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BACKGROUND Primary retroperitoneal choriocarcinoma is a rare form of extragonadal germ cell tumor that is highly aggressive and responds poorly to chemoradiation. Extragonadal choriocarcinomas are notoriously challenging to diagnose, and have often progressed to advanced disease by the time of diagnosis. The survival rate for extragonadal choriocarcinoma is approximately 30%, which is much lower than that of extragonadal non-seminomatous germ cell tumors (GCT) in general. CASE REPORT A 24-year-old man with no significant past medical history presented with left-sided, pleuritic chest pain and back pain radiating down his left leg, of 1-year duration. Computed tomography (CT) of the chest revealed multiple bilateral pulmonary nodules and a CT of the abdomen and pelvis showed a large heterogeneous soft tissue mass measuring 9.3×8×10.5 cm. A CT-guided core needle biopsy of a lung nodule was performed and the findings were consistent with the diagnosis of metastatic choriocarcinoma. Magnetic resonance imaging (MRI) of the brain was negative for metastatic disease. Tumor markers were significant for a markedly elevated beta human chorionic gonadotropin (B-hCG) of 104 712 mIU/mL. He was diagnosed with a stage IIIC germ cell tumor, further classified as a primary retroperitoneal choriocarcinoma with lung metastasis, and was started on urgent inpatient chemotherapy. CONCLUSIONS Due to the poor outcomes associated with extragonadal choriocarcinoma, it is important to promptly and correctly identify this malignancy in order to initiate treatment in a timely manner. The following case report explores the histopathologic characterization of this malignancy and describes the clinical course and outcomes from treatment for this patient.

Patient: Female, 63 Final Diagnosis: Thymic carcinoma Symptoms: Hip pain Medication: — Clinical Procedure: — Specialty: Oncology Objective: Unusual clinical course Background: Thymic carcinoma is a rare malignant neoplasm. High-grade thymic carcinoma has a high recurrence rate following surgery, and a low 5-year survival rate. Approximately 30% of patients with thymic carcinoma will be asymptomatic at the time of diagnosis. Extrathoracic metastasis on presentation is uncommon. Treatment of the primary tumor includes surgery, chemotherapy, and fractionated radiation. A rare case of thymic carcinoma that presented with bone and cerebral metastases is reported in a patient who responded well to stereotactic radiosurgery and chemotherapy. Case Report: A 63-year-old woman presented to the hospital for evaluation of hip pain. She was diagnosed with a lytic bone lesion of the right femur and brain metastasis. Biopsies from the mediastinal mass and right femur showed histological features consistent with carcinoma. Immunohistochemistry showed positive immunostaining of the tumor cells for the c-kit receptor (CD117) and CD5, supporting a diagnosis of stage IVb thymic carcinoma. Treatment included stereotactic radiosurgery, which delivered multiple radiation beams to the tumor tissue from different directions to target the tumor without affecting normal tissues. She was treated as an outpatient with carboplatin and taxol after stereotactic radiosurgery. The patient recovered well following treatment. Conclusions: A case of thymic carcinoma with bone and cerebral metastases was successfully treated with stereotactic radiosurgery and chemotherapy.

Catastrophic thrombotic syndrome, otherwise known as thrombotic storm (TS) is an extreme prothrombotic clinical syndrome that presents as rapid onset of multiple thromboembolic events affecting a large variety of vasculature. In recent studies, there has been a correlation of high plasma levels of factor VIII with thrombotic events. We present the case of a young man who exhibited multi-organ failure due to thrombotic storm. A 38-year-old male presented to the emergency department for progressive dyspnea and was diagnosed to have pulmonary embolism. The patient developed respiratory distress requiring intubation and was diagnosed with both an ST-elevation myocardial infarction and right cerebral infarction during the hospital course. The patient expired and autopsy revealed the cause of death to be myocardial, cerebral and renal infarction from widespread vascular thrombosis. Autopsy revealed cause of death to be elevated factor VIII associated thrombotic coagulopathy. Factor VIII level upon autopsy was 375% (55-200%). Although TS is rare, it can be lifethreatening if not recognized early. Survival depends on the prompt initiation and duration of anticoagulation.

Patient: Female, 38-year-old Final Diagnosis: Hypercalcemia resulting from necrotizing leiomyoma in pregnancy Symptoms: Pain Medication: — Clinical Procedure: Cesarean section Specialty: General and Internal Medicine • Obstetrics and Gynecology Objective: Rare disease Background: Hypercalcemic crisis is defined as a serum calcium level >14 mg/dL in a symptomatic patient. While severe hypercalcemia during pregnancy is rare, it poses a life-threatening risk to both mother and fetus. Hypercalcemia in association with a benign tumor such as a leiomyoma is exceedingly rare. Case Report: A 38-year-old primagravida at 31.2 week’s gestation conceived by in vitro fertilization presented to the emergency department for complaints of nausea, vomiting, and epigastric abdominal pain. Her fetal monitor strip was reassuring. A complete metabolic panel on admission was significant for severely elevated calcium of 15.9 mg/dL (8.6–10.3 mg/dL) and an elevated lipase of 1457U/L (11–82 U/L). She was started on aggressive intravenous fluid resuscitation, but became confused and lethargic, unarousable to verbal stimuli, as a result of hypercalcemia. Computed tomography (CT) scan of the abdomen and pelvis revealed a heterogeneously enhancing, placental-appearing soft tissue mass extending posteriorly and to the right that measured 2414 cm. The patient subsequently underwent planned low transverse cesarean delivery and exploratory laparotomy for myomectomy with removal of a 2834-g benign leiomyoma measuring 19.018.514.0 cm. Her serum parathyroid hormone-related protein (PTHrP) was elevated to 9.6 pmol/L (

