Multiple Bilateral Pulmonary Nodules Research Articles

NCMP-16. A CASE OF WIDESPREAD EXTRACRANIAL METASTASES FROM A GLIOSARCOMA

Abstract BACKGROUND: Glioblastoma (GBM) with sarcomatous features (gliosarcoma) accounts for 2-8% of all glioblastomas1,2, characterized by a biphasic histopathology pattern consisting of glial and sarcomatous components. While GBMs generally do not metastasize outside the central nervous system (CNS), GS has been associated with extracranial metastases in up to 11% of cases3. Case presentation: A 58-year-old right-handed woman with a GBM presented to our institution for a second opinion. She was initially diagnosed 18 months prior and had received radiotherapy with concurrent temozolomide. Her adjuvant temozolomide was discontinued due to rash, and she started on bevacizumab. Her tumor progressed and she sought additional treatment options. On her initial presentation, she was tachycardic with leukocytosis, prompting admission. A chest CT showed thoracic adenopathy, multiple bilateral pulmonary nodules, and a large left malignant pleural effusion. Bronchoscopy revealed spindle cell sarcomatoid neoplasm raising the possibility of metastasis from a CNS primary tumor. Additionally, the patient endorsed development of subacute radicular pain in her bilateral lower extremities as well as weakness. MRI of total spine revealed multilevel osseous and epidural lesions, infiltrating the paraspinal muscles and thickening of cauda roots with concern for leptomeningeal disease. A subsequent PET-CT showed increased FDG avidity in these lesions. Reevaluation of the initial CNS pathology confirmed the presence of mesenchymal/sarcomatous differentiation, consistent with a diagnosis of GS. As confirmed by autopsy, the patient eventually passed away due to widespread and metastatic disease. Discussion: While GBM rarely metastasizes outside the CNS, GBM with sarcomatous features are more likely to exhibit extracranial metastasis. Our patient had widespread involvement, including the lungs, heart, liver, omentum, and bone. Metastasis was thought most likely once EBUS of the lung returned with sarcomatous features. Clinicians should therefore maintain a high suspicion for metastases when dealing with patients diagnosed with GS.

Abstract 14138: A Rare Encounter With Unusual Metastasis: Metastatic Right Ventricular Tumor Secondary to Cervical Cancer

Background: Metastasis of cervical carcinoma to the heart is a rare and uncommon phenomenon. Cervical cancer most commonly metastasizes to the lungs, liver, bones, and lymph nodes in four ways: 1) hematogenous spread, 2) lymphatic spread, 3) transvenous extension, and 4) direct extension. We present a case of a patient with cardiac metastasis from cervical cancer who initially suffered nonspecific symptoms thought to be secondary to a pulmonary embolism. Case presentation: A 41-year-old African American woman with a history of stage IIIB squamous cell carcinoma (SCC) of the cervix was being evaluated in the hospital for exertional dyspnea and chest pain. She was tachycardic and lung auscultation revealed decreased breath sounds bilaterally. Laboratory results were unremarkable. Initially, there was concern for pulmonary embolism (PE), computed tomography angiography with contrast demonstrated no evidence of PE but a hypoenhancing defect within the right ventricle (RV) with multiple diffuse bilateral pulmonary nodules. Echocardiography revealed RV mass vs thrombus. A cardiac MRI revealed a large infiltrative irregular mass. These findings favored evidence of a tumor rather than a thrombus. Imaging findings are illustrated in Figure 1. The patient subsequently underwent a biopsy of the right lower lobe lung nodule. The biopsy revealed metastatic SCC positive for p16, p40, and PD-L1. The patient was being treated but the prognosis was poor. Conclusion: Metastasis from cardiac tumors with primary cervical cancer is uncommon with a poor prognosis and average life expectancy of less than 6 months when diagnosed. Only 4% of cases of cardiac metastasis from cervical cancer are diagnosed as antemortem. A multimodality approach with prompt diagnosis is necessary for improving prognosis.

