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Benign, estrogen-producing testicular Leydig cell tumor: a case report of an incidental finding explaining a patient’s infertility
Full text linkIntroduction: Classified as a sex-cord stromal tumor, testicular Leydig cell tumors (LCTs) are rare, accounting for only 1-2% of all testicular neoplasms. They are most common in men aged 30 to 60 and can produce androgens or less commonly estrogen. For patients with an estrogen-producing LCT, symptoms can include gynecomastia, loss of libido, erectile dysfunction, and infertility.
Case Presentation: A 33-year-old white male presented to his primary care physician with concerns of an inguinal hernia and was referred to a general surgeon, who incidentally discovered a mass involving the right testicle. The timeline for the mass is inconclusive but was estimated to be from two to five years with no obvious change in size noted. At presentation, he had fatigue, gynecomastia, erectile dysfunction, and tenderness of the mass to palpation. Family history included a paternal cousin with testicular cancer with metastasis to the lungs, but follow-up for this relative has not been maintained. Initial blood work showed low testosterone at 102.31 ng/dL [123.06 - 813.36 ng/dL] and negative tumor markers for alpha-fetoprotein, human choriogonadotropin and lactate dehydrogenase.
Scrotal ultrasound revealed a hypervascular solid mass in the inferior pole of the right testicle measuring 1.9 x 1.8 x 1.5 cm with a small right hydrocele and mild thickening of the right epididymis. A computed tomography scan of the chest, abdomen, and pelvis confirmed an inferior right scrotal density measuring 2.0 cm, bilateral gynecomastia, and a small fat-containing right inguinal hernia. The patient underwent a right radical orchiectomy. The gross specimen measured 1.5 x 1.5 x 1.4 cm, had a yellow-orange appearance, and was well-circumscribed with no invasion into the tunica albuginea or tunica vaginalis. Immunostaining only tested positive for inhibin which along with histological morphology confirmed a Leydig cell tumor.
Though pre-orchiectomy estradiol level was never measured, it was concluded to be estrogen-producing due to low levels of testosterone prior to surgery. Two weeks after surgery, bloodwork found low testosterone at 129 ng/dL [264 - 916 ng/dL] and normal estradiol at 27.2 pg/mL [7.6 - 42.6 pg/mL]. Treatment with Clomid showed an initial rise of testosterone to 570.31 ng/dL [123.06 - 813.36 ng/dL]. However, due to the patient’s symptoms of increased fatigue following treatment, additional blood work found normal testosterone at 489 ng/dL [264-916 ng/dL], but elevated estradiol at 60.9 pg/mL [7.6 - 42.6 pg/mL]. Pregnyl and Exemestane were added to the patient’s therapy by an infertility specialist, reducing the estradiol to normal values. The goal of this treatment was to reverse the patient’s hypogonadism while preserving fertility.
Discussion: The U.S. Preventive Services Task Force does not recommend testicular screening currently, but this case illustrates the importance of encouraging testicular self-examinations as well as increasing public awareness of the signs and symptoms of testicular neoplasms. Although rare, LCTs have a great prognosis, making early diagnosis and treatment of utmost importance
Stretch-Induced Hip Injury Causing Septic Arthritis: A Case Report
Full text linkIntroduction: Septic arthritis is a serious bacterial condition commonly affecting kids through hematogenous spread. It is frequently caused by organisms such as Staphylococcus Aureus and Kingella Kingae. The joint space of bones, such as the hips and knees of children, is a common location for septic arthritis to form. Monitoring the ESR and CRP are important in diagnosing and treating the infection. We present a rare case that highlights septic arthritis in a child that was caused by a stretching incident that was not evident due to normal lab values and was considered to be a muscle strain.
Case Report: A 10-year-old girl presents with a hip injury from stretching three days after experiencing upper respiratory symptoms. The child had been to the emergency room and physician\u27s office but did not show any signs of septic arthritis. A couple of days later, the child presented three out of the four symptoms in the Kocher criteria, which led to a high suspicion of septic arthritis. The patient was then admitted into the hospital, and underwent a surgical incision & drainage, followed by administration of a PICC Line. The patient had to undergo rehabilitation services and is on her way to recovery.
Results: Successful treatment of the patient was obtained, and the patient is undergoing multiple forms of rehabilitation to regain normal function.
