Immune checkpoint inhibitor-induced myasthenia gravis, myocarditis, and myositis: A case report.

Key Clinical Message: Immune checkpoint inhibitors can rarely lead to occurrence of myositis, myocarditis, and myasthenia gravis (MG). Early recognition and multidisciplinary management are crucial for optimal outcomes. Vigilance for overlapping toxicities is essential in patients receiving combination immunotherapy. Abstract: The use of immune checkpoint inhibitors (ICIs) has revolutionized cancer treatment, but it is associated with immune-related adverse events (IRAEs) affecting various organ systems. The simultaneous occurrence of MG, myocarditis, and myositis highlights the complex nature of IRAEs. Early recognition and comprehensive multidisciplinary management are crucial for optimal patient outcomes. We present a unique case report of a 76-year-old male patient with advanced melanoma who developed concurrent myositis, myocarditis, and MG while receiving combination immunotherapy with Nivolumab and Ipilimumab. This case underscores the significance of recognizing and addressing the "Terrible Triad" of IRAEs in patients receiving ICIs. Healthcare providers should maintain a high index of suspicion for overlapping toxicities and promptly initiate appropriate interventions.

Swimming-Induced Pulmonary Edema Masquerading as Acute Respiratory Distress Syndrome: A Case Report.

Immersion pulmonary edema, also known as swimming-induced pulmonary edema (SIPE), manifests with cough, dyspnea, hemoptysis, and hypoxemia from flash pulmonary edema after surface swimming, often in healthy young individuals with no predisposing conditions. SIPE commonly resolves spontaneously within 24-48 hours but can be fatal. Post-mortem findings demonstrate heavy, edematous lungs and frothy airways. Although these pathologic findings are like those seen in patients with drowning, SIPE, by definition, is associated with pulmonary edema that develops with a closed glottis without drowning/aspiration. However, patients who develop SIPE during swimming could lose consciousness and drown. Its pathophysiology is poorly understood, and the medical literature infrequently describes SIPE. Due to the multifactorial and complex pathophysiology and the scarcity of medical literature describing SIPE, the diagnosis could be difficult at presentation. This case report elaborates on diagnosing and treating swimming-induced pulmonary edema in a hypertensive and obese female who presented to our emergency room with an acute onset of shortness of breath after recreational swimming in a pool.

Sphincter of oddi dysfunction induced by ketamine: A case report.

Key Clinical Message: Chronic ketamine use can lead to sphincter of oddi dysfunction (SOD), causing various hepatobiliary complications. Recognizing substance abuse history is vital for early detection. Timely intervention can prevent irreversible liver and pancreas damage. Abstract: Ketamine is commonly abused as a recreational drug worldwide due to its ability to induce euphoria-like effects. Ketamine abuse is associated with many hepatobiliary side effects ranging from cholestasis to biliary sepsis and death. Here we present a case of a young 29-year female with upper abdominal pain due to SOD resulting from chronic use of ketamine. SOD can result in obstruction or dysfunction of the bile and pancreatic ducts. Ketamine induces SOD by activation of the muscarinic receptors in the sphincter of oddi. Detail history of substance abuse is crucial for early identification of ketamine-induced SOD. Early identification and treatment of this rare condition can prevent permanent injury to the liver and pancreas.

Atraumatic Bilateral Patella Fracture in Middle-Aged Female: A Rare Case Report.

The patella is the largest sesamoid bone in the body and an important structure of the extensor apparatus which is under undue stress during flexion and extension of the knee. Bilateral fracture of the patella without trauma is a very rare event and may be multifactorial without a single cause. A repetitive stress reaction in a previously predisposed bone can be an important cause. We report a case of a 45-year-old female with a nontraumatic bilateral transverse patella fracture with loss of extensor mechanism. A stable surgical fixation for such a displaced fracture with a good rehabilitation program can lead to a good functional outcome.

Culture-negative endocarditis with multifocal spread and flail mitral valve leaflet: a case report.

Introduction: Blood culture-negative infective endocarditis is the condition in which a causative organism cannot be identified after inoculation of at least three samples using standard blood-culture systems for 7 days. It has a low reported incidence of about 2.5-31%. Causes may be infectious or non-infectious; use of prior antibiotic therapy is usually the leading factor. Case presentation: The authors present a case of true culture-negative endocarditis involving the mitral valve, with multiple foci of spread including brain, spleen, liver, and Intervertebral disc, which remained persistent despite treatment with intravenous broad-spectrum antibiotics on an inpatient and outpatient basis but eventually improved after upgrading alternative broad-spectrum antibiotic for an extended duration. The patient had complications in the form of a flail mitral valve with persistent mitral regurgitation, requiring mitra-clip placement. Discussion: Positive blood culture is one of the major diagnostic criteria to establish infective endocarditis. Patients may have persistent negative cultures due to previous antibiotic use, the presence of fastidious organisms, or the use of inappropriate techniques or media. Involvement of a multidisciplinary team, use of multimodal investigations, and appropriate antibiotic stewardship are crucial. Extended duration of treatment and upgrading antibiotics can be helpful next steps in highly suspicious cases. With multifocal spread as in our case, it further becomes challenging to control and treat the infection as it is frequently connected with higher morbidity and mortality. Conclusion: Blood culture-negative endocarditis is an entity that can present with early complications. It is diagnostically and therapeutically challenging to treat such patients. Multimodal approaches for early diagnosis and appropriate treatment are crucial owing to its high morbidity and mortality.

