Oral lesions as the sole presenting symptom of secondary syphilis

Although the stages and manifestations of syphilis are widely recognized, isolated cases may masquerade as a benign illness. We present the case of a traveler who returned from a long stay in Amsterdam with oral lesions that lasted for 4 months. Syphilis was diagnosed serendipitously by serology. At these times of increasing worldwide travel and promiscuity, sexually transmitted diseases with unusual presentations should always be considered.     

Hairy cell leukemia presenting as multiple discrete hepatic lesions

The involvement of hairy cell leukemia in the liver is in the form of portal and sinusoidal cellular infiltration. Here we describe the first case of hepatic hairy cell leukemia presenting as multiple discrete lesions, which was treated successfully. We suggest that in the investigation of discrete hepatic lesions in cases of cancer of unknown primary, hairy cell leukemia should be considered. The excellent response of hairy cell leukemia to therapy highlights the need for such a consideration.     

Primary syphilis presenting as balanitis

The classical lesion of primary syphilis is a solitary, indurated, painless chancre. Atypical presentations, such as herpetiform ulceration, are well recognized. However, there are few references in the medical literature to primary syphilis presenting as balanitis or balanoposthitis. We report two cases of primary syphilitic balanitis in homosexual men.     

Tertiary syphilis mimicking hepatic metastases of underlying primary peritoneal serous carcinoma

Tertiary syphilis, especially in cases involving visceral gummatous disease, can be confused with cancer of the solid organs. We report a case of tertiary hepatic syphilis that manifested with intrahepatic masses in a patient who had an underlying primary peritoneal serous carcinoma (PPSC). The patient was diagnosed with PPSC and achieved a complete remission of PPSC following six cycles of platinum-based chemotherapy. Two hepatic nodules developed during the follow-up period and were initially labeled as hepatic metastases from the underlying PPSC, based on radiological findings. A resection of hepatic nodules was performed for therapeutic and diagnostic purposes, because there were no other metastatic foci except in the liver. Unexpectedly, serology and histology confirmed tertiary syphilis. This rare case emphasizes the importance of including tertiary syphilis in the differential diagnosis of a space-occupying lesion, even with an existing diagnosis of underlying cancer.     

Acute visual loss as a presenting manifestation of syphilis

A heterosexual man with acquired syphilis had an uncommon presentation in the form of acute visual loss. The unusual clinical presentation and a high cerebrospinal fluid lymphocyte count led to delayed diagnosis and treatment. Recognition of uncommon presentation of syphilis in the current epidemic is essential for the interruption of transmission.     

Bone pain as the presenting manifestation of secondary syphilis.

A 31 year old fireman presented with acute pain and tenderness in both shins and forearms. Radiographs were normal but bone scintigraphy showed widespread increased isotope uptake. Serology was consistent with a diagnosis of secondary syphilis, and the patient's symptoms resolved completely six weeks after a course of penicillin.     

Localized hepatic tuberculosis presenting as severe hypercalcemia

Hypercalcemia might present itself in association with granulomatous diseases such as tuberculosis. We report a rare case of a 62-year-old man with hypercalcemia due to hepatic tuberculosis. The diagnosis was based on laparoscopic and a histopathological examination. After treatment with anti-tuberculosis medication, the patient's serum calcium levels were within normal limits. Tuberculosis needs to be excluded as a diagnosis in any febrile patient with hypercalcemia, especially in countries where tuberculosis is endemic.     

Metastatic carcinoid tumour presenting as hepatic encephalopathy

BackgroundHepatic encephalopathy is rarely encountered with carcinoid syndrome, but massive hepatic replacement by carcinoid tumour can cause neuropsychiatric alterations.Case outlineA man of 42 years presented with carcinoid syndrome accompanied by features of hepatic encephalopathy. Following extended right hepatectomy his mental status returned to normal in line with markers of hepatic failure.ConclusionExtensive replacement of liver parenchyma by carcinoid tumours can lead to hepatic dysfunction as circulating levels of unmetabolised ammonia rise secondary to porto systemic shunting.     

Niemann-Pick disease presenting as hepatic disorder.

A 2 year old female child with Niemann-Pick disease was referred as case of chronic liver disease; clinically, she had neurological involvement. Liver biopsy showed Niemann-Pick cells. Hepatic manifestations of Niemann-Pick disease as seen in nine cases reported from India are discussed.     

