First Case of Infective Endocarditis With Streptococcus equinus in an Immunocompetent Patient in North America: A Case Report and Review of Literature.

Infective endocarditis (IE) can be caused by bacterial or fungal infections invading the endocardial surface of the heart, such as its valves and chambers. Staphylococcus and Streptococcus species are mainly responsible for IE. Streptococcus equinus (S. equinus) has been rarely noted to cause IE. We present a case of a 69-year-old white male with a past medical history of severe aortic regurgitation, who during an elective aortic heart valve replacement surgery was noted to have multiple plaque-like vegetations at the base of the mitral valve that were positive for S. equinus. To date, there are only four cases of S. equinus endocarditis reported worldwide, with a high possibility of our case being the first reported in North America.

A simple test-based frailty index to predict survival among cancer patients with an unplanned hospitalization: An observational cohort study.

BACKGROUND: Frailty is a state of increased vulnerability to stressors, and predicts risk of adverse outcomes, such as mortality. Frailty can be defined by a frailty index (FI) using an accumulation of deficits approach. An FI comprised of 20 items derived from our previously studied test-based frailty index (TBFI) and an additional 33 survey-based elements sourced from the standard CGA was developed to evaluate if predictive validity of survival was improved. METHODS: One hundred eighty-nine cancer patients during acute hospitalization were consented between September 2018 and May 2019. Frailty scores were calculated, and patients were categorized into four groups: non-frail (0-0.2), mildly frail (0.2-0.3), moderately frail (0.3-0.4), and severely frail (>0.4). Patients were followed for 1-year to assess FI and TBFI prediction of survival. Area under the curve (AUC) statistics from ROC analyses were compared for the FI versus TBFI. RESULTS: Increasing frailty was similarly associated with increased risk of mortality (HR, 4.5 [95% CI, 2.519-8.075] and HR, 4.1 [95%CI, 1.692-9.942]) and the likelihood of death at 6 months was about 11-fold (odds ratio, 10.9 [95% CI, 3.97-33.24]) and 9.73-fold (95% CI, 2.85-38.50) higher for severely frail patients compared to non-frail patients for FI and TBFI, respectively. This association was independent of age and type of cancer. The FI and TBFI were predictive of survival for older and younger cancer patients with no significant differences between models in discriminating survival (FI AUC, 0.747 [95% CI, 0.6772-0.8157] and TBFI AUC, 0.724 [95% CI, 0.6513-0.7957]). CONCLUSIONS: The TBFI was predictive of survival, and the addition of an in-person assessment (FI) did not greatly improve predictive validity. Increasing frailty, as measured by a TBFI, resulted in a meaningfully increased risk of mortality and may be well-suited for screening of hospitalized cancer patients.

Cefepime-Induced Encephalopathy.

Cefepime, a fourth-generation cephalosporin, remains an essential antibiotic targeting a broad spectrum of Gram-positive and Gram-negative organisms. However, it also remains an important, yet often unrecognized, cause of encephalopathy. We are here to discuss a case of a 74-year-old male with a common bile duct low-grade adenoma who presented to the hospital for lethargy. He was placed on intravenous cefepime for a Pseudomonas-infected hepatobiliary abscess. Approximately five days later, the patient's spouse reported acutely worsening cognitive changes. The cefepime level was significantly elevated at 160 µg/mL. Although not completely understood, cefepime is felt to antagonize gamma-aminobutyric acid A (GABA-A) receptors and possibly inhibit GABA release. This risk is accentuated in patients with underlying renal dysfunction and increased inflammation across the blood-brain barrier. Clinical manifestations include an impaired level of consciousness, delirium, myoclonus, and seizures. The treatment of choice is the cessation of the antibiotic, which resolves the neurotoxicity within approximately 48 hours. It is important to recognize cefepime as a potential culprit of acute-onset encephalopathy in the appropriate clinical setting, and the cessation of therapy would lead to a complete resolution of its associated neurotoxicity.

Diabetic Ketoacidosis: An Adverse Reaction to Immunotherapy.

Immune checkpoint inhibitors (ICPIs), such as anti-programmed death receptor 1 (PD-1) and anti-cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4), are being utilized in the treatment of many malignancies. Just like their benefits in increasing recurrence-free survival, they also have shown numerous side effects affecting various organ systems. The endocrine adverse events can range from diabetes, hypothyroidism to diabetic ketoacidosis, and adrenal crisis. We would like to report a case of diabetic ketoacidosis (DKA) secondary to combination ipilimumab and nivolumab therapy after two doses. A 49-year-old female presented to the emergency department with nausea and vomiting. Her labs revealed blood glucose of 384 mg/dL, positive ketones, glucose in the urine, and an arterial pH of 7.2. She was treated as per our diabetic ketoacidosis protocol and ultimately discharged on insulin therapy. Clinicians should be vigilant about new hyperglycemic episodes in their patients who are on immunotherapy. Timely detection and management lead to better outcomes. Insulin is the standard treatment of choice in the treatment of immunotherapy mediated type 1 diabetes mellitus.

