North American Journal of Medicine and Science
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Unusual "Subcutaneous Mass" in a Young Adult: A Case Report of Sclerosing Epitrochlear Lymph Node and Brief Review of the Literature
Get PDFLymph nodes are specialized tissues that play an essential role in the immune system. Nodal hyalinization/sclerosis is often seen in the elderly, involving the mediastinum, pelvis, and other areas. Hyalinization of the lymph node might contribute to impaired filtration function of the node. Nevertheless, the clinical significance is still unclear. Here, we report a 35-year-old Caucasian female with an unremarkable past medical history, presented at the dermatology clinic with a subcutaneous mass in the forearm, and an excisional biopsy was performed. The histological findings are consistent with a lymph node with hyalinization and storiform sclerosis. The patient is doing well after the focal excision. Although deposition of hyaline material can be seen in the pelvic and inguinal lymph nodes of the elder, its histology is drastically different from the one seen in our case. In this case report and brief review, we compare and summarize several benign and malignant conditions associated with nodal hyalinization with or without a storiform pattern [N A J Med Sci. 2022;15(1):001-007. DOI: 10.7156/najms.2022.1501001] Key Words: lymph node, hyalinization, sclerosis, storiform patter
Scedosporiosis Transmission from Near-Drowning Donor to Kidney Recipient: A Case Report and Literature Review
Get PDFInfection is a common complication following a near-drowning event. Near-drowning victims as organ donors carry an increased risk for donor-derived infection. We report a rare case of donor to recipient transmission of scedosporiosis in a kidney transplant from a near-drowning organ donor. The patient is a 62-year-old male who received his second deceased-donor kidney transplant from a young man who died of freshwater drowning. The patient’s clinical course was complicated when the heart recipient from the same donor died of invasive scedosporiosis, and the other kidney recipient from the same donor lost the graft due to kidney fungal infection. Our patient had no symptoms with negative urine and blood cultures. Kidney biopsies on three different occasions were performed and revealed no evidence of fungal infection. However, given the high mortality rate of scedosporiosis, the grafted kidney was eventually explanted on the 37th day post-transplantation. Two small cystic lesions were found in the explanted kidney, and microscopic examination with Grocott methenamine silver (GMS) stains revealed fungal colonization within these two cystic lesions. Scedosporium spp. were further identified by PCR. In conclusion, near-drowning donors pose an increased risk for donor-derived scesdoporiosis. Routine screen tests are not sensitive enough to detect scesdoporium infection pre- or post-transplantation. Scedosporiosis is intractable, with a high mortality rate and graft loss in organ recipients. [N A J Med Sci. 2022;15(1):013-016. DOI: 10.7156/najms.2022.1501013]Key Words: near-drowning donor; donor-derived infection; scedosporiosi
Foreign Body Granuloma Induced by Submucosal Lifting Agent Mimicking Adenoma or Colorectal Carcinoma
Get PDFForeign bodies used during surgeries and endoscopy procedures may elicit inflammatory reactions and granuloma formation. The resultant lesion may mimic polyps or tumors, which require cautious interpretation. Here we reported that 69-year-old patient with history of treated rectal cancer underwent surveillance colonoscopy where a tubular adenoma was found in the cecum. A follow-up endoscopy found a flat polyp at the ileocecal valve. Right hemicolectomy was performed. On examining the specimen, two lesions were identified in the wall of the ileocecal valve area. Microscopically, there were foreign body giant cell granulomas filled with eosinophilic amorphous material which is consistent with an inflammatory reaction caused by submucosal lifting material injection used during colonoscopy for polypectomy. The granulomas mimicked recurrence of colorectal carcinoma. Therefore, surgeons and pathologists should be aware of the inflammatory reaction elicited by the new lifting agents that may resemble polyps or tumors. [N A J Med Sci. 2021;1(1):001-003. DOI: 10.7156/najms.2021.1401001]
Mixed High-Grade Neuroendocrine Carcinoma with Villous Adenoma in the Duodenum: A First Case Report
Get PDFMixed neuroendocrine non-neuroendocrine neoplasm (MiNEN) represents a rare diagnosis in the gastrointestinal tract. Only a few cases of MiNEN occurring in the small bowel had been previously reported. Here we report the first case of mixed high grade neuroendocrine carcinoma with villous adenoma arising in the duodenum. The patient is an 87-year-old female who presented for management of a 3.4 cm polypoid-like duodenal mass that was noted on a prior abdominal CT scan. PET scan showed intense uptake within the second portion of the duodenum consistent with a neoplasm. A biopsy previously performed showed tubulovillous adenoma. The patient had a remote history of breast cancer. Esophagogastroduodenoscopy was performed which showed fungating mass occupying 50% of the duodenal lumen and polypectomy was done. Grossly, the duodenal mass appeared as a pink-tan polypoid fragment of tissue. Microscopically, a villous adenoma is seen with focal area of high-grade dysplasia. Admixed with the villous adenoma, there are sheets of homogeneous small cells with high nuclear-cytoplasmic ratio, nuclear molding, high mitotic activity, and finely granular chromatin which stained positive for synaptophysin, CD56, CAM5.2, and CK8/18 while stained negative for chromogranin A, CK7, CK20, and CDX2. These findings support the diagnosis of high-grade neuroendocrine carcinoma arising in a background of villous adenoma. We report a first case of mixed high grade neuroendocrine carcinoma with villous adenoma arising from the duodenum.[N A J Med Sci. 2021;1(1):004-007. DOI: 10.7156/najms.2021.1401004
