Case Reports and Reviews: Open Access

Background: Pleural effusion in advanced illness presents complex challenges in balancing symptom relief with the burden of invasive interventions. Case presentation: We report a 69-year-old bedbound male with a history of cerebrovascular accident, dementia, type 2 diabetes, hypothyroidism, malnutrition, and prior candidemia, who presented with a one-month history of intermittent non-productive cough. Imaging revealed multifocal pneumonia with large left and moderate right pleural effusions. Despite antibiotic therapy with Vancomycin and Piperacillin-Tazobactam, his overall condition remained poor, with profound malnutrition (BMI 17.5 kg/m²) and limited functional capacity. Pulmonology consultation considered bilateral thoracentesis; however, given his steeply declining health, dementia, and poor nutritional status, the family declined invasive interventions and opted for comfort-focused care. His family changed his code status to Do Not Resuscitate (DNR), and the palliative care team was consulted and provided symptom management, psychosocial support, and hospice transition planning. Conclusion: This case emphasizes the importance of collaborative decision-making and involvement of palliative care to ensure that management aligns with the patient's goals and overall health. Choosing to avoid invasive procedures and instead focus on comfort care can better reflect the patient's wishes and uphold the principles of autonomy, beneficence, and quality of life.

Copper deficiency is an uncommon but clinically significant etiology of cytopenias that can closely resemble myelodysplastic syndrome (MDS), particularly when ring sideroblasts and multilineage dysplasia are observed. This morphological overlap presents a diagnostic challenge and may lead to misclassification, unnecessary treatments, and delays in appropriate management. Here, we report the case of a 60-year-old woman who presented with progressive fatigue and was found to have severe neutropenia. Bone marrow examination demonstrated hypercellularity with marked multilineage dysplasia and ring sideroblasts, initially raising concern for MDS with sideroblastic features. Nevertheless, initially exhaustive molecular testing, including an MDS next-generation sequencing panel, SF3B1 mutation analysis, and standard myelodysplastic syndrome fluorescence in situ hybridization (MDS FISH) studies, all yielded negative findings, prompting further evaluation for other reversible causes of dysplasia. Following comprehensive laboratory studies, profound copper deficiency was revealed. The patient started receiving copper repletion, resulting in rapid hematologic recovery, sustained improvement in neutrophil counts, and near-complete resolution of dysplastic morphology on repeat marrow evaluation. The case emphasizes the importance of early consideration of nutritional deficiencies in diagnostic differentials, particularly copper deficiency, in the differential diagnosis of unexplained cytopenias and dysplasia. Early recognition is critical to avoid inappropriate initiation of disease-modifying therapy and to ensure timely, effective, and reversible management and treatment.

Hematopoietic stem cell transplantation (HSCT) is an essential therapy for malignant and non-malignant hematologic, autoimmune, and genetic disorders. However, post-transplant complications, particularly pulmonary infections, remain a leading cause of morbidity and mortality. Case report: We present the case of a 70-year-old male with chronic lymphocytic leukemia (CLL) who underwent allogeneic HSCT several years ago. Post-transplant, he received intravenous immunoglobulin (IVIG) every six weeks for immune support. Despite this, he developed chronic obstructive pulmonary disease (COPD) without any smoking history and has experienced recurrent pneumonia requiring frequent hospitalizations. Extensive microbiologic and imaging evaluations repeatedly failed to identify a causative organism. The patient remains on chronic antibiotic therapy, nebulized bronchodilators, and antiviral prophylaxis with valacyclovir. This case underscores the vulnerability of post-HSCT patients to recurrent, often unexplained pulmonary infections despite ongoing prophylactic and supportive measures. Management focuses on infection prevention and treatment through broad-spectrum antimicrobials, immunoglobulin replacement, and respiratory support, while addressing physical, psychological, and nutritional needs. Discussion: In patients with CLL and T-cell-depleted HSCT, persistent immunodeficiency can lead to refractory pulmonary complications, significantly reducing quality of life and survival. Early recognition, aggressive management, and multidisciplinary care are essential to improving outcomes in this high-risk population.

Background: Light-chain amyloidosis (AL amyloidosis) is a rare, debilitating, heterogeneous, and multisystemic disorder that is often fatal in the absence of treatment. This is because of the conversion of light chains (LCs) produced by plasma cell dyscarasia from their soluble state into organized fibrillar aggregates, resulting in progressive organ damage and dysfunction. The clinical features of the disease are nonspecific and depend on the type of organ affected. Overall prognosis depends on several clinical, laboratory, and pathological parameters. Case presentation: A young Algerian man presenting with the diagnostic challenge of atypical extensive systemic amyloidosis initially presenting with severe neurological manifestations despite a lower burden light chain level and undetected plasma cell dyscarasia that developed over 10 years. Conclusion: Atypical clinical presentation, undetectable plasma cell dyscarasia, and unusual disease evolution led to delayed diagnosis and devastating complications in the patient at the time of diagnosis. A very high clinical suspicion with a combination of several laboratory and histopathological tests is required to confirm the diagnosis. Although biopsy is the gold standard for the diagnosis of AL amyloidosis and confirmation of the involvement of each organ, noninvasive techniques with high sensitivity and specificity have been used.