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Primitive neuroectodermal tumors (PNET) represent malignant neuroectodermal tumors composed of small round cells. They can be differentiated between originating from the peripheral nervous system or the central nervous system. Peripheral PNET (pPNET) can be further subclassified as one of the Ewing family tumors (EFT). Although rare, EFT can originate in the female genital tract and pelvic region. Here, we present a case of a middle-aged female with PNET masses in her uterus, abdomen, and hepatic lobes. We discuss the diagnostic modalities, including immunohistochemistry, histopathology, and imaging findings associated with this rare malignancy.

Immune thrombocytopenic purpura (ITP) is an acquired antibody or cell-mediated platelet damage or decreased platelet production. Steroids, IV immunoglobulins (IVIG), and Rho-anti-D antibodies are the commonly used initial treatments for ITP. However, many ITP patients either do not respond or do not maintain a response to initial therapy. Splenectomy, rituximab, and thrombomimetics are the commonly used second-line treatment. More treatment options include tyrosine kinases inhibitors (TKI), including spleen tyrosine kinase (Syk) and Bruton’s tyrosine kinase (BTK) inhibitors. This review aims to assess the safety and efficacy of TKIs. Methods: Literature was searched on PubMed, Embase, WOS, and clinicaltrials.gov using keywords, “tyrosine kinase” and “idiopathic thrombocytopenic purpura”. PRISMA guidelines were followed. Results: In total, 4 clinical trials were included with 255 adult patients with relapsed/refractory ITP. In all, 101 (39.6%) patients were treated with fostamatinib, 60 (23%) patients with rilzabrutinib, and 34 (13%) with HMPL-523. Patients treated with fostamatinib achieved a stable response (SR) and overall response (OR) in 18/101 (17.8%) and 43/101 (42.5%) of the patients, respectively, while SR and OR were achieved in 1/49 (2%) and 7/49 (14%) of the patients, respectively, in the placebo group. Patients treated with HMPL-523 (300 mg dose expansion) achieved an SR and OR in 5/20 (25%) and 11/20 (55%) of the patients, respectively, while SR and OR were achieved in 1/11 (9%) of the patients treated with the placebo. Patients treated with rilzabrutinib achieved an SR in 17/60 (28%) patients. Dizziness (1%), hypertension (2%), diarrhea (1%), and neutropenia (1%) were serious adverse events in fostamatinib patients. Rilzabrutinib or HMPL-523 patients did not require a dose reduction due to drug-related adverse effects. Conclusions: Rilzabrutinib, fostamatinib, and HMPL-523 were safe and effective in the treatment of relapsed/refractory ITP.

An osteolytic lesion on imaging can be considered malignancy until proven otherwise. However, advanced stages of gout have presented with sclerotic rims and lytic lesions thought to be due to overexpression of osteoclasts. Patients have been found to demonstrate osteolytic lesions in patellar regions, which are common locations for gout to manifest; however, to our knowledge, no other cases of osteolytic gout in the acromioclavicular joint have been reported at this time. We report a rare case of a 56-year-old male who presented with acute-on-chronic left upper extremity pain and was found to have an osteolytic lesion of the shoulder on imaging. This lesion was later biopsied and found to be histologically consistent with gout. This case report aims to elucidate further understanding of the various ways that gout can present, to diagnose and treat these patients more effectively.

Cerebral venous sinus thrombosis (CVST) is a rather uncommon disorder. CVST is potentially lethal, therefore early detection and treatment is critical. CVST has been linked to pregnancy and puerperium, while COVID-19 infection has been linked to a hypercoagulable state. CVST can be difficult to detect and treat due to the wide range of neurological manifestations, especially in patients with hypercoagulability. The goal of this study is to conduct a literature review and present a unique case of a pregnant woman with CVST who had left hemiplegia and headache. After 6 months of treatment in the hospital, the patient's hemiplegia was fully resolved. Here, we discuss the treatment of CVST in pregnant women who have a suspected past COVID-19 infection.

