Where Did the Pericardial Effusion Go? A Case of Cardiopulmonary Resuscitation Acting as Treatment for Pericardial Tamponade.

Pericardial tamponade results in multiple organ dysfunction and can lead to cardiac arrest. Cardiopulmonary resuscitation (CPR), a life-saving measure performed on patients in cardiac arrest, can lead to thoracic organ damage. However, CPR rarely acts as a therapeutic treatment for pericardial tamponade. Our case describes a patient admitted with pericardial tamponade in whom CPR provided therapeutic treatment with pericardial rupture and resolution of the tamponade.

COVID-19 associated Kawasaki-like multisystem inflammatory disease in an adult.

Recent reports have described a secondary Multisystem Inflammatory Syndrome in Children (MIS-C) after a prior COVID-19 infection that often has features of Kawasaki disease (KD). Here, we report the case of a 36-year-old woman who presented to the emergency department hypotensive and tachycardic after 1 week of fevers, abdominal pain, vomiting and diarrhea, and was found to have the classic phenotype of complete Kawasaki's Disease including nonexudative conjunctivitis, cracked lips, edema of the hands and feet, palmar erythema, a diffuse maculopapular rash, and cervical lymphadenopathy. Initial laboratory studies were significant for hyponatremia, elevated liver function tests including direct hyperbilirubinemia, and leukocytosis with neutrophilia. Imaging revealed mild gallbladder wall edema, a small area of colitis, and small pleural effusion. She was treated for Kawasaki Disease Shock Syndrome (KDSS) with pulse dose solumedrol, IVIG, and aspirin with near resolution of symptoms and normalization of vital signs within 1 day and subsequent improvement in her laboratory abnormalities. She was later found to be COVID-19 IgG positive, suggesting past exposure. This case represents an early report of a KD-like illness in an adult with serologic evidence of a previous COVID-19 infection, similar to MIS-C. It suggests that the virulent strain of SARS-CoV-2 appears to cause a post-infectious inflammatory syndrome similar to KD in adults, as well as children. Our understanding of the myriad of COVID-19 symptoms and sequelae is rapidly evolving. We recommend physicians remain vigilant for inflammatory syndromes that mimic KD/KDSS which may warrant prompt treatment with IVIG and steroids.

An Intensive Care Unit Outbreak of Acute Respiratory Distress Syndrome due to Human Metapneumo Virus Infection.

Human metapneumo virus is an emerging cause of upper and lower respiratory tract illness with increasing reports of a varied spectrum of disease over all age groups. We report an outbreak of 6 cases of human metapneumo virus infection in the intensive care unit of a metropolitan tertiary care center over 6 weeks, leading to severe acute respiratory distress syndrome. We report the subsequent favorable outcomes due to the institution of extracorporeal membrane oxygenation.

Racial disparities in incidence & survival of Kaposi's sarcoma in the United States.

Background & objectives: : In the United States (US), Kaposi's sarcoma (KS) is usually seen in the patients affected by human immunodeficiency virus (HIV). The racial differences in the incidence rates and survival of patients with KS have been reported in the US. We undertook this study to analyse the disparities in the race-specific incidence rate and survival of KS patients of two different races in the US based on SEER (Surveillance, Epidemiology and End Results) database. Methods: Data on KS patients of African-American (AA) and non-Hispanic White (NHW) races who were diagnosed during 1973-2013 were extracted from SEER database to estimate the incidence rates and survival of KS patients. Results: A total of 18,388 NHWs and 3,455 AAs were diagnosed with KS. The age-adjusted incidence rate (AAIR) of KS in patients aged 20-44 yr was 3.8 times higher in AAs than in NHWs. The decline in AAIR of KS among NHWs started during 1989-1994 and preceded decline in the AAIR of AAs. After introduction of highly active antiretroviral therapy (HAART), the incidence continued to decline, but the decrease in the AAIR in AAs [annual percentage change (APC): -6.2; 95% confidence interval (CI): -8.8 to -3.5] was slower than that in NHWs (APC: -10.9; 95% CI: -12.6 to -9.1). The hazard ratio for all-cause mortality in KS patients of the AA race increased from 1.1 (95% CI: 1-1.2) in 1981-1995 to 1.55 (95% CI: 1.4-1.7) in 1996-2013 as compared to those of the NHW race. Interpretation & conclusions: : Several significant racial disparities that emerged after HAART introduction in the incidence and survival of KS patients continued to persist, despite improvement in care of patients with HIV. Further studies need to be done to find out the underlying factors leading to these disparities.

