Cervical Node Biopsy Research Articles

Mycobacterium terrae Complex Associated Lymphadenitis: Negative AFB PCR

Abstract Introduction/Objective Nontuberculous mycobacteria included with the Mycobacterium terrae complex (MTC) include a ubiquitous, slow-growing collection of mycobacteria known for causing severe resistant skin, joint, and bone infections. There are limited reports of M. Arupensis, included under MTC, causing human infections despite environmental ubiquity. Low sequencing sensitivity for species such as M. Arupensis may result in negative preliminary PCR speciation thus influencing the negative predictive value of this method of organism detection. No prior case reports have described MTC infection presenting as subacute lymphadenitis. Methods/Case Report A 48 year old El Salvadorian male with known diagnosis of HIV presented with oral thrush and significant left-sided lymphadenopathy. He was initially diagnosed with HIV in El Salvador and on ART until immigrating to the US six months prior. HIV antigen and antibody was positive with positive reflex viral PCR. QuantiFERON-TB Gold resulted positive, but CXR was without evidence of pulmonary TB. TB1, TB2, and mitogen minus NIL were negative. He was referred for fine needle aspiration and core needle biopsy of the left cervical lymph node. AFB and AFB FITE stains were performed, but no definitive mycobacteria were identified. GMS was performed and negative for fungal elements. A final histological diagnosis of necrotizing granuloma was given and the tissue was sent for bacterial, AFB, and fungal DNA PCR; no organisms were detected. A sputum sample was obtained and cultured four months after initial presentation and was positive for acid fast bacilli: Mycobacterium terrae complex, most closely resembling Mycobacterium arupensis. The Fite and AFB stains were again reviewed, revealing one single acid fast bacilli organism identified on Fite stain in the necrotizing granuloma. Results (if a Case Study enter NA) N/A Conclusion The negative AFB DNA PCR result may have been a false negative result due to poor sensitivity or selectivity for M. arupensis. There are no former reported cases of M. Arupensis associated necrotizing granulomas in lymph node. This unusual MTC infection presenting as chronic unilateral lymphadenitis underscores the importance of broadening clinical laboratory AFB DNA PCR sensitivity especially in cases of suspected AFB or modified AFB associated necrotizing granulomas.

8426 Recurrence of Papillary Thyroid Carcinoma Despite Undetectable Levels of Thyroglobulin Measured by Both Immunoassay and LCMS

Abstract Disclosure: M.G. Hamilton: None. G. Patel: None. S. Teja Sathi: None. K. Win: None. P. Lekprasert: None. Serum thyroglobulin (Tg) levels are affected by the presence of anti-thyroglobulin antibodies (anti-Tg Abs) during surveillance of differentiated thyroid cancer (DTC). About 20% of patients have positive anti-Tg Abs post-thyroidectomy and laboratory investigations for DTC surveillance may lead to false negative results. Liquid chromatography-tandem mass spectrometry (LCMS) is superior to immunoassay in measuring Tg levels in patients with the presence of anti-Tg Abs. Mass spectrometry is the only currently available method that could eliminate the interference of anti-Tg Abs in the quantification of Tg but is not readily available. We present the case of a patient who had a recurrence of DTC despite persistently undetectable Tg levels using both immunoassay and LCMS methods. The patient is a 49-year-old female with a history of papillary thyroid cancer who underwent total thyroidectomy followed by adjuvant radio-ablation. She presented to our endocrinology office for routine follow up for her DTC. She reported subjective unknown weight loss over four months. Her physical exam was unremarkable with no palpable neck swelling or mass. Vital signs were within normal limits. She continued to have undetectable levels of Tg as measured by immunoassay, stable levels of anti-Tg Abs ranging from 19 IU/mL to 33 IU/mL, and negative findings on her thyroid ultrasound for the first four years post-op. When she presented to the office five years post-thyroidectomy her anti-Tg Ab level had increased to 114 IU/mL and subsequently to 137 IU/mL a few months later despite undetectable Tg levels on both immunoassay and LCMS. A thyroid ultrasound was completed due to rising anti-Tg Abs levels which showed a suspicious one cm mass at the right thyroid bed and suspicious bilateral cervical lymph nodes. Repeated FNA biopsy of the bilateral cervical lymph nodes confirmed follicular epithelium with nuclear inclusions and grooves, compatible with recurrent papillary thyroid carcinoma. This patient had a recurrence of her DTC despite undetectable Tg levels on both immunoassay and LCMS. Tg is an important aspect of surveillance post-treatment for all patients with DTC because its presence is a surrogate for the presence of thyroid tissue and therefore the recurrence of thyroid malignancy. Clinicians must have a high index of suspicion when monitoring a patient with a history of DTC and the presence of anti-Tg Abs because it interferes with the accurate measurement of Tg levels. A study conducted by Azmat et al. demonstrated that measuring Tg levels via LCMS has been found to eliminate the confounding effect of anti-Tg Abs with a sensitivity and specificity of 44.4% and 94.1% respectively. However, our case illustrates that even LCMS is not always reliable in such situations, and increasing levels of anti-Tg Abs should be an individual risk factor for suspecting recurrence of DTC. Presentation: 6/3/2024

