Acute Pancreatitis Secondary to Pembrolizumab-Induced Hypertriglyceridemia.

Pembrolizumab is a humanized monoclonal antibody targeted against programmed cell death protein 1 (PD-1) receptor of lymphocytes. It is used alone or in combination with many chemotherapy regimens for a wide variety of cancers. It has been reported to cause various side effects including endocrinopathies, colitis, rash, and pneumonitis. Hypertriglyceridemia (HTG) has been recently added to its side effect profile with a possible pathogenic mechanism involving autoantibodies against glycosylphosphatidylinositol-anchored high-density lipoprotein binding protein 1 (GP1HBP1). We are presenting a case of acute pancreatitis secondary to HTG in a cervical cancer patient. HTG was successfully treated with insulin infusion. As the patient's symptoms improved, she was started on the diet. She was discharged on statin and fibrate therapy. We are reporting this case to increase awareness of this rare side effect, inpatient management, and outpatient screening while on immunotherapy.

A Rare Case of Pancreatic Cancer: Undifferentiated Carcinoma of the Pancreas With Osteoclast-Like Giant Cells.

Ductal adenocarcinoma of the pancreas is the most common pancreatic cancer, but undifferentiated carcinoma of the pancreas with osteoclast-like giant cells (UC-OGCs) is an exceedingly rare tumor. Microscopically, this tumor is characterized by the presence of two different cellular elements, namely, spindle or ovoid mononuclear cells and osteoclast-like giant cells (OGCs). Here, we report a rare case of UC-OGCs in a 79-year-old male with a one-month history of epigastric abdominal pain and unintentional weight loss. A blood workup revealed new-onset type 2 diabetes mellitus, and a computed tomography scan of the abdomen showed acute pancreatitis with a hypodense lesion in the head of the pancreas concerning for malignancy. He underwent an endoscopic ultrasound that also revealed a mass in the head of the pancreas, but no lymphadenopathy was observed. Biopsy was obtained and histopathology revealed UC-OGCs. We present this case to increase awareness of this rare clinical entity in patients presenting with acute-onset pancreatitis.

Two Infectious Agents Causing Hemophagocytic Lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immune activation syndrome that should be recognized earlier for effective treatment. Adults usually have secondary HLH. An uncommon cause of secondary HLH is AIDS and simultaneous opportunistic infections. Acute human immunodeficiency virus (HIV) and opportunistic infections are also independent causes of HLH, so the presence of both should raise suspicion, especially if patients fulfill the criteria. HLH secondary to severe babesiosis is a rare entity as well. Some patients might not meet the full criteria of HLH on presentation, especially when some specific lab test results are still pending. A delay in diagnosis can happen in those cases. Here, we present two cases. The first case is of a 35-year-old homosexual male who presented with constitutional symptoms of one-week duration. He was diagnosed and started on the treatment of HIV. His fever was not resolving and further investigations led to a diagnosis of disseminated histoplasma infection. The patient fulfilled the criteria of HLH as well. Prompt therapy resulted in the improvement of clinical and laboratory parameters. The second case is of a 72-year-old female presenting with fever. A diagnosis of severe babesiosis and secondary HLH was made. Treatment of babesia resulted in the improvement of clinical and biochemical parameters.

Anticoagulation in COVID-19: a single-center retrospective study.

Introduction: COVID-19 induces a pro-thrombotic state as evidenced by microvascular thrombi in the renal and pulmonary vasculature. Therapeutic anticoagulation in COVID-19 has been debated and data remain anecdotal. Hypothesis: We hypothesize that therapeutic anticoagulation is associated with a reduction in in-hospital mortality, upgrade to intensive care unit, invasive mechanical ventilation, and acute renal failure necessitating dialysis by decreasing the over-all clot burden. Methods: A retrospective cohort study was done to determine the impact of therapeutic anticoagulation in hospitalized COVID-19 patients. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aOR) with its 95% confidence interval (CI) respectively. Results: A total of 176 hospitalized COVID-19 patients were divided into two groups, therapeutic anticoagulation and prophylactic anticoagulation. The mean age, baseline comorbidities and other medications used during hospitalization were similar in both groups. The aOR for in-hospital mortality (OR 3.05, 95% CI 1.15-8.10, p = 0.04), upgrade to intensive care (OR 3.08, 95% CI 1.43-6.64, p = 0.006) and invasive mechanical ventilation (OR 4.27, 95% CI 1.95-9.34, p = 0.00) were significantly lower while there was no statistically significant difference in the rate of developing acute renal failure (OR 1.87 95% CI 0.46-7.63, p = 0.64) between two groups. Conclusions: In patients with COVID-19, therapeutic anticoagulation offers a significant reduction in the rate of in-hospital mortality, upgrade to intensive medical care, and invasive mechanical ventilation. It should be preferred over prophylactic anticoagulation in COVID-19 patients unless randomized controlled trials prove otherwise.

A rare association of Takotsubo cardiomyopathy with neuroleptic malignant syndrome.

