Multilocular thymic cyst with epithelioid granulomata of unknown etiology: a radiologic and histopathologic correlation

Thymic cysts (congenital or acquired) are believed to account for 3% to 5% of all mediastinal masses. Multilocular thymic cysts are an acquired reactive inflammatory process arising within the thymus gland and are less common than the congenital unilocular type. Multilocular cysts have been reported in association with a variety of neoplastic, autoimmune, and infectious conditions. We report a case of a 23-year-old white man who presented with a 2-week history of progressive right-sided shoulder and chest pain. He was found to have an anterior mediastinal mass involving the thymus. This case of multilocular thymic cyst is particularly unique due to the presence of abundant epithelioid granulomata within the cyst, a finding that has not previously been emphasized as a histologic feature of these lesions, and one that expands the histopathologic differential diagnosis, warranting exclusion of infectious and autoimmune etiologies.

The impact of serum glucose on clinical outcomes in patients hospitalized with community-acquired pneumonia

PURPOSE

Community-acquired pneumonia (CAP) is a common medical condition resulting in excess morbidity, mortality, and high rates of hospitalization. Despite high hospitalization rates for CAP, the relationship between abnormal glucose levels (hyperglycemia and hypoglycemia) and the seriousness of the illness as measured by length of stay (LOS) is not well established. We examined relationships of CAP to multiple factors that impact predictability and severity of the disease process. They include glycemic control; hospital utilization, including LOS; 30-day hospital readmission; intensive care unit (ICU) admissions, adjusting for comorbidities; illness severity; and timing of antibiotic treatment.

METHODS

We conducted a retrospective observational cohort study of adult patients hospitalized for CAP between January 1, 1992 and June 23, 2007. Case screening was conducted electronically using International Classification of Diseases, 9th Revision (ICD-9) codes 480.0-487.9. Subsequent medical record abstraction yielded 969 qualifying cases with comprehensive data on past and current medical problems.

RESULTS

Serum glucose levels at admission were independently associated with LOS for CAP patients. Patients with levels between 90 mg/dL and 140 mg/dL on admission had shorter LOS compared to those with levels of < 90 mg/dL and > 140 mg/dL (median 3.9 vs 4.2 days, P = .04). Multivariate analyses confirmed the univariate results. Serum glucose levels at initial hospitalization were not associated with 30-day hospital readmission (P =.34) or ICU admission (P = .48).

CONCLUSIONS

Abnormal glucose levels are an independent predictor of increased LOS for CAP. Control of blood glucose may lead to improved outcomes, including shortened LOS, and should be a priority in CAP management.

Infectious disease and cancer

With the recent advances in molecular biology and genetics over the past several decades, we have grad-ually uncovered the elusive cause of some of the malignant diseases that have been, and continue to be, a major factor in human mortality. Infectious disease agents, so ubiquitous in our environment, have now become the most credible link in our search for the cause of cancer. The number of malignancies associated with specific infectious disease agents continues to grow and now represents approximately 20% of all cancers. This perspective represents a brief summary of those cancers that have been associated with or caused by infectious disease agents. Hopefully, knowledge of this relationship can be translated into more effective means of treatment.

New oral anticoagulants: a brief review

This manuscript represents a brief review of the current oral anticoagulants that have come on the scene over the past decade and that are now in various stages of development through the process of phase II and III clinical trials. A brief review of the oral thrombin and direct factor Xa inhibitors is presented to apprise the practicing clinician of the status of these new agents. Efficacy and safety issues are mentioned as they relate to each agent and the need for alternative agents to replace the vitamin K antagonists for long-term anticoagulation therapy. Although none of the agents discussed in the review have been approved for clinical use, data accumulated thus far from the clinical studies have provided some degree of encouragement and optimism for their future approval.

