Pathways Case Studies: August 2019

A middle aged woman with destructive sacral mass.

	Nooshin Karamzadeh Dashti, M.D., M.P.H. Fellow, Bone and Soft Tissue Pathology Mayo Clinic
	Carrie Inwards, M.D. Consultant, Anatomic Pathology Mayo Clinic Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine

A 61 year-old men presented to his primary care physician with a chronic course of generalized weakness, fatigue, back bone pain and weight loss (15 lb). Laboratory results shows hemoglobin 11g/dL (RR: 13.2-16.6 g/dL), creatinine 2.5 mg/dL (RR: 0.74-1.35 mg/dL), total calcium 11.5 mg/dL (RR: 8.8-10.2), and the following serum protein electrophoresis (SPEP) and immunofixation (IFE).

	Jose Jara Aguirre, M.D. Resident, Clinical Pathology Mayo Clinic
	David Murray, M.D., Ph.D. Consultant, Clinical Biochemistry Mayo Clinic Assistant Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine

19 year old male with a 7 year history of diarrhea and failure to thrive.

	Holly Berg, D.O. Resident, Anatomic and Clinical Pathology Mayo Clinic
	Thomas Smyrk, M.D. Supplemental Consultant, Anatomic Pathology Mayo Clinic Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine

A 50-year-old man with a past medical history of rheumatoid arthritis (treated with immunosuppressive biologic agents) presented to the Emergency Department with splenomegaly, fevers, thrombocytopenia (platelets 31 x 10⁹/L). After admission, the patient was noted to have decreased fibrinogen, elevated transaminases and total bilirubin, and a ferritin level of 51,000 mcg/L. The patient’s clinical status worsened, necessitating intensive care. A bone marrow biopsy was performed to evaluate the patient’s condition.

	Andrew Norgan, M.D., Ph.D. Mayo Clinic Scholar Instructor in Laboratory Medicine and Pathology Mayo Clinic
	Bobbi Pritt, M.D. Consultant, Clinical Microbiology Mayo Clinic Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine @ParasiteGal

80 y.o. male presents with fever and rigors after nephrostomy tube change on the last day of BCG immunotherapy for urothelial carcinoma. Routine bacterial blood cultures and urine culture are negative. Mycobacterial blood culture flags positive after 27 days of incubation. The bottle is subcultured to Middlebrook 7H11 agar. After 9 days of incubation, dry, rough, non-chromogenic colonies are observed, staining acid-fast (figure). The patient denies international travel, has no known TB contacts, and has a negative quantiFERON-TB Gold Plus.

	Kyle Rodino, Ph.D. Fellow, Clinical Microbiology Mayo Clinic @KGRodinoPhD
	Nancy Wengenack, Ph.D. Consultant, Clinical Microbiology Mayo Clinic Professor of Laboratory Medicine and Pathology and Microbiology Mayo Clinic College of Medicine