Toxoplasmosis in Immunocompetent Military Veteran with Overseas Field Deployment

Introduction: Toxoplasmosis is caused by infection with the protozoan Toxoplasma gondii (T. gondii), an obligate intracellular parasite. T. gondii infects a large portion of the world’s population, but uncommonly causes clinically significant disease. Those that are at greatest risk for more severe disease with toxoplasmosis are the immunologically impaired, fetuses, and newborns. T. gondii infection in immunocompetent patients can present as a self-limiting acute infection, or as an acute systemic disease. There are three main T. gondii genotypes, I, II, and III, with varying geographical prevalence. T. gondii is most commonly acquired via ingestion of infectious oocysts, from the environment, tissue cysts from contaminated food items, vertical transmission, or via organ transplantation from an infected donor. Diagnosis can be made via histological and serologic testing in suspected patients. Seropositive testing should be considered within the clinical context, as IgM antibodies may persist for months to years. IgG antibody avidity patterns further help delineate acute versus chronic infections. Histopathology from tissue biopsy of lymphadenopathy is more commonly pursued to establish diagnosis in immunocompetent patients. Case Report: We present a 37-year-old male who presented to the clinic with persistent bilateral non-tender occipital lymphadenopathy of two months duration. Patient also endorsed an acute fluid filled blister on the penis, recurrent cold sores, and significant fatigue. Review of systems were unremarkable. Patient’s immunizations were up-to-date. Patient is an active military serviceman with history of overseas deployment. Patient reports consuming undercooked meat overseas, as well as game meat preparation while hunting. Similar symptoms were also reported by another fellow veteran. Laboratory studies revealed normal CBC, CMP, and TSH. HIV, gonorrhea, and chlamydia testing were negative. Urology referral found no abnormalities. Aspiration biopsy of the right occipital lymph node demonstrated granulomas and aggregates of histiocytes compatible with reactive hyperplasia. Findings were suggestive of toxoplasmosis and no malignancy was found. Follow up T. gondii serological testing results revealed Ab IgM: 104 AU/ML (reference range 0.0-7.9). Toxoplasma gondii Ab IgG: \u3e400 AU/ML (reference range 0.0-7.1), which were consistent for active infection. Patient was referred to Infectious Disease and supportive therapy was recommended. A three month follow up showed improvement in symptoms. Discussion: Although acute infections with T. gondii in immunocompetent patients typically are self-limiting, more serious systemic infections may occur. A pyrimethamine-containing antibiotic regimen is recommended for treating systemic infections. We propose educating high-risk individuals with appropriate preventive measures, which may be beneficial in preventing Toxoplasmosis

The clinical implications of adult-onset henoch-schonelin purpura

Henoch-Schonlein Purpura (HSP) is a small vessel vasculitis mediated by IgA-immune complex deposition. It is characterized by the clinical tetrad of non-thrombocytopenic palpable purpura, abdominal pain, arthritis and renal involvement. Pathologically, it can be considered a form of immune complex-mediated leukocytoclastic vasculitis (LCV) involving the skin and other organs. Though it primarily affects children (over 90% of cases), the occurrence in adults has been rarely reported. Management often involves the use of immunomodulatory or immune-suppressive regimens

The Clinical Implications of Adult-Onset Henoch-Schonelin purpura

bHenoch-Schonlein Purpura (HSP) is a small vessel vasculitis mediated by IgA-immune complex deposition. It is characterized by the clinical tetrad of non-thrombocytopenic palpable purpura, abdominal pain, arthritis and renal involvement. Pathologically, it can be considered a form of immune complex-mediated leukocytoclastic vasculitis (LCV) involving the skin and other organs. Though it primarily affects children (over 90% of cases), the occurrence in adults has been rarely reported. Management often involves the use of immunomodulatory or immune-suppressive regimens

Rickettsia parkeri in Argentina

Clinical reports of an eschar-associated rickettsiosis in the Paraná River Delta of Argentina prompted an evaluation of Amblyomma triste ticks in this region. When evaluated by PCR, 17 (7.6%) of 223 questing adult A. triste ticks, collected from 2 sites in the lower Paraná River Delta, contained DNA of Rickettsia parkeri

Acute Bilateral Ischemia of Fingers: An Unusual Complication of Temporal Arteritis

We describe the case of a patient with documented temporal arteritis, who presented two years into her course with acute digital ischemia, presumed secondary to small vessel vasculitis. To our knowledge, this complication of temporal arteritis has not been previously reported

Lobular Breast Carcinoma Metastasis to Skeletal Muscle, Two Case Reports Diagnosed by Ultrasound Guided FNA With Evaluation of the Roles of Interventional Cytopathology