SAT572 Concomitant Metastatic Hurthle Cell Carcinoma And Rectal Cancer, Challenges In Diagnosis And Management

Abstract Disclosure: D. Khurram: None. R. Pansare: None. S.L. Mokshagundam: None. Hurthle cell carcinomas (HCC) are aggressive tumors and account for 5% of follicular cell thyroid malignancies. Tumor size, extra-thyroid extension and distant metastases indicate poor prognosis. 20-30% of HCCs have mets at initial diagnosis, frequent sites being lungs and bones. Metastatic HCCs are exceedingly difficult to manage. Detecting two primary cancers concomitantly is uncommon and poses additional challenges in diagnosis and management. We present an interesting case of HCC with mets to the manubrium, vertebrae, lungs and concomitant rectal adenocarcinoma. A 69-year-old male had MRI spine for back pain which showed multiple lytic osseous lesions within T3 and L1 vertebrae. Further imaging revealed a large lesion in the manubrium. Manubrial mass biopsy was positive for poorly differentiated carcinoma, immunohistochemical staining for CAM5.2, cytokeratin, CD 138, CD56 and TTF-1 (weak). He underwent 6 cycles of palliative chemotherapy with carboplatin and Taxol for carcinoma of unknown origin. PET scan following chemotherapy showed a large heterogenous thyroid mass with intense FDG uptake, along with a suspicious rectal mass. Left thyroid nodule FNA reported Bethesda IV follicular neoplasm, Hurthle cell type. Rectal mass biopsy reported moderately differentiated adenocarcinoma. Histology after total thyroidectomy showed unifocal oncocytic HCC, with lymphovascular invasion but no extrathyroidal extension. Molecular markers showed low TMB, stable microsatellite status, negative PDL-1, negative NTRK fusion and positive ATM E839. He received suppressive dose levothyroxine. Radio-iodine ablation was postponed owing to prioritization of radiation therapy for rectal cancer. Thyroglobulin level increased from 53 ng/ML to 216 ng/ML. He received 149 milli Curies of I131 after Thyrogen stimulation. There was mild radioiodine uptake in the thyroid bed, but the metastatic lesions were not radioiodine avid. Follow-up scans showed multiple bilateral pulmonary nodules with worsening osseous mets. Endoscopic biopsy was consistent with HCC, TTF-1 and PAX8 positive. He was started on Lenvatinib but developed diarrhea, hence switched to Pembrolizumab. Thyroglobulin level improved on Pembrolizumab but was complicated by adrenal insufficiency. For rectal cancer, he received radiation therapy and capecitabine. Our case is interesting for several reasons. Firstly, although bone mets are commonly seen in HCC, manubrial mets, especially as the presenting feature is rare. Secondly, concomitant rectal cancer delayed the treatment of the thyroid cancer. Thirdly, there is no major consensus regarding management of HCC, especially metastatic HCC. HCCs are often not radioactive iodine avid. Combination therapy with Lenvatinib and Pembrolizumab is currently under trial for aggressive thyroid malignancy. It will be interesting to follow the clinical outcomes in this individual. Presentation: Saturday, June 17, 2023

Late Presentation of Primary Choriocarcinoma Lung in a Young Male

Primary Choriocarcinoma of the lung is a rare malignant tumor in young patients. It is mostly misdiagnosed as primary or metastatic lung cancer. Poor outcome is seen due to delays in treatment and aggressive behavior of the tumor. We present an 18-year-old male the complaints of chest pain, backache, and hemoptysis. He denied any history of tuberculosis or malignancy though he confirmed to be an occasional smoker. He was tachypneic with decreased air entry bilaterally and the rest of the examination was normal. Investigations revealed multiple bilateral pulmonary nodules. Intraoperatively multiple brown sub-centimeters to more than one-centimeter lung nodules were observed. Histopathology was suggestive of Choriocarcinoma of the lung. Beta-HCG was positive with workup for distant metastasis suggestive of para-aortic lymph node invading left psoas muscle. He was referred to oncology where he expired due to widespread disease and chemotherapy side effects.

18F-FDG PET/CT Findings in Monkeypox Infection in an HIV Patient.

