Management of immune check-point inhibitor-associated colitis in patients with advanced metastatic cancers: A review article.

Immune check-point inhibitors (ICPi) are immunomodulating agents, which have revolutionized the management of advanced metastatic cancers. Being immunomodulating agents, they are predisposed to causing colitis. This descriptive review article emphasized on the management of ICPi-associated colitis in advanced metastatic cancers. We used PubMed, Google Scholar, Scopus, and Embase databases for literature review, and terminologies commonly searched were "management," "immune check-point inhibitors," "colitis," "metastatic," "cancers," "literature," and "review." We reviewed a total of 11 articles done in the last 15 years relevant to ICPi colitis and its management; all the articles showed that diarrhea and colitis are the most common adverse effects observed in patients on ICPi, but prior to establishing the diagnosis of ICPi-causing colitis, possibility of Clostridium difficle or cytomegalovirus infections should be ruled out. Once the diagnosis of ICPi colitis is established, treatment should be started depending upon the severity of colitis. In mild severity, discontinuation of ICPi can resolve the symptoms but, in most of the patients with moderate to high severity of colitis, corticosteroids are considered a cornerstone treatment. Patients unresponsive to steroid treatment should be re-evaluated for infections after which anti-TNF therapy-infliximab or vedolizumab, cyclosporine, mycophenolate mofetil-can be considered.

A systematic review and meta-analysis on utilizing anti-CD19 chimeric antigen receptor T-cell therapy as a second-line treatment for relapsed and refractory diffuse large B-cell lymphoma.

Introduction: Inconsistent results observed in recent phase III trials assessing chimeric antigenic receptor T (CAR-T) cell therapy as a second-line treatment compared to standard of care (SOC) in patients with relapsed/refractory diffuse large B-cell lymphoma (R/R DLBCL) prompted a meta-analysis to assess the effectiveness of CAR-T cell therapy in this setting. Methods: Random-effects meta-analysis was conducted to pool effect estimates for comparison between CAR-T cell therapy and SOC. Mixed treatment comparisons were made using a frequentist network meta-analysis approach. Results: Meta-analysis of three trials with 865 patients showed significant improvement in event-free survival (EFS: HR: 0.51; 95% CI: 0.27-0.97; I2: 92%), progression-free survival (PFS: HR: 0.47; 95% CI: 0.37-0.60; I2: 0%) with CAR-T cell therapy compared to SOC. Although there was a signal of potential overall survival (OS) improvement with CAR-T cell therapy, the difference was not statistically significant between the two groups (HR 0.76; 95% CI: 0.56 to 1.03; I2: 29%). Mixed treatment comparisons showed significant EFS benefit with liso-cel (HR: 0.37; 95% CI: 0.22-0.61) and axi-cel (HR: 0.42; 95% CI: 0.29-0.61) compared to tisa-cel. Discussion: CAR-T cell therapy, as a second-line treatment, appears to be effective in achieving higher response rates and delaying the disease progression compared to SOC in R/R DLBCL.

Propylthiouracil-induced vasculitis.

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is an autoimmune condition characterized by necrotizing inflammation of small vessels throughout the body. Pharmaceutical agents have been noted as an emerging etiology. This case presents a 41-year-old woman with a longstanding history of Graves' disease who previously failed other interventions and was started on propylthiouracil (PTU) nearly 2 years prior to symptom onset. The patient presented with severely pruritic purpuric lesions on her lower extremities that transformed into large bullae and became extremely painful. A thorough workup revealed only slightly elevated perinuclear ANCA and a mild protein S deficiency. Tissue biopsy was consistent with thrombotic vasculitis. A presumptive clinical diagnosis of PTU-induced vasculitis was made. Because the condition is relatively uncommon, the best course of treatment has not clearly been defined. Though PTU was immediately discontinued, the patient also required corticosteroids and referral for tissue debridement. While some cases have had symptom resolution after cessation of PTU, this case adds to a growing body of evidence for the timely use of corticosteroids in controlling PTU-induced vasculitis.

Sub-acute Painless Vision Loss Secondary to Neuro-Ocular Syphilis.

There has been a consistent increase in syphilis cases in the United States over the past two decades. The prevalence of neuro-ocular involvement in syphilis is rare; however, with the increase in the prevalence of syphilis in the United States, more frequent encounters with complications of syphilis may be expected. Here, we present a case of sub-acute painless vision loss secondary to neuro-ocular syphilis.

Classic IgA-Vasculitis With Nephrotic Range Proteinuria - Rare Presentation in an Adult.

