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Waralee Chatchomchaun, Yotsapon Thewjitcharoen, Karndumri Krittadhee, Veekij Veerasomboonsin, Soontaree Nakasatien, Sirinate Krittiyawong, Sriurai Porramatikul, Ekgaluck Wanathayanoroj, Auchai Kanchanapituk, Pairoj Junyangdikul and Thep Himathongkam

consistency ( Fig. 1B ). No dental caries or other signs of skin infection at the neck region were present. His laboratory investigations revealed a leukocytosis level of 15 010 × 10 6 /L (normal range: 4000–11 000 × 10 6 /L). His thyroid function tests

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Carine Ghassan Richa, Khadija Jamal Saad, Ali Khaled Chaaban and Mohamad Souheil El Rawas

complaints even prior to her pregnancy. Past medical history was significant for chronic pruritic rash and nephrolithiasis, which has never been investigated. Investigation Laboratory tests showed leukocytosis with a left shift (14900/µL with 80

Open access

Laila Ennazk, Ghizlane El Mghari and Nawal El Ansari

lymphadenopathies. Investigation Laboratory tests showed an inflammatory syndrome with leukocytosis at 22 400/mL (NR: 4000–10 000/mL). High lipase over ten times the upper limit of normal: 787.9 U/L (NR: 13–60). Creatininemia was at 4 mg/L (NR: 6–13), urea

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Sharmin Jahan, M A Hasanat, Tahseen Mahmood, Shahed Morshed, Raziul Haq and Md Fariduddin

.2–8.5 Investigation Routine hematologic and biochemical investigations showed neutrophilic leukocytosis, elevated liver enzyme, impaired fasting and post-glucose values and evidence of combined dyslipidemia. Other tests including serum creatinine, BUN, and

Open access

Marlene Tarvainen, Satu Mäkelä, Jukka Mustonen and Pia Jaatinen

specific anti-PUUV IgM and IgG antibodies. Other laboratory findings ( Table 1 ) typical of NE included severe thrombocytopenia, leukocytosis and elevated plasma creatinine and urea concentrations, as well as proteinuria and haematuria. On the first few

Open access

Lima Lawrence, Peng Zhang, Humberto Choi, Usman Ahmad, Valeria Arrossi, Andrei Purysko and Vinni Makin

to replacement, metabolic alkalosis, rhabdomyolysis and leukocytosis without fever. Given the clinical presentation, labs and history of elevated ACTH with a mediastinal mass, there arose a concern for ectopic ACTH production resulting in CS. Repeat

Open access

Joanna Prokop, João Estorninho, Sara Marote, Teresa Sabino, Aida Botelho de Sousa, Eduardo Silva and Ana Agapito

work-up at the Emergency Department revealed normochromic, normocytic anemia (Hb = 10 g/dL) leukocytosis (16,000 WBC/µL), high platelet count (705.000/µL) and severe hyperkalemia (8 mEq/L), with normal renal and liver function. Arterial blood gas

Open access

Alessandro Mantovani, Fabrizia Perrone, Vincenzo Stoico, Isabella Pichiri, Laura Salvotelli, Ilaria Teobaldi, Massimiliano Bruti, Michela Conti, Luca Cima, Albino Eccher and Enzo Bonora

Summary

The incidences of type 2 diabetes mellitus and many cancers are rapidly increasing worldwide. Diabetes is a strong risk factor for some cancers (including lymphomas) and is also associated with adverse cancer outcomes. After gastrointestinal tract, the skin is the second most frequent extranodal site involved by non-Hodgkin lymphomas and the cutaneous B-cell lymphomas (CBCLs) range from 25% to 30% of all primary cutaneous lymphomas. The primary cutaneous diffuse large B-cell lymphoma (PCDLBCL) is an aggressive lymphoma with a poor prognosis, representing roughly 20% of all primary CBCLs. Classically, the cutaneous manifestation of this lymphoma is a red or violaceous tumors arising on a leg. To date, despite the large body of evidence suggesting that diabetes is strongly associated with an increased risk of some cancers, very little information is available regarding a possible association between type 2 diabetes and primary cutaneous diffuse large B-cell lymphoma. In this report, we will present the case of a white adult patient with type 2 diabetes with chronic leg ulcers complicated by a primary cutaneous diffuse large B-cell lymphoma.

