COCCIDIOIDOMYCOSIS
RECURRENCE OF DIFFUSE LARGE B CELL LYMPHOMA PRESENTING AS ACUTE PANCREATITIS N. Sahami; R. Poudel, B. Chandamuri; J. Kennedy Department of Internal Medicine, Leonard J. Chabert Medical Center, Houma Introduction: Diffuse large B cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma (NHL) accounting for nearly a third of all cases. Disease can arise in either nodal or extranodal tissues. Extranodal extramedullary tissue account for nearly 40% with the most common site being the primary extranodal disease of stomach/gastrointestinal tract. However diffuse large B cell lymphoma presenting as acute pancreatitis is quite uncommon. Case: A 36 year oldman with past medical history of treatment naïve Hepatitis C, and alcoholic induced cirrhosis, diffuse large B cell lymphoma GCB subtype presents to the Emergency Department for sharp epigastric pain with radiation to the back. Lipase was within normal limits but CT scan showed a soft tissue density mass in the region of the portacaval space measuring 4.6 x 2.8 cm in greatest dimension. Of note, the patient previously had CT scan that showed 11 cm mass in retriperitoneum anteriorly displacing the head of the pancreas. CT- guided biopsy of mass showed DLBCL of the GCB subtype. R-bendamustine chemotherapy was initiated followed by 5 cycles of R-CHOP and ISRT after which repeat CT did not show any evidence of disease. With these persistent symptoms and history of lymphoma, PET CT was performed and biopsy of recurrent mass showed recurrence. A decision was made to proceed with R-DHAP salvage therapy. Initially, the tumor showed some response to the therapy, however the patient was unable to tolerate the side effects with worsening hepatic function with increasing biliary and pancreatic duct dilatation. Subsequently biliary drain was placed to relieve the strictures and extrahepatic compression of the tumor with initial down trend of LFT’s and improvement in bilirubin. Shorty there after the drain became infected, requiring long term antibiotic therapy. Initial plans of auto-hematopoietic stem
symptoms are chest pain, cough and fever. Routine laboratory findings are frequently unremarkable. Common radiographic abnormalities include unilateral infiltrate and ipsilateral hilar adenopathy. In general, mild disease does not require antifungal therapy. Therapy with either fluconazole or itraconazole is recommended for patients who are at higher risk of developing severe disease.
M. Ziada; B. Morehead; M. Modica Department of Internal Medicine, LSU Health Sciences Center - New Orleans Case: A 28 year old man with who worked as a laborer and had a history of tobacco use presented with a 7 day course of intermittent high-grade fevers associated with sweats and generalized body aches which he described as “bone pain” and mild nausea without vomiting. He emigrated from Mexico 3 years prior and had no other recent travel. On physical exam, his vital signs were BP 123/51mmHg, pulse 123 bpm, Temp 100.5° F, Resp 22/min, SaO2 100% on room air. He was diaphoretic, with shallow breathing, but lungs were otherwise clear to auscultation. The remainder of his exam including neuro exam was unremarkable. Shortly after admission, he became hypotensive (88/49 mmHg) and he was not responsive to a 4L fluid bolus. He required presser support and was transferred to the ICU. Labs were significant for Leucopenia (26% bands, 63% neutrophils, 10% Lymp), thrombocytopenia, BUN 28 mg/dl, Cr 1.88mg/dl, transaminitis and elevated bilirubin. Computed tomographic imaging of the chest revealed a solitary necrotic nodule with fluid and gas. AFB smear and T.Spot were negative. He was treated for lung abscess and discharged. Further laboratory studies returned including Leptospira IgM which was positive but PCR was negative. Coccidioides antibodies IgM and IgG were positive. Repeat CT chest did not show improvement and lung biopsy was performed. Fungal culture from biopsy material grew Coccidioides immitis/ posadasii . Discussion: Coccidioidomycosis is an infection caused by the dimorphic fungi of genus Coccidioides. Most infections are caused by inhalation of spores. The clinical expression of disease ranges from self- limited acute pneumonia to disseminated disease, especially in immunosuppressed patients. In the United States, most cases are concentrated in southwest. Less than one-half of all infections come to medical attention because illness is often subclinical. Primary infection manifests as CAP approximately 7-21 days after exposure. Most common
25 J LA MED SOC | VOL 171 | NO. 1
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