Nivolumab Treatment for Cancers in the HIV-infected Population.

Nivolumab is a standard treatment option in several advanced malignancies, but safety and efficacy are still unknown in patients with human immunodeficiency virus (HIV) infection. We describe a case series of people living with HIV (PLWH) receiving nivolumab in the Veterans Health Administration (VA) and report responses and toxicities. We identified all PLWH who received nivolumab at any VA facility since 2000 in the Corporate Data Warehouse (CDW), which provides nationwide research access to VA electronic medical records. We identified 16 HIV-infected nivolumab recipients. The median number of nivolumab doses received was 6 (range, 1-32). Changes in CD4 count during therapy were variable, with 70% (7/10) of patients experiencing increases. Half of PLWH were treated for non-small-cell lung cancer; 2 for Hodgkin lymphoma (HL), 2 for renal cell carcinoma, and 4 for off-label cancers. For non-small-cell lung cancer, 7 patients had evaluable responses. Although 5 of 7 patients immediately progressed, 1 had a partial response and 1 had stable disease, which were both durable. Two of 16 (14%) PLWH had complete responses; both with HL (2/2 HL, 100%). The prevalence of immune-related adverse effects was 40% overall (6/15); 27% (4/15) had pneumonitis. To our knowledge, this is the largest case series reporting outcomes with nivolumab in PLWH. Outcomes were comparable with those seen in studies of HIV-uninfected patients, and particularly interesting for HL. The reason for the high proportions of immune-related adverse effects is unclear, but needs to be confirmed in larger studies.

99mTc Sestamibi Thyroid Scan in Amiodarone-Induced Thyrotoxicosis Type I.

Amiodarone-induced thyrotoxicosis (AIT) type I describes inducement of clinical hyperthyroidism by excessive thyroidal iodine in the setting of latent Graves disease, and therapy differs from that used for AIT type II. A 65-year-old man previously on amiodarone for atrial fibrillation developed clinical hyperthyroidism. Diagnosis of AIT was made, but the type was not clear. Tc sestamibi thyroid scan showed diffusely increased uptake and retention in an enlarged thyroid gland, a pattern consistent with AIT type I. Methimazole was initiated and controlled the thyrotoxicosis. I iodide thyroid scan and uptake study performed later was consistent with Graves disease.

Bronchobiliary fistula localized by cholescintigraphy with single-photon emission computed tomography.

Biliptysis is an important clinical feature to recognize as it is associated with bronchobiliary fistula, a rare entity. Bronchobiliary fistulas have been diagnosed with planar cholescintigraphy. However, cholescintigraphy with single-photon emission computed tomography (SPECT) can better spatially localize a bronchobiliary fistula as compared to planar cholescintigraphy alone, and is useful for preoperative planning if surgical treatment is required. Here, we present the case of a 23-year-old male who developed a bronchobiliary fistula in the setting of posttraumatic and postsurgical infection, which was diagnosed and localized by cholescintigraphy with SPECT.

Two different 18F-FDG brain PET metabolic patterns in autoimmune limbic encephalitis.

PURPOSE: Autoimmune limbic encephalitis (ALE) is a severe, but treatable, neuropsychiatric disorder that is difficult to diagnose clinically. With the goal of improving diagnosis of this disorder, we retrospectively evaluated the cerebral FDG PET pattern in a group of patients with ALE. MATERIALS AND METHODS: Nine adult patients with subacute cognitive decline were eventually diagnosed with ALE based on clinical presentation, cerebrospinal fluid inflammatory markers, and response to immunosuppressive therapy. All patients received FDG PET brain scanning during their diagnostic evaluation, which were retrospectively reviewed for this study. RESULTS: Our patients' scans fell into 2 readily separable patterns. Five younger patients had a mixed metabolic pattern most easily recognized by pronounced occipital hypometabolism, accentuated by hypermetabolism in the temporal and orbitofrontal cortex. Other, milder findings were also present. Once this unusual pattern was established as corresponding to ALE, it helped lead to the correct clinical diagnosis in the last 2 patients. Four older patients had scans that closely resembled diffuse neurodegenerative disease. CONCLUSIONS: We found 2 different PET scan patterns in patients with ALE. One is an easily recognizable mixture of hyper- and hypometabolism that has also been described in a few recent case reports and is potentially specific for ALE. The other is indistinguishable from neurodegenerative disease. We propose that awareness of these patterns may contribute to the diagnosis of this elusive, but treatable, neurologic disorder.

A confirmed case of agranulocytosis after use of cocaine contaminated with levamisole.

More than 2 million Americans use cocaine each month (National Survey on Drug Use and Health, Department of Health and Human Services: Substance Abuse and Mental Health Services Administration (SAMHSA) & Office of Applied Studies (OAS), Rockville, MD 2007). Starting in early 2003, South American cocaine cartels began to add levamisole, a pharmaceutical agent, to bulk cocaine prior to shipment to the USA (Valentino and Fuentecilla 2005). A dramatic increase in the prevalence of levamisole in cocaine was noted in early 2008. By October, 30% of cocaine bricks analyzed by the United States Drug Enforcement Administration contained levamisole (Casale et al. 2008). Exposure to levamisole can cause agranulocytosis (Amery and Bruynseels 1992). We report the first confirmed case of agranulocytosis associated with consumption of levamisole-contaminated cocaine in the USA. A previously healthy adult male presented to the emergency department with 5 days of mouth pain. He admitted to chronic active ethanol and crack cocaine abuse. Laboratory studies revealed severe neutropenia, with an absolute neutrophil count of 19 cells/mm³ (normal = 1,500-8,000 cells/mm³). A urine screen for drugs of abuse was positive for cocaine metabolites and opiates. Evaluation of a peripheral blood smear showed leukopenia with severe absolute neutropenia. A bone marrow biopsy revealed recently injured bone marrow showing early recovery. While in the hospital, the patient had little spontaneous bone marrow recovery. He received granulocyte colony-stimulating factor with improvement in peripheral white blood cell counts. The residue in the patient's crack pipe contained 10% levamisole. Subsequently, levamisole was detected in the patient's urine. Levamisole-associated agranulocytosis should be considered in the diagnosis of patients who present with neutropenia and a history or evidence of cocaine use.