Atezolizumab-induced encephalitis with subdural hemorrhage and subarachnoid hemorrhage in a patient with hepatocellular carcinoma.

We report the case of a 76-year-old man who was diagnosed with advanced stage hepatocellular carcinoma and was treated with atezolizumab plus bevacizumab therapy. Two weeks after 1st dose, he presented with acute changes in consciousness followed by hypothermia. A cerebrospinal fluid test showed an elevated cell count, total protein, and albumin. Infectious, anatomical, endocrinal, and neoplastic etiologies were ruled out. Based on the findings, atezolizumab-induced encephalitis was suspected, and high dose steroid therapy was administered. The patient's conscious level and hypothermia recovered completely about 9 days after starting the steroids, and he recovered without any neurological sequelae. This case report reminds physicians that prompt administration of steroid treatment after early diagnosis of immune checkpoint inhibitor-related encephalitis is the key for patients to recover without apparent neurological sequelae.

A Rare Presentation of Chronic Appendicitis in the Right Upper Quadrant: A Case Report.

Chronic appendicitis is a rare cause of chronic abdominal pain that can be difficult to diagnose. We present a patient with chronic right upper quadrant pain that was finally diagnosed as chronic appendicitis. This 71-year-old male had no systemic diseases and presented to our outpatient clinic with right upper quadrant pain for one month. The pain tended to worsen in the early morning but could be relieved by bowel movements, sitting up, or walking. The findings of a physical examination, laboratory data, and abdominal ultrasound were not significant. Upper endoscopy revealed a shallow gastric ulcer at the antrum. However, the abdominal pain was not relieved by esomeprazole. A computed tomography (CT) scan revealed a dilated appendix with some appendicoliths in the retrocecal region. Due to chronic appendicitis, the patient underwent laparoscopic appendectomy, and the histopathological examination of the removed appendix confirmed the diagnosis. The abdominal pain completely resolved after the surgery. Chronic appendicitis should be kept in mind in patients with chronic abdominal pain without a definite diagnosis. This case illustrates that in addition to right lower quadrant pain, chronic appendicitis can also present with right upper quadrant pain or vague abdominal pain. A CT scan is invaluable in the diagnosis of abdominal pain when medical treatment fails to yield improvement.

Characteristics of primary signet ring cell carcinoma of colon and rectum: a case control study.

BACKGROUND: Primary signet ring cell carcinoma of the colon and rectum (PSRCCR) is rare, usually diagnosed at advanced stage with poor outcomes. We aimed to find possible diagnostic clues in order to help diagnosis. METHODS: A retrospective study of PSRCCR patients from 1993 to 2018 was reviewed at a single tertiary center. Colorectal adenocarcinoma patients as control group with 1:4 ratio was also enrolled. RESULTS: 18 patients with PSRCCR were identified. The prevalence rate was 0.16% (18 of 11,515). The mean age was 50.2 years-old in PSRCCR group and 63 years-old in non-SRCC colorectal cancer patients (p < 0.001). Diagnosis tool depends on colonoscopy were much less in PSRCCR group than control group (44.4% vs 93%, p < 0.001). SRCC patients had higher level of CEA (68.3 vs 17.7 ng/mL, p = 0.004) and lower level of Albumin (3.4 vs 4.3 g/dL, p < 0.001). The majority of PSRCCR tumor configuration was ulcerative and infiltrative. More PSRCCR pathology presented as high-grade carcinoma (66.7 vs 1.4%, p < 0.001) and lymphovascular invasion (77.8 vs 44.4%, p = 0.011) than control group. More PSRCCR patients were diagnosed at advanced stage (88.8 vs 40.3%, p = 0.001). Higher mortality was also noticed in PSRCCR group than control group (72.2 vs 20.8%, p < 0.001). CONCLUSION: For young patients with long segment colonic stenosis and ulcerative/ infiltrative mucosa but endoscopic biopsy failed to identify malignant cells, earlier operation or non-colon site biopsy is suggested for diagnosing the PSRCCR.