Skeletal muscle metastasis from breast carcinoma is a relatively rare clinical entity. We report two cases of breast cancer metastatic to the skeletal muscle, diagnosed by ultrasound guided fine needle aspiration (US-FNA) biopsy done by interventional cytopathologists at an outpatient cytopathology center. Our two patients presented with lower anterior neck firmness and chest wall mass, respectively. Ultrasound evaluation of our first case demonstrated hypo-echoic thickened anterior strap muscles while in the second case there was significant distortion of the anatomy from previous surgeries. It was necessary to proceed with FNA biopsy even when their ultrasound findings were equivocal, to establish a definite rapid diagnosis. The immediate onsite evaluation findings were suggestive of malignancy in both cases with subsequent core biopsy confirming the diagnosis of metastatic breast carcinoma. In cytopathology, point-of-care (POC) ultrasound is used as an adjunct tool that offers visual guidance during FNA of nonpalpable masses and enables sampling of lesional “hot” spots to ensure specimen adequacy. Studies have demonstrated a reduction in FNA nondiagnostic rates with the use of ultrasound-guidance consequently reducing health care costs associated with nondiagnostic FNAs. US-FNA also provides adequate samples for cell block preparations. Metastatic lobular carcinoma of the breast has a wide range of clinical presentations and a high level of suspicion is advised. Cytopathologists-performed US-FNA is a proven, less-invasive, cost-effective tool that provides timely cytologic diagnosis

Lobular breast carcinoma metastasis to skeletal muscle, two case reports diagnosed by ultrasound guided FNA with evaluation of the roles of interventional cytopathology

Skeletal muscle metastasis from breast carcinoma is a relatively rare clinical entity. We report two cases of breast cancer metastatic to the skeletal muscle, diagnosed by ultrasound guided fine needle aspiration (US-FNA) biopsy done by interventional cytopathologists at an outpatient cytopathology center. Our two patients presented with lower anterior neck firmness and chest wall mass, respectively. Ultrasound evaluation of our first case demonstrated hypo-echoic thickened anterior strap muscles while in the second case there was significant distortion of the anatomy from previous surgeries. It was necessary to proceed with FNA biopsy even when their ultrasound findings were equivocal, to establish a definite rapid diagnosis. The immediate onsite evaluation findings were suggestive of malignancy in both cases with subsequent core biopsy confirming the diagnosis of metastatic breast carcinoma. In cytopathology, point-of-care (POC) ultrasound is used as an adjunct tool that offers visual guidance during FNA of nonpalpable masses and enables sampling of lesional “hot” spots to ensure specimen adequacy. Studies have demonstrated a reduction in FNA nondiagnostic rates with the use of ultrasound-guidance consequently reducing health care costs associated with nondiagnostic FNAs. US-FNA also provides adequate samples for cell block preparations. Metastatic lobular carcinoma of the breast has a wide range of clinical presentations and a high level of suspicion is advised. Cytopathologists-performed US-FNA is a proven, less-invasive, cost-effective tool that provides timely cytologic diagnosis

Unusual Clinical Presentation of Cutaneous Malignant Melanoma Metastatic to the Parotid Gland; Initially Discovered by Fine Needle Aspiration: Case Report and Review of Literature

We report a case of malignant melanoma (MM) metastatic to the parotid gland, initially discovered on fine needle aspiration (FNA). The patient presented with a mass in the parotid gland area with previous history only significant for prostatic carcinoma. The initial FNA impression was melanoma. The smears were hypercellular with bloody necrotic background. The cells were epithelioid with mild nuclear atypia. Discrete cytoplasmic pigmentation was seen. No lymphoglandular bodies were noticed. Fragments of benign salivary gland were also identified. The cytological diagnosis of MM triggered onsite thorough physical examination for potential primary, where a scalp pigmented lesion was discovered hidden by overlying covering hair. Our differential diagnosis included melanoma, metastatic carcinoma, and lymphoma. Further work up for melanoma with S100, HMB45, and Mart 1 confirmed our top differential diagnosis. We emphasize thorough physical examination in such circumstances, and the importance of onsite evaluation guiding clinicians looking for primary

Fatal Abdominal Sarcomatosis Secondary to Gastrointestinal Stromal Tumor With Bland Histology

Fatal abdominal sarcomatosis is a rare complication secondary to gastrointestinal stromal tumor (GIST) arising from the small intestine. Here, we describe a 49-year-old man who presented with massive ascites and multiple mesenteric solid masses. Autopsy showed large necrotic mass (19x14x8.0 cm) surrounding the terminal ileum with multiple smaller nodules on the omentum and mesentery. Histological examination revealed highly cellular, predominantly bland, spindle cells with low mitotic activity. Gastrointestinal stromal tumor was confirmed by strong positive staining for c-KIT (CD 117). Our case is an example of fatal intra-abdominal sarcomatosis of GIST where the histological features were essentially bland

Pulmonary Infection With Caseating Mediastinal Lymphadenitis Caused by Mycobacterium Gordonae

It is often difficult to discern true mycobacterial infection from colonization due to Mycobacterium gordonae (. M. gordonae) since this organism is ubiquitous and is commonly an innocuous saprophyte. This study reports a rare case of caseating hilar adenopathy and pulmonary disease caused by M. gordonae in a patient with chronic obstructive pulmonary disease (COPD) and rheumatoid arthritis (RA) on maintenance steroids and methotrexate. Pathologic exam and cultures of lymph node excision biopsy and bronchoalveolar lavage (BAL) confirmed the diagnosis.Triple antimycobacterial therapy with azithromycin, ethambutol and rifabutin was administered. The patient had significant clinical and radiologic improvement and follow-up cultures confirmed microbiologic cure.Mycobacterium gordonae can be a rare cause of significant pulmonary infection, and positive sputum or BAL cultures for M. gordonae should not be automatically discarded and considered as nonpathogenic contaminants or colonizing organisms, especially in immunocompromised hosts with comorbidities. A detailed review of the case and relevant literature is provided