Pathways Case Studies: April 2019

A 75-year-old man presented with acute abdomen and was found to have significant induration of the common bile duct near cystic and common hepatic duct junction causing gallbladder hydrops. Cholecystectomy was performed. Grossly, there was no mass lesion in the gallbladder.

	Hee Eun Lee, M.D., Ph.D. Fellow, Anatomic Pathology Mayo Clinic
	Lizhi Zhang, M.D. Consultant, Anatomic Pathology Mayo Clinic Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine

A 7-month-old male presented in the ED with head injury and seizure concerns. Bilateral subdural hemorrhages of different ages and multilayered intraretinal hemorrhages in both eyes were found, without bone fractures or cervical spine ligamentous injury. In addition, the patient had a rapid progression of macrocephaly. Analysis of urine organic acids revealed 2-hydroxyglutaric acid (2HGA) and 2-hydroxyglutaric lactone (2HGL) markedly elevated (Figure 1). The presence of either the D-form or the L-form of 2HGA was analyzed (Figure 2).

	Ester Perales Clemente, Ph.D. Fellow, Clinical Biochemical Genetics Mayo Clinic
	Piero Rinaldo, M.D., Ph.D. Consultant, Lab Genetics and Genomics Mayo Clinic Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine

26-year-old homeless man with history of substance abuse is found unresponsive on the street following a blizzard. He is in a partial state of undress with shirt removed and pants partially pulled down. Autopsy was notable for the presence of multiple superficial punctate gastric erosions (photo 1) and a pancreatic abnormality (photos 2 and 3). Toxicology was positive for methamphetamine in the blood.

	Rachel Horton, D.O. Resident, Anatomic and Clinical Pathology Mayo Clinic
	Peter Lin, M.D. Consultant, Anatomic Pathology Mayo Clinic Assistant Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine

26-year-old homeless man with history of substance abuse is found unresponsive on the street following a blizzard. He is in a partial state of undress with shirt removed and pants partially pulled down. Autopsy was notable for the presence of multiple superficial punctate gastric erosions (photo 1) and a pancreatic abnormality (photos 2 and 3). Toxicology was positive for methamphetamine in the blood.

	Rachel Horton, D.O. Resident, Anatomic and Clinical Pathology Mayo Clinic
	Peter Lin, M.D. Consultant, Anatomic Pathology Mayo Clinic Assistant Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine

A 70-year-old female presented with refractory gross hematuria one day after uncomplicated cystoscopy and fulguration of a benign bladder mass. She was treated with continuous bladder irrigation, evacuation of blood clot, and transfused red blood cells.

Her only history of bleeding was menorrhagia in the setting of uterine fibroids. She denied epistaxis, melena, hematochezia, or prior history of hematuria. She also denied bleeding with prior surgical procedures.

Prior to surgery, labs demonstrated normal hemoglobin and platelet count.

	Meera Sridharan, M.D., Ph.D. Resident, Special Coagulation Mayo Clinic Assistant Professor of Medicine and Oncology Mayo Clinic College of Medicine
	William Nichols, Jr., M.D. Consultant, Hematology Mayo Clinic Associate Professor of Laboratory Medicine and Pathology and Medicine Mayo Clinic College of Medicine