ABSTRACT
Pembrolizumab is an immune checkpoint inhibitor used in many cancer types, including genitourinary cancers. Although immunotherapies have dramatically changed the landscape of cancer treatment by providing an alternative to traditional chemotherapy, they have been associated with significant immune-related adverse events (IRAEs) with wide-ranging clinical manifestations. We present the case of an elderly woman on pembrolizumab for metastatic bladder cancer who developed cutaneous IRAE with lichenoid eruptions that responded to high-dose intravenous glucocorticoids.
Subject(s)
Lichenoid Eruptions , Neoplasms , Female , Humans , Aged , Immune Checkpoint Inhibitors/therapeutic use , Antibodies, Monoclonal, Humanized/therapeutic use , Lichenoid Eruptions/chemically induced , Lichenoid Eruptions/drug therapy , Neoplasms/drug therapyABSTRACT
Cryptococcal species endocarditis is infrequently described, carries high mortality and nearly always occurs in immunocompromised states or on prosthetic valves. We report the case of a man in his 70s with multiple recent hospitalisations for pneumonia, hypercalcaemia and septic tank exposure who presented with intermittent fevers, progressive weakness,and worsening encephalopathy, manifested as confusion and word-finding difficulties for 3 weeks. Workup revealed cryptococcal species on blood serum gram stain, native aortic valve endocarditis and meningitis. Cerebrospinal fluid analysis demonstrated lymphocytosis, ultimately found to be secondary to chronic lymphocytic leukaemia. Surgical valve replacement was deemed medically contraindicated and antifungal therapy was initiated. Though poorly understood with very few documented cases, management of cryptococcal endocarditis relies on prompt diagnosis, early surgery when indicated, long-term antifungal therapy and treatment of underlying immunocompromising states where possible.
Subject(s)
Cryptococcosis , Cryptococcus neoformans , Cryptococcus , Endocarditis , Meningitis, Cryptococcal , Meningitis , Antifungal Agents/therapeutic use , Cryptococcosis/complications , Cryptococcosis/diagnosis , Cryptococcosis/drug therapy , Endocarditis/complications , Endocarditis/diagnosis , Endocarditis/drug therapy , Humans , Immunocompromised Host , Meningitis/drug therapy , Meningitis, Cryptococcal/complications , Meningitis, Cryptococcal/diagnosis , Meningitis, Cryptococcal/drug therapyABSTRACT
ANCA-associated vasculitis is a multiorgan autoimmune inflammatory disease that has a heterogeneous clinical presentation. Our case report provides additional evidence supporting the association between granulomatosis with polyangiitis and myositis. In our patient with proximal muscle weakness and pain, a normal creatine kinase and lack of antibodies to muscular fiber units ruled out primary myositis. Distinct magnetic resonance imaging of the brain within the deep gray matter in addition to positive serologies were consistent with a diagnosis of granulomatosis with polyangiitis. ANCA-associated vasculitis, specifically granulomatosis with polyangiitis, may be overlooked if musculoskeletal manifestations are the presenting symptoms. Prompt and aggressive treatment prevented this patient from experiencing multiorgan failure.
Subject(s)
Abdominal Pain/chemically induced , Acute Lung Injury/diagnosis , Cough/chemically induced , Electronic Nicotine Delivery Systems , Fever/chemically induced , Vaping/adverse effects , Abdominal Pain/therapy , Acute Lung Injury/chemically induced , Acute Lung Injury/therapy , Analgesics/therapeutic use , Antiemetics/therapeutic use , Dronabinol/adverse effects , Fever/therapy , Fluid Therapy , Humans , Male , Oxygen Inhalation Therapy , Psychotropic Drugs/adverse effects , Young AdultABSTRACT
Lateral medullary syndrome (LMS) is an ischemic disease of the medulla oblongata, which involves the territory of the posterior inferior cerebellar artery. Lateral medullary syndrome is often missed as the cause of autonomic dysregulation in patients with recent brain stem stroke. Due to the location of the baroreceptor regulatory center in the lateral medulla oblongata, patients with LMS occasionally have autonomic dysregulation-associated clinical manifestations. We report a case of LMS-associated autonomic dysregulation. The case presented as sinus arrest and syncope, requiring permanent pacemaker placement. A dual-chamber pacemaker was placed, after failure of conservative measures to alleviate the patient's symptoms. Our case shows the importance of recognizing LMS as a potential cause for life-threatening arrhythmias, heart block, and symptomatic bradycardia. Placement of permanent pacemaker may be necessary in some patients with LMS presenting with syncope, secondary to sinus arrest.
ABSTRACT
Disconnected pancreatic duct syndrome is a circumferential interruption of the pancreatic duct. It usually occurs secondary to pancreatitis and carries significant diagnostic and management challenges. We present a case of disconnected pancreatic duct syndrome that represented a diagnostic and management dilemma for both medical and surgical teams. The aim of this article is to share a successful management experience of disconnected pancreatic duct syndrome with other physicians and to perform a brief but focused literature review on this challenging condition.