Prehospital Analgesic Administration by Parents for Pain Relief in Children.

PURPOSE: Undertreatment of pain by caregivers before presentation to the pediatric emergency department (ED) has been well documented. What has yet to be elucidated are the reasons why caregivers fail to adequately treat pain before arrival in the ED and whether there are differences based on ethnic background or age of the child. The objectives of this study were to determine the barriers to giving pain medication for injuries before ED arrival and to determine if there are any ethnic- or age-related variations to giving pain relief at home. METHODS: This prospective descriptive study was conducted in the ED at a tertiary care, freestanding children's hospital with a current annual census of approximately 80,000. An anonymous prospective questionnaire was given to caregivers of children between 2 and 17 years of age presenting to the ED between August 2013 and September, 2014. The study population was obtained as a convenience sample. All were self-referred with chief complaints of head, ear, or extremity pain. The questionnaire asked about pain medications and doses given at home as well as the reasons parents gave medication or refused to give pain medication before arrival. Charts were then abstracted to obtain demographic information and care received in the ED. RESULTS: A total of 154 (45.6%) of the 338 patients enrolled did not receive pain relief before coming to the ED. There were no differences in pain medication received at home based on ethnicity (P = 0.423) or age (P = 0.580). Parents could choose from a list of multiple reasons as to why pain medications were given and/or free text their own answer. The main reasons given by parents were that the accident did not happen at home (28.6%) and that they did not have time to give pain relief before coming to the ED (13%). Other common answers were "had no pain relievers at home" (12.4%) or "afraid it would be wrong/harmful/did not want to mask symptoms" (9.2%). Seventeen parents responded that their child did not complain of pain. Overall, only 28.1% of participants stated lack of pain medications at home. CONCLUSIONS: In this study, approximately half of all children receive an analgesic for their painful condition before coming to the ED. Continued education regarding pain relief before coming to the ED is needed. Future studies will focus on educating parents to provide analgesia at home.

Emerging Therapies in the Management of Advanced-Stage Gastric Cancer.

Globally, gastric malignancy contributes to significant cancer-related morbidity and mortality. Despite a recent approval of two targeted agents, trastuzumab and ramucirumab, the treatment options for advanced-stage gastric cancer are limited. Consequently, the overall clinical outcomes for patients with advanced-stage gastric cancer remain poor. Numerous agents that are active against novel targets have been evaluated in the course of randomized trials; however, most have produced disappointing results because of the molecular heterogeneity of gastric cancer. The Cancer Genome Atlas (TCGA) project proposed a new classification system for gastric cancer that includes four different tumor subtypes based on molecular characteristics. This change led to the identification of several distinct and potentially targetable pathways. However, most agents targeting these pathways do not elicit any meaningful clinical benefit when employed for the treatment of advanced-stage gastric cancer. Most advanced-stage gastric cancer trials currently focus on agents that modulate tumor microenvironments and cancer cell stemness. In this review, we summarize data regarding novel compounds that have shown efficacy in early phase studies and show promise as effective therapeutic agents, with special emphasis on those for which phase III trials are either planned or underway.

Changing pattern of secondary cancers among patients with malignant thymoma in the USA.

BACKGROUND: The risk of developing secondary cancers (SCs) among patients with malignant thymoma in the US has not been estimated in the more recent time period. Methods: We extracted demographic and treatment data from the SEER database to estimate the standardized incidence ratios (SIRs). Results: Of 1570 patients with thymoma 211 (13.4%) had SCs. The overall risk of developing SCs was higher among patients with thymoma (SIR: 1.54, 95% CI: 1.34-1.76). The SIRs for cancers of lung, esophagus, sigmoid colon, soft tissue and heart, kidney, NHL and leukemia was significantly higher as compared to the general US population. Conclusions: Patients with thymoma are at modestly elevated risk of developing SCs as compared to the general US population. Although the overall risk has not changed after 14 additional years of follow up, the distribution of SCs has significantly broadened, with increased diversity across type and anatomic location of SCs.

