Abdominal Lymphadenopathy Research Articles

Evaluation of pre-operative clinical finding and per-operative assessment of carcinoma stomach in tertiary settings of Bangladesh

Background: Carcinoma stomach, a major killer cancer all over the world, is still presenting late in developing countries due to delay in early diagnosis, lack of awareness, infrastructure etc.
 Objectives: To establish the importance of preoperative evaluation on operability of carcinoma stomach.
 Methods: Sixty clinically and histopathologically diagnosed ca stomach cases who underwent surgery in department of Bangabandhu Sheikh Mujib Medical University, Dhaka, and Dhaka Medical College Hospital, Dhaka in 2011 were assessed with clinical picture, investigations, preoperative evaluation and peroperative findings were recorded. Z test for proportion was used to assess clinical decision predictability with a p value of :s;0.05 as significant.
 Results: Male (73.33%) predominant with 2.75:1 male:female ratio was observed. Mobility, fixity and abdominal lymphadenopathy were not well detected through clinical assessment (p=0.001) while ascites, metastasis and Shelf of Slummer were similar in both clinical and operative finding. The endoscopy of upper GIT finding gave a unique picture as the findings were almost same as were found during operation. USG detected a lesser proportion of the clinical condition compared to peroperative condition whereas CT performed better than the USG except for the lesion detection. Though Computed Tomography (CT) detected higher percentage of lesion, metastasis, ascites and lymph node involvement compared to ultrasonogram (USG), it was significantly higher only for lesion detection (p=0.002) and lymph node involvement (p=<0.001). In the similar manner USG assessment of lesion detection (p=<0.001) and lymph node involvement (p=0.003) was significantly low compared to operative finding. When we looked between CT and operative finding only lesion detection was significantly low (p=0.01) indicating CT to be most effective predictor of clinical picture for operative decision. Preoperative plan were mostly not in accordance with peroperative decision except for total gastrectomy.
 Conclusion: The study indicates weakness in clinical detection and pre-operative plan compared to per-operative finding. Hence combination of clinical feature and investigation tools especially endoscopy of upper GIT combined with CT is recommended to predict a better operative decision.
 Journal of Surgical Sciences (2018) Vol. 22 (1): 43-46

Systemic mastocytosis with chronic myelomonocytic leukemia followed by transformation into acute myeloid leukemia

AbstractIntroductionSystemic mastocytosis (SM) with an associated hematological neoplasm (SM-AHN) constitutes about 40% of all patients with SM. AHN commonly includes myeloid neoplasms and chronic myelomonocytic leukemia (CMML) is seen in about 30% of these patients.Case reportA 67-year-old male presented to hematologist with fatigue and significant weight loss. Abdominal ultrasound and computed tomography (CT) detected hepatosplenomegaly, abdominal lymphadenopathy, and ascites. He was anemic with leukocytosis and eosinophilia. Trephine biopsy showed > 30% of spindle-shaped mast cells. TheKITD816Vmutation was present. Serum tryptase level was elevated to 62 ng/mL. The patient was diagnosed with aggressive SM and received six cycles of cladribine with partial response. Three years later, he developed severe anemia. Eosinophilia and monocytosis (5.6 × 109/L) were demonstrated in blood film. Hepatosplenomegaly and abdominal lymphadenopathy were also present. Trephine biopsy did not demonstrate the presence of spindle-shaped mast cells, but dysplasia in erythroid and myeloid lineages was evident. The histological result of lymph node biopsy as well as blood and bone marrow findings were in line with CMML. He received hydroxyurea, but he transformed soon into fatal acute monocytic leukemia.ConclusionsThe prognosis of SM-AHN depends on AHN component. Leukemic transformation of AHN component may occur in a proportion of patients.

The prognostic significance of POD24 in 106 cases with splenic marginal lymphoma with bone marrow invasion

目的探讨24个月内疾病进展（POD24）对伴骨髓侵犯的脾边缘区淋巴瘤（SMZL）患者总生存的影响，比较POD24与非POD24患者的临床特征。方法回顾性分析2002年1月至2017年1月中国医学科学院血液病医院收治的有治疗指征且经过正规治疗的伴骨髓侵犯的SMZL患者，选取随访时间足以对POD24进行判断的患者（排除因非进展因素发生死亡的患者），进行预后评估及临床特征比较。结果共入组患者106例，中位年龄57（25～79）岁。①临床特征：全部患者均有骨髓侵犯和脾肿大，其中巨脾59.4％（63/106），肝大14.8％（15/101）；复杂核型22.7％（18/79），13q缺失5.1％（4/78），11q缺失1.3％（1/72），17p缺失2.5％（2/80），12号染色体三体（CEP12）7.5％（4/53）。②生存分析：单因素分析提示POD24、HGB<100 g/L以及CEP12为与总生存相关的不良预后因素；多因素分析提示仅POD24有独立预后意义［HR＝20.116（95％CI 2.226～181.820），P＝0.008］。③亚组分析：POD24患者较非POD24患者起病时纵隔淋巴结肿大的发生率（63.6％对18.9％，P＝0.005）及复杂核型发生率（50.0％对17.9％，P＝0.024）明显增高；腹腔淋巴结肿大、贫血、血小板减少、白蛋白下降以及乳酸脱氢酶增高的发生率在POD24患者中更高，与非POD24患者相比差异无统计学意义（P>0.05）。结论POD24为影响伴骨髓侵犯的SMZL患者总生存的独立预后不良因素，起病时伴纵隔淋巴结肿大及复杂核型的患者发生POD24比例更高。

A "happy ending" of mediastinal and abdominal lymphadenopathy associated with hepatosplenomegaly and pulmonary lesions.

