Faculty Bibliography

INTRODUCTION: A case report of an unique presentation of sarcomatoid lung carcinoma. CASE PRESENTATION: The patient is a 52 year old Chinese man with a history of tobacco exposure who presented to the emergency department with melena and loss of consciousness. He relates 1 month of dyspnea on exertion and scant hemoptysis for 10 months. Severe anemia was noted on laboratory results. Gastrointestinal endoscopic evaluation was unremarkable. Small bowel obstruction from Ileoileal intussusception was found on abdominal CT. Exploratory laparotomy revealed a tumor in the proximal small bowel. Pathology revealed poorly differentiated metastatic lung carcinoma with sarcomatoid features. Tumor cells stained positive for TTF1 and vimentin, and focally positive for AE1/3, CK7, and EMA. The cells were negative for desmin, myogenin, S100, CD10, and thyroglobulin. A bronchoscopic lung evaluation and biopsy was non-diagnostic. The final diagnosis was non-small cell lung cancer with sarcomatoid features with metastasis to the small bowel. DISCUSSION: The gastrointestinal tract is an uncommon site for lung cancer metastases.1 Our case is describes a rare presentation of a gastrointestinal bleed as the presenting symptom of a patient with no previous diagnosis of lung cancer. Our patient was also found to have a rare cause of lung cancer. Sarcomatoid carcinoma accounts for only 0.3% of all lung malignancies.2 These lung cancers carry significant mortality and morbidity. Many of these carcinomas present in later stages of the disease process. The patient described in our case was unexpectedly diagnosed with lung cancer only after the development of gastrointestinal symptoms. Clinically significant metastases, specifically intussusception, highlight the need for the clinician to have a high index of suspicion for extraordinary causes of peculiar presentations. CONCLUSIONS: Sarcomatoid lung cancers are rare malignancies that may have unique gastrointestinal presentations

PURPOSE: Improved neurologic outcome has been demonstrated in post-cardiac arrest therapeutic hypothermia (PCATH) due to potential neuroprotective mechanisms. However, infectious complications in PCATH have been increased in out-of-hospital (OHCA) and inpatient cardiac arrest (CA) patients through impaired inflammatory response, increased insulin resistance, and hyperglycemia. Conversely, data are emerging that therapeutic hypothermia (TH) may be beneficial in severe infections in animal model. Our institution excludes patients with sepsis from PCATH. This study seeks to analyze the impact on mortality between patients with uncomplicated TH compared to those with TH who later developed sepsis. METHODS: Our study is a retrospective chart review of patients with PCATH admitted to New York Downtown Hospital from July 2010 to March 2013. We looked at PCATH patients with and without ensuing sepsis and also at those with OHCA and inpatient CA. RESULTS: We identified 22 PCATH patients. 27.3% had uncomplicated PCATH and 72.7% had PCATH which later progressed to sepsis. Survival to discharge or transfer was 83.3% for uncomplicated PCATH group (33.3% discharge, 50% transferred) and 12.5% for the PCATH and sepsis group (p=0.004). In subset analysis, 5 were OHCA and 17 were inpatient CA. Between the two groups: incidence of infection were 40% and 76% (p= 0.27), antibiotic use were 40% and 82% (p=0.10), survival to discharge or transfer were 40% and 29.4%, and mortality were 60% and 70%, respectively, which did not achieve statistical significance. CONCLUSIONS: Our study shows increased survival to discharge or transfer, and reduction in mortality in uncomplicated versus complicated by sepsis PCATH patients. There is no statistical difference in incidence of infection, survival, or mortality between OHCA and inpatient CA patients. We postulate that sepsis that develops after PCATH increases overall mortality

INTRODUCTION: Hemoptysis has been rarely reported as the sole presentation of aortic dissection in elderly, but not in young, healthy patients. Here we present such case. CASE PRESENTATION: A 30 year-old Caucasian woman with history of recurrent sinus infection, remote pneumonia, 7PPY smoking, presented with 2 episodes of hemoptysis over a month. She denied fever, night sweat, weight loss, chronic cough, wheezing, chest pain, SOB or chest trauma. She was born in California, traveled extensively abroad for work, and spent 2 months in Sierra Leone. The first episode of a quarter cup was preceded by throat irritation and hoarseness, with admixture of mucous and blood. The second episode 2 weeks later was mostly blood. The patient underwent unremarkable direct laryngoscopy and chest x-ray. In anticipation of bronchoscopy, the patient underwent CT-chest which showed 5.4cm aneurismal dilatation of the aortic root with intimal dissection (Type A) involving the ascending aorta with extension just proximal to the takeoff of the left subclavian artery. Emergent aortic aneurysm repair revealed extensive cystic medial degeneration and focal hemorrhage. DISCUSSION: Hemoptysis, as the sole presenting symptom of thoracic aortic dissection, is extremely uncommon, especially in young, otherwise healthy person. Over 90% of cases of thoracic aortic dissection present with severe, unremitting chest pain.1 Hemoptysis may occur if the aneurysm compresses the tracheobronchial tree or lungs, erodes into pulmonary vessels or a fistula forms between the aneurysm and tracheobronchial tree. Thoracic aortic aneurysms most often result from cystic medial degeneration, leading to weakening of the aortic wall which occurs usually with aging and hypertension. Aneurysms in young patients occur in inflammatory or infectious vasculitides such as Takayasu arteritis, Rheumatoid arthritis and Syphilitic aortitis or collagen disorders such as Marfan syndrome or Ehlers-Danlos syndrome. There is also a familial association of aortic an!