A Comparative Study of Primary Adenoid Cystic and Mucoepidermoid Carcinoma of Lung.

BACKGROUND: Pulmonary mucoepidermoid carcinoma (PMEC) and pulmonary adenoid cystic carcinoma (PACC) are the two major types of primary salivary gland-type (PSGT) lung cancers. The demographic profile, clinicopathological features, and predictors of survival as an overall group have not been described for PSGT cancers of lung. METHODS: In this study, we analyzed demographic, clinical, and survival data from 1,032 patients (546 PMEC and 486 PACC) who were diagnosed of PSGT lung cancer in the Surveillance, Epidemiology and End Results database from 1973 to 2014. RESULTS: The PSGT constituted 0.09% of all lung cancers with age-adjusted incidence rate of 0.07 per 100,000 person-years and change of -32% from 1973 to 2014. The incidence of PMEC was slightly higher than PACC but there were no differences in the age and sex distribution. PACCs (55%) were significantly higher at trachea and main bronchus while PMECs were more common at peripheral lungs (85%). Most of the tumors were diagnosed at an early stage and were low grade irrespective of histology. As compared to PMEC, significantly higher number of patients with PACC underwent radical surgery and received adjuvant radiation. The 1- and 5-year cause-specific survival was 76.6 and 62.8%, respectively. On multivariate analysis, the survival was affected by age at diagnosis, tumor stage, histological grade, period of diagnosis, and surgical resection. The histology showed strong interaction with time and hazard ratio of patients with PACC was significantly worse than patients with PMEC only after 5 years. CONCLUSION: The incidence of pulmonary PSGT cancer is 7 cases per 10 million population in the United States and is decreasing. There was no difference between demographic profile of patients with PMEC and PACC but pathological features were diverse. The difference in the survival of patients with the two histological types surfaced only after 5 years when survival of patients with PMEC was better than PACC.

Chronic Lymphocytic Leukemia: A Rare Cause of Pathological Fracture of the Femur.

The incidence rate of chronic lymphocytic leukemia (CLL) in the United States is approximately 0.005%; men are at slightly higher risk than women. Bony involvement or pathological fracture rarely occurs in CLL, and it may be the initial presentation. An 85-year-old woman presented with acute respiratory failure secondary to pneumonia. Symptomatology included dyspnea. She was found to have pathological fracture of the femur caused by CLL. The diagnosis of CLL had been made 6 years previously, but the patient had refused therapy. On admission, the patient required endotracheal intubation, mechanical ventilation, and admission to the medical intensive care unit. Endotracheal intubation extubation was successful after 48 hours. The patient then complained of severe left knee pain. Bone radiograph and femoral computed tomography scan revealed acute pathological fracture of the left distal femur. There was no history of trauma. The fracture was stabilized with extension lock splint. Pathological fracture in patients with CLL is associated with hypercalcemia, Richter's transformation, or multiple myeloma. This patient exemplifies the fact that pathological fracture can be caused by CLL in the absence of hypercalcemia, Richter's transformation, or multiple myeloma and can be the initial presentation of CLL.

Enterovirus-Human Rhinovirus: A Rare Cause of Acute Respiratory Distress Syndrome.

A 22-year-old Asian woman presented with respiratory distress, cough, and wheezing for 1 week. Prior history included asthma and Turner syndrome. On presentation to the emergency department, the patient was hypotensive, tachycardic, tachypneic, with an oxyhemoglobin saturation in the mid 80% range while breathing ambient air. Chest radiograph revealed pulmonary vascular congestion and a left lower lobe infiltrate. Endotracheal intubation, mechanical ventilation, and vasopressors were initiated. Empiric therapy for community-acquired pneumonia was administered utilizing broad-spectrum intravenous antibiotics. Routine sputum culture was negative for pathogens. Nasopharyngeal swab submitted for multiplex amplified nucleic acid testing yielded enterovirus-human rhinovirus (EV-HRV). Thus, the diagnosis of EV-HRV pneumonia complicated by acute respiratory distress syndrome (ARDS) was established. Multiple attempts to wean from the ventilator were unsuccessful, and a tracheostomy was performed. This report highlights EV-HRV as a cause of severe ARDS and prolonged respiratory failure in adults.

