Spontaneous development of myasthenia gravis and myositis following treatment with pembrolizumab: a case report.

BACKGROUND: Immune checkpoint inhibitors are a relatively new advancement in the world of cancer therapy. As such, their adverse effects have yet to be fully understood, with only recent literature documenting autoimmune phenomena secondary to their utilization. Specific immune checkpoint inhibitors have recently been linked with the development of myasthenia gravis, which is classically known to manifest spontaneously in patients. Given the relative rarity of this presentation, the risk of misdiagnosis and subsequent mortality and morbidity is concerning. CASE PRESENTATION: We discuss the case of a 73-year-old male who presented with clinical symptoms of myasthenia gravis and myositis shortly after beginning treatment with Pembrolizumab. The diagnosis of myasthenia gravis was initially missed at an outside hospital, which delayed initiation of proper treatment. CONCLUSION: While the incidence of "de-novo" diseases secondary to immune checkpoint inhibitors might be increasing, guidelines regarding best treatment options do not yet exist, leaving many providers at a loss when faced with making clinical decisions surrounding patients with De novo myasthenia gravis. Thus, our goal is to underscore the importance of early recognition of this disease, and emphasize the need for a standard of care as immune checkpoint inhibitors usage becomes more prevalent.

Spontaneous and asymptomatic rupture of an RCC with resolution of symptoms.

There is no standard of care for management of Rathke cleft cysts (RCCs), and protocol for spontaneous rupture or residual capsule fragments is not well documented.Our case involves a Caucasian man in his 80s who presented with muscle weakness, fatigue, bitemporal hemianopia and pain. Further examination demonstrated decreased thyroid and cortisol levels. MRI revealed a 1.6×1.5×1.3 cm sellar homogenous mass with extension into the suprasellar cistern. While the size of the cyst was rather large, a decision was made to follow conservatively with serial MRI. At 3 years, the mass had spontaneously regressed. The patient was asymptomatic without imaging evidence of RCC recurrence at 4-year follow-up.Classic indications for surgical intervention in suprasellar cysts were subtle in our patient and his advanced age made us take a conservative approach. Current data are lacking regarding management of RCCs presenting with endocrine dysfunction. Our case suggests that RCCs presenting with endocrine dysfunction may be managed conservatively with serial imaging-based monitoring.

Unprovoked Atypical Absence Status Epilepticus in a Patient With Allogeneic Stem Cell Transplantation.

Absence status epilepticus (ASE) is a rare but treatable condition, and when present in older adults, it can be misinterpreted as encephalopathy or behavioral changes. Our case discusses a 63-year-old patient with myelofibrosis and allogeneic stem cell transplant with late-onset de novo status epilepticus. This case report adds to the rare body of literature discussing de novo ASE whose clinical presentation can be indistinguishable from other encephalopathic or behavioral conditions. Moreover, its occurrence during oncologic treatment warrants clinicians to be on the lookout for similar presentations and encourages future reports of this condition in association with similar therapies. This case report provides value to providers treating patients with similar oncologic therapies and highlights the need for ASE to be further studied as it is a possible rare complication of allogeneic transplantation of stem cells.

A Case of Abdominal Perforation in a COVID+ Patient Treated With Tocilizumab and Corticosteroids.

Coronavirus Disease 2019 (COVID-19) was first identified in Wuhan province in China in late 2019. Around 15% of patients that develop severe acute respiratory syndrome from COVID-19 also develop severe COVID-19 pneumonia. Since the pandemic's start, various treatments including remdesivir, dexamethasone, baricitinib, convalescent plasma, and tocilizumab have been approved by the Center for Disease Control (CDC). We present a case of a 62-year-old male hospitalized due to COVID-19 pneumonia and was initially treated with methylprednisolone and remdesivir, and later with tocilizumab. Soon after, he developed an abdominal perforation which was surgically treated. In terms of abdominal perforation, proposed mechanisms including the pathogenesis due to the presence of specific angiotensin-converting enzyme 2 (ACE-2) receptors located throughout the gastrointestinal tract, glucocorticoid steroid inflammatory suppression, in addition to the documented adverse effects from tocilizumab which has been previously reported. In summary, tocilizumab may increase the risk of abdominal perforation, especially when used in combination with steroids to treat COVID-19 because steroids may suppress clinical exam findings for abdominal perforation.

Surgical Reconstruction Options for a Case of Near Total Intestinal Aganglionosis.

Hirschsprung's disease is a congenital anomaly affecting neural crest cell migration and proliferation in the myenteric plexi resulting in dysmotility, which can present as bilious emesis, delayed meconium passage, and bowel obstruction in neonates, or chronic constipation in older children. Depending on the extent of aganglionosis, this disease can involve the whole gut. Treatment involves a temporary ostomy and interval definitive surgical reconstruction. In patients with near or total intestinal aganglionosis, however, there is no consensus on the most effective surgical reconstruction as consideration of the length and function of the normal remnant bowel create concerns for complications with short bowel syndrome post-operatively. We present a case of near-total intestinal aganglionosis highlighting the various options for definitive surgical reconstruction.

A Case of Delayed Cecal Perforation After Abdominal (Seat Belt) Injury.

Seatbelts have reduced the number of fatal head, facial, and chest injuries. They have, however, introduced a set of injuries comprising abdominal wall bruising, Intra-abdominal injuries, and lumbar spine fractures collectively termed the seat belt syndrome. Surgical repair is the treatment for encountered bowel injuries. We present a case of delayed bowel perforation following presentation with signs of seat belt trauma identifying a decisional dilemma in the surgical management of serosal tears with no apparent signs of perforation.

Longest reported case of symptomatic COVID-19 reporting positive for over 230 days in an immunocompromised patient in the United States.

Coronavirus 2019 (COVID-19) pneumonia was first noted in Wuhan, China. Since the start of the pandemic, there have been millions of cases diagnosed. The average time from onset of symptoms to testing negative SARS-CoV-2 via reverse transcription polymerase chain reaction is roughly 25 days. In patients who continually test positive for COVID-19, it is essential to determine precisely which risk factors contribute to the increase in viral shedding duration. We present a case about a 62-year-old man who has persistently tested positive for COVID-19 for more than 230 days. We followed his treatment course, in which he had been hospitalized multiple times since the onset of symptoms back in April 2020. We have determined that patients with immunosuppression, especially those taking corticosteroids, are at increased risk of prolonged viral shedding. It is essential to continually monitor these immunocompromised patients as they required a greater time period in order to have an appropriate immune response in which antibodies are created.