Nivolumab-Induced Neuromyopathy: A Case Report.

Nivolumab is an immune checkpoint inhibitor (ICI) that treats various malignancies. Although ICIs have proven efficacious, they can also have detrimental side effects. We present a case of nivolumab-induced quadriparesis mimicking Guillain-Barré syndrome in a patient with stage III squamous cell carcinoma (SCC) of the pharynx with a chronic tracheostomy, who presented after being found unconscious at home. He later developed acute kidney failure, requiring dialysis, and bilateral weakness of his upper and lower extremities. The patient was treated with corticosteroids and intravenous immunoglobulin (IVIG) with minimal improvement. Nivolumab-induced quadriparesis is very threatening and can be fatal if inappropriately managed. Therefore, we strongly advocate for a multidisciplinary team and early corticosteroid prescription to monitor patients on nivolumab therapy to prevent adverse clinical outcomes.

Fusobacterium nucleatum Bacteremia Presenting as Isolated Superior Mesenteric Vein Thrombophlebitis.

Fusobacterium nucleatum (F. nucleatum) is a commensal Gram-negative anaerobic bacterium that lives in the oral cavity and gastrointestinal tract of humans. While it is a regular resident of the human oral cavity, F. nucleatum has been implicated in various infections and inflammatory conditions. This case report highlights an unusual association between F. nucleatum and isolated superior mesenteric vein (SMV) thrombosis.

A Case of acute Myocardial Infarction in a Patient with Essential Thrombocythaemia Treated with Anagrelide.

Anagrelide is a medication primarily used to manage thrombocytosis, an abnormal increase in platelet levels in the blood. It is often prescribed for patients with myeloproliferative disorders, such as essential thrombocythaemia (ET). Given the heightened susceptibility to thromboembolism associated with this condition, the primary emphasis in treatment revolves around reducing the risk of thrombotic events through the administration of cytotoxic agents. While anagrelide is generally effective in reducing platelet counts, it comes with potential side effects, including an increased risk of certain thrombotic events. Anagrelide acts by inhibiting megakaryocyte maturation and platelet release, thereby reducing platelet production. However, this platelet-lowering effect may be accompanied by an increase in platelet activation and reactivity, which could contribute to a prothrombotic state. We present a case of a 60-year-old female with a history of ET, managed with anagrelide and hydroxyurea therapy, who experienced an acute ST-elevation myocardial infarction. LEARNING POINTS: The dual role of anagrelide: although anagrelide is effective in lowering platelet levels in essential thrombocythaemia, it can increase platelet activation, raising thrombotic risk. Clinicians need to monitor patients closely for thrombotic events.Balancing efficacy and side effects: the risk of severe side effects such as myocardial infarction, as seen in this case report, necessitates a balanced approach in using anagrelide, weighing its benefits against potential risks.

Complexities of Infective Endocarditis in a Young Patient With Hypertrophic Obstructive Cardiomyopathy: A Case of Dual Valve Involvement and Neurological Complications.

Infective endocarditis (IE) is a life-threatening infection predominantly affecting the endocardium and heart valves, commonly seen in older patients and those with pre-existing cardiac conditions. Although rare in younger individuals with intact cardiac valves, certain structural heart diseases such as hypertrophic obstructive cardiomyopathy (HOCM) can increase the risk. We present a unique case of a 39-year-old female with a known history of HOCM, a condition characterized by abnormally thickened cardiac muscle primarily affecting the left ventricle. This patient was diagnosed with group B streptococcus infective endocarditis. Notably, this case was complicated by septic emboli to the brain. This case underscores the significant risk of IE in patients with HOCM, a demographic usually less susceptible to IE. It underscores the importance of early recognition and aggressive management of IE, especially in patients with structural heart diseases.

Hypercalcemia and Bone Metastasis in a Case of Large Cell Neuroendocrine Carcinoma With Unknown Primary.