The pattern of secondary cancers in patients with Kaposi sarcoma in the United States.

PURPOSE: In the U.S., Kaposi sarcoma (KS) occurs mostly in HIV-infected patients, who are also at increased risk of developing secondary cancers. The trends in secondary cancer risk are unclear in the HAART era. METHODS: We extracted data from the SEER database on patients diagnosed with KS between 1981 and 2013, stratified into the pre-HAART (1981-1995) and HAART (1996-2013) eras. We compared the risk of secondary cancer in KS patients and the general population, and estimated the absolute risk. RESULTS: We followed 13,535 KS patients for 49,813 person-years, during which 1,041 secondary cancers were diagnosed: 774 in the pre-HAART and 267 in the HAART era. In the pre-HAART era, non-Hodgkin's lymphoma (NHL) and anal carcinomas were the most common secondary cancers. The standard incidence ratio of secondary cancers decreased from 3.44 (pre-HAART era) to 1.94 (HAART era) in patients aged <70 years. The absolute excess risk decreased from 178 to 68 cases per 10,000 person-years. The risk of NHL decreased, while the risk of anal carcinoma did not change significantly. The risk of lung cancer was lower in KS patients than in the general population. The absolute risk of non-AIDS-defining cancers increased fourfold in the HAART era. CONCLUSIONS: The absolute risk of non-AIDS-defining secondary cancers has increased in KS patients in the HAART era. However, the overall relative risk of secondary cancers has decreased, mainly due to a significant decrease in the risk of NHL.

Bilateral Femoral Neuropathy Following Psoas Muscle Hematomas Caused by Enoxaparin Therapy.

BACKGROUND Femoral neuropathy as a result of retroperitoneal hemorrhage most commonly occurs following pelvic and lower extremity trauma, but has been described to develop as a less frequent complication of anticoagulation. CASE REPORT We present the case of a 64-year-old white woman who was being treated for pulmonary embolism and deep venous thrombosis with enoxaparin. In the course of her treatment, she was noted to be hypotensive, with a sudden drop in hematocrit. She had been previously ambulatory, but noted an inability to move her bilateral lower extremities. A diagnosis of bilateral femoral neuropathy as a result of psoas hematomas caused by enoxaparin was made. Anticoagulation was discontinued and she was treated conservatively, with an excellent outcome. At the time of discharge to a rehabilitation center, she had regained most of the motor strength in her lower extremities. CONCLUSIONS We believe this is the first reported case of bilateral femoral nerve neuropathy following use of enoxaparin. A full neurological examination should always be performed when there is sudden loss of function. The constellation of bilateral groin pain, loss of lower extremity mobility, and decreased hematocrit raised the suspicion of massive blood loss into the cavity/compartment. Thus, a high index of suspicion should be maintained by clinicians when presented with such symptoms and signs, as there can be significant morbidity and mortality when prompt diagnosis is not made.

Corrigendum: Current Diagnosis and Management of Immune Related Adverse Events (irAEs) Induced by Immune Checkpoint Inhibitor Therapy.

[This corrects the article on p. 49 in vol. 8, PMID: 28228726.].

Kaposi Sarcoma Mimicking Acute Flare of Ulcerative Colitis.

Besides an AIDS-defining illness, Kaposi sarcoma (KS) is also seen in individuals on long-term immunosuppressant therapy. We report KS in a 70-year-old immunocompetent man, which initially mimicked acute flare of ulcerative colitis (UC). He was hospitalized multiple times for complaints of watery diarrhea and tenesmus. Despite treatment with mesalamine, short courses of methylprednisolone, and one dose of infliximab, his symptoms improved only partially. He underwent colonoscopy, which revealed mild active colitis and a mass in the ascending colon. After treatment of acute flare with methylprednisone and mesalamine, he underwent total colectomy with end ileostomy. The histopathology confirmed stage I adenocarcinoma of colon. He continued to experience watery diarrhea, which was attributed to intractable UC, and he underwent protectomy several weeks later. The histopathology of rectum revealed KS. After surgery, watery diarrhea resolved completely. Review of literature suggests KS has been rarely reported in immunocompetent individuals with inflammatory bowel disease.