Primary Testicular Diffuse Large B-Cell Lymphoma Metastasizing to Skin and Mimicking a Kaposiform Lesion: A Case Report
Get PDFPrimary testicular diffuse large B-cell lymphoma is a well-recognized entity known for its indolent clinical course. Rapid dissemination and extensive dermal infiltration are not commonly encountered sequelae of this malignancy. Only one case report exists about its extensive dissemination and involvement of skin and bone. Here, we report a case of primary testicular diffuse large-B cell lymphoma treated with orchiectomy and adjuvant chemotherapy and recurred with widespread dermal involvement as non-blanching violet papule and nodular lesions clinically mimicking Kaposi sarcoma. Histopathological examination confirmed the lesion to be a recurrence of the original lymphoma with similar morphology and immunophenotype. Despite the adjuvant chemotherapy and radiotherapy, the disease progressed from stage-I to stage-IV within 16 months from the date of diagnosis, making it an unusually aggressive clinical course for primary testicular lymphoma. [N A J Med Sci. 2021;1(1):008-011. DOI: 10.7156/najms.2021.1401008]Key Words: primary testicular diffuse large B-cell lymphoma, Kaposiform lesio
Digital Media Use and its Implication for Sleep Disruption in Patients with ASD: A Qualitative Review with a Focus on The COVID19 Pandemic
Get PDFAutism spectrum disorder is a complex neuropsychiatric disorder characterized by impaired social communication and repetitive and restricted behavioral patterns. Patients often have multiple systemic comorbidities, such as a high prevalence of sleep disturbance. Sleep is regulated by the highly complex interplay between environmental cues, internal hormonal state, as well as neuronal circuitry. In particular, exposure to blue light from electronic devices directly impacts sleep regulation. In patients with ASD, electronic devices are double-edged swords: while they may increase blue light exposure, they often have therapeutic roles that are unique to this patient population. Sleep disorders have detrimental emotional and physical consequences, such as exacerbating behavioral dysregulation and difficulty in social communication in patients with autism. During the COVID19 pandemic, screen time exposure for people of all ages and backgrounds, including patients with autism, increased dramatically. In this qualitative review, we first summarize the recent literature on the mechanisms of sleep regulation and the importance of adequate sleep in patients with ASD. Second, we discuss the pros and cons of electronic device use in patients with ASD. Next, we assess the extent of screen time exposure in patients with autism prior to and during the COVID19 pandemic, in comparison to the control cohorts. We evaluate evidence for altered sleep duration/quality, and behavioral consequences of sleep disturbances based on the recent literature, especially those emerging from the pandemic. Finally, we make recommendations, based on our clinical experience and literature evidence, regarding measures to limit screen time to only productive use for patients with autism. [N A J Med Sci. 2021;1(1):012-020. DOI: 10.7156/najms.2021.1401012]Key Words: Autism spectrum disorder, sleep disruption, anterior hypothalamus, central nervous system, blue light, electronic device
A Rare Case Report of Primary Leiomyosarcoma of Distal Femur Bone in a Patient with Multiple Myeloma and Review of Literature
Get PDFPrimary leiomyosarcoma of bone is rare, with < 0.7% incidence of all primary malignant bone tumors. Here we report a primary leiomyosarcoma of bone arising in a patient with multiple myeloma. The patient is a 72-year-old male who was initially diagnosed with multiple myeloma (IgG Kappa) in 2007 which presented as a large plasmacytoma involving his thoracic vertebrae. He was treated with chemotherapy and eventually had a stem cell transplant in 2015. In 2017, a routine skeletal survey demonstrated a solitary lytic lesion in the right distal femur. The lesion grew fast and doubled in size to 7.9 cm within one year. The lesion was biopsied and proven to be a leiomyosarcoma. A total body PET/CT scan showed no evidence of other primary tumors or metastatic disease. The patient then underwent a distal femur resection. Grossly, majority of the tumor involved distal femur cortical bone and medullary cavity with focal extension into the surrounding soft tissue. Microscopically, the tumor consisted of fascicles of spindle cells with a focal storiform growth pattern. The tumor cells had eosinophilic cytoplasm and focally pleomorphic nuclei. The tumor cells were positive for SMA and Calponin and negative for Desmin, Myo-D1, Myogenin and S-100 immunohistochemical stains. The morphology and immunoprofile favored a diagnosis of pleomorphic leiomyosarcoma. Primary leiomyosarcoma of bone is a rare tumor and this patient’s history of multiple myeloma made it even more challenging to make an early clinical diagnosis.[N A J Med Sci. 2020;1(1):024-027. DOI: 10.7156/najms.2020.1301024] Key Words: primary leiomyosarcoma, femur, multiple myelom
