Differentiating the primary etiology of metastatic lesions in patients with multiple malignancies can create challenges when it is not feasible to perform a biopsy. We present a case of a 62-year-old patient with metastatic estrogen receptor (ER)+/progesterone receptor (PR)+/human epidermal growth factor 2 amplified breast cancer, metastatic melanoma, and chronic lymphocytic leukemia who developed new pulmonary nodules not amenable to biopsy. Classic fluorodeoxyglucose positron emission tomography (PET) computed tomography (CT) imaging revealed metabolically active pulmonary lesions, but was unable to distinguish which primary cancer was responsible for the metastatic lesion. Subsequent PET/CT using 16α-[18F]-fluoro-17β-estradiol ([18F]FES) radioactive tracer, which binds to estrogen receptors, revealed tracer uptake within the pulmonary nodules, supporting that the new nodules were of breast primary, rather than melanoma. This non-invasive imaging was able to provide diagnostic clarity and directly inform management, leading to a change in systemic therapy. This case highlights the value of FES-PET/CT in characterizing ER-positive disease and distinguishing between competing malignancies when tissue biopsy is not feasible.
Primary Sjögren’s syndrome (pSS) is a systemic autoimmune disease that may be complicated by secondary immune thrombocytopenia (ITP), posing substantial risks during pregnancy, particularly regarding anesthetic management. A 25-year-old primigravid woman with pSS-associated secondary ITP developed progressive thrombocytopenia with a nadir platelet count of 13 × 10 9 /L in late pregnancy. Given the profound thrombocytopenia, active cutaneous petechiae, and high bleeding risk, neuraxial anesthesia was contraindicated. An elective cesarean section was successfully performed under general anesthesia using an esketamine-based rapid-sequence induction protocol with perioperative platelet transfusion. Maternal and neonatal outcomes were favorable, with no hemorrhagic complications and Apgar scores of 9 and 10 at 1 and 5 min, respectively. This case demonstrates that cesarean delivery under general anesthesia can be performed safely in patients with pSS complicated by severe ITP through individualized anesthetic planning, perioperative platelet optimization, and multidisciplinary coordination.
Amiodarone-induced thyrotoxicosis (AIT) can complicate the management of atrial tachyarrhythmias, particularly when endocrine and rhythm responses diverge. A man in his early 70s with persistent atrial fibrillation and flutter, prior catheter ablations, and previously recovered tachycardia-induced cardiomyopathy presented with atrial flutter with rapid ventricular response after prolonged amiodarone exposure. Evaluation demonstrated severe thyrotoxicosis and a newly reduced left ventricular ejection fraction. Thyrotoxicosis persisted despite methimazole, prednisone, cholestyramine, and beta-blockade; plasma exchange followed by total thyroidectomy achieved biochemical control. Atrial flutter nevertheless persisted and sinus rhythm was maintained only after amiodarone was reintroduced. Recurrent sinus pauses with syncope subsequently required dual-chamber pacemaker implantation. At follow-up, device interrogation showed no recurrent atrial fibrillation or flutter, and left ventricular ejection fraction had recovered to 50-55%. This case illustrates that definitive treatment of AIT may not by itself resolve a coexisting atrial arrhythmia and that endocrine and rhythm-control strategies may need to proceed independently.
Coronary perforation is a rare but life-threatening complication of percutaneous coronary intervention (PCI). Covered stents achieve hemostasis but may compromise side branch flow near a bifurcation. A woman in her mid 80s underwent PCI for a severely calcified left anterior descending artery (LAD) lesion. After rotational atherectomy and scoring-balloon dilation, coronary perforation became apparent near the LAD-left circumflex artery (LCX) bifurcation after distal LAD stent implantation. Hemodynamic instability required pericardial drainage, intra-aortic balloon pump support, and intensive care. Hemostasis required two PK Papyrus covered stents across the LCX ostium, resulting in LCX flow compromise. Fenestration using a Conquest Pro 12 Sharpened Tip guidewire under dual-lumen catheter guidance, followed by sequential balloon dilation, restored LCX flow. This technique may be an effective bailout strategy for side branch compromise after covered-stent implantation, although its structural and long-term safety remain uncertain.
Pregnancy complicated by methemoglobinemia is a rare clinical condition, primarily characterized by cyanosis and desaturation. The effectiveness of conventional oxygen therapy is often limited, and the optimal respiratory support has not been determined. A 31-year-old Chinese woman at 29 weeks of gestation presented with intermittent chest tightness, cyanosis, and a methemoglobin (MetHb) level of 16.6% on arterial blood gas analysis (ABG). Although conventional oxygen therapy via nasal cannula or face mask maintained her pulse oxygen saturation (SpO 2 ) at 93–95%, it failed to relieve her chest tightness. Her clinical condition subsequently worsened, with the development of respiratory alkalosis and activity-induced oxygen desaturation. High-flow nasal cannula (HFNC) therapy was initiated at a flow rate of 30 L/min, with an inspired oxygen fraction (FiO 2 ) of 40% and a temperature of 34°C, resulting in rapid resolution of chest tightness within 2 hours. The patient underwent an uncomplicated cesarean section, with favorable maternal and fetal outcomes. This case demonstrates that HFNC may have improved respiratory comfort and reduced the work of breathing while definitive medical therapy addressed the underlying methemoglobinemia. Therefore, it may represent a valuable non-invasive respiratory support modality.
