations are uncommon. Here, we present a rare case of isolated LCV on the abdomen. Case Presentation: A 65 year old woman with a history of vitiligo and Raynaud’s Syndrome, presented with a 12 day history of a tender abdominal rash associated with fevers at home, but no other systemic symptoms. The patient was started on multiple antibiotics in the outpatient setting without any improvement. The rash continued to expand and darken prompting her ED visit. On evaluation, vital signs were unremarkable. Abdominal inspection was significant for a large violaceous, palpable rash over the lower abdomen which was tender and warm to touch. Labs showed leukocytosis of 16K, sedimentation rate 104, ANA titer 1:80 but ANCA, antiphospholipid antibodies, HIV/Hepatitis serology, blood cultures, Ds-DNA, and RF were negative. Skin punch biopsy was performed from the right lower abdomen which was consistent with leukocytoclastic vasculitis and thrombotic vasculopathy with ischemic epidermal necrosis. Immunofluorescent studies were negative. Conclusions: Our case represents a rare presentation of LCV, localized in a non-dependent area. LCV should not be missed, as it can clinically mimic cellulitis, but would require a different management

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

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

That Which Keeps on Giving - A Case of Class IV Diffuse Proliferative Lupus Nephritis in a Hispanic Woman with underlying Systemic Lupus Erythematosus

Background: Glomerulonephritis is the primary cause of morbidity and mortality of systemic lupus erythematosus (SLE). Lupus nephritis is characterized by immune complex deposition in the mesangium leading to complement activation and hypocomplementemia. Studies show that up to 60% of adults with lupus develop renal involvement and it has been well established that Hispanic patients show poorer outcomes than Caucasians despite advances in treatment. Preserved kidney function with new-onset proteinuria should raise clinical suspicion for acute lupus nephritis. Further evaluation with a kidney biopsy is paramount in establishing a diagnosis, helping to define treatment strategy, and determining response to treatment. Case Presentation: A 41-yo-Hispanic-Woman with a PMH SLE without previous renal involvement, secondary Sjogren\u27s, hypertension, heart failure and cirrhosis presented to the ER with a worsening SOB, difficulty swallowing, and anasarca over two weeks. On evaluation, the patient was hypertensive, tachypneic, had positive JVD, wheezing in lung bases, +1 pitting edema in the lower extremities and skin hyperpigmentation on the face, neck, and upper extremities. Laboratory studies revealed leukocytosis of 11.1 th/uL, Hgb 10 gm/dL, platelets 192 th/uL, Cr 0.9 mg/dL, BUN 17 mg/dL, bicarbonate 19 mmo/L, sedimentation rate 94 mm/hr, and CRP 4.5 mg/L. A urinalysis was performed, which showed 3+ proteinuria with hematuria with a subsequent protein to creatinine ratio demonstrating 2,000 mg/gm. The workup for nephritic range proteinuria revealed an ANA 10U, anti-dsDNA 2.7 IU/mL, negative ANCA, anti-cardiolipin Ab IgMMPL, anti-cardiolipin Ab IgG 14 GPL, and non-reactive HIV, Hepatitis C, and Hepatitis B panels. Despite negative glomerulonephritis workup including anti-dsDNA antibody, a kidney biopsy was pursued and revealed class IV diffuse proliferative lupus nephritis with a component of thrombotic microangiopathy. Conclusion: Kidney biopsies are imperative when establishing a cause of new-onset proteinuria in a patient with a history of SLE. The goal of treatment is induction with immunosuppressive agents to reduce kidney inflammation promptly and prevent flares, decreasing the long-term risk of renal failure. Despite early recognition strategies and advances in treatment, Hispanic patients are likely to be diagnosed with more severe disease at presentation, specifically with class IV or V lupus nephritis. Subsequently, these patients are more likely to develop chronic renal failure compared to Caucasian patients. This case highlights the importance of screening urinalysis for proteinuria for early detection of renal involvement in patients with SLE

A Two State-Wide Population Based Analysis of Hepatosplenic T-Cell Lymphoma in Hispanic Vs Non-Hispanic Patients in Texas and Florida