Nonbacterial thrombotic endocarditis (NBTE) also called, ''Marantic endocarditis'' occurs due to an underlying hypercoagulable state causing tissue damage and upregulation of the coagulation cascade, with noninfective vegetation formation on heart valves. Mitral and aortic valves are most commonly involved. NBTE is rare, with an incidence of 1.6%, with 65 cases identified during a 10-year autopsy analysis. The most common malignancies associated with NBTE include gynecological cancers, lung cancer, gastric cancer, and pancreatic cancers with adenocarcinoma histology being the greatest risk. Herein, we present a rare case of a 55-year-old male who presented with acute hypoxic respiratory failure secondary to pulmonary embolism due to nonbacterial thrombotic endocarditis. He was found to have advanced pancreatic adenocarcinoma on further investigation of the 2.2 cm hypodense cystic mass in the distal pancreatic body and tail, and complex liver masses which were incidentally found on computed tomography angiography (CTA) of the chest. This is a rare phenomenon and clinicians have to consider the hypercoagulable state associated with cancers, particularly pancreatic adenocarcinoma, and the risk of NBTE.

The SARS-CoV-2 infection has been predominately associated with lung disease. However, emerging evidence has associated the COVID-19 infection with a hypercoagulable state. This hypercoagulable state can occur despite the use of anticoagulants and antiplatelets. In fact, it may even be the presenting symptom of COVID–19 in some patients. Thromboembolism associated with COVID–19 carries a worse prognosis and should be identified as early as possible. Therefore, we report 2 patients with arterial thrombosis in the form of limb ischemia in the setting of COVID-19.

Cannonball lesions are numerous, well-circumscribed, round pulmonary lesions and may be identified on plain radiograph or advanced imaging. This morphology can be associated with infectious causes, rheumatologic disease and metastatic disease. Classically, when cannonball lesions are associated with metastatic disease, they are seen in renal cell carcinoma and choriocarcinoma. We report a case of a 62-year-old Middle Eastern male who presented with shortness of breath, chest pain and fatigue and was found to have bilateral multiple pulmonary cannonball lesions and mass in the pancreas. Biopsy of one the lung lesions was consistent with pancreatic cancer. Our case adds to the limited literature available regarding cannonball lung lesions in the setting of pancreatic cancer. Health care providers should be aware of the various etiologies of cannonball lesions.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the ongoing global pandemic. It can manifest a wide range of complications depending upon the severity of infection and comorbidities of the patient. Vaccines are very important measure to provide protection against COVID‐19. We report a case of 72-year-old female with past medical history of hypertension and diabetes mellitus who underwent imaging with positron emission tomography (PET) scan imaging for staging of her small cell urinary bladder cancer and was found to have hypermetabolic uptake in the deltoid muscle of the left shoulder and hypermetabolic left axillary and pectoral lymph nodes due to mRNA BNT-162b2 (Pfizer-BioNTech COVID-19 vaccine) vaccine administrated 3 days ago prior to PET scan.

Rosai–Dorfman disease (RDD) is a rare disorder characterized by the proliferation of histiocytes in lymph nodes. It can occur anywhere in the body but commonly involves the cervical area of the neck. Its clinical presentation varies and patients with skin manifestations may develop papules, nodules, plaques, or pustules. Histologically, it typically presents with emperipolesis, where intact lymphocytes are found within histiocytes. The definitive treatment of RDD is not well established given the rarity of the disease and indeed skin lesions can regress spontaneously. Therapeutic treatment options include cryotherapy, radiation, or topical agents such as steroids or retinoids. Here we describe the case of a 24-year-old Hispanic female who presented with skin manifestations which proved to be histologically positive for Rosai–Dorfman disease. The patient clinically improved following the administration of intralesional steroids.

Complete blood counts are frequently collected from cancer patients, but laboratory findings may be misleading. Secondary polycythemia can occur in renal cell carcinoma (RCC) due to erythropoietin (EPO) stimulation. Therefore, complete blood counts should be closely monitored to prevent complications such as thrombosis. We discuss the case of a 47-year-old man with metastatic RCC who presented with secondary polycythemia that improved with chemotherapy. His secondary erythrocytosis was anticipated, but his haemoglobin levels were lower than expected after therapy. This article discusses the treatment and diagnosis of secondary polycythemia in patients with RCC.