Unveiling Complexity: A Case Report of Catastrophic Antiphospholipid Syndrome With Coronary Occlusion and a Concomitant Patent Foramen Ovale Shunt.

Antiphospholipid syndrome (APLS) and systemic lupus erythematosus (SLE) are rare autoimmune disorders that afflict a small percentage of the global female population. The complexity of these conditions is further exacerbated by their propensity to give rise to recurrent thrombosis and obstetric morbidity, thereby posing intricate challenges for clinicians and patients alike. One of the most concerning aspects of these diseases is the heightened risk they confer for accelerated atherosclerosis, which can ultimately culminate in the development of acute coronary syndrome (ACS). This case report describes a 27-year-old female with APLS, SLE, and lupus nephritis. She suffered from a catastrophic antiphospholipid syndrome (CAPS) episode and simultaneously developed ACS. She also had a patent foramen ovale (PFO) shunt.

Atrial Fibrillation Ablation in Patients With Chronic Kidney Disease: A Review of Literature.

Atrial fibrillation (AF) is a common arrhythmia among patients with chronic kidney disease (CKD), which leads to increased cardiovascular complications. Catheter ablation (CA) has emerged as an effective and safe treatment for AF in CKD patients. CA offers tailored treatment strategies and presents a safer alternative with fewer adverse outcomes than anti-arrhythmic agents. Although CKD patients undergoing ablation have similar complication rates to non-CKD patients, they face a higher risk of hospitalization due to heart failure. Furthermore, CA shows promise in improving kidney function, particularly in individuals who maintain sinus rhythm. Future research should address limitations by including advanced CKD patients, conducting longer-term follow-ups, and developing individualized treatment approaches.

Outcome of Atrial Fibrillation Ablation in Cancer Patients: A Review.

Atrial fibrillation (AF), a cardiac arrhythmia, exhibits a heightened prevalence among individuals diagnosed with cancer, notably prominent in cases of lung and gastrointestinal malignancies. Robust evidence from extensive studies underscores this association, emphasizing its clinical significance. However, the precise mechanistic underpinnings and specific risk factors linking cancer and AF remain a subject of incomplete understanding. Notably, the prevalence of AF in cancer patients substantially exceeds that in non-cancer counterparts, prompting further exploration of the underlying pathophysiological processes. This review aims to address the existing knowledge void regarding AF management in cancer patients, with a specific focus on the potential role of ablation procedures. While catheter and surgical ablation techniques have been thoroughly investigated and validated as effective treatments within non-cancer populations, their applicability and outcomes in cancer patients have remained inadequately explored. The principal objective of this exhaustive review is to bridge this research gap by conducting a meticulous examination of the feasibility, safety, and effectiveness of ablation interventions for AF in the context of cancer patients. By amalgamating existing evidence and pinpointing critical areas necessitating additional investigation, this review endeavors to provide invaluable insights into AF management in cancer patients, with the ultimate goal of enhancing their clinical care and optimizing outcomes.

Granulomatosis with polyangiitis mimicking COVID-19 pneumonia: A case report.

Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a necrotizing vasculitis characterized by small-to-medium-sized vessel involvement and the presence of antineutrophil cytoplasmic antibodies (ANCA). We present a case of a 26-year-old Asian woman who was transferred to our center from a nearby hospital, where she presented with shortness of breath, tested positive for COVID-19, and was being managed for COVID-19 pneumonia. She also had hemoptysis, skin lesions, and left foot numbness. Serological markers and VATS-guided lung biopsy confirmed the diagnosis. Treatment with methylprednisolone and rituximab led to stabilization, despite complications of subcutaneous emphysema and lower extremity neuropathic symptoms. Early recognition and appropriate management of GPA are crucial for optimal outcomes.

Diagnostic pitfalls in young onset parkinsonism and its unique challenges: A case report from rural Nepal.

