Metachronous Renal Cell Carcinoma: A Rare Presentation of Adrenal Crisis.

Responsible for 2% of global cancer diagnoses, renal cell carcinoma (RCC) can metastasize to almost every organ system; however, metastasis to the contralateral adrenal gland is extremely rare. We report the case of a 59-year-old male who presented with atypical chest pain and altered mental status. The patient developed hypotension, with hyponatremia raising concern for adrenal insufficiency (AI). We confirmed a diagnosis of AI secondary to adrenal metastasis in the setting of radical nephrectomy with ipsilateral adrenalectomy, and the patient's symptoms resolved with adequate treatment. This report emphasizes the importance of complications caused by metastatic disease to the remaining adrenal gland in patients with RCC who have undergone ipsilateral radical nephrectomy.

A Rare Presentation of Checkpoint Inhibitor Induced Distal RTA.

Immune checkpoint inhibitors have opened a new era in treating advanced malignancies, resulting in a rapid increase in utilization, given the remarkable clinical outcomes. The incidence of immune-related adverse events increased due to the immunologic effects of these therapeutic agents. However, immune-related renal adverse events remain low, representing only a small incidence of reported cases. Common renal toxicity described includes acute interstitial nephritis, minimal change disease, and immune complex glomerulonephritis. Renal tubular acidosis has occasionally been reported but is highly uncommon. This report presents a case of a 68-year-old woman with a known history of metastatic melanoma undergoing treatment with ipilimumab+nivolumab, who developed distal renal tubular acidosis requiring stress dose steroids and sodium bicarbonate for treatment. We describe the clinical characteristics, potential mechanisms, and management of this case, highlighting the need among clinicians utilizing immune check inhibitors to be aware of this immune-related disease entity.

Pembrolizumab-Induced Hypophysitis With Isolated Adrenocorticotropic Hormone (ACTH) Deficiency: A Rare Immune-Mediated Adverse Event.

Pembrolizumab is an immune checkpoint inhibitor that targets the programmed cell death protein 1 antigen to stimulate an immune response against tumor cells. It has successfully induced remission in patients with severe metastatic disease, including those refractory to other chemotherapeutic regimens. Immune checkpoint inhibitors may result in immune-related adverse events affecting multiple organs, including endocrine organs, leading to thyroiditis and hypophysitis, among others. Isolated adrenocorticotropic hormone deficiency and hypophysitis have been reported in patients treated with nivolumab, another programmed cell death protein 1 inhibitor. However, clinical characteristics of these side effects associated with pembrolizumab have yet to be described in detail. We describe a case of an 85-year-old Caucasian male undergoing treatment of metastatic urothelial carcinoma with pembrolizumab, who abruptly developed hypophysitis requiring emergent intervention.

Electrical Storm With Incessant Ventricular Tachycardia in a COVID-19 Patient: Review of Current Evidence.

Coronavirus disease 2019 (COVID-19) is associated with various cardiovascular manifestations, including myocarditis, myocardial infarction, and arrhythmias. A prothrombotic state is the primary underlying pathogenic mechanism. While cardiac arrhythmias manifest more commonly amongst critically ill COVID-19 populations, ventricular arrhythmias have been reported only in few cases. This report describes a case of a 95-year-old African American man with COVID-19, who developed sustained monomorphic ventricular tachycardia, which progressed to an electrical storm. The case highlights the importance of high clinical suspicion, early recognition of electrical abnormalities in patients with active COVID-19 infection, and its ability to precipitate fatal ventricular arrhythmia. Also, we provide a literature review on the electrical storm in COVID-19 patients, highlighting the pathophysiologic mechanisms and the management of this deadly arrhythmia.

COVID-19 Presenting as Banti's Syndrome.

COVID causing Banti's syndrome has not been reported in literature yet. Banti's syndrome is a rare disorder characterized by splenomegaly, ascites, and portal hypertension without coexisting cirrhosis of the liver. Here we report a case of a 32-year-old man who presented with hematemesis, and further workup revealed that the patient had bleeding varices, ascites, and splenomegaly, thus completing the picture of Banti's syndrome. Although this is a rare disorder, Banti's syndrome must be taken into account in a patient presenting with hematemesis and splenomegaly. The patient had flu-like symptoms for three weeks but did not seek any medical help and eventually presented with Banti's syndrome. His serology was positive for COVID-19. The coronavirus (COVID-19), discovered in 2019, has been creating havoc since it first emerged in China and is now spreading worldwide. Its presentation is somewhat similar to influenza.