Major diagnosis for mediastinal and abdominal lymphadenopathy is lymphoma and tuberculosis. Spontaneous remarkable evolution should discuss viral infection on the condition that no corticosteroids have been taken before as they could magically improve an authentic lymphoma. Trial of antituberculosis treatment that is used in some cases could lead to a misdiagnosis as the viral‐infected patient can spontaneously heal as it is described in this case.

Clinical characteristics of metastasis-induced acute pancreatitis in patients with lung cancer

Objective: To analyze the clinical features and prognosis of lung cancer patients with metastasis-induced acute pancreatitis (MIAP), and to provide clues for early diagnosis. Methods: The characteristics and prognosis of 8 patients with MIAP in lung cancer admitted to Peking Union Medical College Hospital from January 2002 to September 2019 were retrospectively analyzed and were compared with non-tumor-induced AP. Results: Sevencases(7/8) were Mild AP, one (1/8) was Severe AP. Four patients (4/8) presented with AP as the reporting sign and lung cancer was not diagnosed until (112±36) days after the onset of AP. Clinical manifestations included abdominal pain (8/8), weight loss (4/8), nausea and vomiting (2/8), and jaundice (1/8). Stages of lung cancer were all Ⅳ.Histopathology proved that seven cases (7/8) were small cell lung cancer, and one case (1/8) was poorly differentiated adenocarcinoma. The median survival time was 11 months. Compared with non-tumor-induced AP, lung cancer patients with MIAP were older[(62±9) vs (48±15), P=0.018], the incidence of primary pancreatic duct dilatation (37.5% vs 3.1%, P=0.004) and abdominal lymphadenopathy (37.5% vs 6.3%, P=0.017) were higher; the level of hemoglobin [105.3±15.6) g/L vs (147.9±24.8) g/L, P<0.001] and hematocrit [(31.4±5.3) vs (42.5±6.1), P<0.001] were lower. Conclusions: Patientswith MIAP in lung cancer had poor outcome and unspecific symptoms. Old age, anemia, main pancreatic duct dilatation and abdominal lymphadenopathy are diagnostic clues that merit clinical attention.

Rifampicin Induced Addisonian Crisis In a Patient With Suspected Adrenal Tuberculosis

A 49-year-old Indian gentleman attended A&amp;E reporting a three-day history of fever, rigors and lower back pain. A CT KUB incidentally revealed a left adrenal mass and widespread abdominal lymphadenopathy. A subsequent CT NCAP showed lymphadenopathy above and below the hemidiaphragm with bilateral adrenal masses. A PET scan showed avidity in these locations. A right axillary lymph node biopsy revealed granulomatous lymphadenitis with focal necrosis. No microorganisms, including acid-fast bacilli were seen on staining. His Mantoux test was positive (34mm). Given his epidemiological risks factors, positive Mantoux test and evidence of necrotising granulomas on biopsy, tuberculosis was considered the most likely diagnosis, although lymphoma remained within the differential. He commenced standard first-line anti-tuberculosis treatment. One week later he re-presented reporting fever, dyspnoea, vomiting, generalised abdominal pain and increased skin pigmentation. He was tachycardic, hypotensive and hypoglycaemic (HR 129, BP 105/73, BM 3.8). Investigations showed a marked hyponatraemia, metabolic acidosis (Na+ 115, pH 7.24) and deranged liver function tests (ALT 510). ACTH was raised (869 ng/L) and a short Synacthen test showed no rise in serum cortisol. His tuberculosis medication was held and he was treated for Addisonian crisis with intravenous hydrocortisone and oral fludrocortisone. It is likely that commencing rifampicin induced metabolism of endogenous steroid, thus precipitating the crisis. Potentially, he was already compensating for low endogenous steroid production prior to initiation of rifampicin, caused by adrenal tuberculosis. He subsequently improved and was discharged with oral hydrocortisone and fludrocortisone. His tuberculosis medications with be restarted as an Outpatient.

Successful Use of Brigatinib Followed By Allogeneic Stem Cell Transplantation in Primary Refractory Anaplastic Lymphoma-Kinase Positive Large B Cell Lymphoma