A 29-year-old man diagnosed with monkeypox infection underwent an 18F-FDG PET/CT for the study of organic involvement in the context of a nonsatisfactory clinical evolution. He had a history of HIV (with undetectable viral load). FDG PET/CT showed multiple hypermetabolic lymphadenopathies and bilateral pulmonary nodules with mild 18F-FDG uptake.

A case of postmenopausal benign metastasizing leiomyoma presenting with bilateral multiple pulmonary nodules

A case of postmenopausal benign metastasizing leiomyoma presenting with bilateral multiple pulmonary nodules

Feasibility and safety of one-stage bilateral video-assisted thoracic surgery for resection of bilateral multiple pulmonary nodules

To evaluate the feasibility and safety of one- stage bilateral video-assisted thoracic surgery (VATS) for resection of bilateral multiple pulmonary nodules (BMPNs). We analyzed the clinical characteristics, pathological features, perioperative outcomes and follow-up data of 41 patients with BMPNs undergoing one-stage bilateral VATS from July, 2011 to August, 2021. One-stage bilateral VATS was performed uneventfully in 40 of the patients, and conversion to open surgery occurred in 1 case. The surgical approaches included bilateral lobectomy (4.9%), lobar-sublobar resection (36.6%) and sublobar-sublobar resection (58.5%) with a mean operative time of 196.3±54.5 min, a mean blood loss of 224.6±139.5 mL, a mean thoracic drainage duration of 4.7±1.1 days and a mean hospital stay of 14±3.8 days. Pathological examination revealed bilateral primary lung cancer in 15 cases, unilateral primary lung cancer in 21 cases and bilateral benign lesions in 5 cases. A total of 112 pulmonary nodules were resected, including 67 malignant and 45 benign lesions. Postoperative complications included pulmonary infection (5 cases), respiratory failure (2 cases), asthma attack (2 cases), atrial fibrillation (2 cases), and drug-induced liver injury (1 case). No perioperative death occurred in these patients, who had a 1-year survival rate of 97.6%. With appropriate preoperative screening and perioperative management, one-stage bilateral VATS is feasible and safe for resection of BMPNs.

Atypical Radiology Imaging of Squamous Cell Lung Carcinoma: A Case Report and Narrative Review

Introduction: Multiple well-circumscribed round nodules, also known as “Cannonball” appearance in the lungs, are typically associated with specific pulmonary metastases. However, limited reports denote the finding, especially if correlated with primary squamous cell lung carcinoma in the younger population. This is the first case report in Indonesia of a 19-year-old male with primary squamous cell carcinoma in the lung and chest radiograph image mimicking a “Cannonball” appearance Case Presentation: A 19-year-old male was presented with a history of progressing hemoptysis for two weeks with no other abnormal respiratory symptoms but a reduction of vocal fremitus. The subject is an occasional smoker and had a history of lung tuberculosis in 2009 and a suprarenal or adrenal mass. X-ray imaging revealed multiple bilateral pulmonary nodules, mimicking the “Cannonball” appearance. A fine needle aspiration (FNA) biopsy of a nodule was done and interpreted to be primary squamous cell carcinoma. Symptomatic treatment was given and the subject was discharged on the fifth day. Conclusions: A “Cannonball” appearance or its mimic is not always typical to certain carcinoma based on what this case report finds. In the case of a tumor, radiograph findings should also be correlated with other supporting tests such as biopsy and clinical presentation.

Thymoma: a rare cause for an intracardiac tumour.

A 56-year-old man presented with superior vena cava syndrome after recovery from severe COVID-19. Chest X-rays showed multiple bilateral pulmonary nodules (Panel A). A transthoracic echocardiogram revealed a mass in the right atrium of 54 × 31 mm, that protruded through the tricuspid valve and generated an obstructive gradient of 15 mmHg (Panel B; Supplementary Video 1). Contrast-enhanced chest computed tomography (CT) showed multiple pulmonary nodules (Panel C), and an intravascular extension of the intracardiac mass, deep into the innominate veins (Panels D and E). Volume 3D rendering CT showed extensive collateral venous circulation (Panel F). Steady-state free precession cine magnetic resonance imaging sequence showed an isointense mass with hyperintense areas in the right atrium, that measured 6.8 × 6.3 × 3.8 cm and prolapsed through the tricuspid valve (Panel G; Supplementary Video 2). The intracardiac mass was T1- and T2-weighted hyperintense (Panels H and I). Additionally, a mediastinum mass of 25 × 26 mm was found, with similar characteristics than the intracardiac mass.

