EJINME-02721; No of Pages 2 European Journal of Internal Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
¿Only acute dyspnea?☆ Antonio Lalueza a,b,⁎, Andrea Alcalá-Galiano c a b c
Department of Internal Medicine, University Hospital 12 de Octubre, Madrid, Spain Department of Medicine, Faculty of Medicine, Universidad Complutense, Madrid, Spain Department of Radiology, University Hospital 12 de Octubre, Madrid, Spain
a r t i c l e
i n f o
Article history: Received 11 May 2014 Accepted 13 May 2014 Available online xxxx Keywords: Osteosarcoma Multiple Pulmonary Nodules Pulmonary Embolism
1. Indication A 20-year-old man presented to the emergency department with acute dyspnea. He had history of pain and swelling on his right thigh of at least 6 months of duration accompanied by fever and weight loss of 15 kg. A previous filaria test performed in a hospital in Guinea was negative. On examination, the respiratory rate was 26 breaths per minute and the oxygen saturation 88% with jugular venous distension and rales in both lungs. As shown in Fig. 1, a soft tissue mass, large and tender to palpation was present in the right leg extending from the pelvis to the knee (Panel A). A blood chemical profile showed alkaline phosphatase of 674 IU per liter, lactate dehydrogenase of 2611 IU per liter and a C-reactive protein level of 11 mg per liter. Computed tomography revealed a destructive permeative lesion in the femoral shaft with spiculated periosteal reaction associated with a large soft tissue mass with areas of ossification (Panel B) and subacute bilateral pulmonary embolism (Panel C, arrows) as well as multiple nodules in both lungs (Panel D). What is the diagnosis? Fig. 1. Panel A: mass in right leg extending from the pelvis to the knee. Panel B: destructive permeative lesion in the femoral shaft with spiculated periosteal reaction associated with a large soft tissue mass with areas of ossification. Panel C (arrows): subacute bilateral pulmonary embolism with signs of severe pulmonary hypertension and right heart failure as well as multiple nodules in both lungs consistent with metastasis (Panel D). ☆ Authorship: All authors had access to the data and participated in writing the manuscript. ⁎ Corresponding author at: Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5.400, 28041 Madrid, Spain. E-mail address: [email protected] (A. Lalueza).
http://dx.doi.org/10.1016/j.ejim.2014.05.006 0953-6205/© 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Lalueza A, Alcalá-Galiano A, ¿Only acute dyspnea?, Eur J Intern Med (2014), http://dx.doi.org/10.1016/ j.ejim.2014.05.006
2
A. Lalueza, A. Alcalá-Galiano / European Journal of Internal Medicine xxx (2014) xxx–xxx
2. Diagnosis Pathologic diagnosis of high-grade osteosarcoma was established with a core-needle biopsy. Osteosarcomas are primary malignant tumors of the bone that are characterized by the production of osteoid or immature bone by the malignant cells. Osteosarcomas are uncommon tumors with an incidence in the general population of 2–3 cases/million/year, higher in adolescence. Despite their rarity, osteosarcomas are the most common primary bone malignancy in adolescents. Although osteosarcoma can occur in any bone, it is most common in the metaphyses of long bones, especially the distal femur, proximal tibia and proximal humerus. Osteosarcomas often have a soft tissue component in which patchy calcifications or spiculae may be observed, as occurs in the present case [1]. At the time of presentation, up to 15% of patients have radiographic metastatic disease, most commonly involving the lungs, but metastases can also develop in the bone and lymph nodes [2]. Bone metastasis implies an ominous prognosis [3]. A metastasis work-up is essential at presentation and should include a CT scan of the thorax because 80% of osteosarcoma metastases involve the lungs and radionuclide bone
scanning with technetium. Although osteosarcomas lack specific tumor markers, an elevation of alkaline phosphatase or lactate dehydrogenase levels in serum is found in some patients, 40 and 30% respectively. This elevation, as occurs in our case, has been associated with poor outcomes [1]. Despite supportive treatment, respiratory and hemodynamic status of the patient was progressively worse and he finally died. Conflict of interests The authors state that they have no conflicts of interest. References [1] Ritter J, Bielack SS. Osteosarcoma. Ann Oncol 2010;21:vii320–5. [2] Bielack SS, Kempf-Bielack B, Delling G, Exner GU, Flege S, Helmke K, et al. Prognostic factors in high-grade osteosarcoma of the extremities or trunk: an analysis of 1,702 patients treated on neoadjuvant cooperative osteosarcoma study group protocols. J Clin Oncol 2002;20:776–90. [3] Clark JC, Dass CR, Choong PF. A review of clinical and molecular prognostic factors in osteosarcoma. J Cancer Res Clin Oncol 2008;134:281–97.