Large cell neuroendocrine carcinoma (LCNEC) constitutes a rare subset of highly undifferentiated malignancies known for their aggressive nature. Although these tumors commonly originate in the lungs and gastrointestinal tract, their potential occurrence is not restricted to specific anatomical sites, giving rise to a variety of symptoms. Notably, cases of neuroendocrine tumors (NETs) with an unidentified primary source exhibit a graver prognosis and shorter survival periods compared to those with clearly identified origins. NETs frequently demonstrate a propensity to metastasize, spreading to diverse anatomical regions such as the liver, lungs, lymph nodes, and bones, illustrating their aggressive nature and the complexity of their management. In this context, we present the case of a 59-year-old male who sought medical attention in the emergency department due to right upper quadrant (RUQ) abdominal pain. Initial diagnostic assessments revealed significantly elevated liver function tests and severe hypercalcemia. A right upper quadrant ultrasound (RUQ US) was subsequently performed, which revealed heterogeneous hepatic echotexture with innumerable echogenic masses, suggesting a metastatic process. A computed tomography (CT) scan was then ordered to evaluate further the RUQ US findings, which showed numerous hypovascular liver masses, raising concerns of malignancy. A liver biopsy confirmed a diagnosis of LCNEC with an unidentified primary source.

Failure of the PD-1 Blocking Agent Pembrolizumab to Benefit a Patient with Renal Squamous Cell Cancer.

Introduction: Renal squamous cell carcinoma (SCC) is a neoplasm with an extremely rare occurrence compared to other renal malignancies. The classic presentation includes a palpable mass and flank pain; however, the presentation is seldom non-specific. Our study describes the significance of programmed death ligand-1 (PD-L1) expression in renal cancer and its association with clinical outcomes, alongside available treatment options. Case description: An 80-year-old female with a history of hypertension and cerebral aneurysm presented with right flank pain and blood in urine and was diagnosed with pyelonephritis and left renal mass/phlegmon. A biopsy revealed SCC of the kidney with metastasis to the lung and aortocaval lymph node. Positron emission tomography (PET) scan confirmed malignancy in the kidney and lung. Treatment with pemrolizumab and carboplatin plus paclitaxel was initiated but poorly tolerated as the haemoglobin dropped rapidly. Conclusion: SCC poses a diagnostic challenge due to its rarity and non-specific symptoms, often leading to advanced stage diagnosis. PD-L1 expression is pivotal in assessing tumour aggressiveness and prognosis. PD-L1 inhibitors offer promise, but their efficacy in renal SCC warrants further investigation. Radical nephrectomy and systemic chemotherapy show potential in advanced cases, necessitating vigilant management of treatment-related side effects. This case emphasises the need for ongoing research to refine therapeutic approaches and enhance outcomes in renal SCC patients. LEARNING POINTS: PD-L1 expression is pivotal in assessing tumour aggressiveness and prognosis of renal cell carcinoma.PD-L1 inhibitors hold promise as a therapeutic intervention in renal squamous cancer.Radical nephrectomy and systemic chemotherapy show potential in managing advanced renal cancer.

Uncommon Culprit, Familiar Foe: A Case of Septic Thrombophlebitis of the Internal Jugular Vein Triggered by Klebsiella Bacteremia.

Septic thrombophlebitis of the internal jugular vein is characterized as Lemierre syndrome. Patients typically present with sore throat and fever and may present with a tender neck mass due to thrombophlebitis of the internal jugular vein. We present the case of a 57-year-old male with neck pain, fever, chills, and headaches who was diagnosed with internal jugular vein septic thrombophlebitis associated with catheter-related introduction of bacteria.

Metastatic Fibrosarcomatous Transformation of Dermatofibrosarcoma Protuberans With Lung Metastasis: A Case Report.

