ORAL PRESENTATIONS – RESIDENTS SESSION 1
EXTRANODAL NATURAL KILLER T-CELL LYMPHOMA, NASAL TYPE IN A VETERAN WITH ENDEMIC EXPOSURE Michelle Livitz, Kyle Hoppens, Stephen Kantrow; Department of Medicine, LSU Health Sciences Center, New Orleans, LA.
Introduction: Extranodal Natural Killer T- Cell Lymphoma, nasal type (ENKL-NT) is a rare and aggressive subtype of non-Hodgkin’s Lymphoma within the United States. There does appear to be a genetic predisposition for this type of lymphoma, most commonly presenting in Asia and native populations of Central and South America. Case: A 47-year-old man with HTN and HLD was transferred to our care for 5 months of progressive dysphagia, odynophagia, nasal obstruction, and palatal necrotic ulceration. Associated symptoms included fever, subcutaneous nodules with excoriations of the head and neck, lung nodules, night sweats, an unintentional 40 lb. weight loss, epistaxis, and hypotension. During his hospital admission, multiple biopsies were taken of his cutaneous nodules and necrotic palatal ulceration. His hospital stay was complicated by fever, hypotension, tachycardia, tachypnea, profuse anterior epistaxis that was poorly clotting, anemia, thrombocytopenia, and neutropenia. A full infectious work up was negative. The surgical pathology of the
ulcerating palatal lesion was positive for extranodal NK/T-cell lymphoma, nasal type. This was confirmed on other biopsies of the cutaneous nodules and later a tap of the patient’s chronic pleural effusions. Prior to diagnosis, the initial flow cytometry showed normal levels of CD19, which were helpful in ruling out some subtypes of B-cell lymphoma (e.g. follicular, Hodgkin’s) with a reduced level in CD56+ cells (NK cells) since they were collecting in various portions of the body. The patient was found to have positive EBV IgG and EBV Capsid Ab IgM/IgG antibodies. Discussion: Our patient is an army veteran who spent one year deployed in South Korea when he was 19 years old. Although it is closely associated with latent EBV, there seems to be more epigenetic factors that play a role rather than direct cause and effect. While EBV is strongly correlated with this indolent disease course, it would be interesting to investigate any differences in the viral genome of EBV that is predominantly in these endemic regions and in the United States.
VASCULAR-ESOPHAGEAL FISTULA AFTER DISTAL ESOPHAGEAL BOTULINUM TOXIN INJECTION FOR ESOPHAGEAL ACHALASIA Sana Badar, Department of Medicine, Willis Knighton Health System, Shreveport, LA.
Introduction: Endoscopic injection of botulinum toxin is a common method to treat esophageal dysmotility and achalasia. Patients undergoing this procedure who subsequently present with hematemesis should be evaluated for possible complications of the procedure, including esophageal perforation and an aorto/ vascular- esophageal fistula. Case: A 73 year old female with HTN, HLD, ocular myasthenia gravis, bilateral mastectomies for intraductal carcinoma, hysterectomy, partial thyroidectomy for recurrent cyst and carotid body tumor removal in the past was scheduled for a per- oral endo myotomy (POEM) at a tertiary care center in a nearby city, however during the interim she was
admitted for severe vomiting, dehydration, inability for oral intake and aspiration pneumonia. She had a CT scan which showed 5cm aneurysm in the distal aorta and diffuse lymphadenopathy. After a 2 week hospital stay she was injected with 4 quadrant BTX injections in distal esophagus and discharged. She presented 8 days later with hematemesis and shock. Mass transfusion protocol was initiated and she had an urgent EGD showing brisk bleeding. 4 Hemostatic clips and a bear claw was applied to control the bleed. CT angiogram showed a 6mm blush from an artery at T6 with connection to the esophagus. The 5 cm distal aortic aneurysm was again noted. Coil embolization of the bleeding artery could not be done due to difficulty in visualization and 6
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