IgA vasculitis formerly known as Henoch-Schonlein Purpura is characterized by leukocytoclastic vasculitis and IgA immune complex in small vessels of the affected organ. IgA vasculitis can involve any organ system depending upon the deposition of the IgA immune complex. IgA vasculitis is a clinical diagnosis which manifest with abdominal pain, arthralgia/arthritis, palpable purpura, and kidney involvement. Occasionally, serum IgA levels or skin or kidney biopsy can help in confirming the diagnosis. Treatment is usually supportive, but studies have proved that prednisone or immunosuppressive agents can help in the prevention or progression of the disease. Hereby we present a case of 54-year-old Caucasian male who developed classic tetrad findings of IgA vasculitis most likely after receiving monkeypox vaccine which patient received three weeks prior to presentation to the hospital. Kidney involvement was present but surprisingly proteinuria was above nephrotic range making it as a rare presentation of IgA vasculitis.

Subcutaneous gluteal abscess from Trichosporon asahii in an immunocompetent adult.

Fungal infections have been drastically increasing in incidence in recent years, preferentially affecting immunocompromised hosts and causing potentially fatal outcomes. One of the emerging fatal fungal pathogens is Trichosporon asahii, a non-Candida yeast that has been increasingly reported in recent years. Previous literature has described T. asahii as primarily affecting immunocompromised hosts, specifically those who are neutropenic, and causing fatal disseminated infections. Herein, we describe a case of an isolated subcutaneous abscess with T. asahii in an immunocompetent host without overlying skin manifestations or predisposing factors that resulted in complete mycotic cure when treated with voriconazole and terbinafine.

Lemierre's syndrome with muscle necrosis and chronic osteomyelitis.

Lemierre's syndrome is a rare disorder characterized by thrombophlebitis of the internal jugular vein and is caused by gram-negative anaerobes, primarily Fusobacterium necrophorum. We report a case of a 20-year-old man who developed chronic osteomyelitis of the femur and myonecrosis of thigh muscles secondary to this syndrome. The diagnosis was made based on clinical presentation and evidence of thrombosis in the internal jugular vein on ultrasound. The patient was initially treated with antibiotics, and anticoagulants were added later due to deep vein thrombosis in the lower limb.

Asymptomatic Bacteriuria (ASB) in diabetic patients: Treat or not to treat: A prospective, observational study conducted at a tertiary care hospital.

BACKGROUND: The term asymptomatic bacteriuria (ASB) refers to the isolation of bacteria in a urine specimen of individuals who denied symptoms of urinary tract infection. Diabetes mellitus (DM) is a disease involving multiple organ systems, hallmarked for its chronicity and thus-forth endless complications including asymptomatic bacteriuria. OBJECTIVES: This study aimed to determine the characteristics of asymptomatic bacteriuria and antibiotic susceptibility pattern amongst patients with diabetes. SETTINGS AND DESIGN: A prospective observational study was conducted at a tertiary care hospital in Karachi, Pakistan. METHODS AND MATERIAL: The study included all those patients with a diagnosis of diabetes with no signs and symptoms of urinary tract infection but showing the growth of an organism in urine culture. Pregnant females and subjects who used antibiotics in last two weeks were excluded. A total of 222 urine cultures were observed prospectively who met the inclusion criteria through non-probability consecutive sampling. RESULTS: Out of 222 urine cultures observed, mean age of subjects were 62.89 ± 13.77 out of which 76% were females, and 61% had a family history of diabetes. The most frequent organisms isolated were Escherichia. Coli (E. Coli), Enterococcus, Klebsiella, Pseudomonas, and Enterobacter species. A total of 20 subjects got dual bacterial growth in their cultures among which 17 subjects had a growth of Enterococcus with any other pathogen causing UTI. Gender, family history of diabetes, levels of HBA1c, and older age groups all were found significantly associated with ASB. CONCLUSIONS: Our study is the first to analyze and study the associated risk factors amongst ASB in DM patients, and to identify the pathogens involved along with assessing their antibiotic resistance profiles. Also, due to the increase resistance to antibiotics we would recommend to use antibiotics in ASB patients only if they have any two or more comorbidities.

Prognostic importance of deranged sodium level in critically ill patients: A systemic literature to review.