An acute hemolytic transfusion reaction is a potentially fatal complication resulting from the transfusion of mismatched blood products. Symptoms vary from mild to severe depending on how much incompatible antigen was transfused and the nature of the recipient's antibodies. There is no consensus agreement of appropriate management other than discontinuing the transfusion and basic supportive methods including adjunctive pharmacologic agents. A 40-year-old male presented with a gunshot wound to the upper torso. During surgery, the O+ patient lost 1.3 L of blood and postoperatively was inadvertently given one unit of A+ packed red blood cells. The blood bank noticed the error and notified the floor within the hour. An acute hemolytic transfusion reaction had progressed to shock and disseminated intravascular coagulation within hours. The clinical course continued to decline despite a norepinephrine drip and a red blood cell exchange transfusion was implemented within 5 h of the mismatched transfusion. The patient's hematological parameters and clinical markers improved and he was eventually discharged in stable condition. An adjunctive red blood cell exchange transfusion may be useful when treating an ABO-incompatible acute hemolytic transfusion reaction if there has been a large volume mismatched transfusion and a poor clinical response to basic supportive methods. J Hematol. 2019;8(3):141-143 doi: https://doi.org/10.14740/jh541

Patient: Female, 48 Final Diagnosis: Plummer-Vinson syndrome Symptoms: Chest pain • fatigue • palpitation Medication: — Clinical Procedure: Esophagogastroduodenoscopy (EGD) • colonoscopy Specialty: General and Internal Medicine Objective: Rare disease Background: Plummer-Vinson syndrome (PVS) is a rare disorder composed of the triad of dysphagia, iron-deficiency anemia (IDA), and esophageal webs. It is most prevalent in middle-aged white women, and the dysphagia often improves when the anemia is treated. It is well established that chronic hypertension can lead to congestive heart failure (CHF). While IDA is frequently found concomitantly with CHF, there have been no reported cases of new-onset CHF with anemia presenting as PVS. Case Report: We present the case of a 48-year-old African American woman with symptomatic anemia and new-onset congestive heart failure secondary to hypertension, who presented with the classic symptoms of PVS. Conclusions: CHF with accompanying IDA may be an independent risk factor for the development of PVS. At the very least, there is an association between CHF-induced IDA and PVS. Patients presenting with CHF with symptoms of dysphagia should be considered at risk for the syndrome, and endoscopy may be warranted. Treatment for PVS includes iron replacement, and in some cases requires mechanical dilation.

Methaemoglobinaemia is a life-threatening condition that results from increased methaemoglobin production. As methaemoglobin is unable to reversibly bind to oxygen potentially lethal hypoxia and functional anaemia can occur. Benzocaine can be used as a topical anaesthetic and can be found in many nonprescription preparations marketed for self-application. It is known to cause methaemoglobinaemia in rare cases but most reports describe the complication occurring during endoscopy procedures. Methaemoglobinaemia occurring after topical benzocaine use on the perineum of a perimenopausal woman is exceedingly rare. A 50-year-old woman with methaemoglobinaemia secondary to the perineal application of over-the counter Vagisil (benzocaine 20% and resorcinol 3%- an antiseptic and disinfectant, respectively) presented to the emergency department. She had been using Vagisil for severe, chronic vaginal itching. While methaemoglobinaemia secondary to excessive use of over-the-counter medications such as Vagisil creme is exceedingly rare, it should be included in the differential diagnosis.

Background. Acute esophageal necrosis is an uncommon clinical disorder diagnosed on endoscopy as a black esophagus. It has a multifactorial etiology that probably represents a combination of poor nutritional status, gastric outlet obstruction, and ischemia secondary to hypoperfusion of the distal esophagus. It typically occurs in older males with comorbidities. Case. A 37-year-old woman presented with diabetic ketoacidosis and hematemesis. At esophagogastroduodenoscopy acute esophageal necrosis was diagnosed. The treatment included fluid and electrolyte management, insulin, and a proton pump inhibitor. She improved and left the hospital on day 3. Conclusion. Diabetic ketoacidosis can result in a profound osmotic diuresis, fluid loss, and hypoperfusion of the distal esophagus. This condition can then lead to ischemic injury and acute esophageal necrosis. Awareness of the possibility of its presence in young women with hematemesis and poorly controlled diabetes is important since early identification with esophagogastroduodenoscopy is necessary to prevent serious postnecrotic complications.