Extrahepatic portal hypertension following abdominal surgery

We present a case of non-cirrhotic extrahepatic portal hypertension in a 31-year-old woman following extensive abdominal laparotomy for the drainage of multiple retroperitoneal and liver abscesses following a perforated appendix. Chronic portal, splenic, and mesenteric vein thrombosis with portal hypertension was caused by a hypercoagulable state due to the abdominal infection and abdominal surgery. Various etiological aspects of chronic extraheptic venous thrombosis have not been documented due to the low incidence of these events. We discuss these aspects in the context of our patient.

A phase II trial of arsenic trioxide for relapsed and refractory acute lymphoblastic leukemia

We designed a phase II trial of arsenic trioxide (AT) for the treatment of relapsed and refractory acute lymphoblastic leukemia (ALL). The dose administered was 0.25 mg/kg/day intravenously for 5-7 days per week for up to 60 days. Of 11 patients eligible, eight had B-cell and three T-cell ALL and two were Philadelphia chromosome-positive. The median duration of therapy was 21 days (range 7-28). One patient died of an infection. There were no responses. Ten patients have died. The median survival was 3.2 months (range 1.2-4.1). We conclude that AT is not active in the treatment of ALL.

Recurrent venous thromboembolism in patients with and without anticoagulation after inferior vena caval filter placement

AIM

The aim of this study was to compare the rate of recurrent venothromboembolic (VTE) events and factors contributing to VTE events in patients with inferior vena caval (IVC) filters on chronic anticoagulation to those in whom anticoagulation was discontinued.

METHODS

Retrospective cohort study of 353 patients who received IVC filters between 1986 and 2002.

RESULTS

Anticoagulation status was available for 304 patients (132 on coumadin anticoagulation therapy and 172 who did not receive any anticoagulation therapy) whose IVC filters were placed within 30 days of their qualifying thromboembolic event. Two-year event-free survival for the anticoagulated group was 80.6% (95% confidence interval--CI--76.9, 84.3] and was 67.8% (95% CI 63.2, 72.3) for the non-anticoagulated group. Patients who had Greenfield filter had a higher, but not statistically significant different, rate of recurrence compared to those with other types of filters (hazard ratio 1.4; 95% CI 0.9, 2). The rate of recurrent VTE events was independent of age, gender, smoking status, or underlying medical condition.

CONCLUSIONS

Among those with IVC filters, long-term anticoagulation therapy prolonged event-free survival for up to 2 years but did not prevent recurrent VTE events.

Efficacy of the influenza vaccine in patients with malignant lymphoma

BACKGROUND

The benefits and efficacy of the influenza vaccine have been controversial and have had mixed reviews in the recent literature. Immunosuppressed patients and those receiving chemotherapy are particularly at risk for infectious complications and are therefore given high priority to receiving prophylactic vaccines.

METHOD

We administered the influenza vaccine to 29 patients with malignant lymphoma who were receiving chemotherapy or had recently completed therapy during the flu season of 2003-2004. An aged-matched control group received the same vaccine during the same period. The ability of both groups to mount a protective titer of antibodies to the antigens in the vaccine was measured.

RESULTS

Three of 29 patients (10%) in the lymphoma group were able to mount a 4-fold titer to at least one of the influenza A antigens. One patient developed a protective titer to both influenza A and B antigens and 3 of 29 responded to the influenza B antigen. In the control group 13 of 29 (45%) responded to an influenza A antigen and 14 of 29 (48%) had a 4-fold response to the B antigen. Seven of 29 controls (24%) had a 4-fold increase in their titers to both the A and B antigens.

CONCLUSIONS

This study confirmed the low incidence of response or efficacy to the influenza vaccine reported in previous studies. Only a small percentage (10%) of immunosuppressed patients with malignant lymphoma responded with a 4-fold increase in their antibody titer to the major antigens of the 2003 influenza vaccine. Most interestingly, less than 50% of the aged-matched control population studied responded with a 4-fold increase in their antibody titer. Additional studies are needed to determine methods for improving the efficacy of the vaccine and the effectiveness of the influenza vaccination program in preventing influenza infections in the United States.