Anaplastic lymphoma-kinase (ALK) positive large B cell lymphoma (LBCL) is a rare, aggressive lymphoma with high relapse rates and poor response to standard cytotoxic therapy. Brigatinib, a next-generation multi-kinase inhibitor that blocks signal transduction associated with the ALK mutational re-arrangement, has shown substantial efficacy in patients with ALK-positive non-small cell lung cancer. We present a unique and successful case of a young patient with primary refractory ALK-positive LBCL who received salvage chemotherapy plus brigatinib followed by allogeneic stem cell transplantation. A 26 year-old previously healthy male presented with weight loss, night sweats, and abdominal pain. Exam was notable for a large abdominal mass. PET/CT scan revealed a large, FDG-avid heterogeneous peripherally enhancing pelvic mass, ascites, and diffuse abdominal lymphadenopathy. Testicular ultrasound was unremarkable. Large atypical plasmablastic cells with amphophilic cytoplasm and prominent nucleoli were noted within areas of necrosis. The abnormal cells were negative for CD19, CD20, PAX5, CD30, and CD117. They were positive for CD138 and granular, cytoplasmic ALK-1. Genomic testing revealed RANBP2-ALK fusion. The patient was diagnosed with ALK-positive LBCL. CSF cytology revealed no malignant cells and bone marrow biopsy revealed normal hematopoiesis. Therapy with cyclophosphamide, doxorubicin, vincristine, etoposide, and methylprednisolone (CHOEP) was initiated. Interval PET/CT revealed primary refractory disease with an enlarging abdominal mass and resultant hydronephrosis. He had worsening leukocytosis and liver dysfunction. Salvage therapy with dexamethasone, cytarabine, cisplatin (DHAP) plus brigatinib was initiated after a risk and benefit discussion regarding the off-label use of brigatinib. He achieved a complete metabolic response and subsequently underwent an umbilical cord blood stem cell transplant with a cyclophosphamide, fludarabine, and total body irradiation-based conditioning regimen followed by tacrolimus and mycophenolate mofetil for graft-versus-host-disease (GVHD) prophylaxis. Maintenance brigatinib was initiated post-transplant. The patient remains in complete remission over a year post-transplant with no unexpected toxicities and no GVHD. ALK-positive LBCL carries a poor prognosis with no standard therapeutic options. This case demonstrates safety and efficacy with the novel use of brigatinib. ALK inhibitors may represent a successful therapeutic strategy and further investigation in a clinical trial setting is warranted.

Laparoscopic dissection of the hepatic node: The trans lesser omentum approach.

BACKGROUNDDiagnosis of lympho-proliferative diseases is sometimes challenging. Excisional lymph node biopsy is the standard of care. Five percent of the patients will present with abdominal or retroperitoneal lymphadenopathy alone. Advancements in endoscopic techniques allow for access to fine needle biopsy in complicated areas, but this often does not meet the standard guidelines for diagnosis.AIMTo investigate the results of laparoscopic excisional biopsy of the hepatic node (LEBHN) through a trans lesser omentum approach.METHODSData of all patients undergoing LEBHN were collected retrospectively from patients’ electronic charts over a period of 1 year. Data collected included age, gender, suspected disease, number of previous biopsies and biopsy method, surgical approach, intraoperative complications, operative time, post-operative complications, mortality, and final diagnosis.RESULTSSix patients were operated in this technique during the time frame of the study, 66.6% (n = 4) were females, and median age was 55 years (range: 25-72 years). We present no conversions from laparoscopy to laparotomy, and mean operating time was 51.2 min. Mean length of hospital stay was 1 d, and morbidity and mortality were nil. Most importantly, this technique offered definite diagnosis and appropriate treatment in all patients. Final diagnosis included two patients with lymphoma (Hodgkin and Follicular), two patients with sarcoidosis, and two patients with reactive lymph nodes with no evidence of malignancy.CONCLUSIONIn conclusion, this technique seems to be feasible and safe and may offer a simple approach for a definite diagnosis for what seems to be a complicated anatomical area.

Туберкулез у больных ВИЧ-инфекцией в терапевтическом стационаре в регионе с высокой пораженностью ВИЧ

Objective. To analyze the role and character of tuberculosis (TB) among all respiratory diseases in HIV-infected patients treated in a therapeutic hospital Patients and methods. This longitudinal retrospective study included all consecutive HIV-positive patients with respiratory diseases (n = 185) treated in the Therapeutic Department of the City Hospital No 2 in Novokuznetsk in 2017–2018. Results. TB was diagnosed in 50 HIV-infected patients (27.0%) admitted to hospital. Median CD4 count was 124 cells/μL. Only 14.3% of patients were adherent to antiretroviral therapy. Sputum smear microscopy in TB dispensary was positive twice as often as in the therapeutic hospital (54.4% vs 23.4%). Abdominal lymphadenopathy was detected in 52.8% of patients examined, regardless of the pulmonary lesion pattern (p &gt; 0.05); 25.0% of patients were diagnosed with endobronchial TB. The main radiological syndromes of TB in the HIV-infected population included dissemination (52.0%), infiltration (26.0%), and intrathoracic lymphadenopathy (10.0%). Pleural lesions were identified in 28% of participants with TB and HIV coinfection. Conclusion. TB was the only cause of focal dissemination (100.0%, p &lt; 0.001), while pleural lesions and intrathoracic lymphadenopathy were significantly more common in TB patients than in individuals with non-tuberculosis diseases (11.6% and 0.8%, respectively, p &lt; 0.05). Hospital mortality rate among TB patients in a therapeutic hospital was 8.0%. Key words: HIV infection, immunosuppression, tuberculosis

Bowel Lymphoma Causing Multiple Intussusceptions In Adult- Case Report and Review of Literature

Intussusception in adults is rarer than children and treatment in most cases in adults is surgical. Multiple Intussusceptions in our case with subacute intestinal obstruction and presence of abdominal lymphadenopathy with diffuse bowel wall thickening warrants non-surgical treatment. Presence of multiple intussusceptions is rare findings. We present a case of female aged 35 years presented with palpable abdominal lump associated with loss of weight and appetite. CECT abdomen showed abdominal lymphadenopathy and multisegmental small bowel thickening maximum upto 1.5 cm. Some segments of bowel also show aneurysmal dilatation associated with asymmetrical mural thickening. Telescoping of proximal bowel segment into adjacent distal bowel is seen in at least two places in ascending colon region (colocolic intussusceptions) and another in ileal loops (ileo-ileal). FNAC from the lymph nodes revealed non hodgkins lymphoma.

