• An Atypical Presentation of Raynaud's Disease

      Viswanath, Omar; Peck, Jacquelin; Gill, Jatinder S; Univ Arizona, Coll Med Phoenix, Dept Anesthesiol (KARGER, 2019)
      Objective: A 57-year-old female with a 33-year history of constant hand discoloration and paronychia had undergone multiple evaluations with a failure to find a diagnosis. She continues to undergo an evolving treatment regimen and diagnostic workup in an effort to find a long-eluded diagnosis. Clinical Presentation: She began to develop superficial ulcerations over the proximal phalanx of her fingers, often pruritic and erythematous, with pain and edema. Intervention: She has since been managed with nifedipine and sildenafil and intermittent stellate ganglion blocks. Conclusion: Despite still lacking a formal diagnosis, her constellation of symptoms is most likely the result of an atypical presentation of Raynaud's disease. (C) 2019 The Author(s) Published by S. Karger AG, Basel.
    • Durable and Complete Response to Herceptin Monotherapy in Patients with Metastatic Gastroesophageal Cancer

      Swofford, Brenen P.; Dragovich, Tomislav; Univ Arizona, Coll Med Phoenix (KARGER, 2017-12-11)
      Gastroesophageal cancer is the sixth leading cause of cancer-related death worldwide. The 2 most common histologies are squamous cell carcinoma and adenocarcinoma, which has seen an increase in incidence correlating with an increase in obesity in developed countries. Gastroesophageal adenocarcinoma has a preponderance to metastasize early, making it a highly lethal cancer with a low 5-year survival rate of similar to 15-25%. Therefore, for the majority of patients, treatment focuses on palliation and prolongation of survival. Combination chemotherapy regimens, mostly platinum-based, have only modestly prolonged survival in patients with stage IV disease. Recently, it was discovered that the activation of the HER2 receptor plays an important role in a minority of adenocarcinomas of the distal esophagus and stomach. This introduced the treatment option of trastuzumab (Herceptin), a monoclonal antibody directed at the HER2 receptor, which has demonstrated improvement in overall and progression-free survival as noted in the ToGA trial. Currently, the role of Herceptin therapy beyond first-line therapy and outside of combination regimens is not well established. In this case report we review 2 cases of patients with gastroesophageal cancer, with HER2 overexpression, who achieved a robust response to trastuzumab in combination with chemotherapy and were able to maintain a durable response with maintenance trastuzumab monotherapy. (c) 2017 The Author(s) Published by S. Karger AG, Basel.
    • Hodgkin Lymphoma Mimicking Osteomyelitis

      Majeed, Aneela; Chan, Onyee; Okolo, Onyemaechi; Shponka, Volodymyr; Georgescu, Anca; Persky, Daniel; Univ Arizona, Banner Univ, Med Ctr, Dept Infect Dis; Univ Arizona, Banner Univ, Med Ctr, Dept Med; Univ Arizona, Banner Univ, Med Ctr, Dept Pathol; Univ Arizona, Banner Univ, Med Ctr, Dept Hematol Oncol (KARGER, 2017-06-20)
      Hodgkin lymphoma with symptomatic osseous involvement can have a similar presentation to osteomyelitis. Common findings in symptoms, laboratory workup, and imaging can make it very difficult to distinguish between the two diseases. Excisional biopsy should be pursued if fine-needle biopsy is equivocal and suspicion of lymphoma is high. We report a case of a 40-year-old man who presented with a history of marine animal sting on his neck and later developed erythema in the area, chest pain, constitutional symptoms, adenopathy, and imaging classic for sternal osteomyelitis. Fortunately, initial biopsy prompted the possibility of lymphoma, and further workup was initiated, which confirmed Hodgkin lymphoma. This case is a good reminder that malignancies and infections can share many common features, and keeping a broad differential diagnosis can be lifesaving. Proper staging and risk stratification of Hodgkin lymphoma help determine the optimal treatment. (C) 2017 The Author(s) Published by S. Karger AG, Basel
    • Sigmoid Adenocarcinoma with Regional Scrotal Metastasis