P73-9 Primary ovarian small cell carcinoma of pulmonary type diagnosed with an ultrasound-guided cervical lymph node biopsy

P73-9 Primary ovarian small cell carcinoma of pulmonary type diagnosed with an ultrasound-guided cervical lymph node biopsy

Kikuchi-Fujimoto lymphadenitis in a patient with human immunodeficiency virus infection: The importance of precision pathology.

Kikuchi-Fujimoto lymphadenitis (or histiocytic necrotising lymphadenitis) is a rare disease that is usually benign and self-limiting. A higher prevalence is reported amongst East Asian populations. No clear etiology has been identified although it has been associated with some viruses, rarely the Human Immunodeficiency Virus (HIV) and autoimmune pathologies. To date, there has only been a handful of cases reported globally in association with HIV, and this association is even rarer in the Asian context. A 20-year-old Asian ethnic Malay male, with no past medical history, presented with daily fevers and chills for 2weeks associated with constitutional symptoms and bilateral non-tender cervical, axillary and inguinal lymphadenopathy. Full blood count showed lymphocytosis with large granular lymphocytes. HIV viral load returned positive at >10million copies/mL. His absolute CD4 T helper cell count was 375cells/uL (7%). The rest of the infective and autoimmune workup were negative. Excision biopsy of an enlarged left cervical lymph node revealed Kikuchi lymphadenitis in the proliferative phase, with no evidence of lymphoproliferative disease. He was started on anti-retroviral therapy with resolution of the lymphadenopathy in 3months. We present a case of Kikuchi lymphadenitis associated with HIV. This highlights that Kikuchi lymphadenitis may mimic sinister pathologies (such as tuberculosis and lymphoma) and that it needs to be considered in the differential diagnosis before empirical treatment for tuberculosis or invasive investigations for lymphoma are done.

Kikuchi-Fujimoto disease co-occuring with Hashimoto thyroiditis: A case report and literature review.

We introduce a 16-year-old female who presented with tender cervical lymphadenopathy, prolonged fever, and hypothyroidism. After excluding common causes of fever of unknown origin, a surgical biopsy of cervical lymph nodes revealed Kikuchi-Fujimoto disease. The patient showed improvement with a short-term course of NSAIDs. An increased titre of thyroperoxidase antibody led to a diagnosis of Hashimoto's thyroiditis during stable condition. This report underscores the importance of considering Kikuchi-Fujimoto disease in the differential diagnosis of prolonged fever of unknown origin with lymphadenopathy and highlights the association with Hashimoto's thyroiditis, advocating for vigilance regarding hypothyroidism in long-term follow-up after Kikuchi-Fujimoto disease recovery.

Adenocarcinoma of unknown primary with TP53 gene polymorphism: a rare case report with literature review

BackgroundCancer of unknown primary (CUP) is an orphan disease generally presented by undifferentiated and aggressive morphological phenotype. The treatment of CUP is solely dependent upon the origin of cancer. Despite extensive diagnostic testing, in most of the cases the primary site remains unidentifiable.Case presentationThis case demonstrates a 75-year-old male patient, who initially presented with the complaints of swelling over right side of the neck since 2 months. A cervical lymph node biopsy was taken for immunohistochemistry, which revealed cytokeratin (CK) and CK7 markers to be positive. Computerized tomography (CT) of Thorax showed subcentimetric subpleural nodules in bilateral lungs fields, predominantly in lower lobes (metastatic in nature). A subsequent pulmoCORE 12 gene panel test was recommended, and patient was discharged with tablet gefitinib 250mg and capsule containing vitamins plus minerals. After one month, patient revisited with the pulmoCORE 12 gene test report which revealed polymorphism in TP53. A pathogenic variant of tumor protein p53 (TP53), i.e., p.Glu198Ter (amino acid alteration) and c.592G > T (coding) variant, was detected, which has 17.2% variant allele frequency. There are no treatment guidelines for TP53 mutation; therefore, the patient was treated with injection paclitaxel 70mg and carboplatin 100mg for 12 cycles along with palliative radiotherapy of 20 Gy for 5 fractions. The overall prognosis of patient was found to be favorable.ConclusionsThere is a need for development of comprehensive guidelines and new molecularly targeted therapies for treatment of CUP which can be tailored for each patient and achieve precise therapeutic outcome.