It is common upon admission or during stay at a hospital or intensive care unit (ICU) for patients to present with or acquire a serum sodium abnormality. Hyponatremia, serum sodium level less than 135 mmol/L, frequently associated with critical illnesses such as heart failure and liver cirrhosis, is an indicator of disease severity as well as a risk factor for poor prognosis. Hypernatremia, serum sodium level greater than 145 mmol/L, results due to any ailment disabling a patient's modality of thirst or the ability to relieve it once sensed. Hypernatremia has a more frequent iatrogenic component than hyponatremia. It can develop insidiously among patients through IV fluid administration of saline; both its presentation upon admission and development during stay is associated with mortality. Hyponatremia is associated with increased mortality and its treatment with morbidity as it carries a risk of overcorrection and consequently the development of central pontine myelinolysis. This review article covers the findings, and subsequent correlation between findings sought, of six articles catering to underscore the correlation between sodium disorders and prognosis of hospitalized or critically ill patients. PubMed search engine was utilized to select articles befitting the purpose of this review. Cumulatively, this review article substantiates the need to diligently evaluate and treat serum sodium disorders in hospitalized patients to achieve better prognosis.

Role of immature platelet fraction (IPF) in sepsis patients: A systematic review.

Sepsis is extremely common amongst critically ill patients and requires early diagnosis. Hence, identifying a biomarker that could acknowledge sepsis at its prior stage is of vital significance. Immature platelets are a percentage of circulating platelets that contain RNA and is a newer parameter that is measured using automated hematology analyzers in diagnosing sepsis. This review article discusses 10 articles that reveal the role of immature platelet fraction in predicting the onset of sepsis and its relationship with mortality in sepsis. Literature search was done using PubMed, Scopus and Google Scholar and words like platelet indices and immature platelet fraction were typed in the search bar. The aim of this review article is to present a precise form of data that talk about immature platelet fraction (IPF) and its association with the severity and mortality of sepsis. Five out of 10 articles suggest that immature platelet fraction can predict the onset of sepsis and eight out of 10 articles suggest that increased IPF values are associated with high mortality.

Acute Sensory-Motor Axonal Neuropathy in a 57-Year-Old Male Presenting With Paresthesia and Distal Muscle Weakness.

Guillain-Barré syndrome (GBS) is a relatively uncommon post-infectious, immune-mediated neurologic disorder with an incidence of 0.5-2/100,000. It is usually preceded by an infection that evokes an immune response that cross-reacts with peripheral nerve components via molecular mimicry. The presentation of this disorder has several forms, including acute inflammatory demyelinating polyneuropathy (AIDP), acute motor axonal neuropathy (AMAN), acute motor-sensory axonal neuropathy (AMSAN), and Miller Fisher syndrome (MFS). The case we describe is of a 57-year-old male presenting with sensory features followed by symmetrical ascending paralysis and diagnosed with ASMAN, a recently described subtype of GBS, based on neurological and laboratory findings.

First Reported Case of Hyperchloremic Non-Anion Gap Metabolic Acidosis in a Patient Undergoing Continuous Bladder Irrigation for Hemorrhagic Cystitis.

Radiation cystitis can present as gross hematuria and occurs secondary to irritation of the bladder urothelium. Continuous bladder irrigation (CBI) is commonly used for the treatment of hemorrhagic cystitis for evacuation of blood clots and to maintain catheter drainage. Most commonly, CBI is performed using 0.9% sodium chloride. We report a 77-year-old female who developed hyperchloremic non-anion gap metabolic acidosis (H-NAGMA) and pulmonary edema secondary to absorption of 0.9% normal saline (NS) from CBI. In such cases, ringer lactate with low concentration (109 mEq) of chloride as compared to NS (154 mEq) can prove to be a suitable alternative.

Euglycaemic diabetic ketoacidosis in a 43-year-old woman with type 2 diabetes mellitus on SGLT-2 inhibitor (empagliflozin).

We report a case of euglycaemic diabetic ketoacidosis (EDKA) in a 43-year-old woman with type 2 diabetes mellitus who presented to the emergency department with problems of vomiting, cough, shortness of breath and generalised weakness after following a ketogenic diet for 2 weeks. Therapy with sodium glucose transport protein-2 empagliflozin had been started 2 months prior. Initial evaluation revealed high anion gap metabolic acidosis with blood glucose level of 169 mg/dL. Treatment for EDKA with fluid resuscitation, intravenous insulin and dextrose resolved her acidosis and symptoms in less than 24 hours. Empaglifozin was discontinued on discharge. This entity represents a diagnostic challenge since the differential diagnosis is broad with a potentially misleading clinical presentation that can result in delayed diagnosis and adverse outcomes including acute kidney injury, multiple electrolyte abnormalities, cerebral oedema, acute respiratory distress syndrome, shock and death.