Here we describe the first reported case of Nocardia beijingensis infection in the United States, made rarer by its presence in an immunocompetent patient. CASE REPORTA 48-year-old Caucasian male presented to an outside facility with a 1-month history of nonproductive hacking cough, low-grade fevers, drenching night sweats, and weight loss, which prompted further investigation. His medical history was unremarkable. His social history was remarkable for his work as a cotton farmer and no tobacco or alcohol use. He had traveled to Eastern Europe 1 year earlier. Computed tomography (CT) of the chest, abdomen, and pelvis showed a 5-cm ill-defined mass in the right hilum, causing narrowing of the branches of the upper-lobe bronchus and peripheral lung collapse. Also noted was lymphadenopathy in the hilar, periaortic, and aorticopulmonary window. Findings on the CT scan were concerning for possible carcinoma, lymphoma, or thymoma. A mediastinoscopy with lymph node biopsy was performed, but it was nondiagnostic.The patient was referred to the Mayo Clinic Florida for further evaluation. Physical examination revealed decreased breath sounds in the left apical lung. There was no lymphadenopathy noted in the cervical, supraclavicular, or axillary region. A complete blood count demonstrated mild anemia, neutrophil-predominant leukocytosis of 20,000 cells/l, and thrombocytosis of 935,000/l. The lactate dehydrogenase level was normal at 219 U/liter. C-reactive protein was elevated at 209 mg/liter. Testing for human immunodeficiency virus (HIV) and hepatitis B and C viruses was negative. A positron emission tomography (PET) scan revealed a 9.9-by 5.1-by 6.9-cm left paramediastinal mass extending to the left superhilar region with a maximum standardized uptake value (SUV) of 29.6 ( Fig. 1 and Fig. 2). Compared to the results of the CT scans done previously, a new hypermetabolic 1.4-cm suprasternal notch nodule that was suspicious for an abnormal lymph node was found. A PET scan also revealed a diffusely hyperstimulated bone marrow. A bone marrow biopsy specimen showed myeloid and megakaryocytic hyperplasia, and the findings were consistent with reactive marrow changes.The patient subsequently underwent a Chamberlain-McNeil left thoracotomy, during which a solid lung that was extremely vascular was encountered and biopsy specimens of the left lung and thymus were obtained. Further surgical dissection revealed a round hard lymph node that was noted on imaging and that was palpated and excised. Pathology showed lung tissue with acute and chronic changes of granulomatous inflammation and organizing pneumonia. Thymic tissue had an atrophic appearance and was negative for any neoplasm. Flow cytometry was negative for abnormal T-or B-cell populations. Gram staining and Grocott's methenamine silver staining of the thymic tissue were negative.Mediastinal lymph nodes showed reactive hyperplasia. Interestingly, on the Gram stain, Gram-positive bacilli with a beaded filamentous appearance were identified. The sputum, lung, and lymph node b...

The introduction of new agents immunomodulatory drugs (IMiDs) and proteasome inhibitors has brought a major shift in therapeutic paradigm in the treatment of newly diagnosed and refractory multiple myeloma (MM). Thalidomide was the first immunomodulatory agent approved for use in myeloma. Although highly active, it is associated with considerable toxicity, particularly in older patients. Lenalidomide, an analog of thalidomide, was developed because of its more potent anti-MM activity and better toxicity profile than the parent compound. Since its introduction in 2004, lenalidomide has established a role in all phases of treatment in MM. The pleiotropic antitumor effects of lenalidomide have translated into clinical efficacy in diseases other than MM. Pomalidomide is a highly potent third-generation IMiD that shares similar pharmacologic properties as thalidomide, with very promising activity in MM and myelofibrosis. This review summarizes the mechanisms of action and clinical activity of IMiDs in MM.

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A 48-year-old woman presented with a 2-week history of peripheral neuropathy. She progressively developed motor weakness leading to quadriparesis and respiratory failure requiring intubation. Nerve conduction studies showed diffuse absence of motor and sensory responses. She had a right cervical mass that was excised, which showed regressed follicles with expansion of interfollicular region by sheets of plasma cells. The majority of the follicles contained lymphocyte-depleted germinal center surrounded by a broad mantle zone with an "onion skin" pattern (panel A); some follicles were penetrated by hyalinized blood vessels (panel B). The bone marrow biopsy showed thickened trabeculae and increased atypical megakaryocytes. The overall features were suggestive of Castleman disease, plasma cell variant. Serum immunofixation showed monoclonal IgG l (M-spike, 0.8 g/dL); vascular endothelial growth factor level was elevated at 1101 pg/mL. A diagnosis of POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes) syndrome was made. She was treated with cyclophosphamide and dexamethasone. With four cycles of treatment, she regained upper extremity strength and is now ventilator independent.