Multimodality Imaging Evaluation of Nasal Rhabdomyosarcoma in Adults: A Case Report and Literature Review

BACKGROUND

Alveolar rhabdomyosarcoma (ARMS) predominantly affects adolescents aged 10-15 years and is distinguished by its high aggressiveness and adverse prognosis compared with other sarcomas. It exhibits a pronounced tendency for lymphatic and hematogenous metastases at early stages. ARMS commonly manifests in the limbs and genitourinary system, with occurrences in the head and neck region being relatively uncommon. The role of CT, MRI, and 18F-FDG positron emission tomography combined with computed tomography (PET/CT) in the diagnostic process of ARMS is yet to be fully established.

CASE REPORT

We report the case of a 49-year-old woman who presented with hematological nasal discharge for one month. CT imaging revealed a soft tissue mass in the left nasal cavity. MRI demonstrated a marginally hypo- to isointense signal on T1-weighted images, a hyperintense signal on T2-weighted images, and heterogeneous enhancement post-contrast. 18F-FDG PET/CT identified a hypermetabolic lesion located within the left nasal cavity. Surgical intervention entailed the excision of the left intranasal mass and the skull base lesion. Postoperative pathological analysis indicated ARMS.

CONCLUSION

Sinus ARMS is notably malignant and associated with a dismal prognosis. Accurate diagnosis depends on histopathological and immunohistochemical evaluation, complemented by genetic analysis for specific chromosomal translocations and fusion genes. Imaging techniques, including CT, MRI, and PET/CT, are crucial for assessing lesion extent and metastasis, supporting disease diagnosis, informing treatment choices, facilitating surgical planning, and monitoring response to therapy.

Twenty-four-month Progression-free Survival in HER2-amplified Advanced Gastric Cancer with Brain Metastases after Trastuzumab Deruxtecan Treatment: A Case Report and Literature Review

BACKGROUND

Trastuzumab deruxtecan (T-DXd) has shown promising outcomes as a second or subsequent-line treatment for human epidermal growth factor-2 (HER2)-positive advanced gastric or gastroesophageal junction cancer.

CASE PRESENTATION

We reported a 49-year-old male patient with stage IV HER2-amplified gastric cancer. Despite extensive pretreatments, including first-line trastuzumab plus FOLFOX, second-- line trastuzumab plus FOLFOX, followed by traditional Chinese medicine, third-line nivolumab plus trastuzumab, fourth-line pyrotinib plus paclitaxel and five hepatic arterial chemoembolization procedures, and fifth-line pembrolizumab plus nab-paclitaxel and thoracic radiotherapy, the patient experienced disease progression. In April 2021, T-DXd was initiated as the sixth-line therapy in combination with radiotherapy for brain metastases. After one treatment cycle, the patient achieved a partial response. T-DXd was discontinued in August 2022 due to recurrent anemia attributed to cardiac stenosis-related bleeding.

CONCLUSION

The condition of the patient remained stable until May 2023, indicating a progression-free survival of over 24 months. This case suggests that T-DXd may offer long-term clinical benefits in patients with HER2-amplified advanced gastric cancer with brain metastases.

Large B-cell Lymphoma with IRF4 Rearrangement in the Nasolacrimal Duct: A Clinicopathological Study of One Case and Literature Review

BACKGROUND

Large B-cell lymphoma (LBCL) with interferon regulatory factor 4 (IRF4) rearrangement (LBCL-IRF4) is a rare subtype of LBCL, with a high prevalence in Waldeyer's ring as well as the neck, head and gastrointestinal lymph nodes.

MATERIALS AND METHODS

A patient with 2-month clinical symptoms of nasal obstruction and facial swelling was reported in this short review. A nasal endoscopy examination revealed a neoplasm in the inferior nasal meatus. Both CT and enhanced MRI showed that a soft tissue occupied the nasolacrimal duct, with bone destruction, and extended into the left nasal cavity and left lacrimal gland area. Then, a biopsy of the neoplasm in the inferior nasal meatus was performed.