Dermatofibrosarcoma protuberans (DFSP) is a low- to intermediate-grade dermal soft tissue malignant tumor (sarcoma) with a high local recurrence rate but low metastatic potential. DFSP is characterized by uniform spindle cell fascicles arranged classically in a storiform pattern and by CD34 immunoreactivity. On gross examination, DFSP usually manifests as a white or yellow soft tissue mass with a smooth outer surface and poor circumscription. In this study, we report a case of DFSP with fibrosarcomatous transformation, a rare but well-known phenomenon encountered in DFSP that is correlated with an increased risk of adverse outcomes in patients with DFSP. A 45-year-old male presented with a progressively enlarging lump on his left shoulder, initially suspected of being a lipoma but diagnosed as a fibrosarcomatous transformation of DFSP. Surgical resection was performed, with the subsequent identification of metastatic sarcoma in pulmonary nodules. Robotic-assisted thoracoscopy excised the nodules, confirming metastatic sarcoma with aggressive behavior. Despite negative adjuvant treatment plans, the patient remains under surveillance with imaging, showing no recurrence in recent scans. Continued follow-up with medical and surgical oncology is planned. DFSP is a rare soft tissue sarcoma characterized by indolent growth and low metastatic potential, except in fibrosarcomatous transformation cases. Molecularly, DFSP is defined by a COL1A1-PDGFB fusion transcript that is targetable with imatinib therapy. Treatment involves wide surgical resection, with adjuvant radiation therapy in select cases. Radiation therapy may be employed in cases with close or positive margins, while conventional chemotherapy has limited utility. Multidisciplinary collaboration is crucial for optimal management. Overall, this case underscores the challenges in diagnosing and managing aggressive sarcomas like fibrosarcomatous DFSP, emphasizing the importance of vigilant surveillance and multidisciplinary collaboration in optimizing patient outcomes. Further research is needed to understand the mechanisms underlying fibrosarcomatous transformation and to explore novel therapeutic avenues for this challenging malignancy.

Unmasking the Enigma: Influenza Vaccine and the Rare Case of Post-Vaccination Pericarditis.

Acute pericarditis is an inflammatory condition involving the pericardium, the double-layered sac that surrounds the heart. It is characterized by chest pain, typically pleuritic and sharp, along with other clinical and laboratory findings indicative of pericardial inflammation. While acute pericarditis following influenza vaccination is rare, it has been reported in medical literature. The relationship between vaccinations, including the influenza vaccine, and pericarditis is particularly interesting, as it has implications for public health and vaccination programs. Understanding the pathophysiological mechanisms behind vaccine-induced pericarditis and recognizing the clinical presentation are essential for healthcare professionals to diagnose, manage, and educate patients appropriately.

Case of Circulating Tumor Cells Discovered in Extensive Deep Venous Thrombosis in a Patient with Known Urothelial Carcinoma.

Background: Currently, minimal data are available to explore the composition of venous thromboembolism in patients with cancer. This case report discusses a presentation of venous thromboembolism in a patient with high-grade urothelial carcinoma and highlights the pathology findings in thrombi. Case Presentation. A 55-year-old female who was diagnosed with high-grade urothelial carcinoma with multiple metastases developed an extensive deep vein thrombosis in her left lower extremity. Endovascular revascularization was indicated due to left lower extremity pain and swelling not responsive to anticoagulation. A mechanical thrombectomy was performed, and samples were sent for pathology. Pathologic examination discovered minute fragments of metastatic carcinoma, admixed with laminated blood clots (thrombus). The morphology of metastatic carcinoma and the immunostain profile were compatible with metastatic carcinoma of bladder origin. Conclusion: Cancer is a well-known risk factor for developing VTEs, and it is estimated that approximately 4-20% of cancer patients will experience VTE at some stage, the rate being the highest in the initial period following diagnosis. Annually, 0.5% of cancer patients will experience thrombosis compared with a 0.1% incidence rate in the general population (Elyamany et al., 2014). Despite knowing the increased incidence of VTEs in cancer patients, there are few studies to date that analyze the composition of thrombi in patients with cancer.

Hantavirus-induced cardiac tamponade: A diagnostic dilemma.

