Combined Hepatocellular Carcinoma and Neuroendocrine Carcinoma Presenting with Hypercalcemia

Background: Malignancy-associated hypercalcemia (MAHC) occurs in 20-30% of cancer patients and is a common cause of hypercalcemia among hospitalized patients. Its pathophysiology is generally based on bone metastases or the production of parathyroid hormone-related peptide (PTHrP) by tumor cells. The secreted PTHrP causes hypercalcemia via increased calcium absorption at the kidney and increased bone resorption. Here, we present a rare case of combined hepatocellular carcinoma (HCC) and neuroendocrine carcinoma (NEC) presenting with hypercalcemia. Case History: A 67-year-old male with a past medical history of alcohol abuse and previously treated Hepatitis C infection in 2012 with ledipasvir/sobosbuvir, was referred to our hospital for evaluation of hypercalcemia. Patient was in his usual state of health until 3 weeks ago when he started having fatigue, nausea, and anorexia. This was also associated with impaired memory and confusion. He was seen at an outside hospital and was found to have a calcium of 16.1 mg/dL (normal range 8.5-10.2 mg/dL), so he was given IV fluids, zoledronic acid and calcitonin with improvement in calcium to 10.8 mg/dL. Computerized tomography (CT) scan of chest/abdomen/pelvis showed a cirrhotic liver and a 6.5 cm hypodense mass within the left hepatic lobe. CT thoracolumbar spine was negative for lytic or blastic lesions with no acute fracture or dislocation. Patient was stabilized and transferred to our hospital for escalation of care. His parathyroid hormone (PTH) was low at 8 pg/ml (15-65 pg/ml) and PTHrP was high at 105 pg/ml (14-27 pg/ml). Repeat imaging with MRI showed a 17 x 8 cm area of signal abnormality with 2 more focal anomalies within, suspicious for malignancy which may be infiltrative. MRI thoracolumbar was negative for any metastasis, fractures or lytic lesions. Skeletal series was also negative for lytic lesions. Microscopic evaluation of the CT-guided liver biopsy showed two distinct patterns. A typical moderately differentiated HCC and a second malignant focus composed of hyperchromatic small to intermediate sized cells with apoptosis, atypical mitoses, vaguely palisading tumor cells around foci of necrosis. This second focus stained positively with CD56 and CAM 5.2 was suggestive of neuroendocrine differentiation and epithelial lineage. Background hepatic parenchyma showed early cirrhosis likely secondary to long standing hepatitis C or due to alcohol abuse. Tumor markers including alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), and carbohydrate antigen 19-9 (CA 19-9) were all negative. His workup was negative for another primary malignancy. His disease course was complicated by altered mental status and Klebsiella pneumoniae bacteremia. His PTHrP increased to 335 pg/ml. He received supportive care and expired 3 weeks from initial presentation. Conclusion: Primary HCC and NEC generally tend to have a poorer prognosis than conventional HCC. To our knowledge, this case is the second report of primary mixed HCC and NEC associated with MAHC caused by the production of PTHrP.https://scholarlycommons.henryford.com/merf2020caserpt/1054/thumbnail.jp

Hepatitis C Cirrhosis, Hepatitis B Superimposed Infection, and the Emergence of an Acute Portal Vein Thrombosis: A Case Report

Acute portal vein thrombosis (PVT) is a complication of liver cirrhosis. The presence of viral infections such as hepatitis B (HBV) and hepatitis C (HCV) can further increase cirrhotic patients\u27 risk of developing PVT, especially in the rare case when there is superinfection with both HBV and HCV. We present a patient with HCV cirrhosis whose clinical condition was decompensated secondary to the development of superimposed HBV infection, who developed acute PVT during hospitalization. This case offers a unique presentation of acute PVT that developed within several days of hospitalization for decompensated liver disease, as proven by the interval absence of portal venous flow on repeat imaging. Despite the workup on the initial presentation being negative for PVT, reconsideration of differentials after the change in our patient\u27s clinical status led to the diagnosis. Active HBV infection was likely the initial trigger for the patient\u27s cirrhosis decompensation and presentation; the subsequent coagulopathy and alteration in the portal blood flow triggered the development of an acute PVT. The risk for both prothrombotic and antithrombotic complications remains high in patients with cirrhosis, a risk that is vastly increased by the presence of superimposedinfections. The diagnosis of thrombotic complications such as PVT can be challenging, thus stressing the importance of repeat imaging in instances where clinical suspicion remains high despite negative imaging. Anticoagulation should be considered for cirrhotic patients with PVT on an individual basis for both prevention and treatment. Prompt diagnosis, early intervention, and close monitoring of patients with PVT are crucial for improving clinical outcomes. The goal of this report is to illustrate diagnostic challenges that accompany the diagnosis of acute PVT in cirrhosis, as well as discuss therapeutic options for optimal management of this condition