Expert consensus on ultrasound guided thyroid and neck lymph node puncture (2023 edition)

Thyroid nodule and cervical lymph node biopsy is the main clinical method for evaluating the condition and determining the follow-up treatment plan. The literature on thyroid nodule puncture predominantly focuses on thyroid fine needle puncture, and there are limited systematic articles on coarse needle aspiration for thyroid-related diseases and needle biopsy of thyroid-related cervical lymph node diseases. However, this shortage of articles does not reflect the diagnostic value of coarse needle aspiration in thyroid biopsy and cervical lymph node-related diseases. Currently, different departments of many hospitals in China are conducting or planning to perform needle biopsy of thyroid and cervical lymph node-related diseases to improve the standardization and safety of related operations. Standardization is needed for the indications, contraindications, perioperative period, postoperative complications management, puncture specimen processing, and related genetic analysis of thyroid and cervical lymph node puncture. For this purpose, Interventional Ultrasound Committee of Chinese College of Interventionalists organized a panel of domestic experts in the field of thyroid diseases to discuss and formulate a consensus. Based on the latest research progress, combined with the clinical realities in China, this Expert Consensus on Ultrasound Guided Thyroid and Neck Lymph Node Puncture (2023 edition) is released.

Kikuchi-Fujimoto disease: A rare case of pyrexia of unknown origin

A young male was referred to a clinician for a complaint of fever of short duration with non-specific joint pain and treated for 1 week but after some time again presented with the same complaints with severe epigastric tenderness and vomiting. There was no past medical history before this episode. When cervical lymph node biopsy was performed gave us the diagnosis of histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto disease). A rare form of necrotizing lymphadenitis is an uncommon, benign, self-limiting disorder of obscure etiology. It affects mostly young adults of both genders. Clinically, it presents with fever and lymphadenopathy of a firm to rubbery consistency frequently involving cervical lymph nodes while weight loss, splenomegaly, and leukopenia in severely ill patients.

Ultrasound-based radiomics machine learning models for diagnosing cervical lymph node metastasis in patients with non-small cell lung cancer: a multicentre study

BackgroundCervical lymph node metastasis (LNM) is an important prognostic factor for patients with non-small cell lung cancer (NSCLC). We aimed to develop and validate machine learning models that use ultrasound radiomic and descriptive semantic features to diagnose cervical LNM in patients with NSCLC.MethodsThis study included NSCLC patients who underwent neck ultrasound examination followed by cervical lymph node (LN) biopsy between January 2019 and January 2022 from three institutes. Radiomic features were extracted from the ultrasound images at the maximum cross-sectional areas of cervical LNs. Logistic regression (LR) and random forest (RF) models were developed. Model performance was assessed by the area under the curve (AUC) and accuracy, validated internally and externally by fivefold cross-validation and hold-out method, respectively.ResultsIn total, 313 patients with a median age of 64 years were included, and 276 (88.18%) had cervical LNM. Three descriptive semantic features, including long diameter, shape, and corticomedullary boundary, were selected by multivariate analysis. Out of the 474 identified radiomic features, 9 were determined to fit the LR model, while 15 fit the RF model. The average AUCs of the semantic and radiomics models were 0.876 (range: 0.781–0.961) and 0.883 (range: 0.798–0.966), respectively. However, the average AUC was higher for the semantic-radiomics combined LR model (0.901; range: 0.862–0.927). When the RF algorithm was applied, the average AUCs of the radiomics and semantic-radiomics combined models were improved to 0.908 (range: 0.837–0.966) and 0.922 (range: 0.872–0.982), respectively. The models tested by the hold-out method had similar results, with the semantic-radiomics combined RF model achieving the highest AUC value of 0.901 (95% CI, 0.886–0.968).ConclusionsThe ultrasound radiomic models showed potential for accurately diagnosing cervical LNM in patients with NSCLC when integrated with descriptive semantic features. The RF model outperformed the conventional LR model in diagnosing cervical LNM in NSCLC patients.