Lemierre's syndrome: an evolving disease

Lemierre’s syndrome is characterized by thrombophlebitis of the internal jugular vein with resulting systemic septic emboli. Most cases occur following an oropharyngeal infection and have been historically caused by the bacterial pathogen Fusobacterium necrophorum. However, infection from other pathogens is becoming more common in recent years. Our case is special in the sense that Lemierre’s syndrome was caused by staphylococcus aureus after influenza infection. A 23-month-old male presented with complaints of left neck swelling and recurrent fever for one week, following influenza A infection. The child was ill-appearing with fever, tachycardia, tachypnea, and erythematous swelling on the left cheek. Laboratory results revealed elevated inflammatory markers. Computed tomography (CT) scan of the neck showed loculated fluid collection suggesting an intra parotid abscess with poor visualization of the internal jugular vein (IJV). Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Due to high clinical suspicion of Lemierre’s syndrome, a doppler ultrasound was obtained which showed a left IJV thrombus. CT scan of the chest after the clinical suspicion showed multiple bilateral pulmonary nodules suggesting septic emboli. He was treated with antibiotics and a six-week course of the anticoagulant with a resolution of his thrombus. Though historically, Lemierre’s disease is caused by Fusobacterium necrophorum, other causative organisms such as methicillin-sensitive Staphylococcus aureus are increasingly being recognized. Lemierre’s disease can present as a complication of influenza. A high index of clinical suspicion based on the location of the abscess helped us delineate diagnostic tests and treatment.

Diffuse pulmonary meningotheliomatosis with pan-TRK expression by immunohistochemistry: a novel finding and potential pitfall

BackgroundPulmonary meningothelial-like nodules (PMNs) are benign proliferations of unclear clinical significance. They are mainly asymptomatic lesions that are usually discovered during the pathologic evaluation of resected pulmonary specimens or following post-mortem examination. Diffuse pulmonary meningotheliomatosis (DPM), which presents as bilateral multiple PMNs throughout the lungs, has been described less frequently. DPMs are benign lesions associated with both neoplastic and non-neoplastic pulmonary conditions.Case presentationWe report the case of a 59-year-old female patient who presented with a history of cough. Computerized tomography (CT) imaging revealed multiple subcentimeter bilateral pulmonary nodules. transbronchial biopsies were obtained which revealed foci of nodular interstitial proliferations composed of epithelioid to spindled cells in a vague whorled pattern. Immunohistochemical stains were diffusely positive for EMA and progesterone receptor. Furthermore, pan-TRK exhibited strong and diffuse membranous expression in the lesional cells. INSM1 was negative for expression. RNA-based next-generation sequencing for the detection of NTRK fusions was performed and was negative for gene rearrangements involving NTRK1, NTRK2, and NTRK3.ConclusionHere, we report a rare case of DPM and report pan-TRK expression in PMNs which has not been described. We provide a brief review of the literature and provide insight into the potential physiologic nature of PMNs. Lastly, we emphasize the recognition of pan-TRK immunoexpression in PMNs to avoid potential diagnostic errors.

Ultrasound-Guided Bilateral Sequential Thoracic Paravertebral Block for Simultaneous Bilateral Uniportal Video-Assisted Thoracoscopic Surgery: Study Protocol for a Randomized Controlled Trial.