Conclusion: This case demonstrates an infection that was not suspected due to the injury and no clinical evidence of septic arthritis in the beginning. This case report is designed to bring awareness to how septic arthritis can present in different ways than may be expected. The rare nature of this case led to a delayed presentation of septic arthritis, which should be expected in children who experience any injuries in their musculoskeletal system and report joint pain following the injury
Atypical Presentation of Guillain-Barré Syndrome
No full textIntroduction
Guillain-Barré Syndrome (GBS) is a rare, immune-mediated polyneuropathy that typically presents with ascending muscle weakness and areflexia. However, atypical features can obscure diagnosis, leading to delays in treatment. Primary care physicians (PCPs) often serve as the first point of contact for patients with evolving neurological symptoms. This case illustrates an unusual presentation of GBS with hyperreflexia and no preceding infection, highlighting key diagnostic challenges for PCPs in recognizing non-classical cases early.
Case Description
A 35-year-old female with asthma and depression presented with three weeks of progressive weakness, tremors, and blurred vision, beginning two days after a camping trip. Initial workup, including Lyme titers and inflammatory markers, was unremarkable. Despite a 12-day steroid trial, her symptoms worsened. Examination revealed hyperreflexia, tremors, and proximal weakness—findings atypical of GBS. After multiple evaluations, cerebrospinal fluid analysis and MRI confirmed the diagnosis. She was treated with a five-day course of IVIG, leading to significant improvement. Early respiratory monitoring and rehabilitation were initiated to prevent complications.
Discussion & Conclusion
This case underscores the importance of recognizing atypical GBS presentations in primary care and emergency settings. Hyperreflexia and an absence of preceding infection can lead to misdiagnosis. PCPs and emergency physicians should maintain a high index of suspicion and initiate early neurological evaluation, including cerebrospinal fluid analysis and nerve conduction studies. Prompt treatment with IVIG or plasmapheresis, along with multidisciplinary management, is crucial for improving patient outcomes
Complete Androgen Insensitivity Syndrome in a 76 year-old Cadaver
Full text linkIntroduction:
This case study examines the anatomical and clinical features of a 76-year-old cadaver with Androgen Insensitivity Syndrome (AIS), an X-linked recessive disorder causing androgen resistance, resulting in the feminization of 46, XY individuals. Our case study highlights AIS classification, clinical manifestations, and management strategies, including the risks of testicular cancer, gonadectomy, hormone replacement therapy, and psychological considerations, emphasizing a multidisciplinary approach for optimal patient care.
Methods:
Gross anatomical dissection was conducted to assess the external and internal structures, with high-resolution images captured and enhanced for clarity. Precise measurements were taken and compared to typical female anatomy in order to ascertain the anatomical variations found in AIS.
Results:
The donor, identified as female on the death certificate, exhibited predominantly female external characteristics, including a clitoris, labia, and a blind-ending vaginal pouch; however, internal structures revealed male reproductive anatomy, including a prostate, seminal vesicles, and undescended gonads.
Discussion/Conclusions:
The anatomical results align with a diagnosis of complete androgen insensitivity syndrome (CAIS), where external feminization occurs despite the presence of male internal reproductive structures. This case underscores the complexities of CAIS, emphasizing the need for a multidisciplinary approach to patient management. Key considerations include the risks associated with gonadectomy, hormone therapy, cancer screening, and psychosocial support. By highlighting anatomical variations and clinical challenges, this study contributes to the broader understanding of intersex conditions and informs best practices for medical care
Treatment-Induced Neuropathy of Diabetes Complicated by Orthostatic Hypotension: A Case Report
Full text linkINTRODUCTION/BACKGROUND:
Treatment-induced neuropathy of diabetes (TIND) is a rare, iatrogenic small-fiber neuropathy caused by the rapid lowering of glucose levels in patients with previously poorly controlled diabetes. The prevalence of this condition remains undetermined as TIND remains an unrecognized complication of diabetes. In contrast to the classical sensory-motor polyneuropathy of diabetes, TIND is characterized by a more acute onset neuropathic pain. An important positive correlation exists between the magnitude and rate of change in HbA1c levels and the severity of symptoms. The more significant and rapid the decrease in HbA1c levels, the greater the intensity and distribution of neuropathic pain. This occurs independent of the agent used to correct the high HbA1c.