Please cite this article as: Lalueza A, Alcalá-Galiano A, ¿Only acute dyspnea?, Eur J Intern Med (2014), http://dx.doi.org/10.1016/ j.ejim.2014.05.006
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
¿Only acute dyspnea?☆ Antonio Lalueza a,b,⁎, Andrea Alcalá-Galiano c a b c
Department of Internal Medicine, University Hospital 12 de Octubre, Madrid, Spain Department of Medicine, Faculty of Medicine, Universidad Complutense, Madrid, Spain Department of Radiology, University Hospital 12 de Octubre, Madrid, Spain
a r t i c l e
i n f o
Article history: Received 11 May 2014 Accepted 13 May 2014 Available online xxxx Keywords: Osteosarcoma Multiple Pulmonary Nodules Pulmonary Embolism
1. Indication A 20-year-old man presented to the emergency department with acute dyspnea. He had history of pain and swelling on his right thigh of at least 6 months of duration accompanied by fever and weight loss of 15 kg. A previous filaria test performed in a hospital in Guinea was negative. On examination, the respiratory rate was 26 breaths per minute and the oxygen saturation 88% with jugular venous distension and rales in both lungs. As shown in Fig. 1, a soft tissue mass, large and tender to palpation was present in the right leg extending from the pelvis to the knee (Panel A). A blood chemical profile showed alkaline phosphatase of 674 IU per liter, lactate dehydrogenase of 2611 IU per liter and a C-reactive protein level of 11 mg per liter. Computed tomography revealed a destructive permeative lesion in the femoral shaft with spiculated periosteal reaction associated with a large soft tissue mass with areas of ossification (Panel B) and subacute bilateral pulmonary embolism (Panel C, arrows) as well as multiple nodules in both lungs (Panel D). What is the diagnosis? Fig. 1. Panel A: mass in right leg extending from the pelvis to the knee. Panel B: destructive permeative lesion in the femoral shaft with spiculated periosteal reaction associated with a large soft tissue mass with areas of ossification. Panel C (arrows): subacute bilateral pulmonary embolism with signs of severe pulmonary hypertension and right heart failure as well as multiple nodules in both lungs consistent with metastasis (Panel D). ☆ Authorship: All authors had access to the data and participated in writing the manuscript. ⁎ Corresponding author at: Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5.400, 28041 Madrid, Spain. E-mail address: [email protected] (A. Lalueza).
http://dx.doi.org/10.1016/j.ejim.2014.05.006 0953-6205/© 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Lalueza A, Alcalá-Galiano A, ¿Only acute dyspnea?, Eur J Intern Med (2014), http://dx.doi.org/10.1016/ j.ejim.2014.05.006
2
A. Lalueza, A. Alcalá-Galiano / European Journal of Internal Medicine xxx (2014) xxx–xxx
2. Diagnosis Pathologic diagnosis of high-grade osteosarcoma was established with a core-needle biopsy. Osteosarcomas are primary malignant tumors of the bone that are characterized by the production of osteoid or immature bone by the malignant cells. Osteosarcomas are uncommon tumors with an incidence in the general population of 2–3 cases/million/year, higher in adolescence. Despite their rarity, osteosarcomas are the most common primary bone malignancy in adolescents. Although osteosarcoma can occur in any bone, it is most common in the metaphyses of long bones, especially the distal femur, proximal tibia and proximal humerus. Osteosarcomas often have a soft tissue component in which patchy calcifications or spiculae may be observed, as occurs in the present case [1]. At the time of presentation, up to 15% of patients have radiographic metastatic disease, most commonly involving the lungs, but metastases can also develop in the bone and lymph nodes [2]. Bone metastasis implies an ominous prognosis [3]. A metastasis work-up is essential at presentation and should include a CT scan of the thorax because 80% of osteosarcoma metastases involve the lungs and radionuclide bone
scanning with technetium. Although osteosarcomas lack specific tumor markers, an elevation of alkaline phosphatase or lactate dehydrogenase levels in serum is found in some patients, 40 and 30% respectively. This elevation, as occurs in our case, has been associated with poor outcomes [1]. Despite supportive treatment, respiratory and hemodynamic status of the patient was progressively worse and he finally died. Conflict of interests The authors state that they have no conflicts of interest. References [1] Ritter J, Bielack SS. Osteosarcoma. Ann Oncol 2010;21:vii320–5. [2] Bielack SS, Kempf-Bielack B, Delling G, Exner GU, Flege S, Helmke K, et al. Prognostic factors in high-grade osteosarcoma of the extremities or trunk: an analysis of 1,702 patients treated on neoadjuvant cooperative osteosarcoma study group protocols. J Clin Oncol 2002;20:776–90. [3] Clark JC, Dass CR, Choong PF. A review of clinical and molecular prognostic factors in osteosarcoma. J Cancer Res Clin Oncol 2008;134:281–97.
Please cite this article as: Lalueza A, Alcalá-Galiano A, ¿Only acute dyspnea?, Eur J Intern Med (2014), http://dx.doi.org/10.1016/ j.ejim.2014.05.006
