A 48-year-old male presented to the emergency room for 2 weeks of joint pain and swelling of his four extremities. His symptoms started suddenly and were quite debilitating. His hands, fingers, knees, and ankles were so swollen and painful that he was unable to get out of bed and had to use crutches to ambulate. He also complained of anorexia, nausea, and lack of energy over the past few months, but denied any other complaints. His only medical history was a traumatic left tibia fracture 1 year ago. The patient had a 30-pack year history of smoking tobacco and used marijuana daily. The patient recently had an arthrocentesis at an outside hospital which was nondiagnostic and showed no infection. Given his symptoms, a thorough rheumatic workup was ordered. The ESR and CRP were elevated. ANA, rheumatoid factor, HLA B27, HIV, hepatitis panel, TSH, T4, Coombs antibodies, gonorrhea, chlamydia, CCP, alpha 1 antitrypsin, parvovirus, fungal antibodies, and myeloperoxidase antibodies were all within the normal range. X-rays of the hands, knees, and ankles were ordered. The images showed diffuse joint swelling with no fractures, dislocations, or hardware mispositioning. It also showed tissue swelling in the fingers that could not exclude hypertrophic pulmonary osteoarthropathy. A chest x-ray revealed a large 8.5 cm oval mass in the right upper lobe. A follow-up CT revealed a massive right upper lobe lung mass concerning for malignancy versus fungal etiology. A CT guided biopsy of the mass was performed and revealed a poorly differentiated non-small-cell lung cancer, favoring adenocarcinoma. Further CT imaging revealed limited stage disease. During the hospitalization, the patient was provided with NSAIDs for his joint pain, which provided minimal benefit. There was little to no improvement in his joint swelling. Oncology was consulted and further evaluation in the outpatient setting was recommended to determine if he would be a surgical candidate and/or to decide the best chemotherapeutic regimen. This case demonstrates an unusual presentation of non-small-cell lung cancer and highlights the importance of maintaining malignancy on the differential diagnosis for sudden arthritis.

No abstract

A 61-year-old Han Chinese male presented with 4-5 weeks of failure to thrive, hiccups, malaise, and fevers up to 101.5 at home. The patient had been admitted one week prior due to similar symptoms. His primary care physician recently (within 3 months) started gabapentin and chlorpromazine for hiccups, and allopurinol for gout. Drug fever was suspected, and the patient was asked to discontinue gabapentin, allopurinol and chlorpromazine. A short infectious workup for eosinophilia was negative for Herpes Simplex, Strongyloides, and Mycoplasma Pneumoniae, and he was discharged.On repeat admission he admitted to occasional use of allopurinol since his discharge home. Blood pressure was 90/50, temperature was 100.5 Degrees Fahrenheit, and heart rate was 100. Physical exam showed facial plethora, dry mucus membranes, and a diffuse morbiliform rash covering 70 percent of his body. Labs were notable for white blood cell count of 20,000 per microliter, with 6,200 eosinophils per microliter, and 31% eosinophils. Peripheral blood smear confirmed eosinophilia. A skin biopsy showed combined spongiotic and perivascular dermatitis, with eosinophils and neutrophils, all of which was consistent with Severe Cutaneous Adverse Reaction (SCAR). His symptoms quickly improved with oral prednisone. HLA B58:01 allele was positive, which is associated with allopurinol hypersensitivity. The patient was warned to avoid use of allopurinol in the future. HLA B58:01 allele testing in the Han Chinese population is routine in East Asian countries prior to treatment with allopurinol. Despite recommendations by the American College of Rheumatology, testing is often overlooked.

Gastrointestinal stromal tumors (GISTs) are rare gastrointestinal (GI) tumors, representing a small portion of soft tissue tumors of the abdominal cavity. Extraintestinal gastrointestinal stromal tumors (EGISTs) are uncommon forms of GISTs that present outside the GI tract. There have only been a rare number of reported cases of EGIST presenting above the diaphragm. We present the case of a 50-year-old female with shortness of breath, and found to have bilateral pleural effusions and left-sided lung mass. The initial lung mass aspiration was negative for malignancy; yet, pleural fluid was suggestive of malignancy, and repeat biopsy and immunohistochemical stain were diagnostic for GIST. Ultimately, the patient underwent videoassisted thoracoscopic surgery, pleurodesis with doxycycline, and adjuvant therapy with imatinib. This is a report of primary EGIST presenting as an isolated lung lesion with no involvement of the GI tract. In patients with suspected malignancy, it is of paramount importance to obtain a detailed history, including remote signs and symptoms, while performing a thorough work-up. Especially in the lung where initial biopsies can be skewed due to inflammation and atelectasis, repeat biopsies may be necessary to obtain an accurate diagnosis.

Neurosyphilis is a disease caused by systemic infection with Treponema pallidum , which infiltrates the central nervous system and preganglionic dorsal roots. This process presents as neurological deficits and can occur any time during the infection course, but usually takes many years. Neurosyphilis is rare in the developed world where antibiotics are readily available to treat the early stages of syphilis. This report describes a case of neurosyphilis in a 71-year-old woman who presented with ataxia and vision changes and was ultimately found to have a positive rapid plasma reagin test and protein in the cerebrospinal fluid. She was treated with intravenous penicillin for two weeks with a good response.