Herein we describe a case of a 60-year-old white male from New York City who was admitted to hospital due to worsening dyspnea. He presented with an acute onset of fever, night sweats, and progressively worsening nonproductive cough and orthopnea over the preceding week. Electrocardiogram findings revealed atrial fibrillation. Manifesting signs of hypoperfusion, a trans-esophageal echocardiography was performed, which demonstrated the presence of a cardiac tamponade. An emergency pericardiocentesis was performed, draining 750 cc of serosanguinous content. Laboratory investigations depicted an inflammatory milieu marked by lymphocytic leukocytosis, cardiac function impairment, and remarkably elevated d-dimer and brain natriuretic peptide levels. Notably, high-sensitivity troponin T remained within normal limits. Comprehensive viral panel assays, including COVID-19, Influenza A + B, Respiratory Syncytial Virus, Hepatitis C, HIV, Cytomegalovirus, Coxsackie A + B, and Herpes Simplex Virus, returned negative results. Furthermore, antinuclear factor and rheumatoid factor titers were negative. Blood and fungal cultures, as well as assessments for Mycobacterium tuberculosis, yielded negative findings. On further history-taking, he reported that he had occupational exposure to rat droppings and urine two weeks ago. Serological analysis demonstrated positive hantavirus IgG and IgM antibodies. Supportive management was initiated. Consequently, the patient was discharged asymptomatic, without pericardial effusion. Evaluation after two weeks revealed no recurrence of symptoms.

Systemic oncological therapy in breast cancer patients on dialysis.

The advancement of renal replacement therapy has significantly enhanced the survival rates of patients with end-stage renal disease (ESRD) over time. However, this prolonged survival has also been associated with a higher likelihood of cancer diagnoses among these patients including breast cancer. Breast cancer treatment typically involves surgery, radiation, and systemic therapies, with approaches tailored to cancer type, stage, and patient preferences. However, renal replacement therapy complicates systemic therapy due to altered drug clearance and the necessity for dialysis sessions. This review emphasizes the need for optimized dosing and administration strategies for systemic breast cancer treatments in dialysis patients, aiming to ensure both efficacy and safety. Additionally, challenges in breast cancer screening and diagnosis in this population, including soft-tissue calcifications, are highlighted.

Teratoma to Angiosarcoma: A Metamorphosis in the Mediastinum.

We describe a rare and remarkable transformation of an immature mediastinal teratoma into high-grade angiosarcoma in a 21-year-old male. Mediastinal teratomas, particularly immature ones, are exceedingly rare, representing a small fraction of germ cell tumors (GCTs). Our case describes the clinical journey of the patient, who initially presented with acute chest pain and was subsequently diagnosed with an immature teratoma following imaging studies and elevated tumor markers. Despite an initial positive response to cisplatin-based chemotherapy, surveillance imaging revealed liver masses, which a biopsy confirmed as angiosarcoma. This transformation underscores the aggressive nature of immature teratomas and the propensity for sarcomatous differentiation, particularly in the mediastinum. The case contributes valuable insight into the management and surveillance of mediastinal non-seminoma germ cell tumors (MNGCT), a subset of GCTs with limited literature. We believe this case is the first in the literature to describe a transformation from an immature teratoma in the mediastinum to a high-grade angiosarcoma.

Aplastic Anaemia Associated with Bendamustine Therapy - A Rare Side Effect.