RESULTS

HE staining results showed that neoplastic cells presented diffuse growth patterns, abundant cytoplasm, vacuole shape, lightly stained nuclei, and irregular nuclear membrane. Immunohistochemistry staining results revealed MUM1(+), Bcl6(+), CD20(+), CD79α(+), and CD10(+). FISH analyses detected positive IRF4 rearrangement. LBCL-IRF4 was diagnosed in the patient. The patient received treatment with four cycles of R-CHOP and two times of rituximab, followed up for 2 years, and finally got complete remission.

CONCLUSION

For the first time, we summarize the imaging and pathological features, drug treatment, and curative effect of LBCL-IRF4 in the nasolacrimal duct.

Antidepressant-induced Paradoxical Anxiety, Akathisia, and Complex Vocal Tics in a Patient with Panic Disorder and Crohn's Disease: A Case Report

BACKGROUND

Antidepressant-induced paradoxical anxiety is a fairly common phenomenon seen in patients who are initiated on antidepressants. However, akathisia is a very uncommon manifestation of antidepressants. Much more rarely, antidepressants are also associated with the emergence of motor and vocal tics. This case adds to the growing literature of rare adverse events induced by antidepressants and aims to stimulate future research into the mechanism and risk factors of this phenomenon.

CASE PRESENTATION

In this case report, we describe a patient with panic disorder and co-morbid Crohn's disease who developed worsening anxiety, akathisia and vocal tics upon initiation of fluvoxamine. This is the first case report to describe the emergence of both akathisia and vocal tics in the same patient following antidepressant initiation. After discontinuation of fluvoxamine, the patient's symptoms resolved.

CONCLUSION

Antidepressant-induced akathisia and tics are often distressing both to the patient and their loved ones, and they can be very puzzling to the clinician. It is important for clinicians to recognise that, although rare, antidepressants can have the adverse effects of akathisia and tics in patients. When these symptoms arise, it should prompt immediate discontinuation of the offending antidepressant.

Pulmonary Adenocarcinoma Patient with Complex Mutations on EGFR Benefits from Furmonertinib after Acquiring Gefitinib Resistance: A Case Report

BACKGROUND

Although epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) have been proven a long-lasting treatment effect in pulmonary adenocarcinoma, most patients still progressed within one year due to the acquired resistance. Complex mutations of rare rare sites after acquiring resistance are rarely reported in pulmonary adenocarcinoma.

CASE PRESENTATION

A 62-year-old woman was diagnosed with pulmonary adenocarcinoma with stage IV. Genetic testing at the initial treatment showed EGFR L858R positive. After being treated with gefitinib, persistent 2 years disease progression occurred due to drug resistance. The genetic testing showed that EGFR L858R was eliminated, while a rare rare complex mutation of L861Q/G719X appeared. After 160 mg furmonertinib was treated for 1 month, the primary tumor regressed and the intracranial lesions disappeared. The patient has achieved progression-free survival (PFS) for more than 20 months.

CONCLUSION

Pulmonary adenocarcinoma with rare rare complex mutations in EGFR induced by gefitinib resistance and disease progression might benefit from furmonertinib treatment.

Chondromyxoid Fibroma of the Distal Tibia: A Rare Case Report

Chondromyxoid fibroma is one of the rarest bone tumours, occurring most frequently in adult men in their second and third decades. It generally affects the metaphysis of long bones, particularly the femur and tibia. Diagnosis can pose differential challenges with various tumor types, particularly chondrosarcoma, requiring separate management. We present a case of chondromyxoid fibroma of the distal tibia detected by soft tissue swelling. Clinical, epidemiological and radiological aspects will be discussed.

Hypophysitis Induced by Sintilimab in the Treatment of Bladder Cancer: A Case Report

BACKGROUND

Immune checkpoint inhibitors (ICIs), as novel antitumor drugs, have been widely used in the clinic and have shown good antitumor effects. However, their widespread use has also led to the emergence of various immune-related adverse events (IrAEs). Hypophysitis is a rare but serious IrAE. Due to its complex and changeable clinical manifestations, hypophysitis may be easily overlooked, leading to delayed diagnosis and treatment.

