Nothing Great Comes Without Its Risks: A Rare Case of Pembrolizumab-Induced Hypophysitis.

Pembrolizumab is an immune checkpoint inhibitor that targets the programmed cell death protein 1 and enhances immune activity against cancer cells. This has emerged as a powerful tool in the treatment of cancer in patients with severe metastatic disease. Despite this, immune checkpoint inhibitors are associated with many immune-related adverse effects. Reported endocrinopathies include thyroid dysfunction, insulin-deficient diabetes mellitus, primary adrenal insufficiency, and hypophysitis. Hypophysitis is more commonly associated with cytotoxic T-lymphocyte associated antigen 4 inhibitors like ipilimumab and rarely with pembrolizumab. A high clinical suspicion is needed to pursue a diagnosis of immune checkpoint inhibitorinduced hypophysitis, and prompt diagnosis is of immense importance due to the potentially life-threatening nature of endocrinopathies. We present a case of a 64-year-old Caucasian male individual undergoing treatment with pembrolizumab for undifferentiated lung carcinoma who subsequently developed hypophysitis.

Subacromial contact after acromioplasty in the rotator cuff deficient shoulder.

Subacromial impingement (SAI) is associated with shoulder pain and dysfunction and is exacerbated by rotator cuff tears; however, the role of acromioplasty in mitigating subacromial contact in the rotator cuff deficient shoulder remains debated. This study aimed to quantify the influence of isolated and combined tears involving the supraspinatus on subacromial contact during abduction; and second, to evaluate the influence of acromioplasty on joint space size and subacromial contact under these pathological conditions. Eight fresh-frozen human cadaveric upper limbs were mounted to a computer-controlled testing apparatus that simulated joint motion by simulated force application. Shoulder abduction was performed while three-dimensional joint kinematics was measured using an optoelectronic system, and subacromial contact evaluated using a digital pressure sensor secured to the inferior acromion. Testing was performed after an isolated tear to the supraspinatus, as well as tears involving the subscapularis and infraspinatus-teres minor, both before and after acromioplasty. Rotator cuff tears significantly increased peak subacromial pressure (p < 0.001), average subacromial pressure (p = 0.001), and contact force (p = 0.034) relative to those in the intact shoulder. Following acromioplasty, significantly lower peak subacromial contact pressure, force and area were observed for all rotator cuff tears involving the supraspinatus at 30° of abduction (p < 0.05). Acromioplasty predominantly reduces acromion thickness anteriorly thereby reducing subacromial contact in the rotator cuff deficient shoulder, particularly in early to mid-abduction where superior glenohumeral joint shear force potential is large. These findings provide a biomechanical basis for acromioplasty as an intervention for SAI syndrome and as an adjunct to rotator cuff repairs.

Muscle and joint function in the rotator cuff deficient shoulder.

Full-thickness rotator cuff tears can lead to poor coaptation of the humeral head to the glenoid, disrupting muscle forces required for glenohumeral joint stability, ultimately leading to joint subluxation. The aim of this study was to evaluate muscle forces and glenohumeral joint translations during elevation in the presence of isolated and combined full-thickness rotator cuff tears. Eight fresh-frozen upper limbs were mounted to a computer-controlled testing apparatus that simulated joint motion by simulated muscle force application. Scapular-plane abduction was performed, and glenohumeral joint translations were measured using an optoelectronic system. Testing was performed in the native shoulder, a following an isolated tear to the supraspinatus, as well as combined tears involving the supraspinatus and subscapularis, as well as supraspinatus, infraspinatus, and teres minor. Rotator cuff tears significantly increased middle deltoid force at 30°, 60°, and 90° of abduction relative to that in the native shoulder (p < 0.05). Significantly greater superior translations were observed relative to the intact shoulder due to combined tears to the supraspinatus and infraspinatus at 30° of abduction (mean increase: 1.6 mm, p = 0.020) and 60° of abduction (mean increase: 4.8 mm, p = 0.040). This study illustrates the infraspinatus-teres minor complex as a major humeral head depressor and contributor to glenohumeral joint stability. An increase in deltoid force during abduction occurs in the presence of rotator cuff tears, which exacerbates superior migration of the humeral head. The findings may help in the development of clinical tests in rotator cuff tear diagnostics, in surgical planning of rotator cuff repair, and in planning of targeted rehabilitation.

A Case of STEMI Masquerading Brugada Syndrome: Emphasizing the Importance of Clinical Decision Making in Emergencies.

Brugada syndrome is a rare arrhythmogenic syndrome that is associated with an increased risk of ventricular fibrillation and sudden cardiac death. Electrocardiographic findings include patterns similar to a right bundle branch block (RBBB) and persistent ST-segment elevation in precordial leads (V1 and V2). There are numerous reports of Brugada syndrome mimicking ST-segment elevation myocardial infraction (STEMI); however, we describe a case of 47-year-old male who presented with STEMI mimics Brugada syndrome with preexisting RBBB. The patient developed polymorphic ventricular tachycardia generating into ventricular fibrillation right before catheterization making the diagnosis more challenging. The patient, eventually, was found to have obstructive coronary artery disease and no evidence of abnormal sodium channelopathy on further testing. This case highlights the importance of meticulous history taking and appropriate diagnostic test in establishing proper diagnosis of STEMI in a patient with preexisting RBBB, which can mimic Brugada syndrome.

A Rare Case of Myocarditis Mimicking ST-Elevation Myocardial Infarction.

Myocarditis is caused by acute injury and inflammation of cardiac myocytes and is most commonly caused by a viral infection. Myocarditis remains a rare diagnosis and manifests with a wide spectrum of non-specific symptoms that include chest pain, dyspnea, and palpitations associated with electrocardiographic abnormalities that resemble that of ST-elevation myocardial infarction (STEMI). Therefore, clinical diagnosis is often challenging and is often misdiagnosed. We present a case of a 22-year-old male who presented with left-sided non-radiating chest pain associated with shortness of breath, elevated troponin of 3.2 ng/ml (<0.03 ng/ml). Electrocardiogram (ECG) and cardiac echocardiogram revealed ST-segment elevations in the anterolateral leads and an ejection fraction of 35%, respectively. The patient was initially suspected of having a STEMI; however, cardiac catheterization revealed non-obstructed coronary arteries. Due to elevated inflammatory markers, the patient was then started on colchicine for suspected myocarditis and had complete resolution of symptoms one week after. This case highlights that a high index of clinical suspicion and prompt diagnosis is necessary to prevent any delays in appropriate therapy for myocarditis.

A Case of a Newborn Baby Girl Infected with SARS-CoV-2 Due to Transplacental Viral Transmission.

BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly infectious virus and is responsible for the current pandemic. It mainly infects cells of the lower respiratory tract and has been linked to severe respiratory complications. Although multiple routes of transmission have been reported in the literature, there is no definitive evidence for transplacental transmission. We present a case of neonatal SARS-CoV-2 likely due to transplacental transmission. CASE REPORT 31-year-old Hispanic woman in the final week of pregnancy developed mild respiratory symptoms of COVID-19 pneumonia and tested positive for SARS-CoV-2 infection. She had a history of Human immunodeficiency virus (HIV) infection and gestational diabetes. Two days later, she gave birth to a baby girl who tested positive for SARS-CoV-2 on the first day after birth. She was delivered via elective cesarean section adhering to a strict infection control protocol. CONCLUSIONS This report presents a case of a 31-year-old mother with mild symptoms of COVID-19 pneumonia who was positive for SARS-CoV-2 infection and who gave birth to a baby girl who was also positive for SARS-CoV-2. This case supports the possibility of transplacental transmission of SARS-CoV-2.