Simultaneous bilateral pulmonary resection via uniportal video-assisted thoracoscopic surgery (UVATS) was safe and feasible for the treatment of bilateral multiple pulmonary nodules. But, it should be noted that considerable postoperative pain at the bilateral surgical site was a crucial issue. The safety and efficacy of bilateral thoracic paravertebral block (TPVB) have been reported for postoperative analgesia. But, whether bilateral sequential TPVB can be safely and effectively used in simultaneous bilateral UVATS remains unknown. Therefore, this study aimed to determine the analgesic efficacy and safety of bilateral sequential TPVB after simultaneous bilateral UVATS. In this study, 80 participants scheduled for UVATS will be randomly allocated to the bilateral sequential TPVB group (G2) and the control group (G1). The patient of G2 will be performed bilateral TPVB at 2 time-points: before the start of the first side of pulmonary resection and before the start of the contralateral pulmonary resection. G1 will only receive standard analgesia protocol. The primary outcome is the numeric rating scale score during coughing at 24 h postoperatively. The secondary outcomes include the Prince Henry Pain Score scores, sufentanil consumption, postoperative nausea and vomiting, levels of inflammatory factors, and the Quality of Recovery-40 scores at different time points, as well as chronic pain at postoperative day (POD) 90. This is the first prospective trial to determine the safety and effectiveness of ultrasound-guided bilateral sequential TPVB for postoperative analgesia following simultaneous bilateral UVATS. This study also intended to evaluate the effect of this intervention on postoperative quality of recovery and inflammation levels. The final results will provide clinical evidence related to bilateral sequential TPVB, and promote the application of that acting as a more appropriate analgesic method for simultaneous bilateral UVATS.

Sequential pulmonary resections by uniportal video-assisted thoracic surgery for bilateral multiple pulmonary nodules.

ObjectiveThe aim of this study was to evaluate the effect of sequential pulmonary resections by uniportal video-assisted thoracoscopic surgery (VATS) for bilateral multiple pulmonary nodules (BMPNs).MethodsA single-center, prospective, nonrandomized study was performed on patients who underwent one-stage or two-stage operations by uniportal VATS. The clinical, pathological and perioperative data were summarized and analyzed from January 2021 to December 2021.ResultsA total of 80 patients were included during the study period. Sequential pulmonary resection by uniportal VATS was underwent in 40 patients. There were no perioperative deaths and serious complications, 2 patients had postoperative pneumonia, 3 patients had transient atrial fibrillation, 1 patient had persistent severe air leakage, 1 patient occurred hemoptysis. The one-stage group had less operative time, surgical blood loss, pleural drainage, chest tube duration and postoperative admission duration(P<0.05). The results of pathological examination of pulmonary nodules revealed adenocarcinoma in situ (n=12), minimally invasive adenocarcinoma (n=24), invasive adenocarcinoma (n=42), squamous carcinoma (n=1),and benign nodules (n=10). The pathological diagnosis included multiple primary lung cancers (30/40, 75%), single primary lung cancer (6/40, 15%). The most advanced pathologic stage of the primary lung cancer was classified as IA (n=19), IB (n=5), II (n=3), and IIIA (n=2).ConclusionFor patients with excellent pulmonary function, sequential pulmonary resection by uniportal VATS is a safe and feasible for BMPNs. Strict control of surgical indications, reasonable preoperative planning, accurate intraoperative operation, and standardized perioperative management can effectively reduce complications and maximize benefits for suitable patients.

TULAREMIA PRESENTING AS LARGE GI ULCERATION AND HEMORRHAGE

TULAREMIA PRESENTING AS LARGE GI ULCERATION AND HEMORRHAGE

Rare ectopic thyroid tissue as multiple bilateral pulmonary nodules: a case report and literature review