CASE PRESENTATION

A 68-year-old male patient was diagnosed with bladder cancer (T2bNXM0) in October 2021. He received two cycles of immunotherapy with sintilimab and chemotherapy with gemcitabine and cisplatin (GC). One month after the second treatment, he gradually developed recurrent fever, anorexia, drowsiness, and delirium. Laboratory examination revealed hyponatremia, decreased adrenocorticotropic hormone, and hypocortisolemia. The pituitary MRI showed no abnormality. The patient was diagnosed with immunotherapy-induced hypophysitis (IH) caused by sintilimab, leading to downstream endocrine disorders. With hormone replacement therapy, he was in a good mood, had a good appetite, and made an overall recovery.

CONCLUSION

Immunotherapy-induced hypophysitis (IH) can result in a severe adrenal crisis, and prompt recognition and diagnosis are crucial. Clinicians must remain vigilant for the possibility of IH in patients who exhibit recurrent fever, anorexia, cognitive decline, and personality changes following ICI treatment. It is imperative to consider this diagnosis early to initiate appropriate management promptly.

Retinal artery occlusion after facial filler injection in a patient with patent foramen ovale: a case report and literature review

We describe a young woman with patent foramen ovale who developed multiple retinal artery occlusion in the right eye after injection of hyaluronic acid into the nasal root. She reported a gradual decline in visual acuity, with visual field defects that had developed in two stages. Multiple retinal artery occlusion was confirmed by slit-lamp examination, dilated fundus examination, optical coherence tomography, visual field examination, and fundus fluorescein angiography. A patent foramen ovale was detected by electrocardiography, transesophageal echocardiography, and transthoracic sonography. The patient was treated with intravenous dexamethasone and cobamamide, as well as extracorporeal counterpulsation therapy; this approach has not been described in previous literature regarding retinal artery occlusion. The patient's visual acuity improved from counting fingers at 30 cm to 20/133 within 3 days. Our report emphasizes the need for better understanding of vascular anatomy to minimize the risk of complications. Moreover, patients undergoing hyaluronic acid injection should receive information regarding the potential for mild and severe complications; relevant tests should be performed before surgery to exclude vulnerable patients. Finally, a nursing system is needed to facilitate the emergency recognition, triage, and management of retinal artery occlusion.

Identification of a Novel TSC2 c.170G>A Missense Variant: A Case Report and Elaboration on the Yield of Targeted Options against Tuberous Sclerosis Complex Manifestations

BACKGROUND

Tuberous sclerosis complex (TSC) is a rare genetic disease that affects multiple organs and affects the quality of life. Mutations in TSC1 and TSC2 genes are causing dysregulations in the mammalian target of the rapamycin (mTOR) pathway, inducing mostly benign but also malignant tumors, including renal cell carcinoma (RCC). The diagnosis of TSC, based on established clinical and genetic criteria, is essential for the optimal surveillance and management of patients.

CASE PRESENTATION

With the current report, we present the case of two sisters who were consequently diagnosed with early-stage chromophobe-like RCC, possibly familial given their young age. The younger sister also had a previous diagnosis of differentiated thyroid carcinoma, for which she had been treated properly. Genetic testing of both revealed the same heterozygous TSC2 variant that is currently regarded as a variant of unknown significance, while both patients did not fulfill the clinical criteria for the diagnosis of TSC. Owing to these data, we opted to manage and surveil both sisters as TSC patients, while we also considered the specific TSC2 variant to be pathogenic - but of low penetrance - based on clinical judgment and functional analyses. Furthermore, we discussed the implementation of mTOR inhibitors for the treatment of TSC complications.

CONCLUSION

As novel pathogenic variants of TSC genes are constantly being explored, the identification of TSC variants of unknown significance in combination with absent clinical diagnostic criteria cannot exclude a TSC diagnosis. We support the implementation of clinical judgment in assisting the diagnosis of TSC, as well as the enrollment of patients in clinical trials due to the rarity of the disease.

Coexistence of Non-Hodgkin's Lymphoma And Acute Myeloid Leukemia at Initial Diagnosis: A Case Report

BACKGROUND

Lymphoma and leukemia, both malignant hematological cancers, are primarily separate diseases, with a majority of cases originating independently. The co-occurrence of lymphoma and leukemia at the time of the first diagnosis is extremely rare, and few relevant reports exist in the medical literature. We describe a case of a patient with non-Hodgkin's lymphoma and acute myeloid leukemia, a very rare occurrence.