Splenomegaly is manifested by a variety of etiologies, one of which is macrocytic anemia. Macrocytic anemia has multiple causes in itself that include; folate (Vitamin B9) and Cobalamin (vitamin B12) deficiencies. In this case report, we present a patient with a history of pancytopenia, macrocytic anemia and vitamin B12 deficiency, who underwent a splenectomy. The differential diagnoses for the cause of the patient’s splenomegaly included: lymphoma, infiltrative disease, and idiopathic splenomegaly. The pathology report from the splenectomy did not reveal any evidence of lymphoma or infiltrative disease, however, it did mention vascular congestion of the spleen. In theory, vascular congestion, due to extramedullary hematopoiesis in the spleen or sequestration of blood cell lineages, could lead to pancytopenia. In prior visits to the hospital this patient was diagnosed with: splenomegaly, and macrocytic anemia due to pernicious anemia. A splenectomy puts one at increased risk for infection by encapsulated organisms, and is to be avoided if possible. There are few case reports and studies that show vitamin B12 therapy can potentially cause a reversal in the splenomegaly as well as a reversal in the pancytopenia and macrocytic anemia. We hope to show that the least invasive treatment for vitamin B12, vitamin therapy, can be of use and effective.

Hypertriglyceridemia (HTG) is an uncommon but well-established cause of acute pancreatitis.The patients with pancreatitis are at risk for both local and systemic complications.Abdominal compartment syndrome is underdiagnosed and undertreated in this patient population. We report a case of 39-year-old male with medical history of diabetes mellitus who presented with abdominal pain and was diagnosed with HTG induced pancreatitis, complicated by abdominal compartment syndrome requiring surgical decompression and plasmapheresis.

Erdheim-Chester disease is a rare non-Langerhans cell histiocytosis (LCH) that affects different body systems. It was recently recognized as a neoplastic disorder after identifying an activating mutation of the MAPK pathway. Neurological presentations of ECD are rare. We present a case of a 35-year-old male who presented to the emergency department with neck pain, headache and vomiting for 2 months; MRI showed multiple heterogeneous intracranial masses. Neurosurgery performed a suboccipital craniotomy, partially resected the cerebellar mass, and placed a parietal to frontal shunt catheter. Biopsy results from the cerebellar mass demonstrated cerebellar tissue involved by a diffuse proliferation of foamy histiocytes and spindle cells admixed with prominent lymphoplasmacytic infiltrate and positive for CD68, CD163, Factor XIIIa and Fascin. PET scan showed hypermetabolic uptake within the medullary portions of the diffuse abnormal lesions of the distal femurs, tibias, and fibulas, and cardiac MRI was nonsignificant. The patient was started on vemurafenib and continued to show improvement in a 3-month outpatient follow-up.

Acquired Hemophagocytic Lymphohistiocytosis is a rare and deadly syndrome resulting from an overactive immune system, with uncontrolled activation of macrophages and lymphocytes, hypercytokinemia, and systemic inflammatory response. A 75-year-old male presented with typical anginal pain and was diagnosed with the acute coronary syndrome, which required a percutaneous transluminal coronary angioplasty. Instead of resolving the symptoms, the patient began to exhibit pyrexia and worsening altered sensorium with progressing renal failure, anemia, thrombocytopenia and respiratory failure. This constellation of symptoms caused the patient to require mechanical ventilation and hemodialysis. Upon laboratory analysis, hyperferritinemia provided an indication to the diagnosis of acquired hemophagocytic lymphohistiocytosis. After the initiation of dexamethasone, the patient made a significant recovery and was discharged from the hospital.

Bladder cancer is the most common urinary tract malignancy. Platinum-based chemotherapy is the first line of treatment in locally advanced or metastatic bladder cancer. Immunotherapy has become a novel therapy option in a broad variety of malignancies including bladder cancer. Immunotherapy is approved as first line of treatment in patients who are ineligible for platinum-based chemotherapy and second-line treatment for metastatic urothelial cancer who progressed after platinum-based treatments. We present the case of an 83-year-old female with metastatic bladder cancer who was chemotherapy ineligible and had complete response with immune checkpoint inhibitor pembrolizumab.

We report 11 cases of combined diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic coma (HHNK) in coronavirus 2019 patients who presented to our institution in New Jersey, USA. The median age was 47 years (range 12-88 years). Out of the 11 patients, 7 were male and 4 were female. Out of 11 patients, 8 had type 2 diabetes mellitus (DM), 2 had undiagnosed DM, and 1 had type 1 DM. Presenting complaints included altered mental status, weakness, shortness of breath, cough, fever, vomiting, abdominal pain, chest pain, and foot pain. Out of 11 patients, pneumonia was diagnosed at presentation in 8 patients, while in 3 patients, chest X-ray was clear. Median value of initial glucose on presentation was 974 mg/dL (range 549-1556 mg/dL), and hemoglobin A1c on presentation was 13.8%. The median value of anion gap was 34 mEq/L. Out of the 11 patients, ketonemia was moderate in 6 patients, large in 3, and small in 2 patients. Acute kidney injury (AKI) occurred in 9 patients and 2 patients required renal replacement therapy. Out of the 11 patients, 6 required mechanical ventilation and 7 patients died. All the 6 patients requiring mechanical ventilation died. Our case series shows COVID-19 infection can precipitate acute metabolic complications in known DM patients or as first manifestation in undiagnosed DM patients. Patients can present with DKA/HHNK symptoms and/or respiratory symptoms. Mechanical ventilation is a poor prognostic factor. Further studies are needed to characterize prognostic factors associated with mortality in this vulnerable patient population.