Endoscopic ultrasound guided fine needle aspiration for the diagnosis of intra-abdominal lymphadenopathy: a systematic review and meta-analysis

Background: It is difficult to diagnose the cause of abdominal lymphadenopathy without determining the primary lesions. With the advent of curved ultrasound endoscopy, EUS-FNA can sample lymph nodes safely, accurately and conveniently. Due to the lack of formal quantitative and comprehensive literature review to determine the diagnostic value of EUS-FNA in the diagnosis of enlarged intra-abdominal lymph nodes of unknown origin, we conducted this study to systematically evaluate the diagnostic accuracy of EUS-FNA in the enlarged intra-abdominal lymph nodes.Methods: We performed a systematic review and meta-analysis to evaluate the accuracy of EUS-FNA for the diagnosis of intra-abdominal lymphadenopathy. We searched PubMed, Embase, and Cochrane Library to collect related studies and diagnostic performance data. We used a random-effects model to estimate the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio (DOR). Heterogeneity was assessed by subgroup and meta-regression analysis.Results: Twelve eligible studies involved 774 patients were identified. The pooled sensitivity and specificity of all studies is 94% (95% CI: 91% to 96%) and 98% (95% CI: 96% to 99%), respectively. The pooled positive and negative likelihood ratios are 17.44 (95% CI, 6.50 to 46.79) and 0.09 (95% CI: 0.06 to 0.14). The pooled DOR is 277.82 (95% CI, 97.65 to 790.46).Conclusions: EUS-FNA is a safe and feasible technique with high sensitivity and specificity for the diagnosis of abdominal lymph node enlargement. Considering the limitations and heterogeneity, high-quality studies are needed to further explore the diagnostic value of EUS-FNA.

Angioimmunoblastic T-Cell Lymphoma: Molecular Characterization of Clonal T and B-Cells and a Patient Derived Xenograft Model of Coexisting T and B-Cell Proliferations

Introduction: Angioimmunoblastic T-cell lymphoma (AITL) is a rare and aggressive type of lymphoma that accounts for about 20% of peripheral T-cell lymphomas with a 5 year overall survival rate of 30%. As most patients relapse after anthracycline-containing regimens and newer agents such as histone deacetylase inhibitors, other novel therapeutic approaches are needed. Signaling lymphocytic activation molecule F7 (SLAMF7), a molecule expressed on a subset of T-cells, activated B cells and myeloma cells, is an attractive target to explore based on our previous studies showing SLAMF7 expression in a subset of AITL cases. The association of AITL with Epstein Barr virus (EBV) positive B-cells is nearly always present and the efficacy of treatment in such patients with significant EBV viral load is not well-understood. In this study, we performed the molecular characterization of an aggressive EBV+ AITL case, established a patient-derived xenograft (PDX) AITL model of coexisting T and B-cell proliferations and evaluated novel therapeutic strategies. Methods: Primary tumor cells were injected into a NSG mouse. Flow cytometry, immunohistochemistry (IHC), CISH-EBER and BIOMED 2 PCR based clonality studies were used to confirm the engraftment and compared the consistency of engrafted tumor cells with the primary sample. Genomic DNA extracted from sorted T and B cells and from paired normal neutrophils of the original patient were subjected to Whole Exome sequencing (WES). In vivo AITL PDX model trials were tested for the efficacy of romidepsin (Rom), elotuzumab (Elo), rituximab (Rit) and in combinations of these drugs. Results: A 53 year old woman with AITL was treated with 6 cycles of CHOEP followed by autologous stem cell transplantation. 3 months after transplantation (9 months after diagnosis) she developed progressive fatigue and arthralgias. PET-CT scan showed new cervical, thoracic, abdominal and pelvic lymphadenopathy. A cervical lymph node biopsy was performed to confirm relapse. IHC staining showed atypical T cells expressing CD2, CD3, CD4, CD5, CD7, CD10, BCL6, PD1, SLAMF7 and CXCL13. Scattered CD20+/EBER+ B-immunoblasts were present with focal large clusters/small sheets. Primary tumor cells engrafted in NSG mouse via tail vein injection caused splenomegaly. Flow cytometry assay demonstrated the engraftment of tumor cells in peripheral blood, bone marrow and spleen tissue. CD3+CD19- cells dominated the engrafted cells in all three tissues. Histologic examination and immunophenotyping (IHC and EBER staining) of spleen were consistent with primary tumor tissue. Engrafted tumor cells were capable of serial passage in NSG mice with an increasing malignant B cell percentage that mimics the situation in which the B-cell component masks an underlying T-cell lymphoma in humans. T-cell receptor gene rearrangement assay confirmed the clonal identity of engrafted T-cells matched the primary relapsed tumor. A clonal IGH rearrangement of engrafted B-cells was also detected, while no monoclonal B-cell population was detected in the relapsed AITL sample, possibly due to the low number of EBV+ B-cells present in that biopsy. WES of sorted malignant T-cells showed 33 mutants in 31genes, including RhoA G17V, TET2,STAT3 and VAV1, previously described in AITL or other T-cell lymphomas. In parallel WES assay, 9 mutations were found in 9 genes from sorted EBV+ B immunoblasts. A PDX model using cells harvested from the second passage showed single agent, Elo or Rit, extended the survival of mice compared to the control group (p &amp;lt; 0.05). Rom alone had no such effect (p = 0.27). Combination of Rit with either Elo or Rom further improved survival compared to each single agent exposed cohort (p &amp;lt; 0.05). There was no significant difference between Rit/Elo and Rit/Rom (p = 0.067). PARP cleavage by IHC was higher in the Rit/Rom and Rit/Elo groups compared to other cohorts. Expression of SLAMF7 in a subset of engrafted T and B cells of the control mouse were confirmed via flow cytometry assay. Conclusions: To date, this is the first molecular characterization of AITL tumor cells in comparison with associated EBV+ B cells and use of such a PDX model for therapeutic evaluation of agents targeting both malignant T and B cells simultaneously. The in vivo data support further clinical investigation of applying elotuzumab or romidepsin in combination with rituximab in AITL containing EBV-positive B-cell proliferations. Disclosures Maciejewski: Novartis: Consultancy; Alexion: Consultancy. Hsi:Abbvie: Research Funding; Eli Lilly: Research Funding; Jazz: Consultancy; Cleveland Clinic&amp;Abbvie Biotherapeutics Inc: Patents &amp; Royalties: US8,603,477 B2.