CASE REPORT

A 57-year-old man complained of fatigue and neck tumors. A physical examination revealed several enlarged superficial lymph nodes throughout the body. On admission, routine blood tests revealed anemia, thrombocytopenia, and normal counts of white blood cells. Cytology of two cervical lymph nodes indicated non- Hodgkin's lymphoma, 18F-PET/CT: multiple enlarged lymph nodes with hypermetabolism, diffuse hypermetabolism of the bone marrow, suggesting lymphoma infiltration in the bone marrow, and a bone marrow biopsy revealed acute myeloid leukemia. Ultimately, the patient was diagnosed with non-Hodgkin's lymphoma and acute myeloid leukemia. Conclusion： Primary bilineage hematological malignancies are rare, and the mechanism underlying their incidence is unknown. Infiltration of the bone marrow by lymphoma or leukemia can result in diffuse hypermetabolism, which is mostly diagnosed via bone marrow biopsy.

B-Cell Lymphoma Associated with COVID 19 Infection: A Case Report

PURPOSE

The most commen publications are related about COVID-19 diagnose in hematological malignancy patients, However, here we report a case involving a patient who was diagnosed with B-cell lymphoma while undergoing treatment for COVID-19, including the changes in major clinical symptoms and medical examinations, then explain of the probable causes of the case.

CASE PRESENTATION

A 74-year-old woman with a previous history of oesophageal cancer was admitted to the hospital after having cough and sputum for 15 days. Despite the COVID-19 symptoms, this patient did not have fever at time of the onset. Results of routine blood tests were normal at first but then declined with persistent fever, A whole-body CT examination ruled out the possibility of tumor-metastasis-related fever. This patient had no hepatosplenomegaly or regional lymphadenopathy, and there was no concrete evidence of haemophagocytic lymphohistiocytosis or lymphoma until bone marrow biopsy results confirmed the latter.

CONCLUSION

We describe an uncommen case of COVID-19 who was finally diagnosed with B-cell lymphoma. An awareness of persistent fever and declined routine blood tests caused by haematological malignancies instead of COVID-19 itself can aid in providing appropriate guidelines for management and treatment.

Gorham-Stout disease involving ipsilateral clavicle and scapula in a child - a case report focusing on imaging and histopathological features of this extremely rare condition

Gorham-Stout disease (GSD) is a very rare entity of unknown etiology, characterized by excessive intra-osseous proliferation of blood or lymphatic vessels, resulting in progressive resorption of bone matrix and destruction of bone. To date we have found only seven published cases concerning fully confirmed GSD of the shoulder girdle bones in children. Our case concerns an 8-year-old boy with involvement of the left clavicle and scapula. The knowledge of imaging and histopathological features is crucial for establishing the diagnosis of GSD, therefore the exchange of experiences in this field is essential for improving the care of affected patients.

Long-term Efficacy of Perampanel in a Child with Dravet Syndrome

Dravet syndrome is a genetic developmental and epileptic encephalopathy (DEE) mostly due to mutations in SCN1A gene. Perampanel is a selective and non-competitive alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonist. There is increasing experience in the use of perampanel in this syndrome; however, there is still a lack of evidence of sustained benefit years after the beginning of the treatment.

We report a twelve-year-old girl who was diagnosed with Dravet Syndrome when she was 2 years old and has been on perampanel since she was 7. Her genetic test showed a de novo previously described heterozygous SCN1A mutation in the 24th exon (c.4547C>A, p.Ser1516*). She received previous antiseizure drug combinations with little benefit. When perampanel was started, there was a complete resolution of her spontaneous seizures that has continued five years later. More studies are needed to investigate if there is an association between this excellent response and the genotype of our patient.