A Case of a Large and Rare Incidental Pleural Tumor in an Elderly Female

Solitary fibrous tumors are very rare in the pleura, and they are generally found incidentally. Even though they can potentially become malignant and metastasize, they have minimal clinical symptoms and can still be benign. Due to the low incidence of these tumors, there is no standard of therapy beyond surgical resection. We present an asymptomatic case of a large, rapidly expanding solitary fibrous tumor of the pleura in an elderly female

An Atypical Presentation Of Atypical Pneumonia: Legionella Causing Guillain-Barre Syndrome

Learning Objective #1: Recognize an atypical presentation of Legionella pneumonia Learning Objective #2: Identify the association between Guillain-Barre variants and infectious syndromes CASE: A 29 year-old-female with history of Systemic Lupus Erythema-tosus on plaquenil presented with two weeks of nausea, emesis, and cough. During that time she developed progressive numbness in bilateral lower extremities and began to experience falls at home. On presentation she was afebrile but hypoxic requiring intubation. She had no leukocyto-sis but did present with a moderate hyponatremia to 127. Chest X-ray showed patchy infiltrates and urine legionella antigen was positive. She was started on treatment with moxifloxacin. Her weakness progressed to involve all extremities and respiratory muscles with decreased reflexes. A lumbar puncture was unremarkable with WBC 0, RBC 3 and protein 45 mg/dL. Electromyography (EMG) on day nine of hospitalization showed severe sensorimotor axonal polyneuropathy. She was treated with five days of intravenous immunoglobulin (IVIg) and seven sessions of plas-mapheresis with limited improvement in weakness. The patient eventually required tracheostomy due to persistent weakness. We present an atypical case of legionella pneumonia causing Guillain-Barre Syndrome. IMPACT/DISCUSSION: Legionella is an important cause of community acquired pneumonia, often with severe symptoms and a mortality rate up to 10%. Patients with legionella pneumonia can present with extrapulmonary manifestations including emesis, diarrhea, chest pain, scant hemoptysis, and high fever. Mild neurologic symptoms including headache and encepha-lopathy are sometimes seen. There are few case reports of Guillain Barre variants associated with legionella pneumonia, though over two-thirds of patients with GBS have a proceeding respiratory or gastrointestinal illness. The weakness associated with GBS is typically progressive, symmetrical, and ascending-with maximal weakness occurring within two-four weeks from symptom onset. Though up to one-third of patients may require mechanical ventilation, nearly 80 percent make a near-complete recovery. Both IVIg and plasmapheresis have demonstrated in randomized controlled trials to shorten time to neurologic recovery in GBS, though the recovery phase can take several months and can require intensive rehabilitation. Conclusion: Though weakness in critically ill patients is often attributed to critical illness myopathy, careful attention should be paid to timing, intensity, and progression of neurologic symptoms. Guillain-Barre syndrome has a known association with infections therefore clinical suspicion should remain high in patients with the combination of infection and rapidly progressive weakness

