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Pulmonary embolism (PE) is defined as the obstruction of the pulmonary artery or one of its branches by a blood clot, tumor, air, or fat emboli originating elsewhere in the body. A saddle PE occurs when the obstruction affects the bifurcation of the main pulmonary artery trunk. We present a case of a 46-year-old man who presented to our hospital due to an episode of syncope. Computed tomography angiography (CTA) of the chest showed extensive PE and abdominal CT scan showed a large 8 cm left renal mass with inferior vena cava (IVC) thrombus. Emergent embolectomy, left total nephrectomy, and IVC tumor removal were performed yielding the diagnosis of clear cell renal cell carcinoma (RCC). Interestingly, our patient did not experience any symptoms related to his RCC until the diagnosis of PE due to syncope, and the asymptomatic tumor was found out to be the possible cause of this PE due to the presence of tumor cells constituting the tumor embolus. It is thus recommended to improve the early screening process for RCC. Besides, clinicians should pay attention to patients presenting with uncharacteristic symptoms of RCC who might present with symptoms of saddle PE.

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INTRODUCTION: Microscopic polyangiitis (MPA) is an idiopathic systemic antineutrophil cytoplasmic autoantibodies associated vasculitis (ANCA-AV) affecting small blood vessels. MPA most prominently affects the lungs (25-55%) and kidneys (80-100%). Diagnosis is based on clinical manifestations, ANCA detection, pulmonary imaging, and confirmatory renal/ pulmonary biopsies. Treatment centers around remission induction with corticosteroids and maintenance with immunomodulators(1). We present a case where a presumptive diagnosis was successfully used to initiate treatment of pulmonary hemorrhage in MPA. CASE PRESENTATION: A 50 yo female with a history of HTN presented with 3 months of cough and progressive dyspnea refractory to an outpatient course of azithromycin. On initial presentation, she was found to have bilateral rales and pedal edema on exam. Labs revealed BUN 48; SCr 1.98, prompting a workup for CHF and AKI. She also noted arthralgias, and autoimmune serologies were ordered upon discharge. She returned 3 weeks later with new onset hemoptysis and worsening SOB. She was tachycardic with diffuse wheezing and rales on exam. CT chest was remarkable for bronchiectasis and centrilobular nodules coalescing into a consolidative mass. Aforementioned serologies were significant for ESR > 120, CRP 86.40, RF 189, ANCA positive with MPO >800, p-ANCA 1:160. Infectious workup notable for 3 AFB smears, were negative. A VATS was planned prior to treatment, however, due to clinical deterioration and high suspicion for vasculitis, empiric pulse dose steroids were initiated with almost immediate improvement of her symptoms. Subsequent lung wedge biopsy revealed diffuse alveolar hemorrhage with neutrophilic capillaritis consistent with microscopic polyangiitis. She continued to improve and received a loading dose of Rituximab with plans for continued administration as an outpatient. DISCUSSION: MPA is an ANCA-AV with the potential to affect multiple organ systems. Common pulmonary manifestations include: diffuse alveolar hemorrhage from pulmonary capillaritis, associated with hemoptysis, dyspnea, cough, and pleuritic chest pain. Although histological confirmation is the gold standard for diagnosis, when there is high pretest probability, empiric treatment is warranted(1). This approach is also favorable when patients cannot tolerate or refuse the necessary diagnostic procedure. The failure of outpatient antibiotics, negative infectious workup, positive autoimmune serologies, and suggestive imaging in the setting of continued progression allowed us to have a high clinical suspicion for vasculitis related pulmonary hemorrhage. This facilitated timely treatment and clinical improvement while awaiting confirmatory biopsies. CONCLUSIONS: In summary, if the clinical picture is highly suspicious for ANCA-AV, one can empirically treat with corticosteroid therapy while awaiting definitive diagnostic biopsy.

INTRODUCTION: Castleman's disease (CD) is a rare group of lymphoproliferative disorders characterized by non-neoplastic lymph node hypertrophy, clinically classified as multicentric (MCD) if the disease involves multiple regions of lymph nodes. It manifests as constitutional symptoms due to cytokine dysregulation and systemic inflammation. Human Herpesvirus 8 Associated MCD (HHV-8 MCD), is a subtype of MCD, linked to uncontrolled HHV8 infection known to cause cytokine dysregulation in immunocompromised patients, especially those with HIV. We present a case of HHV-8 MCD which mirrored the clinical presentation and cytokine dysregulation of SARS-COV-2 (COVID-19) infection amidst the current pandemic.