Toxic Epidermal Necrolysis Post COVID-19 Vaccination - First Reported Case

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a spectrum of acute, delayed-type hypersensitivity reactions that affect the skin and the mucous membranes. Medications are the culprit cause of these disorders in addition to infections and in very rare instances vaccinations. We report a case of TEN in a 49-year-old woman with no previous medical history. The disorder developed one week after receiving the first dose of COVID-19 vaccine with no other identifiable causes. The patient received two doses of tumor necrosis factor-alpha inhibitor (etanercept) and she stopped developing new lesions after two days of the initial dose; complete healing was observed after 22 days and no side effects were observed in our patient. This case demonstrates an extremely rare complication to the COVID-19 vaccine. The benefits of receiving the COVID-19 outweigh the potential risk.

A case report of disseminated histoplasmosis in AIDS diagnosed through peripheral blood smear

BACKGROUND

Histoplasma capsulatum is an environmental fungus that causes opportunistic infections in AIDS patients in endemic areas, but is uncommon in Europe. It shares clinical features with other opportunistic infections and lymphoproliferative disorders common in AIDS patients. The World Health Organization included Histoplasma antigen tests on the Lists of Essential In Vitro Diagnostics; however, they are not routinely available in non-endemic countries. Consequently, mycoses can be a great challenge for clinicians in non-endemic countries.

CASE PRESENTATION

We report the case of a 42-year-old Colombian woman admitted to an Italian university hospital with diarrhea, acute renal failure, psychomotor impairment and fever. When a screening HIV test came positive, she was screened for opportunistic infections with no results. Given the severity of her clinical condition, a broad-spectrum antibacterial and antifungal therapy was started in addition to HAART. A blood smear documented leucocytes inclusions, identified as capsular structures. On the suspicion of Histoplasma capsulatum, the patient was started on empiric amphotericin B. The diagnosis was confirmed by positive serology. Despite therapy, the patient died shortly after. In the following days, the mycology laboratory managed to grow Histoplasma capsulatum, thus confirming the diagnosis of invasive histoplasmosis in AIDS.

CONCLUSION

The case highlights the need for a high index of suspicion for the diagnosis of endemic mycosis outside of endemic areas, and the necessity of expanding access to tests. Even if antigen/antibody tests are not available, blood smear has worldwide feasibility and allows a rapid diagnosis.

Disseminated TB in an Immunocompetent Patient: A Case Report

BACKGROUND

Tuberculosis considered as a chronic infectious disease caused by Mycobacterium tuberculosis, may invade all organs but mainly affects the lungs. Overall, disseminated TB is rare in immunocompetent patients and its association with seborrheic keratosis has never been reported. ; Case Presentation: We reported a 54-year-old man with a complaint prolonged fever, abdominal pain, weight loss and lymphadenopathy without any immunosuppression who was eventually treated based on the diagnosis of diffuse tuberculosis.

Corynebacterium Striatum, an Emerging Nosocomial Pathogen: Case Reports

Corynebacterium striatum is an emerging nosocomial pathogen, capable of causing a variety of infections in immunocompromised and hospitalized patients. ; Case Presentation: We describe three cases of infection by C. striatum that were initially considered as contamination. Clinical suspicion in the wake of predisposing factors and accurate identification, using the Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry (MALDI-TOF MS), were key to implicate this commensal bacterium as a cause of infection.

Potential novel proteomic biomarkers for diagnosis of vertebral osteomyelitis identified using an immunomics protein array technique: Two cases reports

RATIONALE

Although vertebral osteomyelitis (VO) is commonly associated with high morbidity and high recurrence rate, effective diagnostic and prognostic biomarkers of VO are still lacking.

PATIENTS CONCERNS

Case 1: a 60-year-old male had had upper back pain for 3 days. Case 2: a 71-year-old female presented upper back pain for 2 days.

DIAGNOSES

Based on physical examination and findings of magnetic resonance imaging and findings by matrix-assisted laser desorption ionization-time of flight mass spectrometry, they were diagnosed with Staphylococcus aureus VO.

INTERVENTIONS

Using Sengenics Immunome Protein Array by analyzing autoantibodies in both VO patients, potential biomarkers of VO were explored.