Introduction: Peripheral T-cell lymphomas (PTCLs) are a diverse, aggressive form of neoplasms that are rare and constitute % of all non-Hodgkin lymphoma cases (Am J Pathol, PMID:1698028). A sub-set of PTCLs is hepatosplenic T-cell Lymphoma (HSTCL) which is described as an extra-nodal T-cell lymphoma of mature gamma or delta T-cells (Am J Pathol, PMID:1698028). HSTCL is extremely rare accounting for less than 1% of all cases of NHL and because of this, epidemiological research is lacking (Blood PMID: 21300984). Hispanics (H) are one of the fastest growing races in the US but tend to have poorer cancer related health outcomes in comparison to non-Hispanic (NH) (J Lat Psychol. PMID: 27429867). Despite the rapid growth of H, research remains lacking in this population. The goal of this study is to compare demographic, treatment patterns, and survival outcomes in H v Non-Hispanic (NH) of Texas (TX) and Florida (FL). Methods: This is a retrospective study of a cohort of patients diagnosed with HSTCL from the Texas and Florida Cancer Registry databases. The population included in this study were adults of 18 years (y) of age and older during 2006-2017, patients were identified by the International Classification of Diseases for Oncology Third Edition (ICD-O-3) code list, and data was provided to us completely de-identified. Patients were divided into H and NH for comparison. Standard demographic, socioeconomic, clinical, and survival variables were reviewed. All statistical testing was determined using Fisher’s Exact test, Pearson’s Chi-square test, T-test or Wilcoxon test, as appropriate. Survival time was measured using the day of diagnosis to last date of follow-up or death. Survival distributions were calculated based on Kaplan-Meier curves. All statistical testing was two-sided with a significance level of 5%. Results: A total of 27 patients in TX and 29 patients in FL met the inclusion criteria for the analysis. From those, 2 in TX and 4 in FL were H, and 25 in each state were NH. The median age at diagnosis in y was 46 y for H and 50 y for NH in TX [p-value 0.69] versus 53 y for H and 49 y for NH in FL [p-value 0.67]. In TX, 32% of NH patients fell within the poverty indicator of 5-9.9% while 50% of H patients were between 10-19.9%% and 50% between 20-100%. In FL 36% NH fell within 10-19.9% versus 50% H fell within poverty index of 5-9.9%. However, there was no statistical significance between poverty index or race in either state. Although no statistical difference was noted, in TX 39.1% of NH had private insurance versus 100% of H (n=2) whereas in FL 64% of NH and 50% of H had private insurance. In TX, both NH and H were more likely to receive chemotherapy with multiple agents, 48% and 100%, respectively. In FL 56% of NH and 50% H received chemotherapy with multiple agents. The median survival time for H in TX was 0.5 y vs 0.6 y of the NH in contrast to the H in FL with 5.1 y vs 1.0 y of NH. In TX, the survival probability at 2 and 5 y for the H was 0.5 (CI 0.125-1) and 0.5 (CI 0.125-1) vs 0.254 (CI 0.122-0.529) and 0.191 (CI 0.076-0.481) for the NH. In FL, the H survival probability at 2 and 5 y was 0.5 (CI 0.188-1) and 0.5 (CI 0.188-1); for the NH, the survival probability at 2 y was 0.29 (CI 0.148-0.558), at 5 y 0.19 (CI 0.08-0.459) and 10 y 0.19 (CI 0.08-0.459). Conclusion: There were no statistical differences when comparing survival time, demographics, treatment, or insurance status between NH and H in either TX or FL. Of note, the median survival time was greater for H in FL when compared to H in TX while most H patients in FL fell within a lower poverty index compared to H patients in TX. It is possible to deduce that socioeconomic status plays a role in healthcare outcomes in the H regardless of insurance status. This is imperative because healthcare literacy can be correlated to socioeconomic status which can potentially affect adherence to medications, follow-up appointments, and understanding of the disease process and its impact on quality of life. Although this data does not show any statistical differences between patient populations, it highlights the importance of the progress that needs to be made to determine how ethnicity and socioeconomic status impact disease burden in H