RESULTS:
A 50-year-old female with a significant history of poorly controlled type 2 diabetes mellitus (DM2) complicated by peripheral neuropathy presented to the ED following syncopal fall. During syncopal evaluation, the patient denied a prior history of stroke or seizures but reported long-standing orthostatic hypotension. A CT pan-scan revealed no acute processes. During the current admission, laboratory evaluations were unremarkable.
Per chart review, the patient previously presented with bilateral lower extremity weakness and paresthesias. A formal diagnosis of type II diabetes mellitus was made 5 months prior, when the patient’s HbA1c levels were reduced from 15.0 to 7.1. The patient was ultimately assigned a diagnosis of treatment-induced neuropathy of diabetes following confirmation by EMG.
DISCUSSION:
Gabapentin dose was increased, and duloxetine was initiated for neuropathic pain. The insulin regimen was optimized with increased glargine and prandial lispro to maintain glycemic control. The patient was referred for further rehabilitation and discharged to a skilled nursing facility (SNF) in stable condition.
This case highlights the complexity of managing treatment-induced neuropathy of diabetes, particularly when complicated by autonomic dysfunction. Rapid glycemic control was associated with significant peripheral neuropathy and orthostatic hypotension, consistent with TIND. Our case stresses the need for ongoing research due to the wide gap in the literature regarding TIND and reinforces for clinicians the importance of recognizing symptoms of TIND and its potential multisystem involvement
A scoping review of trauma-informed care in reproductive healthcare settings: implications for healthcare education, training, and practice
Full text linkThe experience of trauma is highly prevalent and results in physiological and psychological consequences. Trauma-informed care (TIC) has emerged in recent years as a patient-centered culture of care delivery that emphasizes physical and psychological safety for all in the healthcare setting. Even though the research on TIC shows positive outcomes for patients, and healthcare professionals desire more education on TIC, there are few standard curriculums at the undergraduate, postgraduate, and residency levels of healthcare education. Utilizing a TIC framework could be especially impactful in reproductive healthcare settings due to the invasiveness of certain examinations and the way trauma presents itself in these settings. We used a scoping review framework to examine the existing knowledge on TIC in reproductive healthcare settings and assess implications for healthcare provider training and education on TIC. Eligible articles were located by searching databases such as PubMed and Google Scholar, and then relevant articles were reviewed and categorized by three coders. This project summarizes the current literature on trauma-informed care, emphasizing reproductive healthcare settings. This project also identifies gaps in healthcare education that perpetuate our current shortcomings in care delivery. Implications of this project are relevant for healthcare students and faculty, practicing clinicians and healthcare providers, and patients both with or without a trauma history
Bilateral Carotid Artery Dissection After a Fall: A Case of Horner\u27s Syndrome Revealed on Examination
Full text linkTraumatic carotid artery dissections (TCAD) are rare and occasionally present with third-order Horner\u27s syndrome, defined as ipsilateral ptosis, miosis, and anhidrosis. We present a case involving a 53-year-old female with no significant past medical history who presented to the emergency department after tripping and falling down a flight of stairs. Over three weeks, the patient had persistent tinnitus, right neck pain and, on the exam, was noted to have right-sided miosis and ptosis. These exam findings led us to obtain a CT angiogram of the head and neck, which revealed a bilateral internal carotid dissection. The patient was taken for cerebral angiography, which confirmed the diagnosis, and was started on Aspirin and Plavix. Horner\u27s syndrome in the setting of trauma, while subtle, can reveal carotid artery dissections
Applying the Updated Renfrew Error Classification and Osteopathic Principles to Radiology Interpretation: A Case-Based Approach
Full text linkBackground: Diagnostic errors in radiology can lead to delayed or incorrect diagnoses. The updated Renfrew error classification system (updated by Kim and Mansfield in 2014) is a commonly cited framework for classifying diagnostic errors in radiology. Osteopathic medicine principles, on the other hand, provide a more general framework that focuses on a whole-person, patient-centered approach to diagnosis and interpretation in medicine. This study examines three documented cases of diagnostic errors in radiology through the lens of both frameworks to propose strategies for error reduction.
Methods: Three radiology cases with documented errors were analyzed and classified according to the updated Renfrew error classification system. Each case was assessed for factors contributing to the errors with a focus on how application of osteopathic tenets and principles may mitigate these errors.