OUTCOMES

Four subjects with more than 1600 antigens screened while the results showed that 14-3-3 protein gamma, pterin-4-alpha-carbinolamine dehydratase, fructose-bisphosphate aldolase A, and keratin type II cytoskeletal 8 were highly differentially expressed among VO and controls. Relevant auto-antibody profiles were discovered after intra-group and inter-group comparison, and based on functional rationality, an adapter protein 14-3-3 protein gamma, and pterin-4-alpha-carbinolamine dehydratase that involved in tetrahydrobiopterin biosynthesis, might serve as valuable diagnostic biomarkers.

LESSONS

This pilot study on 4 subjects with more than 1600 antigens screened on the Sengenics Immunome protein array provided a general outlook on autoantibody biomarker profiles of VO subjects. Future large-scale trials with longer follow-up times are warranted.

Takotsubo cardiomyopathy triggered by delirium tremens in a cirrhotic patient with acute-on-chronic liver failure: A case report

A 64-year-old cirrhotic woman was admitted for alcoholic hepatitis associated with renal failure. Subsequently, she displayed symptoms of alcohol withdrawal progressing to delirium tremens. During hospitalization, she developed acute respiratory distress. The electrocardiogram showed diffuse anteroseptal ST elevation. Transthoracic echocardiography revealed systolic left ventricular apical balloon-like dilation, hypokinesis of the left ventricular mid- and apical segments, and a left ventricular ejection fraction of 30%. Coronary angiography was normal and led to the diagnosis of Takotsubo cardiomyopathy. This report describes a singular case of Takotsubo cardiomyopathy precipitated by delirium tremens in a cirrhotic patient with acute-on-chronic liver failure.

Case Report: Three's a crowd: a case report examining the diagnostic and pharmacokinetic challenges in HIV-tuberculous meningitis-malaria co-infection

In 2016, 10.4 million cases of tuberculosis (TB) were reported globally. Malaria also continues to be a global public health threat. Due to marked epidemiological overlap in the global burden of TB and malaria, co-infection does occur.

An HIV-infected, 32-year-old male presented with a two-week history of headache with fevers to Mulago National Referral Hospital, Uganda. Five months prior, he was diagnosed with pulmonary TB. He endorsed poor adherence to anti-tuberculous medications. Mycobacterium tuberculosis in CSF was confirmed on Xpert MTB/RIF Ultra. On day 2, he was initiated on dexamethasone at 0.4mg/kg/day and induction TB-medications were re-commenced (rifampicin, isoniazid, ethambutol, pyrazinamide) for TBM. He continued to spike high-grade fevers, a peripheral blood smear showed P. falciparum parasites despite a negative malaria rapid diagnostic test (RDT). He received three doses of IV artesunate and then completed 3 days of oral artemether/lumefantrine. To our knowledge this is the first published case of HIV-TBM-malaria co-infection.

TBM/malaria co-infection poses a number of management challenges. Due to potential overlap in symptoms between TBM and malaria, it is important to remain vigilant for co-infection. Access to accurate parasitological diagnostics is essential, as RDT use continues to expand, it is essential that clinicians are aware of the potential for false negative results. Anti-malarial therapeutic options are limited due to important drug-drug interactions (DDIs). Rifampicin is a potent enzyme inducer of several hepatic cytochrome P450 enzymes, this induction results in reduced plasma concentrations of several anti-malarial medications. Despite recognition of potential DDIs between rifampicin and artemisinin compounds, and rifampicin and quinine, no treatment guidelines currently exist for managing patients with co-infection.

There is both an urgent need for the development of new anti-malarial drugs which do not interact with rifampicin and for pharmacokinetic studies to guide dose modification of existing anti-malarial drugs to inform clinical practice guidelines.

Cardiac magnetic resonance imaging of a patient with an magnetic resonance imaging conditional permanent pacemaker

Cardiac magnetic resonance imaging (MRI) is increasingly used as the optimum modality for cardiac imaging. An aging population and rising numbers of patients with permanent pacemakers means many such individuals may require cardiac MRI scanning in the future. Whilst the presence of a permanent pacemaker is historically regarded as a contra-indication to MRI scanning, pacemaker systems have been developed to limit any associated risks. No reports have been published regarding the use of such devices with cardiac MRI in a clinical setting. We present the safe, successful cardiac MRI scan of a patient with an MRI-conditional permanent pacing system.