Introduction: During treatment for malignant lymphoma, cytopenia can develop for several reasons. This can range from mild cytopenias leading to infection and bleeding to full-blown drug-induced aplastic anaemia. While aplastic anaemia affects individuals of all genders and ages, here, we describe aplastic anaemia after chemotherapy exposure to bendamustine in a 65-year-old female with non-Hodgkin's lymphoma. Case description: A 65-year-old woman with recurrent indolent marginal zone lymphoma and post-chemotherapy with bendamustine and rituximab, presented with a neutropenic fever and was admitted with a leading diagnosis of sepsis. In the previous two weeks, the patient required regular transfusions of packed red blood cells and platelets and maintained a daily ZARXIO® regimen. Laboratory results revealed pancytopenia, and broad-spectrum antibiotics (cefepime/vancomycin) were given. The patient was subsequently admitted to the hospital under the care of the haematology/oncology team and was ultimately diagnosed with aplastic anaemia, likely as a consequence of bendamustine chemoimmunotherapy. She elicited a positive response to the triple immunosuppressive therapy (IST) regimen (two immunotherapeutic agents plus one anti-thymocyte globulin (ATG), after which her cell counts returned to normal. Conclusions: This case underscores the importance of recognising haematologic complications linked to bendamustine and advocates for further research to increase the understanding among healthcare professionals of drug-induced aplastic anaemia. Bendamustine can cause severe autoimmune haemolytic anaemia and aplastic anaemia and may require multiple transfusions and a multidrug regimen for treatment. The use of ATG as a therapeutic intervention is appropriate because it has been effective in treating aplastic anaemia. LEARNING POINTS: Bendamustine can cause severe autoimmune haemolytic anaemia and aplastic anaemia, a side effect which has rarely been reported but is of significant clinical importance.Drug-induced aplastic anaemia is a complex, potentially devastating consequence of treating blood cancers and is a relatively unexplored area that requires further understanding.Anti-thymocyte globulin is effective in treating bendamustine-induced aplastic anaemia as it degrades lymphocytes that destroy the bone marrow.

Oxygen Overshoot: A Case Report Navigating the Perils of Unsupervised Supplementation in Chronic Obstructive Pulmonary Disease (COPD).

Supplemental oxygen administration is a delicate balance in managing chronic obstructive pulmonary disease (COPD), where the risk of exacerbating hypercapnia must be carefully considered. This case report describes a 69-year-old male with COPD who, after self-medicating with commercially available portable oxygen bottles, experienced hypercapnic respiratory failure and severe respiratory acidosis, leading to intensive care unit (ICU) admission and non-invasive ventilation. The patient's unsupervised use of commercially available portable oxygen bottles emphasizes the risks associated with unregulated supplemental oxygen in COPD. This case highlights the critical importance of cautious oxygen supplementation in COPD, urging high-risk patients to seek medical guidance, even with over-the-counter products. This case emphasizes the need for expert medical opinion to ensure safe oxygen use in vulnerable populations.

Breathless Revelation: Unmasking Acute Myeloid Leukemia Through Acute Respiratory Failure.

Establishing a diagnosis of acute myeloid leukemia (AML) in a patient presenting with acute respiratory failure is rare. Here, we present a case of AML initially appearing as hypoxemic respiratory failure linked to presumed community-acquired pneumonia. This case report unravels the intricate diagnostic odyssey of an atypical AML presentation masquerading as an acute respiratory failure, accentuating the multifaceted challenges clinicians encounter in discerning the actual underlying pathology amidst the haze of mimicry. Upon meticulous diagnostic expedition, infection was ruled out as a cause of respiratory failure, and the patient underwent a malignancy workup, ultimately culminating in the diagnosis. This case underscores the importance of broader diagnostic vigilance. Comprehensive assessments, combined with interdisciplinary collaboration, emerged as crucial for accurate diagnosis, emphasizing the need to consider hematologic pathologies despite seemingly unrelated clinical presentations.

Rare Case of a Clival Chondroma Resulting in Panhypopituitarism.

Chondromas are rare benign tumors composed of hyaline cartilage that can arise in various locations in the body. Their occurrence in the clivus, leading to panhypopituitarism, is exceptionally rare. This case report describes a 93-year-old female with a known clival chondroma who presented with altered mental status, presumed to be secondary to toxic metabolic encephalopathy due to an infectious cause. Further diagnostic evaluation revealed pituitary hormone levels below the normal range. This case report aims to highlight a unique case of panhypopituitarism attributed to a chondroma in the clivus with tumor extension to the sellar region, emphasizing the diagnostic challenges and treatment options for this unusual pathology.