Role of immunohistochemistry in clinicohistopathology-A rare case study

Disease affecting Lymph nodes form wide range of spectrum from simple to malignant pathology. Such cases are an important element to rule out malignancy in early stages. However Generalised Lymphedenopathy diagnosis become huge challenge. Hence, an insight into clinocohistopathological correlation with help of IHC markers becomes highly important to decide morphologic differential diagnosis.: To study lymph node lesions with clinicohistopathological correlation with the help of IHC study. This is a combined observational and prospective study held in District hospital Vijayapur during August 2022 to September 2023. Patient details were taken with the questionnaires. During his first visit clinical examinations and investigations, CBC, PS study, FNAC of left lower cervical region, Urine routine, chest X-ray & USG of abdomen performed and patient was analyzed & diagnosed as Chronic appendicitis and treated. During patient’s second visit, clinical examinations and investigations CBC, PS study, FNAC of left Axillary swelling, Urine routine, chest X-ray, USG of neck & abdomen, CT Neck & abdomen, USG guided FNAC of Liver, Bone marrow aspiration study, Biopsy of left lower Cervical lymph node for Histopathology study & IHC study performed. Case was studied using routine H&E, PAP stain slides of Biopsy material were evaluated by light microscopy. And for IHC, patient biopsy material referred to higher center, using specific monoclonal or polyclonal antibodies, paraffin sections were stained immunohistochemically (IHC) using a Peroxidase antiperoxidase (PAP) technique in referred higher center. Patient was diagnosed as B-cell Lymphoma as per WHO guidelines with the help of IHC markers.: From this study, concluded that IHC plays a significant role clinicopathology and helped in the definitive diagnosis and typing of tumours and appropriate treatment can be planned.

Quality of life and functional outcomes in tongue cancer patients: a long-term, prospective, comparative study.

The tongue has an indispensable role in communication, swallowing and breathing. Tongue cancer treatment involves direct resection of the tumor and surrounding tissue, which can limit many essential functions of the tongue. There are few patient-reported quality of life studies involving tongue cancer exclusively. There is also a lack of data on the outcomes of quality of life regarding different reconstructive methods, adjuvant non-surgical therapies and other predicting factors. Our objective is to assess the quality of life, functional status, and predicting factors in patients with tongue cancer up to one year after surgical resection. Thirty-six patients with tongue cancer were prospectively identified between October of 2017 and January 2021. Patients were examined before and one, three, six and twelve months after surgical resection with the validated University of Washington Quality of Life questionnaire (UW-QOL). Data collection included patient age, sex, TNM staging, size of resection, neck dissection, tracheostomy, reconstructive method and adjuvant therapies. Outcome scores were compared using the Friedman test. Multiple linear regression analysis was used to identify the predictors of quality of life and functional status. The use of UWQOL scores as dependent variables revealed the following predicting factors: age, tobacco use, radiotherapy, chemotherapy, reconstruction method and neck dissection. The most relevant findings in our study are that flap reconstruction becomes increasingly necessary when a glossectomy resection is over 45 mm, in order to maintain tongue function. We established that the reconstructive flap type does not influence quality of life in the long term. Also, we have found that cervical sentinel node biopsy provides better quality of life over neck dissection in the first 3 months after surgery.

Development of Diffuse Large B-cell Lymphoma Serendipitously Led to Life-Saving Treatment in a Patient with Refractory Classical Hodgkin Lymphoma.

A 65-year-old man with generalized lymphadenopathy was diagnosed with classical Hodgkin lymphoma-Mixed cellularity via left cervical lymph node biopsy. Initial treatment with doxorubicin, bleomycin, vinblastine, and dacarbazine led to complete metabolic remission (CMR); however, recurrence developed after 6 months. Brentuximab vedotin induced partial remission followed by systemic relapse after 10 months. Nivolumab led to a second CMR, but disease progression persisted over nearly 4 years, despite treatment adjustments and local radiotherapy. Eventually, the patient was diagnosed with diffuse large B-cell lymphoma during routine esophagogastroduodenoscopy. Four courses of rituximab-CHOP therapy led to a CMR. This case highlights the importance of performing re-biopsies to detect the recurrence or progression of lymphoma.