PULMONARY CRYPTOCOCCOSIS IN A HIV POSITIVE INDIVIDUAL

CASE: We present the case of a 53-year-old male with a history of COPD, chronic hepatitis B, and HIV who presented for evaluation of productive cough, shortness of breath and pleuritic chest pain. Symptoms had been gradually worsening for two-weeks. He was no longer established with an Infectious Disease physician nor taking any antiretroviral medication. Initial lab work revealed a HIV viral load of 125,000 copies/ml and a CD4 count of 42 cells/μl. Further investigation revealed patchy airspace opacities in the mid-lung fields on chest x-ray, concerning for multifocal pneumonia. CT chest demonstrated ground-glass and tree-in-bud airspace opacities throughout all pulmonary lobes, with more nodular opacities seen in the left lower lobe. He was initially treated with ceftriaxone and azithromycin for community acquired pneumonia, and prednisone for coinciding COPD exacerbation. Despite 3 days of treatment, he failed to show any clinical improvement, which prompted broadening of infectious work-up. Serum cryptococcal antigen resulted positive with a titer of 1:10. Lumbar puncture was immediately performed to rule out CNS involvement, and he was started on amphotericin B while awaiting CSF cryptococcal antigen result. Within 48 hours of starting anti-fungal treatment, his shortness of breath improved drastically. Cryptococcal antigen in the CSF resulted negative, so he was deescalated to oral fluconazole. He was discharged with plan to continue fluconazole for 3 months. At follow-up appointment one month later, he continued to endorse improvement in his respiratory symptoms. IMPACT/DISCUSSION: Pulmonary cryptococcosis is most often seen in immunocompromised patients, either as a primary infection or reactivation of a latent infection. Conditions that increase risk for pulmonary cryptococcosis include HIV infection, malignancies, chronic lung disease, and treatment with immunomodulating medications. In HIV positive patients, the presentation of pulmonary cryptococcosis is more severe, with symptoms inversely proportional to CD4 count. Most cases present with a CD4 count less than 50. Common presenting symptoms are cough, fever, dyspnea, and headache. Serum cryptococcal antigen is an excellent screening test, as it is positive in virtually all HIV patients with pulmonary cryptococcosis. This study is highly predictive of who will later develop Cryptococcal meningitis, on average detecting infection 2-3 weeks before symptoms of meningitis present. Early identification allows for treatment prior to the development of CNS manifestations, thus reducing morbidity and mortality. CONCLUSION: Our patient highlights how pulmonary cryptococcosis presents in a patient with uncontrolled HIV. In this population, serum cryptococcal antigen is an excellent screening test as it is highly sensitive for active infection. In addition, it is predictive of patients who will later develop highly morbid cryptococcal meningitis, which allows for treatment prior to CNS involvement

An Atypical Presentation Of Atypical Pneumonia: Legionella Causing Guillain-Barre Syndrome

Learning Objective #1: Recognize an atypical presentation of Legionella pneumonia Learning Objective #2: Identify the association between Guillain-Barre variants and infectious syndromes CASE: A 29 year-old-female with history of Systemic Lupus Erythema-tosus on plaquenil presented with two weeks of nausea, emesis, and cough. During that time she developed progressive numbness in bilateral lower extremities and began to experience falls at home. On presentation she was afebrile but hypoxic requiring intubation. She had no leukocyto-sis but did present with a moderate hyponatremia to 127. Chest X-ray showed patchy infiltrates and urine legionella antigen was positive. She was started on treatment with moxifloxacin. Her weakness progressed to involve all extremities and respiratory muscles with decreased reflexes. A lumbar puncture was unremarkable with WBC 0, RBC 3 and protein 45 mg/dL. Electromyography (EMG) on day nine of hospitalization showed severe sensorimotor axonal polyneuropathy. She was treated with five days of intravenous immunoglobulin (IVIg) and seven sessions of plas-mapheresis with limited improvement in weakness. The patient eventually required tracheostomy due to persistent weakness. We present an atypical case of legionella pneumonia causing Guillain-Barre Syndrome. IMPACT/DISCUSSION: Legionella is an important cause of community acquired pneumonia, often with severe symptoms and a mortality rate up to 10%. Patients with legionella pneumonia can present with extrapulmonary manifestations including emesis, diarrhea, chest pain, scant hemoptysis, and high fever. Mild neurologic symptoms including headache and encepha-lopathy are sometimes seen. There are few case reports of Guillain Barre variants associated with legionella pneumonia, though over two-thirds of patients with GBS have a proceeding respiratory or gastrointestinal illness. The weakness associated with GBS is typically progressive, symmetrical, and ascending-with maximal weakness occurring within two-four weeks from symptom onset. Though up to one-third of patients may require mechanical ventilation, nearly 80 percent make a near-complete recovery. Both IVIg and plasmapheresis have demonstrated in randomized controlled trials to shorten time to neurologic recovery in GBS, though the recovery phase can take several months and can require intensive rehabilitation. Conclusion: Though weakness in critically ill patients is often attributed to critical illness myopathy, careful attention should be paid to timing, intensity, and progression of neurologic symptoms. Guillain-Barre syndrome has a known association with infections therefore clinical suspicion should remain high in patients with the combination of infection and rapidly progressive weakness