Neuroleptic malignant syndrome is a potentially fatal neurological condition secondary to antipsychotic medication. It is characterized by distinctive clinical findings and autonomic disturbances. NMS has not been associated with Takotsubo cardiomyopathy (TCM). TCM is an abnormal response to physiological stressors resulting from the autonomic abnormalities which at times can mimic myocardial infarction (MI). We present a unique case of a 54-year-old female with bipolar disease presenting with lithium and haloperidol-induced NMS complicated by TCM. The purpose of this case is to make clinicians aware of this rare association.

Takotsubo cardiomyopathy: a rare complication of acute viral gastroenteritis.

Takotsubo Cardiomyopathy (TCM) is characterized by a transient but reversible ventricular dysfunction in post-menopausal females following, but not always, a recent emotional or physical stress. Typically, chest pain is reported as a presenting symptom in the majority of patients. The severe diarrheal illness secondary to acute viral gastroenteritis is not commonly reported as the stressor event prior to TCM. We report a unique case of a middle-aged male presented with syncope shortly after loose bowel movements. He was diagnosed with TCM and was successfully managed with supportive care. The purpose of this case is to make clinicians aware of this rare association.

Is therapeutic anticoagulation improving renal outcomes in COVID-19?

We present three patients with COVID-19 who developed acute renal failure during hospitalization and were seen to have an improvement in their kidney function after being started on therapeutic anticoagulation with heparin (Target PTT 58-93 seconds) for varying indications (atrial fibrillation, popliteal vein thrombosis and a pulmonary embolism). Their kidney functions improved significantly following anticoagulation with a clear temporal relationship between the former and latter. Anticoagulation was held for one patient due to concern of gastrointestinal bleeding and his kidney functions worsened a day after stopping anticoagulation. D-dimer levels also improved with anticoagulation but the trend of other inflammatory markers remained unpredictable.

Idiosyncratic Reaction Causing a Rare Side Effect: Isotretenoin-induced Pancreatitis.

Isotretinoin is a frequently prescribed medication for severe nodulocystic acne. It is also used in higher doses and other forms to treat some carcinomas. Pancreatitis remains a well-known but rare side effect of this medication. Two proposed mechanisms for pancreatitis are hypertriglyceridemia induced and idiosyncratic reaction. Here, we present a case of a young man who presented for the evaluation of abdominal pain. His blood work showed elevated lipase levels but computed tomography (CT) of the abdomen did not show any pancreatic inflammation.

Helicobacter pylori: An Underrated Cause of Immune Thrombocytopenic Purpura. A Comprehensive Review.

Idiopathic thrombocytopenic purpura (ITP) is the autoimmune-mediated destruction of platelets. ITP is a diagnosis of exclusion after other identifiable etiologies have been ruled out. After the first report by Gasbarrini et al. (1998) showing rising platelet counts in ITP patients following Helicobacter pylori (HP) eradication therapy, there is growing evidence that highlights the role of HP in triggering ITP. However, the exact pathophysiology of HP-associated ITP is still unclear, but many theories have been implicated in this regard. According to various reports, the postulated mechanisms for the role of HP in cITP include molecular mimicry, increased plasmacytoid dendritic cell numbers, phagocytic perturbation, and variable host immune response to HP virulence factors. One famous theory suggested molecular mimicry between platelet surface antigen and bacterial virulence factor, i.e. cytotoxin-associated gene A (CagA). It is thought that a chronic inflammatory response following an HP infection induces the host autoantibodies' response against CagA, which cross-reacts with platelet surface glycoproteins; therefore, it may accelerate platelet destruction in the host reticuloendothelial system. However, further studies are mandated to better understand the causal link between ITP and HP and study the role of biogeography. Nowadays, it is recommended that every patient with ITP should undergo HP diagnostic testing and triple therapy should be administered in all those candidates who test positive for HP infection. In our review, there were a few pregnant female ITP patients who took HP eradication therapy mainly after 20 weeks of gestation without maternal or fetal worst outcomes. However, large-scale studies are advisable to study the adverse fetal outcomes following triple therapy use.

Atrial fibrillation: a leading cause of heart failure-related hospitalizations; a dual epidemic.

BACKGROUND: Atrial fibrillation (AF), and heart failure (HF) are a major cardiovascular epidemic over the last decade. The prevalence and rehospitalization of heart failure are on rising edge, and many factors are responsible for these re-exacerbations of heart failure. In this study, we sought to determine an association of a risk factor for frequent rehospitalization of heart failure at our institute. We aimed to find the re-admission rate, heart rate, and rhythm of heart failure exacerbation. METHODS: We performed a single-center retrospective study at the Abington Hospital - Jefferson health and 418 patients having a history of heart failure, and AF were selected. The heart failure readmission rate (days), heart rate, and rhythm were analyzed. RESULTS: The mean age of the included population was 82.8 years SD ± 9.2. About 53% had AF with a mean heart rate 90 SD ± 21 bpm, and 47% had normal sinus rhythm (NSR) with a mean heart rate of 78 ± 16 bpm on re-admission. This difference was statistically significant (p=0.02). The mean re-admission rate for atrial fibrillation was 27.49 days SD ± 18.97, compared to 32.68 SD ± 20.26 days for NSR, statistically significant (p=0.007) and the Pearson Chi-square was also significant P = 0.006. CONCLUSION: There is a significantly increased rate of re-admission in heart failure patients with atrial fibrillation with a rapid ventricular rate. Efforts should be taken to keep the patient in NSR or controlled AF to minimize the rehospitalization rate, and this, in turn, reduces the financial burden on patients and institutes.

