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A patient presented with shortness of breath and pleuritic pain shortly after bilateral knee synovial injections with sodium hyaluronate (HA). He was discharged after a brief hospitalization without a diagnosis when no Doppler or radiologic evidence of deep vein thrombosis or pulmonary emboli was found. Radiologic studies found patchy ground glass opacities that were predominantly peripheral in disposition, with prominent septal lines in the lungs; a subsequent pulmonary function test showed a reduced diffusing capacity of the lung for carbon monoxide (D(LCO)). These results prompted a lung biopsy that revealed multiple emboli composed of HA and fibrin in medium size pulmonary arteries, enlarged lymphatic vessels, and a bone marrow embolus. This is the first report of HA emboli following therapeutic HA injections and demonstrates that pulmonary function tests can be used to infer the reduction in pulmonary vascular area consequent to pulmonary emboli, and so can contribute to the detection of pulmonary emboli in unusual presentations.

Adenoid cystic carcinoma is a rare but aggressive malignant tumor of the lacrimal gland. Mortality rates have been found to be quite high (>50%). This has led to the traditional method of treatment with radical surgery including orbital exenteration and bone resection, followed by external beam radiotherapy to the orbital bed. Despite this aggressive treatment strategy, mortality rates still remain high with only a few reported cases with long-term survival. Recently, several cases of successful treatment of adenoid cystic carcinoma with plaque radiotherapy have been documented. These may show promise of a conservative treatment strategy in selected cases. The authors present a functionally monocular patient with a well-circumscribed adenoid cystic carcinoma that was treated with local excision of the tumor with reverse plaque brachytherapy "boost" to the lacrimal tumor bed followed by a lower dose of radiotherapy to the orbit. The patient is alive and without local recurrence at nearly 4 years.