Severe Lactic Acidosis Due to Inappropriate Use of Biktarvy in a Patient With AIDS.

Bictegravir-emtricitabine-tenofovir alafenamide is an approved medication for the treatment of acquired immunodeficiency syndrome (AIDS). This medication, also called Biktarvy, includes an integrase strand inhibitor combined with nucleoside reverse transcriptase inhibitors (NRTIs) to prevent viral DNA synthesis and lead to improvements in disease progression and mortality in patients with AIDS. A rare but previously documented adverse effect of NRTIs present in Biktarvy is lactic acidosis. NRTIs can cause lactic acidosis through mitochondrial impairment, as mitochondria depend on DNA polymerase gamma for replication. This enzyme is very similar to HIV's reverse transcriptase. Inhibition of mitochondrial production results in increased anaerobic metabolism and lactic acid production. We present a case where an inappropriately high dosage of Biktarvy in a patient with septic shock led to persistent lactic acidosis despite clinical improvement. After a thorough medication review, Biktarvy was temporarily held, and the lactic acidosis resolved. This clinical presentation stresses the importance of maintaining wide differentials for lactic acidosis and thorough medication reconciliation.

Ignatzschineria indica Bacteremia Initially Misdiagnosed in a Patient With a Maggot-Infested Wound.

Gram-negative bacteremia in hospitalized patients often leads to prolonged hospital stays, increased healthcare costs, and mortality rates. Simultaneously, the presence of comorbidities like chronic wounds increases the risk of severe infection and complicated hospital courses involving amputation, broad-spectrum antibiotic use, and repeat hospital admissions, after discharge. This case presents a 72-year-old male with a past medical history significant for chronic lower extremity cellulitis with multiple prior hospitalizations. On admission, the patient had a chief complaint of progressively worsening left lower extremity pain along with nausea, vomiting, and diarrhea. CT imaging of the left lower extremity suggested severe cellulitis without signs of osteomyelitis. Blood cultures initially suggested Corynebacterium jeikeium, but were sent to an outside facility due to ambiguity of results. The outside facility identified the pathogen as Ignatzschineria indica. After confirming the results, antibiotics were appropriately de-escalated to oral levofloxacin. The patient continued to show clinical improvement and was discharged with follow-up appointments scheduled for infectious disease and bi-weekly visits to wound care. Considering the increasing prevalence of chronic wounds in the United States, awareness and recognition of emerging pathogens are crucial for the timely diagnosis, treatment, and management of these complex patients. Our case adds to the growing body of reports on the management of I. indica bacteremia resulting from maggot-infested wounds.

Transient Acquired Amegakaryocytic Thrombocytopenia in the Setting of Severe Sepsis: A Case Report.

Acquired amegakaryocytic thrombocytopenia (AATP) is a rare disorder in which severely low platelet levels occur due to reduced or complete absence of megakaryocytes in the bone marrow. The pathophysiology of this disease is not fully understood, although anti-thyroid peroxidase antibodies (anti-TPO) binding to cellular-myeloproliferative leukemia (c-mpl) receptors is a proposed mechanism. Currently, no standard published guideline for treatment exists, but immunosuppressive therapies have been used based on the proposed mechanism and associated conditions. We present a case of a 57-year-old male who presented to the hospital with a 3-day history of progressive weakness and dysphagia. He had recently been discharged from an outside health system after evaluation for suspected gastrointestinal bleeding, although esophagogastroduodenoscopy and colonoscopy did not uncover a source of bleeding. Fifteen days later, he was admitted to our hospital for septic shock and acute renal failure with suspected lower gastrointestinal bleeding (melena on presentation). He was found to have a rapidly declining platelet count with a nadir of 0. Due to severe thrombocytopenia, filgrastim was administered. A bone marrow biopsy revealed findings consistent with amegakaryocytosis with otherwise preserved cell lines. Hematologic labs improved with the initiation of appropriate treatment for severe sepsis. After performing an extensive workup, the likely etiology of transient AATP in this case was severe sepsis-induced immune dysregulation and bone marrow suppression.

Dual Oncological Challenges: Management of Simultaneous Lung Adenocarcinoma and Primary Cardiac Lymphoma.

Adenocarcinoma of the lung and primary cardiac lymphoma are both significant malignancies with serious health impacts. This case involves a 67-year-old woman who presented with progressive shortness of breath and fatigue. Initial computed tomography (CT) imaging identified possible cardiac and pulmonary masses, leading to her transfer to a specialized care center. Subsequent analysis confirmed adenocarcinoma of the lung, and further imaging and biopsy of the cardiac mass revealed diffuse large B-cell lymphoma. The patient received treatments targeted to each cancer, including chemotherapy and immunotherapy. This concurrence of malignancies highlights the importance of comprehensive diagnostic evaluations and personalized therapeutic strategies. Further research is needed to improve the management of patients with concurrent primary cancers.

Hypercalcemia Secondary to Calcitriol Production From Dual Combination Immunotherapy in Pulmonary Metastatic Melanoma.

Nivolumab and ipilimumab are immunotherapy agents recommended for the treatment of metastatic melanoma. A rare adverse effect of these agents is hypercalcemia. The mechanism of immunotherapy-mediated hypercalcemia is thought to be due to ectopic calcitriol production from activated macrophages, similar to sarcoidosis. We present a case of a 76-year-old female with metastatic melanoma who developed severe hypercalcemia after completing a cycle of combined nivolumab and ipilimumab therapy. After other common causes of hypercalcemia in malignancy were ruled out, the decision was made to aggressively treat her hypercalcemia while inpatient and hold immunotherapy at discharge. Since holding immunotherapy, she has not had a repeat occurrence of hypercalcemia. This case stresses the importance of including immunotherapy adverse effects in the differential diagnosis for hypercalcemia in malignancy.