We herein describe the case of a 63-year-old man who died from relapsed epidermal growth factor receptor gene (EGFR) exon 19 deletion lung adenocarcinoma treated with erlotinib. According to the autopsy results, he was confirmed to have small cell carcinoma without the EGFR T790M mutation in his pancreas and left kidney metastatic specimens, while the adenocarcinoma metastatic lesion in his right kidney had the EGFR T790M mutation; both retained the somatic EGFR exon 19 deletion. We herein report an autopsy case of resistance to an EGFR tyrosine kinase inhibitor via small cell carcinoma transformation and the EGFR T790M mutation in separate metastatic organs.

A 73-year-old man presented with odynophagia and retrosternal pain of 3 days' duration following a fish meal. Physical examination disclosed normal vital signs and a temperature of 37.2°C. Laboratory studies showed elevated white blood cells of 13 900/μL and C-reactive protein of 14.8 mg/dL. A computed tomography (CT) of the chest revealed a suspicious fish bone that measured 3 cm in length and had perforated through the esophageal wall (• " Fig. 1 and• " Fig. 2). Three-dimensional CT showed the bone (blue matter) penetrating close to the left common carotid artery (• " Fig. 3). Subsequent upper endoscopy revealed only a small submucosal nodule, which was located at 19 cm from the incisors, not an impacted fish bone in the upper esophagus (• " Fig. 4). A tiny white linear scar (arrow) was observed on its top, suggesting the site of perforation (• " Fig. 5). Surgical exploration was performed via a lateral neck incision, and the fish bone was successfully retrieved. The postoperative course was uneventful. Most ingested foreign bodies can pass through the gastrointestinal tract spontaneously. However, 10 % -20 % of such bodies require nonoperative intervention and 1 % need surgery [1]. Based on a largescale retrospective study including 316 cases of foreign bodies in the esophagus [2], the most common foreign bodies in the pharynx and the upper esophagus were fish bones. The risk of complications was increased with a longer duration of impaction (> 24 hours), bone type, and longer bone length (> 3 cm). The current case had all of these risk factors. As for endoscopic features of fish bones, most visible bodies can be retrieved by biopsy forceps [3]. Extremely rare cases with imbedded or perforating fish bones may present submucosal tumor-like nodules [4,5], as in this case. Endoscopy_UCTN_Code_CCL_1AB_2AC_3AHCompeting interests: None Upper endoscopy showed only a small submucosal nodule in the upper esophagus not an impacted fish bone. Fig. 1 An axial computed tomography of the chest disclosed a suspicious fish bone that measured 3 cm in length (black arrow) and had perforated the esophagus (white arrow). Cases and Techniques Library (CTL) E216Hokama Akira et al. A fish bone perforation of the esophagus … Endoscopy 2014; 46: E216-E217This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Acute lung injury during pregnancy results in morbidity and mortality in both the mother and the fetus. Pneumocystis jirovecii pneumonia (PCP) is a rare disease but may occur in pregnant immune-suppressed women. Here, we describe a case of acute lung injury due to PCP and alveolar hemorrhage in a pregnant woman who was a human T lymphotropic virus type-1 (HTLV-1) carrier. PCP should be considered in the differential diagnosis of pulmonary complications during pregnancy in HTLV-1 endemic areas.