Primary hepatic actinomycosis is rare, with less than 100 cases reported in English literature. Most of these cases are cryptogenic. We describe a 35-year-old woman who presented with a retained common bile duct stent for 6 years and found to have a hepatic mass with altered perfusion and enhancement, and minimal degree of washout on enhanced cross-sectional imaging. Fine-needle aspiration revealed presence of filamentous bacteria morphologically consistent with Actinomyces species. This report is a demonstration of a rare instance in which a retained biliary stent led to primary hepatic actinomycosis.

Introduction Lymph node sampling by endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) is the state of art procedure for staging the mediastinum and hilar regions in lung cancer patients. Our experience of implementing the real‐time cytopathology intervention (RTCI) process for intraoperative EBUS‐TBNAs is presented. This study is aimed to describe in detail the RTCI process for EBUS‐TBNAs, and assess its utility and diagnostic yield before and after its implementation in parallel to conventional rapid on‐site evaluation (c‐ROSE). Methods A retrospective review of all EBUS‐TBNAs between July 2016 and July 2017 at the University of Rochester Medical Center was performed. Final diagnoses, patient clinical data, and number of non‐diagnostic samples (NDS) were reviewed. The numbers of NDS obtained from EBUS‐TBNAs with no cytology assistance (NCA), with RTCI and with c‐ROSE were analysed. Results Non‐diagnostic lymph node samples were found in 20 out of 116 (17%), three out of 114 (2.6%) and 33 out of 286 (11.5%) cases with NCA, RTCI and c‐ROSE, respectively. Application of statistical analysis revealed significant difference in the NDS between the groups of cases in the operating room with NCA and RTCI (P = .005). The different settings and variables between the cases performed using RTCI in the operating room and those assisted with c‐ROSE in the bronchoscopy suite preclude legitimate comparison. Conclusion Our results indicate that the use of RTCI could yield a significantly low proportion of NDS when assisting EBUS‐TBNA of mediastinal and hilar lymph node for lung cancer patients enhancing the diagnostic efficiency of the procedure.

Septic shock can result from the dissemination of infections and can lead to hypoperfusion secondary to vasodilation. Methylene blue can help stabilize blood pressure refractory to other measures in shock. We report a case of a 58-year-old male who died of septic shock due to Pseudomonas aeroginosa bacteremia secondary to acute folliculitis and epididymo-orchitis. He was given methylene blue for reversal of septic shock but he did not respond and expired. Autopsy findings were significant for bluish-green discoloration of organs, especially the heart, lungs, and brain during prosection secondary to methylene blue treatment. It is important to recognize artifacts of treatment and to discern them from changes due to putrefaction or the classic green pigmentation associated with Pseudomonas aeruginosa infection, such as chloronychia. The case report illustrates that circulating methylene blue and its metabolites can accumulate in the organs in a dose-related fashion, imparting an interesting turquoise to dark blue-green pigment during the autopsy. Additional studies are warranted to enable pathologists to differentiate among the pigmentation associated with Pseudomonas aeruginosa bacteremia, putrefaction, and methylene blue treatment.

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