Parkinson's disease is a neurodegenerative disease resulting from the loss of dopamine-secreting neurons present in the substantia nigra of the brain. Parkinson's disease is classified as early-onset and late-onset disease based on the time of its presentation. Since young patients with Parkinson's disease have an atypical clinical presentation and have to deal with their careers, raising families, or both at the time of diagnosis and also have a higher risk of drug-related side effects, it poses unique challenges for the patient, clinical team, and community. We present the case of a 40-year-old female with young onset Parkinson's disease from rural Nepal and the challenges faced during and after the disease in a resource-limited setting.

Unilateral proptosis in a patient with thyroid eye disease: A case report.

Unilateral proptosis is an abnormality in which one eye sticks out forward more than the other. Bulging of the eye is commonly seen in Graves' ophthalmopathy, but it's mostly bilateral. Thyroid eye disease presents as the most common extrathyroidal manifestation of Graves' disease, and rarely leads to unilateral proptosis. A 25-year-old female with a history of weight loss, menstrual irregularities, and palpitations presented with progressive right eye bulging, which was further confirmed by magnetic resonance imaging and biochemical investigations. Magnetic resonance imaging of the orbit revealed unilateral extraocular muscle enlargement and enhancement with sparing of the tendons. Timely therapy is crucial for reversing the ocular manifestations of thyroid eye disease.

Reverse takotsubo syndrome heralding as ventricular fibrillation: a case report.

Reverse takotsubo syndrome, a variant of takotsubo cardiomyopathy, is an acute left ventricular failure characterized by the basal akinesis/hypokinesis associated with apical hyperkinesis. Its presentation is similar to that of the acute coronary syndrome. Case presentation: The authors present a case of a 49-year-old woman, a vice principal at a local school with a history of hypertension, who was brought to our center after she collapsed while giving a graduation speech. Reverse takotsubo was a presumed diagnosis after we ruled out other differentials. Clinical discussion: The pathophysiology of reverse takotsubo syndrome is poorly understood. It might be due to a different pattern of catecholamine-mediated myocardial dysfunction than classic takotsubo cardiomyopathy. It is often associated with physical and/or emotional stressors. Conclusion: Supportive treatment and identification and prevention of triggers can reduce the recurrence of reverse takotsubo cardiomyopathy. Physicians should be aware of various triggers for this condition.

Infective endocarditis presenting as meningitis: a case report.

Infective endocarditis (IE) primarily affects the endocardium of heart valves. Neurologic manifestations include strokes, intracerebral hemorrhages, meningitis, cerebral and spinal abscess, and mycotic aneurysms. Although rare, meningitis is a potentially life-threatening complication of IE, so physicians should be aware of this rare and fatal complication of IE. Case presentation: Here, the authors present a case of a 53-year-old male who presented with bacterial meningitis secondary to IE. His blood culture was positive for methicillin-sensitive staphylococcal aureus. Echocardiography findings were suggestive of endocarditis. Despite aggressive intensive care management, our patient did not survive. Clinical discussion: The isolation of Staphylococcus aureus in culture should raise a suspicion of foci being elsewhere outside the central nervous system. Treatment of complications like meningitis may require intrathecal antibiotics. The vegetation and neurological complications are often difficult to treat and require the participation of a multidisciplinary team. Conclusions: The diagnosis of IE in patients presenting with neurologic deficits and fever should be considered. A physician should raise a suspicion of infective foci being elsewhere outside the central nervous system if the organism isolated in culture is Staphylococcus aureus.

A case report on agenesis of dorsal pancreas with insulin-dependent diabetes mellitus: a rare entity.

Agenesis of the dorsal pancreas (ADP) is a clinically rare entity that occasionally presents with abdominal pain. It is also association with various disorders of glucose metabolism. Case presentation: A 23-year-old male presented with continuous epigastric pain for 4 h and intermittent vomiting. He has a history of experiencing recurrent abdominal pain and diarrhoea for the past 5 years. Additionally, he has been diagnosed with type 1 diabetes mellitus for 15 years. Contrast-enhanced computed tomography of the abdomen showed the absence of body and tail of the pancreas. Discussion: ADP is caused by unknown factors, but may be linked to genetic mutations or changes in signalling pathways related to retinoic acid and hedgehog. Symptoms can be absent, but may include abdominal pain, pancreatitis, and hyperglycaemia due to beta-cell dysfunction and insulin deficiency. Imaging modalities, such as contrast tomography or magnetic resonance cholangiopancreatography, or endoscopic retrograde cholangiopancreatography, are crucial in the diagnosis of ADP. Conclusion: It is important to consider ADP as a differential diagnosis in patients with glucose metabolism disorders and associated symptoms such as abdominal pain, pancreatitis, or steatorrhea. It requires the combined use of imaging modalities such as ultrasound, contrast tomography, magnetic resonance cholangiopancreatography, or endoscopic retrograde cholangiopancreatography, as ultrasound alone may not provide a complete diagnosis.

