Bone metastases as initial presentation of hepatocellular carcinoma

Extra-hepatic spread is present in 5% to 15% of patients with hepatocellular carcinoma(HCC) at the time of diagnosis. The most frequent sites are lung and regional lymph nodes. Here, we report 3 cases of unsuspected HCC with symptoms due to bone lesions as initial presentation. Morphological characteristics and immunohistochemistry from the examined bone were the key data for diagnosis. None of the patients had an already known chronic liver disease. Differential diagnoses with HCC upon ectopic liver disease or hepatoid adenocarcinoma were shown. Therapy with the orally active multikinase inhibitor sorafenib plus symptomatic treatment was indicated.     

Pancarditis as initial presentation of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a multisystem disorder with cardiac involvement in about 50% of cases, yet clinically significant lesions are less common. SLE with pancarditis at initial presentation has so far not been reported. We present a rare case of SLE with culture negative endocarditis, reversible left ventricular (LV) dysfunction and mild pericardial effusion. Treatment with steroids showed improvement in cardiac contractile function and mitral valve vegetations disappeared over 3 months. In a case of pancarditis with culture negative endocarditis, SLE as a possibility must be explored. After excluding infective endocarditis, a short trial of high dose corticosteroids effects overall improvement in carditis of SLE.     

Cardiac tamponade as the initial presentation of malignancy

Although neoplastic involvement of the pericardium frequently is present postmortem, cardiac manifestations before death are uncommon, and cardiac tamponade as the initial presentation of cancer is rare. In this study, a malignancy was first recognized in eight of 23 patients (35 percent) who presented with cardiac tamponade. Seven of these eight patients had lung and one patient thyroid carcinoma. The prognosis of these eight patients was poor with seven of eight patients dead within a mean of seven weeks (range 2.5 to 16). Overall, pericardial fluid cytology demonstrated a specific diagnosis of malignancy in 14 of 19 patients (74 percent). Earlier recognition of the possibility of malignancy may allow initiation of appropriate local or systemic treatment to lessen the probability of cardiac tamponade and improve survival. We recommend that all patients who present with tamponade have cytology performed on the pericardial fluid, even if malignancy is not suspected initially.     

Intestinal pseudo-obstruction as initial presentation of thymoma.

A 45-year-old-man presented with severe vomiting, constipation, abdominal distention and bilateral ocular abductor palsy. Evaluation revealed diffuse autonomic dysfunction characterized by intestinal pseudo-obstruction, xerophthalmia, xerostomia, postural hypotension, erectile dysfunction and loss of sinus arrhythmia. Paraneoplastic work-up revealed thymoma. Most symptoms resolved after surgical removal of the thymoma. Six weeks later he developed worsening of external ophthalmoparesis with ptosis, responding to acetylcholinesterase inhibitor, confirming myasthenia gravis.     

Cardiac tamponade as the initial presentation of malignancy

We describe a series of five patients who had cardiac tamponade at the time of initial presentation as a result of extracardiac malignancy. Three cases had adenocarcinoma and two had squamous cell carcinoma. The diagnosis of bronchogenic carcinoma was established after appropriate investigations in three cases. One patient possibly had a primary malignancy of the gastro-intestinal tract. The relevant literature is reviewed.     

Retinal artery macroaneurysm as initial presentation of hypertension

A case of uncontrolled hypertension with a vitreoretinal hemorrhage due to a retinal artery macroaneurysm of the right eye and chorio-retinal scars of the left eye as initial symptom of hypertension is presented. End organ damage was undiagnosed until an intraocular hemorrhage appeared in the right eye. The hemorrhage and retinal macroaneursym disappeared spontaneously with proper medical therapy for hypertension.     

Cholestasis as the initial presentation of relapsing polychondritis

Relapsing polychondritis is an immune-mediated disease associated with inflammation in cartilaginous structures and other tissues throughout the body, particularly the ears, nose, eyes, joints, and respiratory tract. Although association with other conditions is seen in about one-third of the cases, liver involvement is not usually observed in those patients. We described a case of liver involvement in relapsing polychondritis, presenting with a predominantly cholestatic pattern. Other conditions associated with abnormal liver tests were excluded and the patient showed a prompt response to steroid therapy. We discuss the spectrum of the liver involvement in relapsing and review the literature.     

Tracheobronchitis as an initial presentation of ulcerative colitis

We present a case of multiple myeloma (MM) complicated by recurrent amyloidosis-induced gastrointestinal bleeding. The patient presented with episodes of coffee-ground vomitus or massive hematochezia. No bleeding focus could be identified using endoscopy, a red blood cell scan, or angiography. Finally, a tissue biopsy taken at the irregular mucosa beside protruding vessels in the duodenum confirmed the diagnosis of gastrointestinal amyloidosis. As this case illustrates, the absence of systemic symptoms of amyloidosis and nonspecific endoscopic findings in gastrointestinal amyloidosis may make diagnosis difficult. Therefore, we recommend that a diagnosis of amyloidosis-induced gastrointestinal bleeding should be considered in patients with MM with an obscure hemorrhage.     

Abdominal pain as the initial presentation of Takayasu arteritis

Abdominal pain is rarely described as a clinical manifestation of Takayasu arteritis, although abdominal vascular involvement is common in this disease. We report the case of a 20-year-old female with Takayasu arteritis who complained of chronic and intermittent abdominal pain. Computed tomographic angiography and ultrasonography were useful in evaluating the abdominal arterial involvement. Takayasu arteritis must be considered one of the underlying diseases that may cause chronic abdominal pain in young females.     

Cardiac arrhythmia as initial presentation of aneurysmal subarachnoid hemorrhage

Cardiac arrhythmia and sudden death are most frequently caused by preexisting heart disease. Rarely, cardiac arrhythmia is a first symptom of an acute neurological event. We describe a patient with asystole and other cardiac arrhythmias, as initial symptoms of acute aneurysmal subarachnoid hemorrhage. Several aspects of cardiac arrhythmias and acute aneurysmal subarachnoid hemorrhage are discussed.     

Abdominal pain as the initial presentation of Takayasu arteritis

Abstract

Abdominal pain is rarely described as a clinical manifestation of Takayasu arteritis, although abdominal vascular involvement is common in this disease. We report the case of a 20-year-old female with Takayasu arteritis who complained of chronic and intermittent abdominal pain. Computed tomographic angiography and ultrasonography were useful in evaluating the abdominal arterial involvement. Takayasu arteritis must be considered one of the underlying diseases that may cause chronic abdominal pain in young females.