BackgroundThe prevalence of ectopic thyroid tissue is 1 in every 100,000 to 300,000 persons in the general population, and ectopic thyroid tissue in the bilateral lung lobes is even rarer. Due to its rarity, there is no definitive or standard guidance on the diagnosis and treatment of ectopic thyroid tissue presenting as multiple bilateral pulmonary nodules.Case presentationA 56-year-old woman presented with multiple bilateral pulmonary nodules, and the patient had a history of hyperthyroidism but had no symptoms of ectopic thyroid tissue. Computed tomography (CT) demonstrated multiple solid nodules in both lungs, and the largest nodule (sized 15 × 14 mm) was located in segment 5 of the upper left lung. The initial diagnosis based on imaging was metastatic malignancies. Positron emission tomography-computed tomography (PET-CT) showed multiple bilateral intrapulmonary nodules that had slightly increased metabolism (SUVmax 1.7). The largest pulmonary nodule and another nodule in the left lung were resected by video-assisted thoracoscopy surgery (VATS). The pathological and immunohistochemical (IHC) examinations confirmed a diagnosis of ectopic thyroid tissue. No postoperative adjuvant therapy was given, and the patient was discharged 3 days after the operation and had regular follow-up examinations.ConclusionThe diagnosis of ectopic thyroid tissue in the bilateral lung lobes is extremely difficult and should be considered carefully. PET-CT and surgical resection of intrapulmonary nodules are alternatives for clinicians in diagnosing ectopic thyroid tissue. Regular postoperative follow-up is needed.

Sarcoïdose venant de la galaxie

Manifestations of sarcoidosis are variable and non-specific. We are reporting on the case of a 23-year-old man who presented multiple bilateral pulmonary nodules spiculated with peripherical micronodules (galaxy sign). He had no clinical symptom. Investigations led to the diagnosis of sarcoidosis. The galaxy sign is a rare manifestation of sarcoidosis which can be useful for diagnosis.

MYCOBACTERIAL INFECTION MIMICKING LUNG METASTASIS

TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: Tuberculosis (TB) may present as multiple pulmonary nodules mimicking lung metastases. CASE PRESENTATION: A 57-year-old female presented to the hospital with generalized weakness, failure to thrive, and shortness of breath. She had lost 10 pounds in the past 10 months. She had shortness of breath for 3 weeks, associated with cough productive of white–greenish sputum. She denied any fevers, chills, recent travel. On further evaluation- CXR showed a thick-walled cavitary lesion in the right lung apex, irregular wedge-shaped opacification in the left lung apex. CT Angiography chest showed multifocal pneumonia with multiple ground glass nodular foci throughout the lungs. Multifocal pneumonia or malignancy was considered. She was empirically treated with ceftriaxone, azithromycin. Work up for pneumonia was negative. As a part of the malignancy workup, EGD and colonoscopy were unremarkable. CT-guided lung biopsy was done with the suspicion of malignancy. The pathology report showed markedly necrotic lung parenchyma with ill-defined granuloma, many acid-fast bacilli on AFB stain with no evidence of malignancy. Unfortunately, the patient was lost to follow-up and thus could not peruse further workup. DISCUSSION: Bilateral multiple pulmonary nodules are suggestive of metastases, multiple nodules with an upper lobe predominance, Pulmonary Tuberculosis, or Mycobacterium Avium Complex should be considered in the differential diagnosis. CONCLUSIONS: Many asymptomatic cases of TB are detected incidentally on chest radiography, and patients are often negative for acid-fast bacilli staining and culture despite having active TB. It is important to know the imaging findings characteristic of pulmonary TB and its variant forms. DISCLOSURE: Nothing to declare. KEYWORD: Tuberculosis

Do not Forget the ‘Forgotten Disease’ in the Covid Era: A Case Report of Lemierre’s Disease with a Rare Complication of Acute Renal Failure