Optic Neuritis: A Rare Paraneoplastic Phenomenon of Hodgkin's Lymphoma.

Hodgkin's lymphoma (HL) is a hematological disorder that has a high cure rate. It usually presents as asymptomatic lymphadenopathy or a mass on chest radiograph along with constitutional symptoms ("B" symptoms such as fever, night sweats, or unintended weight loss) in less than half the cases. Optic neuritis is a demyelinating condition that is rarely associated with HL. We present a case of HL that presented with optic neuritis as a paraneoplastic syndrome.

"Takotsubo cardiomyopathy presenting with QT prolongation: an atypical presentation."

Takotasubo Cardiomyopathy (TCM), also known as broken heart syndrome, is a syndrome of transient and reversible cardiac dysfunction in the absence of obstructive coronary artery disease following an unpleasant emotional event. TCM commonly presents as chest pain mimicking acute coronary syndrome (ACS) in character. The most common electrocardiogram (EKG) findings associated with TCM are ST-segment elevation or T wave inversion. Herein, we present a case of TCM in an individual who presented with a sudden onset chest pressure following a stressful event. She was found to have QT interval prolongation on EKG and elevated troponins. Initially thought to have non-ST elevation myocardial infarction (NSTEMI). Cardiac catheterization did not reveal coronary artery disease. The ventriculography suggested apical ballooning and the diagnosis of TCM with atypical EKG presentation. Our case is unique as we describe an atypical electrocardiographic presentation of TCM. Our case emphasizes that physicians should refrain from prescribing QT-prolonging drugs to patients with TCM, to avert potential QT prolongation and progression to torsade de pointes (TDP).

A Late Presentation of Substance-related Rhabdomyolysis with Normal Serum Creatine Kinase Levels and Complicated with Acute Tubular Necrosis.

Substance abusers are at increased risk of acute kidney injury (AKI) compared to the general population due to nontraumatic rhabdomyolysis. The primary target of these nephrotoxic agents is the tubulointerstitial compartment and the most frequent findings on biopsy are consistent with acute tubular necrosis (ATN) and acute interstitial nephritis. We present a rare case of an intravenous cocaine and heroin abuser who presented with recent onset oliguria, hematuria, and reduced peroral intake. The urine dipstick testing showed guaiac positivity but no red blood cells on microscopy. The blood workup showed elevated serum creatinine and urea levels but normal creatinine kinase (CK) level. Renal biopsy showed tubular epithelial cell necrosis and positive immunoperoxidase staining for myoglobin pigment casts in renal tubules. The diagnosis of rhabdomyolysis-associated ATN secondary to substance abuse was suggested. However, normal serum CK levels as well as urine drug panel supported the delayed presentation of rhabdomyolysis complicated with ATN. The patient returned to normal health with no residual kidney dysfunction after undergoing temporary hemofiltration.

Clot Mayhem: A Case of May-Thurner Syndrome.

May-Thurner syndrome (MTS), also known as the iliac vein compression syndrome, is an anatomic anomaly in which the compression of the left common iliac vein by an overlying right common iliac artery leads to blood stasis, which predisposes to deep venous thrombosis (DVT) in the iliofemoral venous system. We present a case of a female with a history of DVT and currently on warfarin with a therapeutic international normalized ratio (INR), admitted with left leg swelling, redness, and intractable pain. Venous Doppler scan confirmed a massive DVT from the level of the left common femoral vein to the popliteal vein. The clot recurred after an unsuccessful trial of argatroban, in-line pharmacokinetic thrombolysis with local catheter-based alteplase infusion, and interventional radiology (IR)-guided mechanical thrombectomy. Subsequently, the patient was diagnosed as MTS with overlying left common iliac vein compression, as evident on venous Doppler ultrasound. She was managed successfully by venous stent placement and ongoing systemic anticoagulation with fondaparinux.

Immune-mediated Colitis from Dual Checkpoint Inhibitors.

Melanoma is a deadly disease with immunotherapy treatment options that emerged in the last few years and have changed the disease outcome. However, it is associated with immune-related toxic effects despite improving survival. We present the case of a 53-year-old woman who had two weeks of diarrhea after she was treated with dual immunotherapy agents for her advanced melanoma. The final workup revealed pancolitis, possibly due to immunotherapy adverse effects. Initial conservative treatment, unfortunately, did not lead to a clinical improvement until a steroid was introduced. We are reporting this case to alert our fellow physicians about the immune-mediated toxicities of the relatively new checkpoint inhibitors.