Results: The Renfrew errors identified in the four cases we reviewed include missed edge-of-image pathology, satisfaction of search, faulty, communication breakdown, and underreading.
Case one involved a pathological humeral fracture missed on a chest X-ray, likely due to distraction–satisfaction of search error–by a complete left hemithorax white-out with mediastinal shift. The fracture was also at the image’s edge. An osteopathic implementation of a holistic approach—integrating the patient’s malignancy history and using a standardized search pattern—may have prevented errors of satisfaction of search and missed edge-of-image pathology.
Case two involved a skull fracture on a scout image–which was overlooked. While scout images are primarily for positioning, they can still reveal pathology not captured in diagnostic images. A more osteopathic approach—systematically reviewing all images holistically and applying a standardized search pattern that includes all available images—could have prevented this edge-of-image pathology error.
Case three involved a missed diagnosis of slipped capital femoral epiphysis (SCFE), initially interpreted as normal in the emergency department. The abnormality was later identified after discharge, but due to a communication breakdown, the patient was lost to follow-up. Months later, the patient presented to his PCP with worsening pain and decreased mobility, and repeat imaging confirmed SCFE progression. This case illustrates the errors of underreading and communication breakdown, emphasizing the osteopathic tenet that structure and function are interrelated—disease progression led to impaired mobility and increased pain. Improved interdisciplinary and physician-patient communication, which aligns with the osteopathic principle of facilitating patient-centered care, could have mitigated disease progression and its impact on physical function.
Conclusion: Applying osteopathic principles to image interpretation may help reduce errors in radiology. Integrating patient history with imaging findings and systematically reviewing all aspects of the image, including areas at the periphery, can reduce errors classified by the Renfrew system. This approach highlights the application of the osteopathic tenet of the body as a unified system of body, mind, and spirit. Additionally, improving communication among physicians and with patients aligns with the osteopathic principle of patient-centered care, emphasizing the importance of collaboration and closed-loop communication. These strategies, grounded in osteopathic medicine, may enhance diagnostic accuracy and promote better patient care and outcomes
Cell permeable PKCβII peptide inhibition reduced cell viability in MCF-7 breast cancer cells: Implications for ER+ breast cancer treatment
No full textIntroduction
MCF-7 human breast cancer cells have long been used as a model for hormone receptor-positive breast cancer, which is characterized by estrogen receptor-positive (ER+), progesterone receptor-positive (PR+), and human epidermal growth factor receptor 2-negative (HER2-) status. In ER+ breast cancer, estrogen binding stimulates the transcription of genes crucial to unchecked cell proliferation, such as cyclin D1. Protein Kinase C beta II (PKCβII) has been shown to enhance estrogen-driven growth in ER+ breast cancer through phosphorylation of estrogen receptors (ERs), leading to increased transcriptional activity and faster tumor growth. Additionally, PKCβII reduces apoptosis through upregulation of Bcl-2 expression and suppression of p53. By simultaneously enhancing proliferation and inhibiting apoptosis, PKCβ-II contributes to therapeutic resistance in hormone-positive breast cancer, limiting the efficacy of standard treatments. We hypothesize that treatment of MCF-7 cells with PKCβII inhibitor (PKCβII-) in vitro will reduce breast cancer cell viability. By targeting key signaling pathways implicated in the pathogenesis of ER+ breast cancer, we aim to explore the potential of PKCβII inhibition as a therapeutic adjunct to current treatment modalities.
Methods
MCF-7 were cultured in a 96-well plate, with 8 wells serving as untreated controls and 32 wells allocated for treatment with varying concentrations of PKCβII- conjugated to cell-permeable N-terminus conjugation of myristic acid (Myr) and Transactivator of Transcription (Tat) peptide (YGRKKRRQRRR) along with a cysteine-cysteine (C-C) spacer conjugated to PKCβII- cargo sequence (SLNPEWNET) (Myr-Tat-PKCβII-). Each concentration was tested in 8 replicate wells, while the remaining wells were left unused. The concentrations of Myr-Tat-PKCβII- used were obtained through serial dilution to achieve concentrations of 0.5-20μM. MCF-7 cells were treated with Myr-Tat-PKCβII- (0.5-20μM) or untreated control for 37 minutes. Cell viability was assessed by light microscopy and spectrophotometric analysis using a cell counting kit. Lower absorbance (measured at 450nm) indicates reduced cell viability or increased cell death. Absorbance data were analyzed using student T-test.