<strong>Background:</strong> Lemierre’s disease, also known as the “Forgotten disease”, is a rare yet rapidly deteriorating clinical entity associated with high morbidity and mortality. We present a unique case of acute renal failure in Lemierre’s Disease which has not been previously reported in published literature. <strong>Case report:</strong> An obese 18-year-old female with intermittent asthma presented with a one-week history of sore throat, dysphagia and odynophagia associated with anuria. She was found to be in severe sepsis with tachycardia (163 bpm), hypotension (BP 113/43) and acute renal failure with bilateral tonsillar exudates, mild anterior neck swelling and trismus. Initial labs were also significant for leukocytosis (WBC 29.4 k/ul), transaminitis (AST 1115 u/L, ALT 240 u/L), and severe rhabdomyolysis (creatine kinase 96848 u/L). She received intravenous fluids with good response and started on vancomycin and piperacillin-tazobactam. Initial infectious work-up was negative for group A streptococcus (throat), SARS-CoV-2 PCR and antibody, HIV, RPR, EBV, hepatitis A/B/C. Initial chest x-ray revealed bilateral nodular opacities with likely miliary distribution for which TB evaluation was considered but later aborted. Admitting diagnoses were severe sepsis from soft tissue infection (neck vs. pneumonia) with possible bacteremia and acute renal failure (pre-renal exacerbated by severe rhabdomyolysis). The patient’s case was complicated early on by the development of anuric renal failure (creatinine 7.5 mg/dL) and hyperkalemia for which she required hemodialysis by day 3 of hospitalization. Other complications included respiratory distress and hypoxia requiring transient BiPAP support and transiently elevated pro-BNP and troponin which all spontaneously resolved. An echocardiogram revealed borderline normal LV systolic function. A non-contrast head and neck CT showed asymmetric enlargement of the left parotid gland and palatine tonsil with no obstruction and enlargement of left internal jugular lymph nodes compatible with reactive changes. On the 4th hospital day, the initial blood culture was found to be positive forFuscobacterium necrophorum, for which metronidazole was added pending culture sensitivity results. Due to concerns for septic thromboemboli, contrast CT studies of the head, neck and chest were done revealing multiple large bilateral pulmonary nodules with cavitation and bilateral lower lobe consolidation concerning for septic emboli and pneumonia as well as diminished calibre and poor opacification of the left internal jugular (IJV) concerning for thrombosis, solidifying the diagnosis of Lemierre’s Disease. A Doppler ultrasound of the neck showed diminished flow through the left IJV and a venogram study confirmed the presence of the left IJV thrombus. In consultation with vascular surgery and interventional radiology specialists, it was decided that medical anticoagulation with heparin was preferable over thrombectomy. An abdominal CT on hospital day 9 further revealed bilateral renal infarcts thought to be from septic emboli. The patient completed a course of piperacillin-tazobactam and transitioned from heparin infusion to apixaban once repeat studies showed resolution of LIJV thrombus. She underwent 8 cycles of dialysis over the period of two weeks with subsequent spontaneous return of adequate renal function without need for further dialysis. <strong>Discussion:</strong> Lemierre’s disease presents with fever, sore throat, lymphadenopathy, thrombosis of IJV and metastatic infection to other organs, mainly the lungs. This patient’s case was uniquely complicated by renal infarcts from septic emboli with acute kidney failure requiring hemodialysis. With antibiotics, anticoagulation and hemodialysis, the patient has fully recovered without any long-term organ system deficits.

TTF-1 Immunoexpression in Primary Rectal Adenocarcinoma with Brain Metastasis

Abstract Introduction/Objective Rectal adenocarcinoma metastatic to the brain occurs in 0.6%-3% of cases and is associated with advanced-stage disease.TTF-1 expression in rectal adenocarcinoma is an uncommon finding and less than five cases of TTF-1 positive rectal adenocarcinomas have been reported in the literature. Herein, we report a primary rectal adenocarcinoma with biopsy-proven brain metastasis, radiographic evidence of hepatic and pulmonary involvement and unique expression of TTF-1, a marker with high sensitivity for primary pulmonary and thyroid lesions. Furthermore, we discuss the importance of distinguishing this entity from Pulmonary Enteric Adenocarcinoma (PEA). Methods/Case Report A 68-year-old male with hypertension presented with a two-day history of left facial drooping and dysarthria. Brain MRI revealed a 2.9 cm, contrast-enhancing, solitary, right insular mass. A pterional craniotomy and gross total resection of the lesion was performed. Microscopic examination revealed metastatic adenocarcinoma with immunohistochemical expression of CAM 5.2, CDX2, CK20, focal immunoreactivity with Napsin A and TTF-1, and lack of expression of CK7 and Synaptophysin. Radiographic investigation revealed a right posterior rectal lesion and multiple hepatic and bilateral pulmonary nodules. Sigmoidoscopy a fungating, partially circumferential, ulcerated, and friable rectal mass extending 6 cm proximally from the anal verge. Biopsy demonstrated invasive well- differentiated rectal adenocarcinoma with microsatellite stable phenotype, expression of CDX2, CD20, TTF-1 in the lesional cells, and lack of immunostaining with CK7. Given these findings, we favored a diagnosis of invasive well- differentiated rectal adenocarcinoma. Results (if a Case Study enter NA) N/A Conclusion TTF-1 positive rectal adenocarcinoma is an important differential diagnosis for PEA. As the two primary lesions share histomorphological features, clinical history, radiological findings and immunohistochemical staining with CK7 can aid in distinguishing between the two entities. Recent literature suggests a possible role for CDH17 and SATB2 immunostaining to increase the sensitivity and specificity of distinction between the two entities. Lack of expression of CK7 in both the rectal and brain lesion biopsies, radiological finding of numerous bilateral pulmonary infiltrates and one large, solitary rectal mass supports the diagnosis of advanced stage primary rectal adenocarcinoma with distal metastasis in our patient.