Sodium-Glucose Cotransporter-2 Inhibitors in Odontogenic Infections

On top of improving glycemic control, sodium-glucose cotransporter-2 inhibitors have been shown to reduce cardiovascular mortality & heart failure hospitalization. Sodium-glucose cotransporter-2 inhibitors have also been gaining momentum as effective reno-protective agents. Recent evidences have shown that sodium-glucose cotransporter-2 inhibitors are transforming the management of heart failure and chronic kidney disease in patients without type 2 diabetes mellitus. In view of the cardioprotective and reno-protective outcomes, as well as the potential benefits that outweigh adverse effects, it is no doubt that there will be continued increased use of sodium-glucose cotransporter-2 inhibitors. However, with use of sodium-glucose cotransporter-2 inhibitors comes risk of adverse effects, in particular diabetic ketoacidosis. Although uncommon, diabetic ketoacidosis is a potentially life-threatening acute metabolic complication. Diabetic ketoacidosis developing during sodium-glucose cotransporter-2 inhibitors use can present with normal blood glucose concentrations (euglycemia). This atypical presentation can delay diagnosis and hence, treatment. It is therefore crucial for dental practitioners to be cognizant of the increased risk of euglycemic diabetic ketoacidosis associated with sodium-glucose cotransporter-2 inhibitors use, especially during periods of reduced oral intake, such as in patients with odontogenic infection. Euglycemic diabetic ketoacidosis is a diagnosis of exclusion and should be considered as a differential in an ill patient on sodium-glucose cotransporter-2 inhibitors, despite normal blood glucose or absent urine ketones. We report a case of starvation ketosis in a patient with well-controlled type 2 diabetes mellitus, after excisional biopsy of right cervical lymph node and extractions of two lower right molars. Although the patient did not develop euglycemic diabetic ketoacidosis peri-operatively, it was an important diagnosis to exclude considering his high-risk profile of developing euglycemic diabetic ketoacidosis and the potential sequelae of missing the diagnosis.

A rare case of EBV-positive gray zone lymphoma

Abstract Introduction/Objective Gray zone lymphoma (GZL) is a rare and novel category of lymphoid neoplasms, first described in 2005. It is derived from B-cells and exhibits characteristics that fall between diffuse large B-cell lymphoma (DLBCL) and classical Hodgkin lymphoma(cHL). Its association with EBV is extremely rare. Here we present one such case Methods/Case Report 80-year-old female presented with progressive neck swelling and significant weight loss for over a month. It was not associated with fever, pain, or night sweats. Her past medical history was significant for hypertension, cerebrovascular accident, breast carcinoma status post-mastectomy, and non-specific B-cell lymphoma on complete remission for 9 years (post rituximab therapy). Complete blood count and metabolic profile were within normal limits. A PET scan revealed hypermetabolic cervical, supraclavicular, right axillary, and mediastinal lymph nodes, suspicious for lymphoma recurrence. The patient underwent an excisional biopsy of the left cervical lymph node which on microscopy showed lymphoid tissue in a nodular pattern with fibrosis and large areas of necrosis. The well-preserved areas showed lymphohistiocytic proliferation composed of large atypical lymphoid cells with prominent nucleoli. An area with increased eosinophils was also noted. Immunohistochemical staining showed strong positivity for EBER, CD30, MUM1, and OCT2 with dim PAX5 positivity. The cells were negative for CD20 and BOB1. Cytogenetics and molecular studies did not reveal any rearrangements or mutations. Flow cytometric study was inconclusive due to insufficient cells. A diagnosis of EBV-positive GZL was rendered. She has received brentuximab and her symptoms are improving with regressing lymph node size. Results (if a Case Study enter NA) NA Conclusion The presence of EBV positivity in GZL further complicates the diagnostic process, as it adds another layer of complexity in determining the appropriate classification and treatment. Our case highlights the importance of comprehensive morphologic phenotypic and cytogenetic investigation to diagnose GZL.

Solving the mystery of Reed Sternberg like cells in a composite Peripheral T Cell Lymphoma with Epstein Barr Virus and Epstein Barr Virus driven Lymphoproliferative Disorder