Malignant Cardiac Tamponade: A Complication of Untreated Breast Cancer

Carcinomatous pericarditis is a rare complication of locally aggressive breast cancer in which malignant cells directly extend into the pericardium causing inflammation and creating a pericardial effusion. A 40-year-old woman with untreated metastatic breast cancer presented to an outpatient clinic in significant distress with symptoms of progressive shortness of breath and bilateral leg swelling. An urgent echocardiogram demonstrated a large pericardial effusion with echocardiographic evidence of cardiac tamponade. She underwent emergent pericardiocentesis of the effusion that was deemed to be malignant after cytologic evaluation. Subsequently, she opted for palliative treatment involving the surgical creation of a right pericardial window and placement of an indwelling pleural catheter. Internists should maintain a high index of suspicion for malignant cardiac tamponade in at-risk patients, especially those with locally aggressive and advanced malignancies

Demographic Predictors of Telehealth Use for Integrated Psychological Services in Primary Care During the COVID-19 Pandemic

OBJECTIVE: Prior to the COVID-19 pandemic, growing mental health needs were well documented, particularly those of diverse patient populations. The current study aims to better understand racial and psychosocial factors associated with patient utilization of integrated psychological services via telehealth during the COVID-19 pandemic within a diverse primary care clinic. METHODS: Retrospective chart reviews were completed for patients seen by an integrated psychology team within a general internal medicine clinic at a large urban health system during the year 2020. Demographics were extracted from the medical record. Multivariate logistic regression analyses were conducted to examine demographic predictors for (1) telehealth video visits vs. audio only telehealth visits and (2) in-person vs. telehealth visits (both video and audio). RESULTS: Older patients, Black patients, and those with Medicare and Medicaid were more likely to complete audio only telehealth visits vs. video visits. There were no significant demographic predictors when comparing in-person vs. telehealth (both video and audio). DISCUSSION: Some underserved and vulnerable patient populations are more likely to utilize audio-only integrated psychological visits to video visits. The utilization of audio visits over video for certain demographics speaks to the need to better understand how this type of care may benefit psychological services in the future and continued advocacy to extend audio mental health visits beyond the public health emergency to address patient populations with significant mental health needs

Predictors of Major Adverse Cardiac Events in Asymptomatic Low Gradient Aortic Stenosis with Preserved Ejection

