No abstract

Sump syndrome is a rare, long-term complication with a prevalence ranging from 0% to 9.6% in patients with a history of side-to-side choledochoduodenostomy. Choledochoduodenostomy was originally performed to achieve drainage of the common bile duct in high-risk patients with low morbidity, which was commonly done in the pre-endoscopic retrograde cholangiopancreatography era. “Sump” comes from the segment of the common bile duct between the anastomosis and the ampulla of Vater, which acts as a stagnant reservoir for debris, stones, and static bile. This predisposes patients to changes in the biliary tree with signs and symptoms in relation to that area. If left untreated, cholangitis, pancreatitis, hepatic abscesses, and secondary biliary cirrhosis can develop. Here, we have a case of a 77-year-old male with a history significant for choledochoduodenostomy, who presented with the clinical signs and symptoms of pancreatitis, choledocholithiasis, and urinary tract infection. Computed tomography (CT) scan findings revealed choledocholithiasis and an enlarged common bile duct with smaller adjacent calculi along with pneumobilia consistent with sump syndrome. The patient’s clinical status improved without invasive measures being taken, i.e. endoscopic retrograde cholangiopancreatography. He was subsequently discharged home after improving clinically and no invasive measures were pursued.

No abstract

Limbic encephalitis (LE) is a rare neurological paraneoplastic complication that occurs secondary to malignant tumors. It is commonly presented as refractory seizures that are resistant to most anti-epileptics. We are presenting a unique case of small cell lung cancer complicated with LE. The challenging part of our case is that the patient had a history of seizure disorder in the past, and she was treated initially as an anti-epileptic treatment failure. A 68-year-old patient with a history of epilepsy was admitted to the ICU with resistant status epilepticus (SE), and respiratory failure secondary to pneumonia. Further workup revealed that the patient has small cell lung carcinoma. An extensive workup done to investigate resistant seizures revealed that she had a rare type of paraneoplastic autoantibodies (Anti-Hu) in the cerebrospinal fluid, which supported the diagnosis of the paraneoplastic autoimmune LE. High dose steroids helped to decrease the seizures episodes, but the family decided to proceed with palliative measures only at the end. Diagnosing LE requires ruling out other common causes of SE. Treatment options include treating underlying cancer as well as means of immunosuppression or antibody removal by tacrolimus and cyclophosphamide and even intravenous immunoglobulin (IVIG) or plasma exchange. It is important to consider LE in the differential diagnosis when managing patients with resistant SE in the ICU, even if the brain imaging and cerebrospinal fluid (CSF) analysis were within normal limits.

Extraosseous Ewing sarcoma is an uncommon entity in the adult population. Cardiac metastases or local invasion of a tumor into the heart is a known but also infrequent occurrence for most malignancies. We present a case of a patient with a history of extraosseous Ewing sarcoma who presented to the emergency room with chest pain and was found to have an inferior ST-elevation myocardial infarction and systemic emboli and was found to have recurrence of sarcoma invading the left atrium.