Learning points:

  • Diabetes mellitus is increasing worldwide as well as the incidence of many cancers.
  • Diabetes mellitus is a powerful risk factor for some cancers (including lymphomas) and is strongly associated with adverse cancer outcomes.
  • Seen that diabetes is strongly associated with an increased risk of cancers (including cutaneous lymphomas), clinicians should always keep in mind this complication in elderly patients with type 2 diabetes, even in a chronic leg ulcer with hypertrophy of the wound edge, which is hard to heal and does not have the typical characteristics of a diabetic or vascular ulcer. In these cases, a biopsy should be performed to rule out a neoplasm.
  • Early diagnosis and correct management of cancer in a patient with type 2 diabetes are crucial to improve clinical outcomes.
Open access

Albert S Kim, Rashida Hakeem, Azaliya Abdullah, Amanda J Hooper, Michel C Tchan, Thushari I Alahakoon and Christian M Girgis

Summary

A 19-year-old female presented at 25-weeks gestation with pancreatitis. She was found to have significant hypertriglyceridaemia in context of an unconfirmed history of familial hypertriglyceridaemia. This was initially managed with fasting and insulin infusion and she was commenced on conventional interventions to lower triglycerides, including a fat-restricted diet, heparin, marine oil and gemfibrozil. Despite these measures, the triglyceride levels continued to increase as she progressed through the pregnancy, and it was postulated that she had an underlying lipoprotein lipase defect. Therefore, a multidisciplinary decision was made to commence therapeutic plasma exchange to prevent further episodes of pancreatitis. She underwent a total of 13 sessions of plasma exchange, and labour was induced at 37-weeks gestation in which a healthy female infant was delivered. There was a rapid and significant reduction in triglycerides in the 48 h post-delivery. Subsequent genetic testing of hypertriglyceridaemia genes revealed a missense mutation of the LPL gene. Fenofibrate and rosuvastatin was commenced to manage her hypertriglyceridaemia postpartum and the importance of preconception counselling for future pregnancies was discussed. Hormonal changes in pregnancy lead to an overall increase in plasma lipids to ensure adequate nutrient delivery to the fetus. These physiological changes become problematic, where a genetic abnormality in lipid metabolism exists and severe complications such as pancreatitis can arise. Available therapies for gestational hypertriglyceridaemia rely on augmentation of LPL activity. Where there is an underlying LPL defect, these therapies are ineffective and removal of triglyceride-rich lipoproteins via plasma exchange should be considered.

Learning points:

  • Hormonal changes in pregnancy, mediated by progesterone,oestrogen and human placental lactogen, lead to a two- to three-fold increase in serum triglyceride levels.
  • Pharmacological intervention for management of gestational hypertriglyceridaemia rely on the augmentation of lipoprotein lipase (LPL) activity to enhance catabolism of triglyceride-rich lipoproteins.
  • Genetic mutations affecting the LPL gene can lead to severe hypertriglyceridaemia.
  • Therapeutic plasma exchange (TPE) is an effective intervention for the management of severe gestational hypertriglyceridaemia and should be considered in cases where there is an underlying LPL defect.
  • Preconception counselling and discussion regarding contraception is of paramount importance in women with familial hypertriglyceridaemia.
Open access

Carlos Tavares Bello, Emma van der Poest Clement and Richard Feelders

Summary

Cushing’s syndrome is a rare disease that results from prolonged exposure to supraphysiological levels of glucocorticoids. Severe and rapidly progressive cases are often, but not exclusively, attributable to ectopic ACTH secretion. Extreme hypercortisolism usually has florid metabolic consequences and is associated with an increased infectious and thrombotic risk. The authors report on a case of a 51-year-old male that presented with severe Cushing’s syndrome secondary to an ACTH-secreting pituitary macroadenoma, whose diagnostic workup was affected by concurrent subclinical multifocal pulmonary infectious nodules. The case is noteworthy for the atypically severe presentation of Cushing’s disease, and it should remind the clinician of the possible infectious and thrombotic complications associated with Cushing’s syndrome.

Learning points:

  • Severe Cushing’s syndrome is not always caused by ectopic ACTH secretion.
  • Hypercortisolism is a state of immunosuppression, being associated with an increased risk for opportunistic infections.
  • Infectious pulmonary infiltrates may lead to imaging diagnostic dilemmas when investigating a suspected ectopic ACTH secretion.
  • Cushing’s syndrome carries an increased thromboembolic risk that may even persist after successful surgical management.
  • Antibiotic and venous thromboembolism prophylaxis should be considered in every patient with severe Cushing’s syndrome.