Immunophenotypic characterization and clinical outcome in cats with lymphocytosis.

BackgroundLymphocytosis is relatively common in cats, but few studies describe lymphocyte populations or the clinical course associated with different immunophenotypic expansions.Hypothesis/ObjectivesWe hypothesized that cats frequently develop non‐neoplastic lymphocytosis and that different neoplastic immunophenotypes have variable prognoses. We aimed to characterize the lymphocyte expansions in a large population of cats with lymphocytosis and to assess clinical presentation and outcome in a subset.AnimalsThree cohorts of cats older than 1 year with lymphocytosis (>6000/μL) were examined to define immunophenotypic categories (n = 146), evaluate outcome (n = 94), and determine prevalence of immunophenotypes (n = 350).MethodsRetrospective study of cats with blood submitted for flow cytometry. Medical records (n = 94) were reviewed for clinical data, treatment, and survival information.ResultsFive major immunophenotypic categories were identified: B cell, heterogeneous (≥2 lineages expanded), CD4+ T cell, CD4−CD8− (double negative [DN]) T cell, and CD5‐low‐expressing T cell. B‐cell and heterogeneous phenotypes were more consistent with a non‐neoplastic process, having polyclonal antigen receptor gene rearrangements, younger age at presentation, lower lymphocyte counts, and prolonged survival. The neoplastic phenotypes, CD4+ T cell, DN T cell, and CD5 low T cell, had different median survival times (752 days [n = 37], 271 days [n = 7], 27.5 days [n = 12], respectively). Among CD4+ T‐cell cases, cats with abdominal lymphadenopathy, intestinal involvement, or both and females had shorter survival. Among 350 cats with lymphocytosis, CD4+ T‐cell lymphocytosis was most common, followed by heterogeneous and B‐cell phenotypes.Conclusions and Clinical ImportanceNeoplastic CD4+ T‐cell lymphocytosis is common in cats and has a prolonged clinical course compared to aberrant T‐cell phenotypes. Cats with heterogeneous and B‐cell lymphocyte expansions commonly have non‐neoplastic disease.

Multifocal abdominal abscessation in a three-month-old puppy due to Escherichia coli

A 12-week-old, crossbreed, male entire dog was evaluated for a three-week history of lethargy, nausea, anorexia, haemorrhagic diarrhoea and free abdominal fluid. Abdominal ultrasound revealed multiple cavitated hepatic masses, abdominal...