Abstract Introduction/Objective Nodal PTCL with EBV positivity can occasionally contain Reed Sternberg-like cells, and EBV- LPD can mimic Hodgkin lymphoma. Coexistence of these two unusual lymphomas in the same lymph node is very rare. We present a case of a 56-year-old male with Composite EBV+ PTCL NOS and EBV LPD, with positive B-cell gene rearrangement and negative T-cell gene rearrangement presenting a significant diagnostic challenge. Methods/Case Report A 56-year-old male with a history of abdominal tuberculosis presented with lethargy, fatigue, and poor appetite. Physical examination revealed generalized lymphadenopathy. CT scan confirmed lymphadenopathy in bilateral axilla, supraclavicular lymph nodes along with lytic lesions on illiac crest. Ill defined splenic lesions raised concerns for metastasis. Cervical lymph node and bone marrow biopsies were performed. Flow cytometry on the lymph node was not done due to tuberculosis history. Flow cytometry on the bone marrow showed an inverted CD4:CD8 ratio. H&E sections of the lymph node revealed a polymorphic lymphoid infiltrate with prominent Reed Sternberg-like cells. Immunohistochemical staining showed CD30-positive and CD45-negative large cells. T-cell and B-cell gene rearrangements were performed. Initially, B-cell gene rearrangements were positive, while T-gamma was negative. Further testing by IHC and morphological evaluation revealed two distinct cell populations, one with CD3, CD5, and CD7 positivity with partial weak positivity for PD1, CD43, and CD8 and the other consisting of B-cells expressing CD30, EBV, MUM1, and partial expression of BCL6 rare CD79a, and partial weak Pax5. Outside molecular testing showed positive T-cell gene rearrangements. The diagnosis of Composite EBV+ Peripheral T Cell Lymphoma, not otherwise specified, with cytotoxic profile along with EBV driven LPD was made. Bone marrow studies confirmed involvement by the same lymphoma. Results (if a Case Study enter NA) NA Conclusion Identifying EBV-positive Reed Sternberg-like cells in both EBV LPD and PTCL-NOS in a composite lymphoma can be challenging. In the absence of flow cytometry, a composite lymphoma can potentially be misdiagnosed, leading to under-treatment. Repeat testing can be helpful in case of any doubt. Although EBV-positive PTCL with cytotoxic profile and EBV-positive LPD has been reported, the combination of these two lymphomas together is exceedingly rare.

SAT531 Thyroid Metastasis From Non-small Cell Lung Cancer: An Unusual Case Presentation

Abstract Disclosure: E.Y. Ibrahim: None. I. Guillen Alvarez: None. I. Hulinsky: None. D. Regelmann: None. C. Janowiecki: None. Background: Cases of thyroid tumors metastasizing from the lungs are rare, and their diagnosis is often challenging and can be mistaken for primary thyroid tumors or subacute thyroiditis. Thyroid function tests are typically normal and not helpful in establishing the diagnosis. Ultrasonography commonly shows focal or diffuse hypoechoic lesions. Correspondingly, heterogeneous hypodense areas with mild contrast enhancement are seen on CT scans. Clinical Case: Our patient is a 61-year-old male with a history of diabetes mellitus and 40 years tobacco use, who presented with a 1-week history of right-sided weakness and 3-weeks of dry cough. The weakness of his leg progressed to the point he could not ambulate. Initially, he was evaluated for a stroke and underwent CT imaging showing extensive lesions of the bilateral frontal, temporal, and parietal lobes. These findings were suspicious, and confirmed by MRI, to reflect multifocal metastatic lesions with vasogenic edema. Initial physical examination revealed a palpable thyroid nodule in the right lobe with bilateral cervical lymphadenopathy. CT of the neck demonstrated lymphadenopathy as well as multiple bilateral hypoechoic thyroid nodules, the largest of which measured 0.8 cm in the right thyroid lobe. TSH was 0.34 (0.48-4.17mU/L) with Free T4 at 1.39 (0.8-1.90ng/dL). The patient had denied symptoms of heat intolerance, tremor, or palpitations. A CT chest with contrast found a 3.5 cm cavitary lesion in the right upper lobe concerning for a primary lung neoplasm, as well as multiple bilateral lung nodules, mediastinal and hilar lymphadenopathy, and bilateral adrenal masses. Subsequent ultrasound-guided biopsy of the thyroid tumor revealed histologic features of a poorly differentiated non-small cell carcinoma, with features of a primary lung origin. These features were also present on a concurrent fine needle biopsy of an enlarged cervical lymph node. Immunohistochemistry staining showed the tumor was highly expressive for PDL1, focally positive for p40, pancytokeratin AE1/AE3, and negative for TTF-1 and thyroglobulinDue to the vasogenic cerebral edema, he was given dexamethasone with good response, and his weakness improved to the point that patient was able to ambulate. Treatment also included radiation therapy with subsequent pembrolizumab upon completion of radiotherapy. Conclusion: Several thyroid lesions representing metastases may go unnoticed because the physician’s attention toward lesions at other, more common sites, and detailed thyroid examination can be commonly overlooked. Patients with newly diagnosed malignancies should also be screened for thyroid involvement, including detailed physical, radiographic, and histologic examination of pathologic findings. Presentation Date: Saturday, June 17, 2023

Early occurrence of acute myelomonocytic leukemia (M4/M5) after liver transplantation: a case report

