control can be achieved through timely recognition
and early initiation of aggressive immunosuppression.
A RARE PRESENTATION OF RETROPERITONEAL PRIMARY EXTRAGONADAL SEMINOMA James Peeples, Victoria Chung, Brian Halbert, Melanie Sheen; Department of Medicine, Ochsner Medical Center, New Orleans, LA.
Introduction: Seminoma is a malignant germ cell tumor (GCT) usually found in the seminiferous tubules of the testicle, but it can rarely occur in extragonadal sites accounting for 2-5% of adult GCTs. It is thought that extragonadal GCTs are a result of mis-migration of germ cells along the urogenital ridge during embryogenesis. The most common extragonadal primary sites are the anterior mediastinum and retroperitoneum. Here, we report a rare case of retroperitoneal primary extragonadal GCT (RPGCT). Case: A 61-year-old male with coronary artery disease and benign prostatic hypertrophy was referred to hematology/oncology for evaluation of lymphopenia over five years with associated back pain for several months. Physical exam was unremarkable. He underwent imaging which showed multiple enlarged retroperitoneal lymph nodes, with a 3.6 x 6.0 centimeter left para-aortic lymph node conglomerate. A lymph node biopsy was performed and demonstrated cells with clear cytoplasm, large nuclei, and prominent nucleoli. The cells stained positive for PLAP, OCT ¾, and SALL4
which was consistent with seminoma. Testicular ultrasound was negative. AFP was 5.7, LDH was 231, and B-HCG was 9.4. The patient was referred to urology and medical oncology and started on systemic chemotherapy with cisplatin and etoposide. Discussion: RPGCTs are rare, and this unusual presentation is a reminder to clinicians to keep a broad differential. GCTs are highly curable when diagnosed in early stages, and prompt diagnosis is essential. This patient was diagnosed at stage IIC and is expected to have a favorable outcome. RPGCTs are treated similarly to testicular GCT, with systemic chemotherapy followed by retroperitoneal lymph node dissection if there are residual masses measuring more than 3 centimeters. The role of orchiectomy remains unclear. It is thought that there may be occult primary testicular GCT which is not evident on ultrasound in cases of RPGCT. However, this remains an area of speculation; at time of writing, this patient has started systemic chemotherapy and there are no plans for surgery.
THE GREAT IMITATOR: DISSEMINATED INTRAVASCULAR COAGULATION (DIC) De’Angellica Vaughn, Brad Broussard; Department of Medicine, LSU Health Sciences Center, Lafayette, LA.
Introduction: Disseminated intravascular coagulation (DIC) is a systemic process that causes thrombocytosis and hemorrhage. It can be triggered by a multitude of conditions, including sepsis, trauma, or malignancy. However, there are some cases where the diagnosis of DIC is much harder to make and can be mistaken for similar thrombotic diseases. Case: A 76 y/o female presented with acute renal failure, worsening fatigue, weakness, and decreased PO intake. On initial presentation, the patient was tachycardic and hypotensive with a metabolic acidosis. Prior to admission, the patient reported diarrhea that started two weeks prior but had since resolved. CT abdomen showed possible ileus but no signs of obstruction. The patient did improve clinically the next day; however, her renal function continued to decline, and she
remained hypotensive despite IVF resuscitation. Labs were significant for thrombocytopenia, elevated LDH, d-dimer, INR, normal haptoglobin, and decreased fibrinogen. She was treated for sepsis with suspicion for developing DIC. Over the next several days, the patient’s clinical picture became more obscure, and concern developed for other processes such as hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenia purpura (TTP). All of her cultures were negative and her peripheral smear was normal. As the patient’s uremia worsened, she eventually required intubation and subsequently hemodialysis. She received numerous blood products with no improvement, with her H&H remaining stable. Corticosteroids were started with some improvement in her thrombocytopenia. Despite 36
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