Penoscrotal haematoma after cardiac catheterisation.

Scrotal haematoma is an extremely rare complication after cardiac catheterisation (CC) with only few cases reported in literature. We report a 56-year-old patient who developed large scrotal haematoma after CC via transfemoral approach requiring blood transfusion due to haemodynamic instability. After an uneventful elective procedure, he was discharged with a collagen plug-based vascular closure device (Angio-Seal). He developed sudden onset, excruciating groin pain with scrotal swelling and shock. Bleeding was stopped with manual compression over the femoral artery and 2 units of packed red blood cells were transfused. CT angiogram revealed scrotal haematoma without active bleeding. Testicular blood supply remained intact. Scrotal swelling improved with conservative management and patient got discharged 3 days later in a stable condition. The review of literature suggests that penoscrotal haematoma is unusual after CC but may result from arterial injury or bleeding into the fascial planes. Majority of patients require observation but surgery is indicated in selected cases for vascular complications.

Current Diagnosis and Management of Immune Related Adverse Events (irAEs) Induced by Immune Checkpoint Inhibitor Therapy.

The indications of immune checkpoint inhibitors (ICIs) are set to rise further with the approval of newer agent like atezolimumab for use in patients with advanced stage urothelial carcinoma. More frequent use of ICIs has improved our understanding of their unique side effects, which are known as immune-related adverse events (irAEs). The spectrum of irAEs has expanded beyond more common manifestations such as dermatological, gastrointestinal and endocrine effects to rarer presentations involving nervous, hematopoietic and urinary systems. There are new safety data accumulating on ICIs in patients with previously diagnosed autoimmune conditions. It is challenging for clinicians to continuously update their working knowledge to diagnose and manage these events successfully. If diagnosed timely, the majority of events are completely reversible, and temporary immunosuppression with glucocorticoids, infliximab or other agents is warranted only in the most severe grade illnesses. The same principles of management will possibly apply as newer anti- cytotoxic T lymphocytes-associated antigen 4 (CTLA-4) and programmed cell death protein 1 (PD-1/PD-L1) antibodies are introduced. The current focus of research is for prophylaxis and for biomarkers to predict the onset of these toxicities. In this review we summarize the irAEs of ICIs and emphasize their growing spectrum and their management algorithms, to update oncology practitioners.

Unusual Presentation of Diffuse Large B-Cell Lymphoma With Splenic Infarcts.

A 67-year-old man presented with a 3-day history of abdominal pain, fever, and significant weight loss over 2 months. Physical examination revealed left upper quadrant tenderness, hepatomegaly, splenomegaly, and bilateral pitting edema but peripheral lymphadenopathy was absent. Laboratory tests showed anemia, thrombocytopenia, elevated prothrombin time (PT), partial thromboplastin time (PTT), and increased lactate dehydrogenase (LDH). PTT was corrected completely in mixing study. Further workup for the cause of coagulopathy revealed decreased levels of all clotting factors except factor VIII and increase fibrinogen levels, which ruled out disseminated intravascular coagulation (DIC). Flow cytometry of peripheral blood was normal. Contrast-enhanced computed tomography (CECT) revealed splenomegaly with multiple splenic infarcts without any mediastinal or intraabdominal lymphadenopathy. Further investigations for infective endocarditis (blood cultures and transthoracic echocardiography) and autoimmune disorders (ANA, dsDNA, RA factors) were negative. The patient received treatment for sepsis empirically without any significant clinical improvement. The diagnosis remained unclear despite extensive workup and liver biopsy was conducted due to high suspicion of granulomatous diseases. However, the liver biopsy revealed high-grade diffuse large B-cell lymphoma (DLBCL). Unfortunately, patient died shortly after the diagnosis. Here we report a case of high-grade DLBCL with hepatosplenomegaly and splenic infarcts in the absence of any lymphadenopathy or focal lesions. This case highlights the fact that unusually lymphoma can present in the absence of lymphadenopathy or mass lesion mimicking autoimmune and granulomatous disorders. The diagnosis in these cases can only be made on histology, and hence the threshold for biopsy should be low in patients with unclear presentations and multiorgan involvement.