CSF TO ACE THE DIAGNOSIS

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Sarcoidosis is a granulomatous disorder characterized by noncaseating granulomas affecting involved organs. Although the majority of sarcoidosis is diagnosed as pulmonary sarcoidosis incidentally on chest imaging, extrapulmonary sarcoidosis is the presenting symptom for approximately 30% of all cases, with 5-10% affecting the nervous system. Angiotensin Converting Enzyme can be produced by granulomas, with 55% of cases demonstrating positive ACE levels within cerebrospinal fluid. CASE PRESENTATION: A 28 year old man with no past medical history presented with bilateral lower extremity weakness and numbness, gradually worsening over four weeks, starting in the pelvic area causing urinary urgency and painful defecation with distal spread. Over the few days prior to admission his family had also noticed dysarthria. Physical exam was notable for anisocoria, dysarthria, ataxic gait, diminished lower extremity reflexes, and saddle anesthesia. Serum was unremarkable except a sed rate of 39 and a positive ANA. Lumbar puncture showed an elevated white count of 43 cells/uL, predominantly lymphocytes, and an elevated protein at 336mg/dL. CSF ACE level was elevated (7.0 units/L). An MRI of the brain and spine showed diffuse nodular leptomeningeal enhancement of the entire spinal cord and brain. A CT of chest abdomen and pelvis was obtained which demonstrated innumerable pulmonary nodules and masses in a perilymphatic distribution with upper lobe predominance and subcarinal, pelvic and abdominal lymphadenopathy. Endobronchial biopsies of right mainstem bronchus nodularity and EBUS guided transbronchial needle aspiration of the subcarinal lymph node revealed granulomatous inflammation. He was treated with IV pulsed Solumedrol for 3 days with improvement in his neurologic symptoms. He was discharged on prednisone 1 mg/kg and methotrexate 15 mg weekly. Repeat MRI 5 days post treatment showed improvement of leptomeningeal enhancement. DISCUSSION: In this case, we observed a young man who developed neurologic symptoms as his first sign of sarcoidosis. Neurosarcoidosis can effect any portion of the peripheral or central nervous system. Cranial mononeuropathy, cognitive deficits, radiculopathy, and aseptic meningitis are common manifestations, wherever a granuloma can obstruct a nerve. A helpful diagnostic cue is angiotensin I-converting enzyme within the CSF itself, as granulomas synthesize this enzyme which can diffuse into various fluid compartments. The mainstay of treatment for any neurologic symptom is to treat the underlying sarcoidosis with steroids, as was done on our patient. CONCLUSIONS: In a younger patient with a pulmonary nodules and masses with associated neurologic complaints, neurosarcoidosis is a unique diagnosis that physicians should consider on their differential, while excluding malignancy. Angiotensin Converting Enzyme in CSF can be a helpful diagnostic cue. Reference #1: "Neurosarcoidosis” by Burns, Arch Neurol. 2003 Aug;60(8):1166-8. Reference #2: "Clinical characteristics of patients in a case control study of sarcoidosis” by Baughman, Teirstein, Et Al. Am J Respir Crit Care Med. 2001 Nov 15;164(10 Pt 1):1885-9. Reference #3: "Cerebrospinal fluid angiotensin-converting enzyme for diagnosis of central nervous system sarcoidosis.” By Khoury, Wellik, Et Al. Neurologist. 2009 Mar;15(2):108-11. https://doi.org/10.1097/NRL.0b013e31819bcf84. DISCLOSURES: No relevant relationships by Elena Burke, source=Web Response no disclosure on file for Christine Fleury; No relevant relationships by Kellen Mulhern, source=Web Response

2577 Dysdiadochokinesia, Ataxia, and Anemia: A Sign of Intraluminal Malignant Mesothelioma in the Small Bowel?

INTRODUCTION: Malignant mesothelioma (MM) is a rare cancer of the serosal membranes, the pleura and peritoneum, and causes significant morbidity and mortality. While implants of the bowel wall are common, only two case reports on intraluminal involvement exist. We present a case of an elderly male with dysdiadochokinesia found to have abdominal lymphadenopathy, and a jejunal mass from peritoneal mesothelioma (PM). CASE DESCRIPTION/METHODS: An 87 year-old male with a family history (FH) of colon cancer in one first-degree relative presented with one month of unintentional weight loss, gait instability, and trouble performing alternating movements. Two months prior to admission, evaluation included a negative MRI of the brain but positive CSF analysis for neuron-restricted autoantibody treated empirically with five days of intravenous immunoglobulin (IVIG) and three days of pulse dose steroids. Physical examination was notable for ataxia and dysdiadochokinesia and a benign abdominal exam. He had normal electrolytes and liver chemistries, but was anemic. PET/CT revealed intensely FDG-avid abdominal and mesenteric lymph nodes, one inseparable from the small bowel (Figures 1 and 2). Lymph nodes were not accessible by IR-guided biopsy, so he underwent push enteroscopy and colonoscopy, in light of his FH, to evaluate for anemia. A large, oozing ulcerated mass was found in the jejunum and biopsied (Figure 3). Immunostaining was positive for cytokeratin, CK7, WT1, and calretinin consistent with PM. His neurologic decline was then linked to PNS secondary to PM. He was discharged with plans for carboplatin therapy. DISCUSSION: MM is strongly associated with asbestos exposure, and is four to five times more prevalent in men than women. PM limited to the small bowel is exceedingly rare. Only one previous case report describes a mass spanning the entire small bowel, identified as mucin-positive epithelial mesothelioma. PNS affects 1 in 10,000 patients with cancer; more than 85% of cases are linked to gynecologic and breast cancers causing cerebellar dysfunction via purkinje cell destruction by anti-Yo antibody (Ab). Two cases of PM associated PNS with anti-Yo Ab in the CSF have been reported; one was treated with IVIG and high dose steroids. The treatment of PM is key to stabilizing neurologic symptoms, such as dysdiadochokinesia. The prognosis of PM and associated PNS remains poor. Anemia with cerebellar symptoms should trigger a search for malignancy and rarer causes such as PM.