Low-Value Inpatient Gastrointestinal Practices among Non-Gastroenterologists
Get PDFBackground and Aims:Management of common gastrointestinal diseases by non-gastroenterologists often includes diagnostic tests that do not positively impact patient care but increases cost of care. Our study aimed to determine the prevalence of common inpatient practices by non-gastroenterologist providers. Methods:A validated anonymous survey was designed using ‘Google Forms’ (google.com/forms) and responses were collected on a handheld tablet. The questions included basic demographics, level of training, training specialty and practices related to common gastrointestinal diseases. The practices included fecal occult blood testing (FOBT), recognition of melena, use of lipase in management of acute pancreatitis, placement of nasogastric tube in cirrhosis, duration of nil per oral (NPO) before procedures and international normalized ratio (INR) threshold for paracentesis. Descriptive analysis was performed. Results:We collected 150 responses from 4 different residency training hospitals in the United States. Of the respondents, 84% were resident trainees. Primary specialties of practice were internal medicine (82%), family medicine (11%), and others (7%). Inpatient FOBT was available in 95% of the facilities surveyed. With regards to melena, 77.5% correctly identified it as black tarry stool, but 17% also considered FOBT positive brown stool as melena. 21% correlated high lipase levels with more severe acute pancreatitis.19% considered history of cirrhosis a contraindication for placement of nasogastric tube. Only 35% performed abdominal paracentesis regardless of INR value. Discussion:Low value tests and procedures related to common gastrointestinal diseases are prevalent among non-gastroenterologists. Better communication between primary team and specialist and education is needed to optimize patient care
Evaluation of Glypican-3 Expression in Poorly Differentiated Carcinomas of Lung Origin
Get PDFGlypican-3 (GPC-3) is a glycoconjugate protein of heparan sulfate proteoglycan family and is important for embryogenesis but silenced in adult healthy tissue. GPC-3 protein is abnormally expressed in hepatocellular carcinoma (HCC) and has been used as a marker for pathological diagnosis of primary and metastatic HCC. However, GPC-3 expression has also been found in some tumors other than HCC. This study is to investigate the expression of GPC-3 expression immunohistochemically and the staining pattern in poorly differentiated carcinomas of lung primary in order to assess the value of GPC-3 as a marker for diagnosing metastatic HCC in lung. Lung tissue from 44 patients diagnosed with poorly differentiated carcinoma were evaluated, including 23 lung adenocarcinomas, 19 squamous cell carcinomas and 2 adenosquamous carcinomas. Immunohistochemical stains of GPC-3 was performed on tumor tissue samples. The expression pattern of GPC-3 was analyzed. Expression of GPC-3 was found in 45% of primary lung cancers, including 79% of squamous cell carcinomas, 18 % of adenocarcinomas, and 50% of adenosquamous carcinomas. The poorly differentiated carcinomas showed predominantly patchy positivity. The staining pattern ranged from weak granular cytoplasmic positivity to a strong membranous and cytoplasmic positivity, and both cytoplasmic and nuclear positivity. GPC-3 expression was not seen in non-neoplastic lung tissue. GPC-3 is a relatively specific marker for HCC. In this study, we demonstrated the expression of GPC-3 in a significant number of poorly differentiated carcinoma of lung. Therefore, in context of a possible metastatic HCC to the lung, caution should be made by using GPC-3 as a differential marker for HCC, and a panel of stains should be considered. [N A J Med Sci. 2020;1(1):018-023. DOI: 10.7156/najms.2020.1301018] Key Words: glypican-3, lung carcinomas, immunohistochemistry, hepatocellular carcinom
Unusual Lymphocytic and Granulomatous Pattern in Inflammatory Bowel Disease: A Case Report and Review of the Literature
Get PDFThe interpretation of colonic biopsies can be challenging if the histologic presentation is not characteristic. The association between microscopic colitis and inflammatory bowel disease is weak and unclear. Collagenous colitis has been most frequently reported in association with ulcerative colitis either before or many years after ulcerative colitis is established. There are few reports of Lymphocytic colitis in association with Crohn’s disease. To the best of our knowledge however Crohn’s disease presenting as lymphocytic pattern colitis with granulomas has rarely if ever been reported. We present a case of a 34 year old male who presented initially with perianal abscess and fistula-in-ano and subsequent colonoscopic biopsies demonstrated minimal active chronic colitis with granulomas that progressed to lymphocytic colitis pattern inflammation with granulomas within a period of 6-8 months of suboptimal compliance with therapy. [N A J Med Sci. 2020;1(1):009-013. DOI: 10.7156/najms.2020.1301009] Key Words: Microscopic colitis, Collagenous Colitis, Lymphocytic Colitis, Ulcerative Colitis, Crohn’s diseas