Ipilimumab-induced necrotic myelopathy in a patient with metastatic melanoma: A case report and review of literature.

Ipilimumab is a novel humanized monoclonal antibody directed against cytotoxic T lymphocyte antigen 4, a T-cell surface molecule involved in down-regulation and suppression of the T cell response to stimuli. Patients treated with ipilimumab are at risk for immune-related adverse events involving the skin, digestive tract, liver and endocrine organs. Few case reports of immune-related adverse effects involving central or peripheral nervous system due to ipilimumab are published. These include inflammatory myopathy, aseptic meningitis, severe meningo-radiculo-neuritis, temporal arteritis, Guillain-Barre syndrome, and posterior reversible encephalopathy syndrome. We report the first case of ipilimumab-induced progressive necrotic myelopathy.

Improving Communication on Intent of Chemotherapy Using QOPI Scores and PDSA Cycles.

Using the standardized ASCO Quality Oncology Practice Initiative (QOPI) guidelines for assessing quality cancer care, we identified communication about intent of chemotherapy as an area needing improvement in our program at the University of Arkansas for Medical Sciences (UAMS) and the Central Arkansas Veterans Healthcare System (CAVHS). We organized training in communications on intent of treatment (palliative vs curative) and added optional checkboxes to our electronic templates for progress notes. Afterwards, we conducted a retrospective review of electronic medical records of initially often randomly selected patient charts. The first 10 patient charts after 1 month of implementation showed intent of treatment in 80 % of charts compared to 74 % at baseline. We then changed checkboxes from mandatory to optional and reviewed 30 randomly selected patient charts. Intent of treatment was documented in 96.7 % of cases compared to 74 % at baseline. We also assessed patient satisfaction through surveys distributed in clinic. Patient satisfaction scores were close to 100 % for receiving clear information, understanding the reason for which they were receiving chemotherapy, and willingness of oncologists to listen carefully, to take time to answer questions, to explain things clearly, and to spend adequate time with them. In this study, we showed that training in communication of intent of chemotherapy and use of checkboxes in progress note templates could improve competency in communication of intent of therapy in cancer patients.

Coma blisters with hypoxemic respiratory failure.

A 24-year-old woman with quadriplegia was admitted with respiratory failure because of pneumonia. She was on multiple medications including diazepam, oxycodone, and amitriptyline, known to be associated with coma blisters, though she did not overdose on any of them. On hospital day 2, she developed multiple blisters on both sides of her right forearm and hand. Skin biopsy showed eccrine gland degeneration consistent with coma blisters. It was felt that hypoxemia from her pneumonia contributed to the development of these blisters, which occurred on both pressure and non-pressure bearing areas of the arm. Coma blisters are self-limited skin lesions that occur at sites of maximal pressure, mostly in the setting of drug overdose. However, coma blisters may occur with metabolic and neurological conditions resulting in coma.

Dysphagia due to cervical osteophytes.

Cervical bony outgrowths or osteophytes are common and usually asymptomatic. In some cases, they may be associated with dysphagia, dysphonia, dyspnea and pulmonary aspiration. The most common causes of cervical osteophytes are osteoarthritis, ankylosing spondylitis and ankylosing hyperostosis or Diffuse Idiopathic Spinal Hyperostosis (DISH), also known as Forestier's Disease. Other causes are hypoparathyroidism, trauma, acromegaly, ochronosis and flourosis. However, while dysphagia due to osteophytes is reported in the setting of DISH, it is very rare with osteoarthritis. We report a case of a patient who developed dysphagia due to anterior cervical osteophytes in the setting of osteoarthritis.

Bilateral subcapsular and perinephric hemorrhage as the initial presentation of polyarteritis nodosa.

Polyarteritis nodosa is a systemic vasculitis of medium and small-sized arteries associated with aneurysm formation. Aneurysms may be complicated by thrombosis, rupture and hemorrhage. Kidney involvement in polyarteritis nodosa can rarely be complicated by Wunderlich syndrome which is characterized by acute onset of spontaneous, nontraumatic subcapsular and perirenal hematomas. A 22-year-old woman with mental retardation due to childhood cytomegalovirus infection presented with flank pain, weight loss and fever, and was found to have bilateral subcapsular and perinephric hematomas. Spontaneous bilateral renal hemorrhage as the initial manifestation of polyarteritis nodosa is rare, and it can be associated with delays in diagnosis and treatment.

Bilateral Pleural Effusions due to Pulmonary Amyloidosis as the Presenting Manifestation of Multiple Myeloma.

Multiple Myeloma is a hematologic malignancy of plasma cell origin. Pleural effusion may develop in the setting of myeloma due to various reasons but is extremely uncommon as a presenting symptom. A 69-year-old Caucasian man presented with pleural effusions of undetermined etiology after extensive work up, and multiple failed pleurodesis. Lung biopsy revealed pulmonary amyloidosis and led to the diagnosis of multiple myeloma. Patient was started on chemotherapy but died within 6 weeks of his diagnosis due to multiorgan failure. Pulmonary amyloidosis should be suspected as a cause of intractable pleural effusions, even in patient who do not have evidence of lung involvement on imaging studies or typical features of multiple myeloma. Pleural effusions due to amyloidosis are often refractory to treatment, and a high index of suspicion is required for early diagnosis and treatment.

A rapidly progressing Pancoast syndrome due to pulmonary mucormycosis: a case report.

INTRODUCTION: Pancoast syndrome is characterized by Horner syndrome, shoulder pain radiating down the arm, compression of the brachial blood vessels, and, in long-standing cases, atrophy of the arm and hand muscles. It is most commonly associated with lung carcinoma but rarely is seen with certain infections. CASE PRESENTATION: We present the case of a 51-year-old Caucasian man who had acute myeloid leukemia and who developed a rapidly fulminating pneumonia along with signs and symptoms of acute brachial plexopathy and left Horner syndrome. Also, a purpuric plaque developed over his left chest wall and progressed to skin necrosis. The skin biopsy and bronchoalveolar lavage showed a Rhizopus species, leading to a diagnosis of mucormycosis. This is a rare case of pneumonia due to mucormycosis associated with acute Pancoast syndrome. CONCLUSIONS: According to our review of the literature, only a few infectious agents have been reported to be associated with Pancoast syndrome. We found only three case reports of mucormycosis associated with acute Pancoast syndrome. Clinicians should consider mucormycosis in their differential diagnosis in a patient with pulmonary lesions and chest wall invasion with or without neurological symptoms, especially in the setting of neutropenia or other immunosuppressed conditions. It is important to recognize this condition early in order to target therapy and interventions.