CONSIDERATIONS FOR CHYLOTHORAX IN PATIENTS WITH CHRONIC LYMPHOCYTIC LEUKEMIA

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Chylothorax is a rare complication of chronic lymphocytic leukemia (CLL). Diagnosis is challenging due to its rarity and nonspecific clinical presentation. We report a case of CLL-associated chylothorax. CASE PRESENTATION: A 71 year-old woman with no known medical history presented with dyspnea, weakness, and weight loss. Exam was significant for cachexia and respiratory distress with absent left-sided breath sounds. Labs were notable for WBC 376,800 cells/μL (91% lymphocytes and smudge cells), Hgb 7.1g/dL, platelets 557,000 cells/μL, LDH 408U/L, protein 6.6g/dL. A large left-sided pleural effusion was noted on chest radiograph. CT demonstrated a large left effusion with left lung atelectasis, hepatosplenomegaly, and mediastinal and abdominal lymphadenopathy. Peripheral flow cytometry was consistent with CLL (Rai Stage III). Lung ultrasonography demonstrated multiple septations. Thoracentesis and 8-French chest tube placement were performed. Pleural fluid studies: WBC 4,010 cells/μL (61% neutrophils, 34% lymphocytes), protein 4.4g/dL, LDH 568U/L, amylase 35U/L, and triglycerides 49mg/dL. Pleural fluid was sent for cytology and empiric antibiotics were started. Intrapleural alteplase and DNAse were instilled for 6 doses in attempt to reexpand the lung. Initial cytology and cultures were negative. Pleural fluid analysis was repeated hospital day 11, demonstrating triglycerides 189mg/dL and cholesterol 10mg/dL, consistent with chylothorax. Low fat diet, octreotide, chlorambucil and prednisone were initiated. Daily chest tube output was >500mL and she underwent CT venography. Interventional radiology attempted thoracic duct embolization but were unable to successfully cannulate it. Lymphoscintigraphy identified the thoracic duct leak. Cisterna chyli access via groin lymph node was aborted due to distress when the patient was supine. The patient chose to focus on comfort and the chest tube was removed. She was discharged to home hospice. DISCUSSION: Chylothorax from CLL is uncommon, reported in few cases. The rarity may be attributed to infrequent mediastinal lymphadenopathy in CLL.1,2 In the setting loculated pleural effusions, diagnosis may be difficult due to sampling error; chylothorax is diagnosed by pleural fluid triglycerides >110mg/dl. If levels are indeterminate, repeat analysis is warranted if suspicion remains high. Management focuses on treating the underlying disease and implementing a low fat diet with medium-chain triglycerides. Thoracic duct embolization may be an option for poor surgical candidates failing initial therapy.3 CONCLUSIONS: High suspicion for chylothorax must be maintained in CLL patients with pleural effusion to avoid delaying directed intervention. Reference #1: Zimhony et al. Chronic lymphocytic leukaemia complicated by chylothorax. Journal of internal medicine. 1994 Apr;235(4):375-7. Reference #2: Antón E. Chylothorax in hematologic malignancies. Chest. 2005 May 1;127(5):1866. Reference #3: Bender et al. The changing management of chylothorax in the modern era. European Journal of Cardio-Thoracic Surgery. 2015 Mar 1;49(1):18-24. DISCLOSURES: No relevant relationships by Scott Ferrara, source=Web Response No relevant relationships by Yonatan Greenstein, source=Web Response No relevant relationships by Omry Zuckerman, source=Web Response

1939 A Malignant Case of Gastrointestinal Bleed

INTRODUCTION: Richter’s Syndrome (RS) is an infrequent complication of chronic lymphocytic leukemia (CLL) involving transformation of CLL into aggressive large-cell lymphoma. Gastrointestinal (GI) involvement with RS is rare, previously described in only 9 case reports in literature. Here we present a unique case of RS manifesting as GI bleed. CASE DESCRIPTION/METHODS: A 70-year old male presented with one day history of painless hematochezia. He was diagnosed with CLL four years prior and was currently in remission following chemotherapy. Vitals revealed a blood pressure of 88/35 mmHg and pulse rate of 114/minute. Abdominal exam was unremarkable. Rectal exam showed blood in the vault. Work-up showed a hemoglobin of 4.8 g/dl and white cell count of 5300/microliter. Coagulation profile was normal. After initial resuscitation, an esophagogastroduodenoscopy (EGD) was performed showing an excavated lesion with minimal oozing in second part of duodenum; biopsy was obtained and endoclip was applied. Colonoscopy showed blood in terminal ileum and throughout the colon. Capsule study revealed scattered erosions and ulcers with hemorrhage in the jejunum and active bleeding from the distal ileum. Urgent tagged red-cell scan was obtained followed by coil embolization of a focus of brisk active extravasation arising from a terminal ileal branch of ileocolic artery by Intervention Radiology (IR). Duodenal biopsy demonstrated lymphocytic infiltrate consistent with his history of CLL with a background of larger lymphocytes concerning for Richter’s transformation to diffuse large B-cell lymphoma (DLBCL). Computed Tomography (CT) abdomen/pelvis showed splenomegaly and diffuse abdominal and pelvic lymphadenopathy. Pathology report of an excisional biopsy of left axillary lymph node confirmed Richter’s transformation to DLBCL. Systemic chemotherapy and immunotherapy was initiated. GI bleed resolved few days into chemotherapy. DISCUSSION: Patients with prior history of hematological malignancies presenting with GI symptoms such as nausea/vomiting, intestinal obstruction, acute perforation or GI bleed should be evaluated for recurrence. In addition to imaging, a low threshold for invasive work-up such as EGD or colonoscopy with biopsy of any lesions seen may be necessary for timely initiation of therapy. This case demonstrates that evaluation for etiology in each case of GI bleed has to be individualized. Identifying the correct diagnosis is the key to successful patient treatment.