Results
Myr-Tat-PKCβII- concentration-dependently promoted MCF-7 cell death at 20μM 0.5±0.06; n=5, p\u3c 0.05 compared to controls (1.03±0.09, n=5). Notably, lower doses of Myr-Tat-PKCβII- (0.5-5μM) demonstrated higher absorbance values (1.16±0.05, 1.20±0.07, 1.17±0.06, 1.2±0.05, 1.13±0.04; n=5, p\u3e0.05, respectively) than untreated control.
Discussion
The decrease in absorbance following Myr-Tat-PKCβII- treatment suggests a reduction in metabolic activity and cell survival in MCF-7 cells at 20μM of Myr-Tat-PKCβII- compared to untreated controls. These findings support the possibility of a potential benefit for the adjunctive use of Myr-Tat-PKCβII- in current ER+ breast cancer treatment at specific doses. Cancer cells often respond to partial inhibition of pro-survival signaling proteins, such as kinases, by compensatory activation of the same or parallel pathways. At lower doses of Myr-Tat-PKCβII-, MCF-7 cells may utilize these compensatory mechanisms to sustain cell viability, as indicated by increased absorbance. Compensation may become less effective once a higher threshold of inhibitory treatment is reached. Further testing with an increased sample size at an optimized concentration of Myr-Tat-PKCβII- could strengthen the statistical power of these findings and provide more insight into the molecular mechanisms underlying PKCβII inhibitor-mediated MCF-7 cell death
Investigation of Generalized Lymphadenopathy and Lung Cancer: A Cadaveric Case Study
Full text linkIntroduction:
Generalized lymphadenopathy is characterized by the abnormal enlargement of lymph nodes throughout the body. This finding is clinically significant and can be indicative of potential systemic diseases, including but not limited to infections, autoimmune disorders, and malignancies. Lung cancer, one of the leading causes of cancer-related mortality worldwide, often metastasizes to the lymph nodes. This case report aims to investigate and analyze the relationship between generalized lymphadenopathy and lung cancer through cadaveric dissection and laboratory testing. In this study, we observe a case where widespread lymph node enlargement is present in conjunction with diagnosed lung cancer, offering an opportunity to explore both the anatomical and pathological aspects of these conditions.
Objective:
The primary objective of this study is to investigate and analyze the relationship between generalized lymphadenopathy and lung cancer, exploring potential metastatic patterns through a cadaveric dissection.
Methods:
A detailed cadaveric dissection was performed to examine and document lymph node character, location, and potential sites of metastasis. Photography and thorough notes were captured for documentation. Enlarged lymph nodes from the axilla, inguinal region, and other areas, along with normal and abnormal lung tissue samples, were collected and sent for comprehensive laboratory analysis, including histopathological examination. Additional abnormalities identified during the dissection will be documented and subjected to further testing to ensure a comprehensive report. Laboratory results were analyzed and compared with existing literature to assess the relationship between generalized lymphadenopathy and lung cancer, with a focus on potential metastasis.
Results:
The laboratory results and histopathological results are ongoing and pending. The comparison of our results with existing literature aims to expand our knowledge regarding generalized lymphadenopathy and lung cancer, highlighting the potential role of lymphatic spread in cancer progression. Through comprehensive analysis of our findings, we aim to enhance the understanding of oncologic pathology and metastatic patterns.
Discussion:
The findings gained in this investigation aim to contribute valuable insight to the current medical literature regarding the relationship between generalized lymphadenopathy and lung cancer. It will aid in understanding the role of lymphadenopathy in the potential metastasis of lung cancer. This report seeks to raise awareness and emphasize the importance of early detection and clinical features associated with lung cancer. This report will highlight the significance of cadaveric dissections in providing valuable insights into cancer pathology and its associated lymphadenopathy. The anatomical and pathological correlations observed in this study further emphasize the critical role of cadaveric dissection in medical education and research. Through direct examination of metastatic pathways, this study offers a unique perspective that enhances our understanding of disease progression beyond what is typically observed in non-cadaveric studies. The findings aim to enhance the current understanding of metastatic cancer processes and to help inform diagnostic and therapeutic strategies in oncology