Primary small cell neuroendocrine cancer of adrenal gland: a rare extrapulmonary small cell cancer.

Small cell cancer is an aggressive neoplasm of neuroendocrine origin that is most commonly found in the lungs. However, up to 5% of cases can be extrapulmonary. These have been reported to be located in the gastrointestinal and genitourinary systems and rarely in other locations. Only five prior cases of small cell cancer have been reported where the primary lesion is at the adrenal gland. Here we present the case of a female patient in her mid-50s who presented with right upper quadrant pain and was diagnosed with metastatic small cell carcinoma of the adrenal gland. The patient received palliative chemotherapy for her metastatic cancer and was ultimately admitted to hospice after progression of her disease. This case and the accompanying literature review highlight a rare manifestation of extrapulmonary small cell cancer.

Acute Non-Traumatic Sub-Arachnoid Hemorrhage in a Young Female With Diabetic Ketoacidosis.

Diabetic ketoacidosis (DKA) is one of the most common causes of morbidity and mortality in patients with type 1 DM. Due to severe acidosis, ketonemia and electrolyte disturbances it can lead to various complications in the body, which can be fatal in some cases. Neurological complications related to DKA include cerebral edema, cerebral infarction, brain herniation, cortical venous thrombosis. It is very rare for DKA to cause subarachnoid hemorrhage (SAH). We present a case 19-year-old female with severe DKA, who developed SAH without any pre-existing aneurysm or other common risk factors. The patient did not have any neurologic deficits and was managed conservatively with the resolution of her symptoms. We have also summarized the existing literature regarding the association of DKA with subarachnoid hemorrhage.

Amiodarone-induced diffuse alveolar haemorrhage: a rare but potentially life-threatening complication of a commonly prescribed medication.

Amiodarone is an antiarrhythmic agent that is used commonly in clinical practice. It is associated with many side effects, the most common being pulmonary manifestations. Interstitial pneumonitis is one of the most common complications, however rarely amiodarone can cause diffuse alveolar haemorrhage (DAH) too. We describe the case of a 73-year-old woman who presented with shortness of breath and haemoptysis 4 days after starting amiodarone. She was diagnosed with amiodarone-induced DAH based on imaging and bronchoalveolar lavage. She was treated with intravenous and then oral steroids, and amiodarone was discontinued. The patient made a significant clinical and radiological recovery. She was discharged 10 days after her presentation. This case highlights a rare but potentially life-threatening complication of a commonly used medication.

Rapid onset type-1 diabetes and diabetic ketoacidosis secondary to nivolumab immunotherapy: a review of existing literature.

Nivolumab is a programmed cell death receptor (PD-1) inhibitor that is increasingly used for various malignancies, both as a first line agent and as salvage therapy. Being a PD-1/PD-1 ligand checkpoint inhibitor, it is known to cause autoimmune inflammation of various organs and has been associated with thyroiditis, insulitis, colitis, hepatitis and encephalitis to name a few. There are increasing reports of nivolumab leading to acute onset fulminant type 1 diabetes and diabetic ketoacidosis (DKA). We present a case of a 68-year-old man who developed DKA after 2 doses of nivolumab for metastatic melanoma. He was found to have type 1 diabetes, but no diabetes related antibodies were positive. He recovered from diabetes and continues to use insulin 1 year after his diagnosis. This case and associated review illustrates the importance of educating and monitoring patients who start nivolumab therapy regarding this potentially life threatening complication.

Human cytomegalovirus pneumonia in an immunocompetent patient: a very uncommon but treatable condition.

Human cytomegalovirus (CMV) is a double-stranded DNA virus that can cause widespread severe infection in immunocompromised individuals but is more typically a subclinical infection in immunocompetent individuals. Rarely, it can cause a serious infection in immunocompetent individuals. Here, we describe a 36-year-old otherwise healthy male who presented with fever, cough and malaise who was diagnosed with CMV pneumonia. He made a rapid recovery after initiation of ganciclovir and has been doing well on follow-up visits. We performed a comprehensive review of CMV pneumonia in immunocompetent individuals and have summarised the prior 16 reported cases of CMV pneumonia in immunocompetent patients. This article highlights the importance of considering CMV as a cause of pneumonia even in immunocompetent individuals, especially when the more common causes have been excluded. Early diagnosis allows prompt treatment and potentially complete recovery.

Cardiac tamponade and purulent pericarditis secondary to an oesophageal pericardial fistula as an initial presentation of squamous cell carcinoma of the oesophagus.

Pericardial effusions resulting in a cardiac tamponade have previously been reported with oesophageal cancers. However, most of these cases have been reported in association with radiation and chemotherapy. Rarely as oesophageal pericardial fistuls (OPF) have been reported as the culprits in causing pericardial effusions in patients with oesophageal cancers. Here we present the case of a 61-year-old woman who presented clinically with cardiac tamponade. She was found to have an OPF due to oesophageal squamous cell cancer that resulted in a purulent pericardial effusion. She underwent a median sternotomy, pericardial decompression, and mediastinal debridement. An oesophageal stent was attempted unsuccessfully. The patient refused any more aggressive treatments and was discharged to a hospice where she passed away 13 days after presentation. This case and the associated literature review highlights an unusual presentation of oesophageal cancer and an uncommon cause of cardiac tamponade.

Plasma Cell Leukaemia: A Rare Yet Aggressive Plasma Cell Dyscrasia With A Very Poor Response To Conventional Therapy.

Plasma cell leukaemia (PCL) is a very rare plasma cell dyscrasia with a significant number of monoclonal plasma cells in the peripheral blood. It is diagnosed by the presence of ≥ 2x109 /L plasma cells in the blood or by plasma cells making up ≥20% of the leukocyte count. It can arise from a leukemic transformation of multiple myeloma, or more commonly it can be primary. Regardless of its origin, it carries a very dire prognosis. It responds very poorly to the traditional chemotherapy regimens used for multiple myeloma. We present the case of a 50 years old female who presented to our hospital with a complicated UTI and severe generalized body aches. She was diagnosed as a case of plasma cell leukaemia and was treated with cyclophosphamide and dexamethasone, however she failed to go into remission. Her condition deteriorated and she ultimately passed away 1.5 months after diagnosis. The recommended treatment for PCL is aggressive combination chemotherapy followed by stem cell transplantation. However, there is no consensus regarding the treatment of plasma cell leukaemia, and treatment should be individualized based on the patient profile. Once diagnosed, the prognosis is poor.

A not so happy ending: coital cephalgia resulting from an acute non-traumatic intraparenchymal haemorrhage in a female with no comorbidities.

A sexual headache or coital cephalgia is a headache associated with sexual activity and is a well-recognised condition. It is usually benign, primary and self-limiting. However, occasionally sexual headaches can result from more sinister causes. Intraparenchymal and subdural haemorrhages have been reported as secondary causes of sexual headaches. We present the case of a 61-year-old woman with no comorbidities who presented acutely with a sexual headache and vision loss, and was found to have an occipital and parietal intraparenchymal haemorrhage. She was normotensive and after extensive workup was found to have no predisposing condition for her haemorrhage. The patient had an uneventful recovery with physical rehabilitation and had regular follow-ups, with no residual weakness. She was in a completely normal state of health 1 year after her event, and continued to be off any medications.