Paroxysmal nocturnal hemoglobinuria with hepatic vein thrombosis presenting as hepatic encephalopathy

We present a patient with paroxysmal nocturnal hemoglobinuria with diffuse hepatic central vein thrombosis who presented with encephalopathy and recovered from the hepatic manifestations with antihepatic coma measures alone.     

Budd-Chiari syndrome presenting as fulminant hepatic failure.

Two cases of the Budd-Chiari syndrome are described in whom the diagnosis was finally confirmed at necropsy. The presentation was with encephalopathy, occurring within eight weeks of first symptoms and coming therefore within the definition of fulminant hepatic failure. In one, thought to have non-A, non-B hepatitis, encephalopathy progressed to grade 4 coma with death 12 days after presentation. In the other, mistakenly thought to have intra-abdominal malignancy, an exploratory laparotomy exacerbated the encephalopathy with death three weeks later. In neither case were non-invasive investigations, such as ultrasound and isotope scanning, carried out which might have facilitated an earlier diagnosis and consideration for orthotopic liver transplantation, probably the most appropriate form of therapy for these very severe cases.     

Miliary tuberculosis presenting as hepatic and renal failure

A 67-year-old man developed hepatic and renal failure over a six-day period. Despite full supportive measures, he died on his 11th day of hospitalization with fulminant DIC and hepatic, renal, and respiratory failure. Postmortem examination revealed acid-fast bacilli in virtually all organ systems. Miliary tuberculosis should be considered as a potentially treatable cause of hepatic failure.     

Primary hepatic carcinoid tumor presenting as Cushing's syndrome

Hepatic carcinoid tumors are very uncommon; most are clinically non-functional and very few present with the symptoms of carcinoid syndrome. ACTH-producing carcinoid tumors most commonly originate in the lung or thymus and present insidiously with bronchospasm and/or chest mass. Occasionally, ectopic ACTH syndromes have been reported in association with pancreatic islet cell tumors, medullary thyroid cancer, pheochromocytoma, small-cell lung carcinoma, and rarely, ovarian and prostate tumors. We report here a patient with an ectopic ACTH-secreting primary hepatic carcinoid tumor who presented with cushingoid appearance, profound proximal muscle weakness, severe lower extremity edema, and markedly elevated urinary free cortisol. ACTH levels were in the low normal range. A solitary vascular hepatic lesion was found on magnetic resonance imaging, which was isodense with the surrounding liver on octreotide scan and photopenic on an 18-fluorodeoxyglucose (18FDG)-positron emission tomography (PET) scan. Following surgical resection of the hepatic tumor, histopathology confirmed an ACTH-secreting neuroendocrine tumor (NET), the patient had complete resolution of hypercortisolemic symptoms and remains in remission, now 4 yr after hepatic tumor resection. This case reports the first ACTH-secreting primary hepatic NET presenting as ectopic Cushing's syndrome. Interesting aspects of this case include the presence of a pituitary incidentaloma, the low normal ACTH, and photopenia on 18FDG-PET imaging.     

Metastatic carcinoma presenting as fulminant hepatic failure.

An unusual cause of fulminant hepatic failure is described. The patient, who presented with symptoms of liver disease, proved to have a small primary oat cell carcinoma of the lung with massive hepatic metastases. The clinical evolution was rapid, with marked elevations of SGOT (this without a prior hypotensive episode) and hepatic coma. Examination of the liver showed two types of necrosis: 1. infarction secondary to multiple tumor emboli in portal vessels and 2. overrunning of hepatic cell plates by expanding masses of tumor cells (somewhat analogous to piecemeal necrosis).     

Chronic pyelonephritis presenting as multiple tumor-like renal lesions

We encountered a 49-year-old Japanese man in whom tumor-like renal lesions developed as a result of chronic Staphylococcus aureus pyelonephritis. The patient complained of general fatigue, weight loss, and anorexia for 6 months. Contrast-enhanced computed tomography (CT) of the abdomen revealed multiple low-density lesions in both kidneys and paraaortic lymphadenopathy. A strong uptake of Ga67 citrate in the lesions and elevation of serum soluble interleukin-2 receptor and thymidine kinase activity were strongly suggestive of primary renal lymphoma; however, histologic examination of renal biopsy specimens revealed severe tubulointerstitial change, consistent with chronic pyelonephritis. Following systemic antibiotic treatment, multiple tumor-like lesions regressed 4 months later. This case suggested that chronic pyelonephritis could present as bilateral renal tumors.