Retinal Metastases as the Initial Presentation of Advanced Lung Adenocarcinoma.

Introduction: Most lung cancers are diagnosed at an advanced stage. Common metastatic sites include the brain, bone, liver and adrenal glands. Ocular metastases, however, are extremely rare. We present a case of advanced lung adenocarcinoma presenting exclusively with photopsias attributable to retinal metastases. Case description: We describe a woman in her fifties, a lifetime non-smoker with an unremarkable medical and family history, who presented to the emergency department with photopsias for a week. Ophthalmology evaluation revealed decreased visual acuity bilaterally, and a fundus examination disclosed lesions suggestive of bilateral retinal metastases. A comprehensive evaluation diagnosed a stage IVb lung adenocarcinoma with exon 19 mutation on epidermal growth factor receptor gene. Subsequently, she developed complaints of headaches and dizziness. She received frontline osimertinib 80 mg daily, preceded by upfront whole-brain radiation therapy with partial orbital inclusion for symptomatic ocular and brain metastases. After ten radiation therapy sessions, her complaints were resolved and an ophthalmology revaluation revealed improvement in visual acuity and resolution of photopsia complaints. The patient is currently on osimertinib and preserves an ECOG score of 0. Conclusion: Retinal metastases usually indicate advanced disease, so presenting with isolated ocular symptoms is exceedingly rare. Especially in cases of uncommon metastases, a multidisciplinary approach is fundamental for a prompt diagnosis and timely treatment, impacting prognosis and quality of life. LEARNING POINTS: Ocular metastases in lung cancer are usually a sign of advanced disease.Advanced lung adenocarcinoma presenting solely with retinal metastases is extremely rare.A multidisciplinary team is essential for the diagnosis and treatment of lung cancer with uncommon metastases.

Drug Rash with Eosinophilia and Systemic Symptoms (DRESS Syndrome).

DRESS syndrome is an idiosyncratic drug reaction and potentially life-threatening. The authors report a case of this syndrome presenting with fever, rash, mucosal involvement, liver and muscle involvement associated with moxifloxacin treatment.

Nonbacterial thrombotic endocarditis. / Endocardite trombótica não bacteriana.

An 83-year-old woman with a 10-year history of rheumatoid arthritis was admitted for urinary tract infection with exacerbation of chronic kidney disease and decompensated heart failure of unknown etiology. Transesophageal echocardiography (TEE) showed a vegetation involving the posterior mitral valve leaflet, and a hypothesis of infective endocarditis was proposed. Empirical antibiotic therapy was initiated. TEE was repeated after antibiotic therapy, and showed persistence of the original vegetation and revealed the presence of another, smaller vegetation. Clinical investigation revealed no infectious process, and so a diagnosis of nonbacterial thrombotic endocarditis (NBTE) was established. Anticoagulant therapy was started immediately. The NBTE lesion had disappeared on the follow-up echocardiogram two months after anticoagulant therapy.

Autoimmune hepatitis unmasked by nimesulide.

A 49-year-old woman presented at the emergency department, with acute hepatic failure, 2 weeks after taking nimesulide. Presenting with a MELD score of 25.0, the patient was transferred to a specialised liver transplant unit, with the probable diagnosis of toxic hepatitis. After a clinical improvement with supportive care and acetylcysteine, a liver biopsy was executed. The histology revealed micronodular cirrhosis associated with acute hepatitis, with features suggestive of autoimmune hepatitis. The patient was then started on azathioprine 50 mg/day and prednisolone 30 mg/day, and tapering of prednisolone was carried out in the following months. Twenty eight months after treatment, another liver biopsy was performed, showing almost full remission of the disease, with only mild fibrosis and no significant inflammatory infiltrate.