IntroductionAcute myeloid leukemia is a rare event in post-liver-transplantation recipients. In the present report, we described a case of extramedullary acute myeloid leukemia, M4/M5 subtype, following orthotopic liver transplant.Case presentationThe patient was a 50-year-old Iranian woman who underwent orthotopic liver transplant due to hepatitis B-related cirrhosis (Child C, MELD (model for end-stage liver disease score) = 22). Orthotopic liver transplant was performed using the piggy back technique in January 2022. Induction immunosuppressive therapy was 1 gm methylprednisolone for 3 days followed by a triple maintenance immunosuppressive regimen including mycophenolate mofetil, prednisolone, and tacrolimus. About 5 months after orthotopic liver transplant in June 2022, the patient presented with leukocytosis, with white blood cell count of 99.4 × 103/µl, and physical examination revealed only cervical lymphadenopathy. Biopsy of cervical lymph nodes showed a myeloid tumor. She was immediately hospitalized. Eight hours after hospitalization, the patient gradually developed lethargy and decreased O2 saturation to approximately 89%. Flow cytometry demonstrated the markers of a myelomonocytic acute myeloid leukemia (M4/M5). Cytoreduction was immediately started by intensive leukopheresis followed by induction therapy. Because of a septic complication during the induction therapy, further chemotherapy was discontinued and broad-spectrum antibiotics and antifungal treatments started. Unfortunately, our patient died of severe septic shock 42 days after hospitalization.ConclusionAcute myeloid leukemia is a rare phenomenon after liver transplantation, and it can follow a rapidly fatal clinical course.

Abstract #1406373: A Rare Case of Hyperthyroidism in a Patient with Metastatic Thyroid Cancer Presenting as Flaccid Paralysis

Hyperthyroidism in patients with thyroid cancer is rare although increasingly reported. We describe an unusual case of hyperthyroidism associated with metastatic thyroid cancer presenting as flaccid paralysis. A 53-year-old man with a history of a goiter presented to our hospital with severe low back pain for 1 month and inability to walk. He experienced loss of sensation and motor strength in his legs a few days prior to admission. Of note, he was informed about a neck mass years ago, but elected not to follow-up with any medical providers. MRI and CT imaging revealed a large mediastinal mass with cervical lymphadenopathy and multiple lytic lesions in the spine (T11, L1, L5), right ilium, lung, and liver. Initial labs showed mild hyperthyroidism. Biopsy of a right cervical lymph node revealed metastatic thyroid carcinoma, favoring follicular variant of papillary thyroid carcinoma. His hospital course was further complicated by bowel perforation and atrial fibrillation, requiring amiodarone to control his tachyarrhythmia. Subsequent labs revealed worsening thyrotoxicosis with free T4 of 7.62 ng/dL, free T3 of 14.55 pmol/L, and negative thyroid antibodies. He was a poor surgical candidate and unable to receive radioiodine for diagnosis or treatment due to his recent iodine exposure. Methimazole and PTU were not administered as he was strict NPO due to concerns of worsening his bowel perforation. Instead, he received high-dose dexamethasone for both his spinal cord compression and hyperthyroidism. After extensive goals of care discussion, he was eventually transitioned to hospice care. Hyperthyroidism associated with thyroid cancer is rare, as these cancers are typically hypo-functioning and suppression of thyrotropin helps decrease cancer progression. However, these cases are increasingly described in the literature, with a recent systematic review reporting 28 cases of hyperthyroidism in metastatic thyroid cancer patients. Among patients with thyroid cancers, hyperthyroidism can arise from the primary lesion, metastatic lesions, underlying Graves’ disease, toxic nodules, or even precipitated by a large iodine load. The etiology of hyperthyroidism in our patient is unconfirmed, but given the degree of his thyrotoxicosis, we suspect it was primarily from his metastatic disease and worsened by iodinated contrast and/or amiodarone. Our case highlights the importance of monitoring thyroid hormone levels in patients with thyroid cancers and the consequence of using iodine-containing medications, which can precipitate thyroid hormone dysfunction and delay appropriate treatments such as radioiodine ablation.

