JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Discussion: This case highlights C. catenulate, a rare cause of fungemia. The previously reported case involved a gastric cancer patient and a presumed GI portal of entry. In our case although the organism may have entered through the GI tract the PICC line and TPN represented additional risk factors. Thus, this case underscores the importance of maintaining a high index of suspicion for fungal pathogens when risk factors are present as well as the need to promptly initiate antifungal therapy when fungemia is confirmed.
novel approach reportedby Hoss et.al with a non-CHOP induction therapy with or without splenectomy followed by autologous SCT may have better outcomes as demonstrated with our case.
DIULAFOY’S LESION – AN UNCANNY ETIOLOGY OF GASTROINTESTINAL BLEED
V. Gasia, MD; O. Lamendola, MD. Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA Introduction: Dieulafoy’s lesion is a relatively rare, but potentially life-threatening, condition. It accounts for 1–2% of acute gastrointestinal (GI) bleeding. Case: A 99-year-old woman was initially admitted due to left lower extremity cellulitis related to chronic venous stasis ulcer andwas receiving broad-spectrum IV antibiotics. Upon admission to the medical floor, she had an episode of hematemesis and multiple bowel movements with black-tarry stools. The patient denied chronic non-steroidal anti-inflammatory drug use. Her past medical history was significant for dyslipidemia and remote history of colon cancer status post colon resection. Home medications included atorvastatin 20 mg and aspirin 81 mg. Digital rectal examdemonstratedmelenic stool in the rectal vault. Hemoglobin and hematocrit on admissionwere noted to be 12.1 g/dl and 40.7 % respectively which dropped to 8.1 g/dl and 28.3 % following her GI bleed. A rise on BUN was also noted from 14 mg/dl to 34 mg/dl. Platelets and INR were normal. She received fluid resuscitation with 2 liters of crystalloid and a total of 2 units of pack red blood cells. Emergent EGD revealed a protruding and oozing vessel surrounded by normal gastric mucosa located at the greater curvature of the stomach body. The lesion was covered by a prominent fresh clot, whichwas cleared. Endoscopic hemostasis was achieved with a combination of epinephrine injection followed by BI-CAP electrocautery. The patient had an uncomplicated post-operative course and hemoglobin remained stable. Discussion: Given this patient’s clinical presentation, an upper GI bleed was suspected. Based on the patient’s advanced age and history of previous history of colon cancer, the initial differential diagnosis included peptic ulcer disease versus a GI malignancy. However, her EGD findings were consistent with a Dieulafoy’s lesion. Dieulafoy’s lesions are twice as common in men as compared towomen. These lesions can occur in any age group are diagnosedmore frequently in the elderly population. Dieulafoy’s lesions should be included in the differential diagnosis of obscure GI bleeding in all age groups.
A CASE OF HEPATOSPLENIC T CELL LYMPHOMA-A RARE, AGGRESSIVE TUMOR OF THE YOUNG
S. Cingam, MD; S. Patel, MD; N. Koshy, MD Department of Medicine, LSU Health Sciences Center, Shreveport, LA Introduction: Hepatosplenic T-cell lymphoma (HSTCL) is an unusual entity first described in 1990 that predominantly affects middle-agedmen and is classified byWHOunder peripheral T-cell lymphomas. We present a 26-year-old man with HSCTL treated with a non-CHOP regimen. Case: A 26 year old immigrant fromCameroonwithout significant past medical history presented with abdominal discomfort that was first noted 1 month prior at which time he was elbowed in abdomen during a basketball game. His abdominal discomfort continued to gradually worsen and was associated with nausea, vomiting, early satiety and decreased appetite. He developed subjective fever, chills, night sweats, fatigue and epistaxis 3 days prior to presentation. CBC with differential revealed WBC 8 x 103/ul, RBC 4.50 x 103/ul, Hemoglobin 12.9 mg/dl, Hematocrit 38.2 %, Platelets 30 x 103/ul, elevated monocytes and nRBC’s. EBV serology was positive for VCA IgG and Nuclear-antigen Antibody IgG, indicating past infection. Abdominal CT revealed marked hepatosplenomegaly with displacement of abdominal viscera. PET revealed heterogeneously increased FDG uptake in liver and spleen. Bone marrow showed increased cellularity, increased atypical lymphocytes with clustering, and sinusoidal infiltration. Lymphoid cells mainly expressed CD2, CD3 and CD8. Cells were negative for TdT, CD1a, and increase in Ki-67 expression. Bonemarrowflowcytometry revealed predominance of atypical gamma/delta T cells. Cytogenetics revealed normal male karyotype. Based on imaging, bone marrow, and flow cytometry, diagnosis of HSCTLwasmade. The patient was treated with 4 cycles of Ifosfamide, Carboplatin and Etoposide (ICE). PET showed complete resolution of uptake in liver and spleen. Repeat bone marrow showed no residual disease. He underwent splenectomy and pathology revealed no evidence of residual T-cell lymphoma. The patient then underwent autologous SCT with BEAM (Carmustine-Etoposide-Cytarabine-Melphalan) conditioning. He remains in remission after transplantation. Discussion: Although HSTCL is rare, recognition is important as it is aggressive, refractory to conventional therapies, and carries a uniformly poor prognosis. Conventional therapy consists of CHOP (cyclophosphamide-doxorubicin-vincristine-prednisone) with or without autologous stem cell transplantation (SCT). A
THREE’S A CROWD – AN EXTREMELY RARE CASE OF COR TRIATRIATUM DEXTER
A. Elagizi, MD; R. Marvin, MD; G. O’Bryan MD; V. Vyas, MD; L. Arcement, MD. Department of Medicine, Leonard J. Chabert Medical Center, Houma, LA
50 J La State Med Soc VOL 169 MARCH/APRIL 2017
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