The World Health Organization has declared novel coronavirus disease 2019 (COVID-19) a global public health emergency. Although respiratory symptoms predominate in COVID-19, thrombosis can occur in patients with COVID-19. This paper reports a case of an 82-year-old female with a prior medical history of hypertension, diabetes presenting with fever and cough, and was diagnosed with COVID-19. The patient subsequently developed progressively worsening of abdominal distention, tenderness, and underwent emergent laparotomy. She was found to have a gangrenous colon. This case adds to the limited literature regarding the extrapulmonary complications of COVID-19.

Mycobacterial spindle cell pseudotumor (MSP) is characterized by benign proliferation of spindle-shaped histiocytes containing acid-fast Mycobacterium . It is usually seen in immunocompromised patients. Limited literature is available regarding MSP. In this article, we report a case of 36-year-old African American male with past medical history of HIV (diagnosed in 2005), noncompliance who presented with generalized weakness, fever, and dizziness on ambulation and was found to have generalized lymphadenopathy and underwent biopsy of the lymph nodes, which was consistent with MSP.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus responsible for the current global pandemic, coronavirus disease 2019 (COVID-19). COVID-19 usually presents with respiratory symptoms but can affect multiple organ systems. A wide spectrum of complications can occur depending upon the comorbidities of patients. There is limited literature available regarding the presentation and outcome of COVID-19 in chronic lymphocytic leukaemia (CLL) patients. We report 2 cases of COVID-19-induced hyperleucocytosis (WBC count >100,000/?l) in CLL patients.

Immune checkpoint inhibitors have emerged as a novel treatment in a wide variety of malignancies; however, it is associated with a distinctive array of side effects known as immune-related adverse events. Hyperprogression is defined as an accelerated growth of disease burden in patients treated with immunotherapy. Limited literature is available regarding hyperprogression in hepatocellular cancer. We report a case of a 36-year-old male with no past medical history who presented with nausea, vomiting, and abdominal pain and was diagnosed with unresectable hepatocellular cancer and thereby started on atezolizumab and bevacizumab. The patient got only 1 cycle of treatment and unfortunately had hyperprogression of disease.

COVID-19, caused by severe acute respiratory syndrome coronavirus 2 infection, has caused the ongoing global pandemic. Initially considered a respiratory disease, it can manifest with a wide range of complications (gastrointestinal, neurological, thromboembolic and cardiovascular) leading to multiple organ dysfunction. A range of immune complications have also been described. We report the case of a 57-year-old man with a medical history of hypertension, prediabetes and beta thalassemia minor, who was diagnosed with COVID-19 and subsequently developed fatigue and arthralgias, and whose blood work showed hyperferritinemia, elevated liver enzymes (AST/ALT/GGT), hypergammaglobulinemia, anti-smooth muscle antibody, anti-mitochondrial antibody, and anti-double-stranded DNA antibodies. The patient was diagnosed with autoimmune hepatitis–primary biliary cholangitis overlap syndrome triggered by COVID-19. To our knowledge, this is the first such case reported.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), has caused a global health crisis. COVID-19 can have a multifaceted presentation. A wide range of complications and outcomes can emerge based on the severity and comorbidities of the infected patient. We report a 42-year-old male with past medical history of CML on Dasatinib (in Major Molecular Response) who was diagnosed with COVID-19 and developed pancytopenia. Our case and review of available reports add to the limited literature available regarding COVID-19 in CML.