Primary immunodeficiency with autoimmunity, two facets of same coin?-A novel case with therapeutic dilemma

12 year female born of Grade 2 consanguineous marriage presented with history of painful swelling in the right axilla and neck for 2 months. She also had history of multiple joint pain involving small and large joints with early morning stiffness for 2 months. She had past history of treatment for tubercular cervical lymphadenitis (caseating granuloma in biopsy) at 4 years of age. She was immunized appropriate for her age. Her father and paternal aunt had psoriasis. On examination she had warm and tender subcutaneous swelling 2 × 2 cm in right axilla. Significant lymphadenopathy noted in right cervical and femoral region. Psoriatic plaque was noted over scalp and right retroauricular area.Musculoskeletal examination showed bilateral wrist, ankle arthritis and bilateral achilles tendinitis. On evaluation her hemoglobin 11 mg/dl, WBC count 19000 (N88%, L9%, M3%), platelet 665000 with neutrophilic leukocytosis and shift to left. Ultrasound of right axilla confirmed abscess. Incision and drainage of abscess was done. Pus culture grew S.aureus. She was diagnosed as psoriatic arthritis with axillary abscess and generalized significant lymphadenopathy. In view of abscess, generalized lymphadenopathy, leukocytosis and neutrophilia, PID workup was done. Her immunoglobulin levels were normal. Lymphocyte subset analysis showed reduced CD8+T lymphocytes. NBT activity was seen in 55% of stimulated neutrophils (90% in control sample). DHR assay (test done twice 2 weeks apart) showed markedly decreased Neutrophil oxidative burst. Cervical lymph node biopsy revealed granulomatous inflammation. CBNAAT of sample was negative for tuberculosis. Her genetic workup showed mutation for a novel missense variant c.908T>G in Exon 10 of NCF4 and carrier state in parents and her HLA typing was positive for HLACw6. She was diagnosed as chronic granulomatous disease with psoriatic arthritis. She received sulfamethoxazole/trimethoprim, itraconazole prophylaxis and treatment with methotrexate 7.5 mg/week for arthritis. Discussion1. CGD is associated with few autoimmune manifestations like colitis, arthritis etc. To the best of our knowledge, association with Psoriatic arthritis is not reported. 2. Treatment of our case has unique challenging issues as use of DMARDS for psoriatic arthritis may increase infection chance in preexisting CGD and use of steroids for granuloma may cause rebound flare of psoriasis.

All that enhances is not cancer: Cerebral amyloid angiopathy mimicking leptomeningeal enhancement in the two patients with advanced cancer (P14-13.002)

<h3>Objective:</h3> N/A <h3>Background:</h3> Cerebral amyloid angiopathy (CAA) leads to deposition of amyloid-beta-peptide in leptomeninges and cerebral blood vessels. A <i>β</i>-related angiitis (ABRA) is a severe form of CAA characterized by transmural inflammation and/or, granulomatous inflammation. We report two patients with advanced malignancy presenting with leptomeningeal enhancement (LME) concerning for leptomeningeal metastases, with biopsy demonstrating ABRA. <h3>Design/Methods:</h3> 76-year-old man presented with left facial droop, dysarthria and imbalance. MRI head showed acute infarcts in multiple vascular distributions and diffuse LME. CTA showed bilateral cervical lymphadenopathy, without evidence of vasculitis. CSF analysis demonstrated lymphocytic pleocytosis and negative flow cytometry and cytology. Cervical lymph node biopsy revealed a new diagnosis of metastatic papillary thyroid cancer. Repeat MRI brain one month later showed persistent and worsening cortical LME. Prior to surgery for the thyroid cancer, a brain biopsy was performed for staging. Pathology demonstrated fibrinoid necrosis of vessels walls and foci of thrombosis, consistent with CAA. The patient was treated with corticosteroids followed by cyclophosphamide for ABRA. 78-year-old woman with cognitive impairment and stage IV serous endometrial cancer presented after incidental findings of subarachnoid hemorrhage (SAH) with LME on MRI brain. CSF analysis was normal with negative cytology. Head CTA was negative for aneurysm or vascular malformation. A repeat MRI showed new small SAH in the right superior frontal gyrus and multiple new punctate cerebellar infarcts. Brain biopsy revealed amyloid positivity with congo red staining in cerebellar leptomeningeal vessels, consistent with CAA. She received a 5-day course of IVIG (steroids contraindicated) with plan to start immunosuppressive therapy outpatient. <h3>Results:</h3> N/A <h3>Conclusions:</h3> Our patients presented with LME in the setting of newly diagnosed malignancy, which raised concern for leptomeningeal metastases. The presence of SAH and infarcts are uncommon in leptomeningeal metastatic disease. In these cases, pathologic confirmation of CAA on brain biopsy changed the cancer-related prognosis and treatment plan. <b>Disclosure:</b> Dr. Waheed has nothing to disclose. Dr. Seyam has nothing to disclose. Dr. Thomas has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Roon. The institution of Dr. Thomas has received research support from Novocure. The institution of Dr. Thomas has received research support from Spectrum Pharmaceuticals. The institution of Dr. Thomas has received research support from Ono Pharmaceuticals.