Isolated cryptococcal osteomyelitis in the setting of immune reconstitution inflammatory syndrome

Cryptococcal infections, though rare, must be considered in all immunocompromised patients. Patients with HIV/AIDS on antiretrovirals may have a treatment course complicated by immune reconstitution inflammatory syndrome. Here we present a case of a 38-year-old woman with HIV/AIDS with knee pain who only began to experience severe pain after induction of antiretroviral therapy. She was found to have cryptococcal osteomyelitis without dissemination to the central nervous system, an unusual presentation for immunocompromised patients. She was treated with oral fluconazole with a resolution of symptoms. This case report suggests conservative management of isolated cryptococcal infection with fluconazole, regardless of immune status.

A Case of Radiologically Compatible Chronic Lymphocytic Inflammation With Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) With Demyelinating Lesions

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a recently identified diagnosis that can cause a variety of severe symptoms, including ataxia, dysarthria, diplopia, paraparesis, and vertigo. These symptoms rarely present in isolation but often accompany one another in various combinations. Magnetic Resonance Imaging (MRI) of the brain is critical for making the diagnosis and typically reveals scattered enhancement within the pons and adjacent structures. The syndrome responds well to high-dose steroids, and maintenance therapy is required to prevent a recurrence. In this report, we present a case of a 62-year-old man who developed CLIPPERS syndrome. The patient presented with hemiparesis and dysarthria, which developed over four months and then acutely worsened within 24 hours. After diagnosing CLIPPERS, the patient was placed on high-dose steroids and experienced rapid clinical improvement, as well as improvement on repeat MRI. The patient's treatment was complicated by an incidental diagnosis of tuberculosis, which required simultaneous management with isoniazid.

Pathological fracture due to primary bone lymphoma in a patient with a history of prostate cancer: A case report and review of literature

Primary bone lymphoma (PBL) is a rare extranodal presentation within lymphomas and primary bone malignancies. Pathologic fracture (PF) is a common complication of metastatic bone disease but is, rarely, the presentation of a primary bone tumor. We report a case of an 83-year-old man with a history of untreated prostate cancer, presenting with atraumatic fracture of his left femur after months of intermittent pains and weight loss. Radiographic workup revealed a lytic lesion suspicious for PF secondary to metastatic prostate cancer; however, initial core biopsy results were inconclusive for malignancy. A complete blood count with differential and complete metabolic panel was within normal limits. During surgical fixation and nailing of the femur, a reaming biopsy was performed as a repeat measure and revealed diffuse large B-cell lymphoma. Staging with positron emission tomography and computed tomography found no evidence of lymphatic or visceral involvement and chemotherapy was promptly initiated. This case highlights the diagnostic workup challenges for PF secondary to PBL, especially in the setting of concurrent malignancy. Because of the non-specific presentation of a lytic lesion on imaging associated with atraumatic fracture, we highlight PBL as an important diagnostic consideration.

Diffuse Idiopathic Neuroendocrine Cell Hyperplasia (DIPNECH) on Electromagnetic Navigation Bronchoscopy (EMN) Guided Fine Needle Aspiration (FNA): A Case Report

Introduction/Objective

DIPNECH is a clinicopathological diagnosis characterized by abnormal proliferation of single or clusters of neuroendocrine cells in the bronchial mucosa. The World health organization includes DIPNECH as a preinvasive lesion to carcinoid tumors of the lung. Diagnosis is often delayed or missed due to insidious presentation and rarity of the disease. High degree of suspicion in the appropriate clinical and radiological context is important for early diagnosis. We describe a unique case of DIPNECH diagnosed by EMN guided aspiration cytology in the setting of multiple incidental lung nodules and confirmed on surgical resection.

Methods/Case Report

A 69-year-old female with history of insidious cough was referred to pulmonology clinic for multiple incidental bilateral lung nodules detected by CT scan, largest involving the right middle lobe. Although the main diagnostic consideration was pulmonary metastasis, several radiological features, including diffuse mosaic attenuation pattern, prompted the possibility of a diffuse neuroendocrine process. Electromagnetic navigation bronchoscopy (ENB) guided fine needle aspiration cytology was performed. Air-dried and Papanicolaou stained smears were scant but showed dispersed and clusters of small cells with fine chromatin with minimal cytoplasm. No necrosis or mitosis were seen. A cell block was prepared that showed rare clusters of tumor cells positive for immunostains synaptophysin, chromogranin, CD56, with a Ki-67 of 1%. In the appropriate clinical and radiological context findings were consistent with a well differentiated neuroendocrine process such as DIPNECH. Right middle lobe resection confirmed extensive DIPNECH with multiple typical carcinoid tumors and tumorlets.

Results (if a Case Study enter NA)

NA

Conclusion

It is essential to be familiar with the clinical and radiological findings of DIPNECH and include it in the differential diagnosis of its mimickers. Although the diagnosis is challenging on limited specimens, this report indicates that EMN guided aspiration cytology can be used as a valuable early tool for accurate diagnosis and timely management of DIPNECH.