      Swofford, Brenen P.; Dragovich, Tomislav; Univ Arizona, Coll Med Phoenix (KARGER, 2017-05-05)
      Colorectal cancer is a common disease, representing the third and second most common cause of cancer death in the United States in women and men, respectively. [Ahnen et al.: Mayo Clin Proc 2014;89:216-224; Siegel et al.: CA Cancer J Clin 2016;66:7]. It is estimated that 20% of patients have distant metastatic disease at time of diagnosis [Ahnen et al.: Mayo Clin Proc 2014;89:216-224; Siegel et al.: CA Cancer J Clin 2016;66:7]. The most common metastatic sites include regional lymph nodes, liver, lungs, and peritoneum via lymphatic/hematogenous dissemination as well as contiguous and transperitoneal routes [Ahnen et al.: Mayo Clin Proc 2014;89:216-224; Siegel et al.: CA Cancer J Clin 2016;66:7]. Upon review of the literature, we found that metastatic colon cancer to the scrotum is rare. The following case report proved to be a unique example of this type of metastasis. This rare regional metastasis is theorized to have resulted from a colo-urethro-scrotal fistula that precipitated from the patient's prior traumatic event. (C) 2017 The Author(s) Published by S. Karger AG, Basel
    • When the Tumor Lyses: A Case Report on Spontaneous Tumor Lysis Syndrome

      Dong, Jiaxi; Cao, Thanh; Tanner, Natalee; Kundranda, Madappa; Univ Arizona, Dept Internal Med (KARGER, 2020)
      Tumor lysis syndrome (TLS) is an oncological emergency characterized by severe electrolyte disturbance that typically occurs when hematologic cancer patients have been started on systemic chemotherapy. We present an uncommon case of spontaneous TLS (STLS) occurring in a patient with cholangiocarcinoma. The patient was a 59-year-old male with newly diagnosed differentiated carcinoma of unknown origin who presented with weakness, fatigue, and lightheadedness. Initial imaging revealed cholangiocarcinoma with innumerable pulmonary and hepatic metastases. The laboratory values showed leukocytosis, hypercalcemia, and lactic acidosis. He was diagnosed and treated for sepsis of pulmonary origin. Over the next 3 days, the patient's clinical condition steadily worsened despite aggressive treatment, with new-onset hypoxic respiratory failure, acute kidney injury, and septic shock. Chemotherapy was administered, with new laboratory values showing hyperuricemia and hyperkalemia, consistent with STLS. The patient was transferred to the ICU and emergently started on dialysis but expired a day later from multi-organ failure. To our knowledge, this is the second case of STLS in cholangiocarcinoma. Our patient was unique in that he presented with hypercalcemia and normal phosphorus levels, instead of the typical hyperphosphatemia and secondary consumptive hypocalcemia. While the exact pathophysiology of STLS is still elusive, we believe that the patient's initial sepsis-induced hypotension, aggressively enlarging tumor, and extent of metastasis all contributed to his rapid decline. Given the high mortality rate with TLS and its vague presentation, particularly in a chemotherapy-naive solid tumor, a high level of clinical suspicion is needed to improve patients' outcome.
    • Widespread Hypertrophic Lichen Planus following Programmed Cell Death Ligand 1 Blockade

      Myrdal, Caitlyn N.; Sundararajan, Srinath; Curiel-Lewandrowski, Clara; Univ Arizona, Coll Med; Univ Arizona, Coll Med, Banner Univ, Med Ctr Tucson, Dept Dermatol & Oncol (KARGER, 2020)
      Hypertrophic lichen planus (HLP) may not have the typical histological findings of lichen planus and often mimics squamous cell carcinoma (SCC). Distinguishing between the two can pose a diagnostic challenge. Here, we present a case of eruptive HLP mimicking SCC in the context of programmed cell death ligand 1 (PD-L1) immune checkpoint inhibition. A 73-year-old woman recently treated with durvalumab, an anti-PD-L1 antibody, presented to our clinic with diffuse hyperkeratotic papules and plaques previously thought to be eruptive SCC. The lesions did not respond to topical fluorouracil and continued to appear despite discontinuation of immunotherapy. Further histological analysis revealed intraepidermal epithelial proliferation with lichenoid inflammation. Subsequent treatment with topical corticosteroids significantly improved the size and number of lesions. The diagnosis of HLP was made based on histological features and response to topical steroids in the context of recent immunotherapy. This case reveals HLP as a potential adverse effect of PD-L1 inhibition and highlights the need for additional diagnostic assessment in patients presenting with eruptive hyperkeratotic lesions, especially on the lower extremities.