Risk assessment model for venothromboembolism in post-hospitalized patients

AIM

Venothromboembolism (VTE) is an important condition in hospitalized patients accounting for significant morbidity and mortality, and the risk of VTE often continues post-hospitalization. Although risk assessment models have been developed to predict the risk of deep venous thrombosis (DVT) in hospitalized patients, no models have been developed that determine the risk of DVT during the post-hospitalization period. The objective of this study was to create a risk profile using risk factor assessment that could be used to predict which patients are at highest risk of developing DVT within 60 days following hospital discharge.

METHODS

The computerized medical records of 380 patients (190 with DVT and 190 without DVT) who received care from 1995-2002 and were subsequently re-hospitalized within 60 days of discharge were retrospectively reviewed. Univariate and multivariate logistic regression analyses were conducted to identify risk variables related to VTE. A novel risk assessment model was created using risk factors from the logistic regression analyses.

RESULTS

The prevalence of VTE was found to be 93.2% (69/74) in the high-risk category, 52.9% (109/206) in the moderate-risk category, and 12% (12/100) in the low-risk category.

CONCLUSIONS

Once validated, this risk assessment model may be applied to identify patients who may be at increased risk of developing VTE post-hospitalization. Those at high risk should be considered for anticoagulation therapy during the post-hospitalization period. Availability of a risk profile using risk factor assessment to guide decisions related to anticoagulation therapy will have important ramifications relative to patient outcomes including morbidity, mortality, and reductions in VTE-associated cost.

Auer rods galore! Acute promyelocytic leukemia

The diagnostic intracellular inclusions (Auer rods) found in this touch preparation of a core bone marrow biopsy helped provide basis for the diagnosis in this case. The patient, a 48-year-old man, presented with increasing fatigue and pancytopenia. A bone marrow biopsy demonstrated a marked increase in hypergranular, immature myeloid cells, as well as a plethora of Auer rods. The diagnosis was confirmed by cytogenetic studies which showed a C15:17 translocation [t(15:17)].

Disorders of flushing

Disorders of flushing encompass a broad spectrum of diverse acquired and inherited conditions. Chemical mediators involved in the flushing response are incompletely understood. Flushing episodes rarely can be associated with significant morbidity and mortality. The goal of the physician is to separate benign from potentially life-threatening conditions. Accurate diagnosis requires a thorough history and physical examination emphasizing the age of the patient, temporal association of flushing with occupation, environmental, stress, food, or drug exposure, and the duration of the episode. In some cases, despite a thorough evaluation, the etiology for flushing remains unknown. Understanding the distinct mechanisms that lead to flushing helps provide a rational approach to treatment.

Hypercoagulability and venous thromboembolism: a review

This review addresses the numerous factors that predispose individuals for venous thromboembolic events (VTE). Both acquired and genetically inherited factors are reviewed with their approximate relative risk of developing VTE. Oral contraceptive use and hormone replacement therapy, as well as the prevalence of VTE associated with pregnancy, are also addressed. Particular attention is directed to the frequency of more than 1 predisposing factor being present, further increasing the risk of VTE or its recurrence.

Hematologic and metabolic abnormalities in a patient with anorexia nervosa

Anorexia nervosa is a common problem in young adults that may present with a variety of metabolic and hematologic abnormalities, as well as weight loss and psychological disturbances. We present a young man with a long history of anorexia nervosa who developed pancytopenia associated with decreased bone marrow cellularity and abnormal architecture and marrow infiltration with an amorphous, gelatinous substance characteristic of anorexia nervosa. The patient also developed osteopenia with evidence of excessive calcium excretion. The pancytopenia and marrow function reverted to normal with therapeutic and dietary intervention. The effects of eating disorders can result in serious consequences with respect to an individual's health and well-being. A host of hematologic abnormalities that are associated with anorexia nervosa have the potential of increasing the risk of infection and bleeding. Additionally, because of the insidious development of anemia in some patients, decreased performance status and chronic fatigue can pose significant compromises in one's daily activities and work effort. Anorexia nervosa is a chronic illness that is distinctly more common in females than in males (ratio of 10 to 1), but can affect males in an equally debilitating manner, requiring multiple modalities of therapeutic intervention and consultation. We present the case of a male referred to the hematology department because of pancytopenia, chronic fatigue, and back pain. A diagnosis of anorexia nervosa had been made 10 years prior at the age of 18 years.