2520 Burkitt's Lymphoma of the Duodenum

INTRODUCTION: Burkitt's lymphoma is an aggressively growing tumor commonly, involving the jaw and facial bones. A rare variant of this type of lymphoma is found in immunocompromised patients specifically in the gastrointestinal tract, usually affecting the stomach, distal ileum, and cecum and rarely the duodenum. We are reporting a case of primary lymphoma of the duodenum in a patient with newly diagnosed AIDS. CASE DESCRIPTION/METHODS: A 50-years-old male with no significant past medical history presented with gradually progressive generalized weakness with easy fatigability of one-month duration. He had no history of shortness of breath, dysphagia, nausea, vomiting, hematemesis, melena, hematochezia or bleeding from any sites. Vitals were normal and examination was negative for abdominal tenderness, organomegaly or lymphadenopathy. Labs showed severe iron deficiency anemia with hemoglobin of 5.9 g/dl with ferritin of 21 ng/ml and Transferrin saturation of 8.8%. Other labs including WBC count, platelets count, creatinine, liver enzymes and LDH were normal. In suspicious of occult gastrointestinal tract bleeding, upper endoscopy was performed revealing a large semi circumferential malignant appearing mass partially obstructing the lumen of the third portion of the duodenum. Multiple biopsied where taken showing small bowel mucosa infiltrated by uniform, intermediate sized cells strongly staining positive for CD10, CD20, Ki-67 (100%) and BCL-6; diagnostic for Burkitt's lymphoma. CT Abdomen/Pelvis/Chest for evaluation of other masses or lymphadenopathy showed a 41 × 40 mm mass arising from the third and fourth portions of the duodenum with short segment wall thickening of the distal small bowel and soft tissue nodule in the right hemipelvis with no significant lymphadenoptahy. His labs reveleaed came positive for HIV-1 with 144,000 and CD4 count of 161. Bone marrow was negative for any involvement He received 2 cycles of alternating chemotherapy with R-CODOX-M and R-IVAC for 4 months duration. PET scan after 2 month of chemotherapy completion was negative for any uptake. Patient is currently doing well, on HAART therapy with no recurrence of his symptoms. DISCUSSION: Primary duodenal Burkitt lymphoma is a subtype of non-Hodgkin's lymphoma and represents an aggressive and rare malignancy with only a small number of cases reported worldwide. Clinical and radiological presentation is non-specific and usually mimics other gastric lymphomas, leading usually to late presentation and diagnosis.

2468 Humeral Fracture as the Only Presenting Symptom of a Metastatic Intra-Hepatic Cholangiocarcinoma: A Rare Cancer With Rare Presentation

INTRODUCTION: Cholangiocarcinoma (CCA) is a malignant tumor which originates from the epithelial cells of bile ducts. Abdominal pain and jaundice are the most common presenting symptoms. It commonly metastasizes through lymphatics to regional lymph nodes, followed by involvement of liver, lungs and peritoneum via blood. Bone metastasis is very rare although it has been reported. We are presenting an unusual case with initial presentation of appendicular bony metastatic disease without any GI symptoms. CASE DESCRIPTION/METHODS: 59-year-old non-smoker male with past medical history of obstructive sleep apnea initially presented to ER with right arm pain while standing from a chair and felt crack in his arm. Physical exam was unremarkable except right mid arm mild swelling and tenderness. Right arm x-ray showed an acute comminuted fracture of proximal humeral shaft with minimal displacement. A CT scan was obtained due to the low energy nature of this injury to rule out pathologic etiology, but this was negative. Blood work up was positive only for normocytic anemia with hemoglobin of 10 g/dl. He was placed in a sling and scheduled to follow-up with orthopedics as outpatient. Four weeks follow up x-ray showed persistent fracture and prominent bone resorption concerning for its pathological nature. Patient was referred to oncologist. Patient remained asymptomatic except right arm pain and some swelling. Extensive work up was initiated. Laboratory investigation showed elevated LFTs with cholestatic pattern. CT CAP with contrast showed significant metastatic abdominal lymphadenopathy, ill-defined mass in the right lobe of the liver and splenomegaly. A bone scan showed uptake in the right mid humerus but no additional findings. Patient underwent CT guided bone biopsy which was consistent with metastatic intrahepatic CCA. Given aggressive growth in short duration and refractory pain, intralesional debulking and metallic end prosthetic segmental reconstruction of the right humeral diaphysis was performed followed by radiation therapy. Oncology recommended to start chemotherapy although prognosis is grim. DISCUSSION: CCA is an aggressive tumor with poor prognosis. The pattern of metastasis is usually through lymphatics and further spread via hematogenous route. Appendicular bone metastasis is very rare phenomena and only few cases reported so far. Physicians should have low threshold to investigate low energy injuries leading to bone fractures, in depth for pathological fractures and possibly underlying malignancy.