Subject(s)
Pancreas/pathology , Pancreatic Ducts/pathology , Pancreatitis, Alcoholic/complications , Abdominal Pain/drug therapy , Adult , Humans , Male , Necrosis/etiology , Necrosis/surgery , Pancreas/surgery , Pancreatic Ducts/surgery , Patient Care Team , SyndromeABSTRACT
An 81-year-old woman with well-controlled hypertension presented to the emergency department with new-onset atrial fibrillation with rapid ventricular response. Treatment for atrial fibrillation was initiated, including rate control and anticoagulation with 5â mg of apixaban two times per day for primary stroke prophylaxis. Three days after initiation of apixaban, the patient noted new-onset abdominal pain, worsening shortness of breath and weakness. Laboratory results showed elevated liver enzymes. Workup for elevated transaminase did not reveal any underlying infectious or autoimmune process. Apixaban, a probable cause for the hepatocellular injury, was discontinued and replaced with intravenous unfractionated heparin to bridge anticoagulation with warfarin. The patient's symptoms resolved as her transaminases improved by discontinuation of apixaban. We illustrate this case of drug-induced hepatotoxicity secondary to treatment with apixaban. It is important for physicians to be aware of this rare adverse effect caused by a widely used novel oral anticoagulant.
Subject(s)
Abdominal Pain/chemically induced , Anticoagulants/adverse effects , Atrial Fibrillation/drug therapy , Chemical and Drug Induced Liver Injury/diagnosis , Heparin/therapeutic use , Pyrazoles/adverse effects , Pyridones/adverse effects , Administration, Oral , Aged, 80 and over , Anticoagulants/administration & dosage , Atrial Fibrillation/physiopathology , Female , Humans , Practice Guidelines as Topic , Pyrazoles/administration & dosage , Pyridones/administration & dosage , Treatment OutcomeABSTRACT
BACKGROUND: Preanesthesia medical examination is a common procedure performed before ophthalmic surgery. The frequency and characteristics of new medical issues and unstable medical conditions revealed by ophthalmic preanesthesia medical examination are unknown. We conducted a prospective observational study to estimate the proportion of patients with new medical issues and unstable medical conditions discovered during ophthalmic preanesthesia medical examination. Secondary aims were to characterize abnormal findings and assess surgical delay and adverse perioperative events, in relation to findings. METHODS: Patients having preanesthesia medical examination, before ophthalmic surgery, were enrolled over a period of 2 years. A review was conducted of historical, physical examination, and test findings from the preanesthesia medical examination. RESULTS: From review of medical records of 530 patients, 100 patients (19%; 95% CI, 16-23%) were reported by providers to have abnormal conditions requiring further medical evaluation. Of these, 12 (12%) had surgery delayed. Retrospective review of examination results identified an additional 114 patients with abnormal findings for a total of 214 (40%; 95% CI, 36-45%) patients. Among the 214 patients, primary findings were cardiovascular (139, 26%), endocrine (26, 5%), and renal (24, 5%). Complications occurred in 49 (9%; 95% CI, 7-12%) patients within 1 month of surgery. CONCLUSIONS: Ophthalmic preanesthesia medical examination frequently detects new medical issues or unstable existing conditions, which do not typically alter conduct of perioperative procedures or outcomes. However, these conditions are relevant to long-term patient health and should be conveyed to primary care physicians for further evaluation.
Subject(s)
Anesthesia , Diagnostic Tests, Routine , Ophthalmologic Surgical Procedures/methods , Preoperative Care , Aged , Blood Pressure/physiology , Cataract Extraction , Comorbidity , Data Collection , Electrocardiography , Female , Humans , Intraoperative Complications/epidemiology , Male , Middle Aged , Ophthalmologic Surgical Procedures/adverse effects , Postoperative Complications/epidemiology , Retrospective Studies , Risk FactorsSubject(s)
Bone Density Conservation Agents/adverse effects , Chemical and Drug Induced Liver Injury , Etidronic Acid/analogs & derivatives , Transaminases/blood , Aged, 80 and over , Bone Density Conservation Agents/therapeutic use , Dose-Response Relationship, Drug , Drug Administration Schedule , Etidronic Acid/adverse effects , Etidronic Acid/therapeutic use , Female , Follow-Up Studies , Humans , Liver Diseases/physiopathology , Liver Function Tests , Long-Term Care , Osteoporosis, Postmenopausal/diagnosis , Osteoporosis, Postmenopausal/drug therapy , Risedronic Acid , Risk Assessment , Severity of Illness IndexABSTRACT
Intraoperative floppy-iris syndrome (IFIS) is a recently identified condition associated with phacoemulsification in patients using the alpha1-antagonist tamsulosin (Flomax). Patients with IFIS manifest a triad of symptoms during cataract surgery: fluttering and billowing of iris stroma due to normal fluid movement, propensity of iris prolapse to phaco and side-port incisions, and progressive constriction of the pupil. Prevention of IFIS by withdrawing tamsulosin preoperatively has not shown consistent benefit. We describe the preoperative administration of atropine, which effectively prevented the occurrence of IFIS in patients receiving tamsulosin.