Tumor lysis syndrome (TLS) following fludarabine therapy for chronic lymphocytic leukemia (CLL): case report and review of the literature

Adenosine deaminase inhibitors have proven superior to alkylating agent-based therapies in inducing clinical and hematologic remissions in treated and previously untreated chronic lymphocytic leukemia (CLL) patients, and they have become increasingly accepted as a standard for therapy. We report the case of a 66-year-old patient with a 7-year history of CLL who had been previously treated with alkylating agents. Upon presentation with abdominal lymphadenopathy, a 5-day course of the nucleoside analogue, fludarabine, was administered. Two days after completion, the patient developed acute tumor lysis syndrome (TLS) that induced renal failure with hyperkalemia and hyperuricemia. This resulted in critical, life-threatening complications requiring hospitalization, aggressive hemodialysis and fluid replacement therapy. While only 5 other cases of TLS associated with fludarabine therapy have been reported since 1989, we recommend that adenosine deaminase inhibitor therapy be initiated with the addition of allopurinol, and that hydration with copious amounts of oral fluids during therapy be encouraged in order to help protect against the renal effects of potential TLS induced by these agents.

Regulation of colony-stimulating factor-induced human myelopoiesis by transforming growth factor-beta isoforms

Transforming growth factor-beta (TGF-beta) proteins are multifunctional regulators of cell growth and differentiation. The three isoforms, TGF-beta1, -beta2, -beta3 share approximately 70% identical amino acid sequence and are coded by three distinct genes. Growth and differentiation functions in which the isoforms have differential activity include: inhibition of colorectal cancer cell growth, migration of aortic endothelial cells, survival of ciliary ganglionic neurons, and binding to cell surface receptors. A previous paper reported that TGF-beta1 and TGF-beta2 had bimodal dose-dependent stimulatory and inhibitory effects on granulocyte-macrophage colony-stimulating factor induced Day 7 granulocyte-macrophage colony-forming units. The effects of TGF-beta3 were only inhibitory. At low concentrations, TGF-beta1 and -beta2 stimulated growth, whereas at higher concentrations both isoforms inhibited growth. We now report that TGF-beta1, TGF-beta2, and TGF-beta3 are similar to each other at low concentrations; at higher concentrations TGF-beta1 and TGF-beta3 inhibit growth, but TGF-beta2 stimulates growth. Our results are consistent with the known affinities of the TGF-beta isoforms with the Type II TGF-beta signaling receptor, which has greater affinity for TGF-beta1 and TGF-beta3 than TGF-beta2.

Activity involvement among suicidal and nonsuicidal high-risk and typical adolescents

The purpose of this study was to compare weekly activities among four groups of randomly selected high-risk and typical high school students: (1) potential dropouts at suicide risk, (2) typical youth at suicide risk, (3) potential dropouts not at suicide risk, and (4) typical youth not at suicide risk. Of the 1,286 participants, 39.4% of the high-risk and 30.1% of typical high school students screened in at suicide risk. Weekly activity comparisons across the four groups showed that suicide-risk adolescents, regardless of potential dropout status, engaged in more solitary activities on weekdays and weekends than did their nonsuicide risk peers. High-risk potential dropout youth engaged in less homework and more social activities during weekdays and weekends than did the typical high school students. These results provide important insight into the weekly activity involvement of at-risk youth while helping to gain a better understanding of suicide-risk adolescents. Implications of these findings are discussed for identifying youth at risk for suicidal behavior and for prevention programming.

Approach to diagnosing lower extremity edema

Edema, a sign of a localized or systemic disease process, results from a disruption in the normal physiological forces controlling extracellular fluid volume. This review utilizes an anatomical approach in discussing the various causes of edema.