Traumatic retroclival hematoma complicated with hyponatremia and delayed traumatic intracranial hematoma in an adult: A case report.

Intracranial hematoma is a common variety of brain insults in trauma. However, posterior fossa hematoma in the retroclival location is quite unusual. There are limited numbers of case reports regarding traumatic retroclival hematoma. Some are managed with surgery in this condition. We present a traumatic retroclival hematoma in a 34-year-old gentleman who sustained brain trauma in a motor vehicle accident. His condition was further complicated by hyponatremia and delayed traumatic intracerebral hematoma in a distant location. The only symptom he had later was severe headache which could be attributed to delayed traumatic intracerebral hematoma and hyponatremia. He was managed conservatively and discharged on the 12th day from the hospital.

Kimura disease masquerading tuberculosis: a rare case presentation.

Kimura disease (KD) is an inflammatory disorder characterized by the development of subcutaneous lymphoid masses and regional lymphadenopathy. Due to its rarity and similarity to another disease, the diagnosis is complex. Case presentation: Here, the authors present a case of KD in 26-year-old male from Nepal who initially did not respond to antitubercular therapy. Later on, KD was diagnosed based on histopathology. He was followed up in medical outpatient with a good response to corticosteroid therapy. Clinical discussion: The diagnosis of KD is quite difficult in low-resource settings. The diagnosis is histopathological. Associated lymphadenopathy may mimic tuberculosis. Many patients respond well to the high-dose of steroid therapy; some might also require surgical excision or chemotherapy. Conclusion: Hence, the physician should include KD as a differential when a male in his 20s or 30s presents with a subcutaneous nodular mass in the head and neck.

Use of midodrine in heart failure: a review.

Heart failure is a global health concern, affecting millions of individuals worldwide. Midodrine, an alpha-1 receptor agonist, might be a potential treatment option for patients with heart failure and concurrent hypotension. This review provides a comprehensive summary of the existing literature on the use of midodrine in heart failure patients, focusing on its pharmacology, epidemiology, and public health impact. Guideline-directed medical therapy (GDMT) is essential in heart failure management, but hypotension may limit its initiation or up-titration. Studies have shown that midodrine can improve blood pressure, reduce the need for vasopressor support, and enable the prescription of GDMT in patients who are intolerant to it due to hypotension. However, there are concerns over increased all-cause mortality in some studies, small sample sizes, and nonrandomized study designs in others. Further research, including large-scale randomized controlled trials and long-term follow-up studies, is needed to better understand the risks and benefits of midodrine use in heart failure patients, particularly in relation to GDMT. Clinicians should consider the potential advantages of midodrine against the limited evidence and potential risks before incorporating it into their clinical practice for heart failure treatment.

Diagnostic Dilemma of Central Nervous System Tuberculosis with Neurocysticercosis and Neurosarcoidosis: A Case Report.

Multiple ring-enhancing lesions are commonly encountered abnormalities in neuroimaging. There are many differentials for such lesions as infections, neoplasms, vascular lesions, inflammatory and demyelinating conditions, and granulomatous diseases. In developing countries, tuberculoma and neurocysticercosis are the two important etiologies to be considered. This case report illustrates how multiple ring-enhancing lesions can lead to our management in one direction while the true diagnosis remains elusive. A 53-year-old male who presented with a headache was initially diagnosed and treated as neurocysticercosis, then neurosarcoidosis ultimately turned out to be a case of Central Nervous System Tuberculosis on further evaluation. Consideration of only clinical scenarios and neurological imaging can lead to diagnostic inaccuracy, mismanagement and poor outcome, therefore, other supporting lab investigations should be considered for making a correct diagnosis. Keywords: brain; case reports; neurocysticercosis; sarcoidosis; tuberculoma.

Cervical spondylotic myelopathy presenting as a "pancake enhancement" on MRI of the spinal cord: A case report and review of literature.

Spondylotic myelopathy involves chronic spinal cord compression from degenerative spine changes presenting a myriad of neurological and pain symptoms. We report a case of cervical myelopathy with transverse pancake-like gadolinium enhancement seen on MRI in a 42-year-old gentleman with progressive bilateral upper extremity numbness, tingling, and impaired gait.

The Dilemma Behind Negative Troponin: A Case Report.

Acute coronary syndrome remains the primary cause of mortality and morbidity in the United States. Cardiac ischemia is a consequence of an imbalance between oxygen demand and supply. The sensitivity of troponin is above 99% in diagnosing cardiac injury; rare exceptions can occur, however. We present a case of acute coronary syndrome with a negative troponin level, even on repeated testing using different methods at two different centers.