A Case of a COVID-19-positive Patient.

The coronavirus (COVID-19), discovered in 2019, has been creating havoc since it first emerged in China and is now spreading worldwide. Its presentation is somewhat similar to influenza. We hereby discuss the salient features of the coronavirus and present the case of a 33-year-old male who was tested positive for COVID-19.

Thrombotic Thrombocytopenic Purpura Associated with Myelodysplastic Syndrome.

Myelodysplasia and thrombotic thrombocytopenic purpura (TTP) are both rare diseases. TTP is a blood abnormality in which blood clots form in blood vessels leading to fatal outcomes. Myelodysplastic syndrome is a group of disorders caused by poorly formed blood cells or ones that do not work properly. We are hereby presenting the case of a 69-year-old female who presented with anemia, thrombocytopenia, changes in mental status and reduced kidney function, and further investigations revealed that the patient had underlying myelodysplasia.

Autoimmune Thyroiditis with Hypothyroidism Induced by Sugar Substitutes.

The use of sugar substitutes (artificial sweeteners or non-nutritive sweeteners) has increased dramatically in the past few decades. They have been used as a substitute for sucrose (table sugar) in various diet-related disorders. Their excessive use has been linked to hyperphagia and obesity-related disorders. Hashimoto's thyroiditis (chronic autoimmune thyroiditis) is a disease that involves the immune-mediated destruction of the thyroid gland, gradually leading to its failure. Animal studies report that artificial sweeteners affect the immune system. Moreover, animal studies show that sucralose diminishes the thyroid axis activity. We are presenting the case of a 52-year-old female with autoimmune thyroiditis with hypothyroidism (Hashimoto's thyroiditis) induced by an excessive intake of beverages containing non-nutritive sweeteners. She was ruled out for any other autoimmune disorder. The association between Hashimoto's thyroiditis and the excessive consumption of sugar substitutes is shown by the quick return of thyroid stimulating hormone and antibody levels to normal after eliminating the use of sugar substitutes. Thus, it suggests that the sugar substitutes were the culprit in the development of Hashimoto's thyroiditis in our patient.

Hypokalemic Paralysis Secondary to Renal Tubular Acidosis Revealing Underlying Sjogren's Syndrome.

There is a well-established association of Sjogren's syndrome with renal tubular acidosis (RTA). Rarely there is a retrospective diagnosis where the patient presents with RTA and the workup reveals Sjogren's syndrome. Our case report is about a patient who presented with generalized weakness and hypokalemia, which upon further workup turned out to be RTA. Various tests were performed to find out the cause of RTA. A favorable profile for the anti-nuclear antibody, anti-Ro/SSA, and anti-La/SSB was consistent with Sjogren's syndrome. Treatment with corticosteroid improved hypokalemia. The patient did not have typical glandular symptoms of Sjogren's syndrome, and follow-up is needed to see whether the patient develops symptoms in the future and to prevent any possible complication.

Amyloidosis Presenting with Macroglossia.

Macroglossia is an uncommon condition that causes cosmetic and functional disabilities. We present a case of a 67-year-old patient with the past medical history of vitamin B12 deficiencies who presented with macroglossia and was found to have amyloidosis. She had an enlarged tongue with multiple ulcerations secondary to traumatic injury from dentation along with difficulty swallowing. Laboratory workup was unremarkable apart from elevated C reactive protein (CRP) and low complement 3 (C3) levels. On the second day of admission she had gastrointestinal bleed; computed tomography (CT) scan of the abdomen with oral contrast was performed which revealed nodular thickening of the stomach suspicious for gastric malignancy. Endoscopy was postponed as there was concern that macroglossia could comprise the airway. A biopsy of the tongue was performed and histological staining was positive suggestive of the amyloidosis. We discuss here the probable underlying causes of macroglossia and amyloidosis.

Thrombotic Thrombocytopenic Purpura Associated with Dermatomyositis.

Dermatomyositis and thrombotic thrombocytopenic purpura (TTP) are both rare diseases. TTP is a blood abnormality in which blood clots form in blood vessels leading to fatal outcomes. Dermatomyositis is an inflammatory myopathy which causes a distinctive skin rash and muscle weakness. We are hereby presenting the case of a 27-year-old female who presented with characteristic skin findings on the face pathognomic of dermatomyositis and further investigation revealed that she had underlying TTP.