Background: Patients with low mean pressure gradient (\u3c40mmHg) severe aortic stenosis (Aortic valve area \u3c1.0 cm2) despite preserved ejection fraction (≥50%) have had varying outcomes in prior studies. We sought to evaluate what clinical and echocardiographic parameters would help predict major adverse cardiac events (MACE) in these patients. Methods: A retrospective data review of patients with asymptomatic low gradient aortic stenosis with preserved ejection fraction was performed. Patients with prior valvuloplasty, surgical aortic valve replacement (SAVR), or transcatheter aortic valve replacement (TAVR) were excluded. Comprehensive demographic, clinical, echocardiographic parameters of 287 patients from January 2014 till December 2015 were obtained. Left ventricular global longitudinal strain (GLS) was able to be measured in 94 patients by using speckle tracking imaging. Composite MACE included congestive heart failure, myocardial infarction, SAVR, TAVR, or death were obtained after the initial echocardiogram date. Results: The average age of our studied population is 79.4 years (SD: 13.6). Of them, 67% (n=63) are females. Nineteen patients (20%) have atrial fibrillation, 77 patients have hypertension (82%), and 40 patients (43%) have history of coronary artery disease. Baseline echocardiographic parameters include mean aortic valve area of 0.8 cm2 (SD: 0.2) with indexed aortic valve area of 0.5 cm2/m2 (SD: 0.1). The average of mean pressure gradient is 27.8 mmHg (SD: 12.6) and the average stroke volume index (SVi) is 38.6 mL/m2 (SD: 11.5). Sixty-three patients had normal-flow low-gradient severe aortic stenosis (SVi ≥34mL/m2), while 31 patients had paradoxical low-flow low-gradient aortic stenosis (SVi \u3c34mL/m2). Composite outcomes of MACE developed in 58.5% (n=55) of the studied population (n=94). Independent univariate predictors of MACE were atrial fibrillation (OR, 4.9; 95% CI, 1.3-18.3; p=0.0174). Using a multivariate logistic regression, there were higher odds of having MACE among patients with higher mean gradient across aortic valve (OR, 1.1; 95% CI, 1.0-1.1; p=0.0025), with lower SVi (OR, 0.9; 95% CI, 0.9-1.0; p=0.0061), and with history of atrial fibrillation (OR, 5.3; 95% CI, 1.4-20.6; p=0.0163). Valvuloarterial impedance or GLS did not add any independent predictive value for MACE. Conclusion: Our single center study of low gradient aortic stenosis patients suggests that commonly used indices such as SVi, mean pressure gradient, and history of atrial fibrillation could best help predict MACE. Larger studies are necessary for further assessment

Clinical Characteristics and Morbidity Associated With Coronavirus Disease 2019 in a Series of Patients in Metropolitan Detroit

Importance: In late December 2019, an outbreak caused by a novel severe acute respiratory syndrome coronavirus 2 emerged in Wuhan, China. Data on the clinical characteristics and outcomes of infected patients in urban communities in the US are limited. Objectives: To describe the clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) and to perform a comparative analysis of hospitalized and ambulatory patient populations. Design, Setting, and Participants: This study is a case series of 463 consecutive patients with COVID-19 evaluated at Henry Ford Health System in metropolitan Detroit, Michigan, from March 9 to March 27, 2020. Data analysis was performed from March to April 2020. Exposure: Laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection. Main Outcomes and Measures: Demographic data, underlying comorbidities, clinical presentation, complications, treatment, and outcomes were collected. Results: Of 463 patients with COVID-19 (mean [SD] age, 57.5 [16.8] years), 259 (55.9%) were female, and 334 (72.1%) were African American. Most patients (435 [94.0%]) had at least 1 comorbidity, including hypertension (295 patients [63.7%]), chronic kidney disease (182 patients [39.3%]), and diabetes (178 patients [38.4%]). Common symptoms at presentation were cough (347 patients [74.9%]), fever (315 patients [68.0%]), and dyspnea (282 patients [60.9%]). Three hundred fifty-five patients (76.7%) were hospitalized; 141 (39.7%) required intensive care unit management and 114 (80.8%) of those patients required invasive mechanical ventilation. Male sex (odds ratio [OR], 2.0; 95% CI, 1.3-3.2; P = .001), severe obesity (OR, 2.0; 95% CI, 1.4-3.6; P = .02), and chronic kidney disease (OR, 2.0; 95% CI, 1.3-3.3; P = .006) were independently associated with intensive care unit admission. Patients admitted to the intensive care unit had longer length of stay and higher incidence of respiratory failure and acute respiratory distress syndrome requiring invasive mechanical ventilation, acute kidney injury requiring dialysis, shock, and mortality (57 patients [40.4%] vs 15 patients [7.0%]) compared with patients in the general practice unit. Twenty-nine (11.2%) of those discharged from the hospital were readmitted and, overall, 20.0% died within 30 days. Male sex (OR, 1.8; 95% CI, 1.1-3.1; P = .03) and age older than 60 years (OR, 5.3; 95% CI, 2.9-9.7; P \u3c .001) were significantly associated with mortality, whereas African American race was not (OR, 0.98; 95% CI, 0.54-1.8; P = .86). Conclusions and Relevance: In this review of urban metropolitan patients with COVID-19, most were African American with a high prevalence of comorbid conditions and high rates of hospitalization, intensive care unit admission, complications, and mortality due to COVID-19