Clozapine has been widely used as an antipsychotic drug for the treatment of refractory schizophrenia. Unfortunately, a wide range of blood dyscrasias have been reported as adverse effects of this drug. Agranulocytosis has gotten the most clinical vigilance; however, there are substantial reports of other blood dyscrasias associated with Clozapine some more serious than others. Of relevance, there have been previous claims of Clozapine-associated leukocytosis and acute myeloid leukemia. We report the case of a 31-year-old patient who developed Acute lymphoblastic leukemia shortly after starting treatment with Clozapine for refractory schizophrenia. We suggest Clozapine may play a causal role in the development of leukemias in patients taking this medication and we encourage vigilance for such correlation.

Calcium elevation, Renal dysfunction, Anaemia and Bone disease (CRAB criteria) are usually seen in multiple myeloma (MM). We report a unique case of lymphoma with all the features of CRAB criteria. We describe a 59-year-old patient who presented with confusion, severe back pain, fatigue and constipation and was found to have hypercalcaemia, kidney dysfunction, anaemia and multiple osteolytic lesions. Physical examination and imaging did not reveal any enlarged lymph nodes. Work-up for MM (serum protein electrophoresis, serum immunofixation, bone marrow biopsy) was negative. The patient was diagnosed with diffuse large B-cell lymphoma based on a pelvic mass biopsy. Hence, our case report suggests that CRAB criteria are not pathognomonic of MM and that in the appropriate clinical scenario, lymphoma is a possible diagnosis.

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disease, usually diagnosed with high index of suspicion. The pathophysiology of TTP is due to severe deficiency of von Willebrand factor cleaving protease, known as ADAMTS 13. Early diagnosis is crucial as without treatment TTP is associated with high mortality rate. Plasma exchange is currently the mainstay of treatment. Nonetheless, the classical pentad of microangiopathic hemolytic anemia (MAHA), thrombocytopenia, neurological dysfunction, kidney dysfunction and fever are seen only in 40 percent of the patients. MAHA and thrombocytopenia are the common presenting features. Presentation with thrombotic complication without hematological features (MAHA and thrombocytopenia) is rare and makes the diagnosis difficult. Herein, we report an unusual presentation of a 53-year-old male, who was initially presented in 2014 with classical features of TTP, however had an atypical presentation of TTP in 2016 with only neurological features without hematological features.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic that developed in late 2019 and early 2020 has caused thousands of deaths and has had an enormous impact on our health systems and economies. Coronavirus disease 2019 (COVID-19) complications include disseminated coagulation and thrombosis, but, to the best of our knowledge, the literature to date on these manifestations has been limited. Herein, we report an unusual presentation in a 43-year-old man with a medical history of diabetes and hypertension who presented with dyspnoea and acute pain in his right leg and was found to have acute limb ischaemia and diabetic ketoacidosis. Our case adds to the literature regarding arterial thrombosis in COVID-19.

As one of the leading causes of hypercalcemia, malignancy is an essential consideration when patients present with such symptomology. While certain tumors are more known to cause hypercalcemia, it can occur with almost any type of cancer. Hodgkin lymphoma is an infrequent cause of hypercalcemia. Only a few case reports have been published in the literature to date. We report an unusual case of a 61-year-old female who presented with altered mental status, nausea, vomiting, and dizziness and was found to have multiple enlarged lymph nodes, and blood work showed hypercalcemia. Biopsy of the cervical lymph node showed Hodgkin lymphoma of the nodular sclerosis subtype. Our case aims to raise awareness of this rare but significant presentation of hypercalcemia and how timely treatment of calcium levels can facilitate the employment of available chemotherapeutic options.

Malignancy associated lactic acidosis is a rare metabolic complication that may accompany various types of malignancies. To date, most cases that have been reported are associated with hematologic malignancies (lymphoma and leukemia). Many theories have been proposed to explain the pathophysiology of lactic acidosis in malignancies. We are reporting an unusual case of a 62-year-old female who presented with a complaint of generalized weakness. Patient was found to have pancytopenia and metabolic acidosis with an anion gap secondary to lactic acid in addition to non-anion gap acidosis (NAGA). The lactic acidosis resolved only after initiation of chemotherapy as she was diagnosed with B-cell acute lymphoblastic leukemia. Our patient also had a coexistent Renal Tubular Acidosis (RTA) with large kidneys. The kidney size also decreased with chemotherapy. Our case is unique as evidenced by aleukemic leukemia combined with anion gap acidosis and non-anion gap acidosis. Lactic acidosis has many different causes; although rare, hematologic malignancies should be included in the differential diagnosis regardless of cell counts or tumor burden.