A RARE CASE OF CHRONIC COUGH

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Chronic cough is one of the most common symptoms for which outpatient care is sought. The differential diagnosis is broad, and many patients undergo extensive evaluation. We here report a rare case of chronic cough with progressive dyspnea due to Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia( DIPNECH), followed by a brief literature review of DIPNECH. CASE PRESENTATION: 70-year-old female, non smoker, history of Crohn's disease presented to the Pulmonology clinic in 2005 with cough and shortness of breath. PFT's showed restrictive pattern. CT scan showed multiple bilateral pulmonary nodules. Bronchoscopy could not identify cause. On periodic CT, lung nodules remained stable. In the meantime, she continued to have chronic cough and progressively worsening shortness of breath. She received multiple trials of steroids, antibiotics, and inhalers with mild improvement. Repeat PFT's now showed severe obstructive disease. Her coughing spells made it difficult to perform on PFTs. She underwent repeat bronchoscopy with extensive testing, including bacterial, fungal, malignancy, and autoimmune causes of her symptoms, all of which came back negative. The working diagnosis was necrobiotic nodules secondary to her Crohn's disease vs. Asthma. She was put on a prolonged steroid course and developed severe side effects like muscle weakness, mood changes, tremors and worsening kidney function. The patient was hesitant to go back on steroids. She had suffered for 17 years. A trial of steroid-sparing medication CellCept was considered. However, before committing the patient to these, a wedge biopsy of the pulmonary nodule was performed and revealed neuroendocrine cells that stained positive for synaptophysin, chromogranin, and CD56.8 confirming the diagnosis of DIPNECH. The patient was subsequently referred to oncology and started on Octreotide infusions causing significant improvement in symptoms. DISCUSSION: DIPNECH is a rare condition that is becoming increasingly recognized. It is typically characterized by an insidious onset with chronic nonproductive cough, exertional dyspnoea, and wheezing, spuriously attributed to Asthma, chronic obstructive pulmonary disease, or GERD. Indeed, the diagnosis of DIPNECH is usually made several years after the onset of clinical symptoms, often following the incidental discovery of a lung nodule (or nodules) on imaging, usually computed tomography (CT). It is characterized histologically by a diffuse, bronchiolo-centric proliferation of neuroendocrine cells at the periphery of the lung, radiologically by ground-glass opacity, mosaic attenuation with air trapping, bronchial wall thickening, and pulmonary nodules and, Clinically by symptoms of airflow limitation. CONCLUSIONS: We hope this case can increase awareness of DIPNECH among clinicians as patients may otherwise be misdiagnosed and undergo unnecessary treatments or procedures causing permanent harm. REFERENCE #1: Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia 1Margaret Wei, MD and 2Mehri Manouchehr-Pour CLINICAL VIGNETTE1UCLA Department of Medicine2UC Riverside Department of Cell, Molecular, and Developmental Biology DISCLOSURES: No relevant relationships by Venkatkiran Kanchustambham, source=Web Response No relevant relationships by Swetha Saladi, source=Web Response No relevant relationships by Khurram Shafique, source=Web Response No relevant relationships by Vinita Vaidya, source=Web Response