Immune-Mediated Toxic Epidermal Necrolysis.

The treatment of melanoma has advanced over time with the latest modalities being immune checkpoint blockade by programmed death receptor 1 and cytotoxic T-lymphocyte-associated antigen 4 inhibitors. Programmed death receptor 1 inhibitors have been noted to cause multi-system adverse reactions. The dermatological adverse events can range from pruritus to severe toxic epidermal necrolysis. We report a fatal case of toxic epidermal necrolysis secondary to nivolumab therapy. Checkpoint inhibitors are becoming the standard treatment option in many malignancies. Their safety profile is still evolving as more cases are being reported. Many individuals who are immunocompromised or undergoing concomitant treatment with combination therapy could develop significant overlapping toxicities. Physicians must be vigilant for dermatological complications that lead to opportunistic infections and sepsis.

Dapsone-Induced Hypoxia.

Dapsone is a common medication that is utilized in the treatment of dermatological conditions, pneumocystis pneumonia, and toxoplasmosis. Methemoglobinemia is a known but rare complication of dapsone therapy that can result in cyanosis. We present a case of a patient on dapsone therapy who developed hypoxia due to methemoglobinemia. This case emphasizes the importance of knowledge of drugs likely to cause methemoglobinemia which requires clinicians to have a high degree of suspicion especially when the patient's oxygen saturation does not improve with treatment.

Flexural Exanthema From Enfortumab Vedotin.

Urothelial malignancies are commonly treated with platinum-based therapies. Newer trials have tested antimitotic therapies such as enfortumab vedotin as viable treatment therapy for refractory malignany. Enfortumab vedotin targets nectin-4, a member of a family of calcium-dependent, immunoglobulin-like adhesion molecules found in adherens junctions and expressed in various epithelial malignancies, including bladder, breast, lung, ovarian, head/neck, and esophageal cancers. We present a case of a patient with symmetrical drug-related intertriginous and flexural exanthema secondary to enfortumab. He was successfully treated with topical corticosteroids. Cutaneous toxicity appears to be a common adverse reaction in this growing class of antibody-drug conjugates.

Lymphocele Containing Staphylococcus lugdunensis.

Staphylococcus species are a leading cause of community-acquired bacteremia. Of them, the most serious cause of mortality is from methicillin-resistant Staphylococcus aureus, with mortality rates as high as 40%. Another Staphylococcus species that has been noted to cause equal levels of infection and mortality is Staphylococcus lugdunensis (S. lugdunensis). It can cause harmless skin infections to life-threatening endocardial complications. We would like to report a rare presentation of S. lugdunensis bacteremia from a lymphocele that developed post surgery. An 80-year-old male presented to the emergency department with complaints of abdominal pain and fevers. Cultures of lymphocele fluid grew S. lugdunensis. A computed tomography of the abdomen and pelvis with contrast showed the presence of a large lymphocele. S. lugdunensis is a coagulase-negative staphylococci normally known to be a skin colonizer. Over the years, it has shown to cause a wide variety of infections especially involving prosthetic joints and heart valves. S. lugdunensis has been noted to be highly susceptible to penicillins, such as oxacillin, erythromycin, linezolid and a wide a variety of other antibiotics. S. lugdunensis produces a biofilm that makes treatment challenging even with susceptible antibiotics. However, the data on S. lugdunensis is growing as more case reports are being published in regards to source and susceptibilities.

A retrospective analysis of the effect of intraoperative opioid dose on cancer recurrence after non-small cell lung cancer resection.

Preclinical studies have demonstrated that opioid receptor agonists increase the rate of non-small cell lung cancer (NSCLC) growth and metastasis. Following institutional review board approval, we retrieved data on 901 patients who underwent surgery for NSCLC at MD Anderson Cancer Center. Comprehensive demographics, intraoperative data, and recurrence-free survival (RFS) and overall survival (OS) at 3 and 5 years were obtained. Cox proportional analyses were conducted to assess the association between intraoperative opioid exposure and RFS and OS. The median intraoperative fentanyl equivalents dosage was 10.15 µg/kg. The multivariate analysis by stage indicated that a trend toward significance for opioid consumption as a risk factor in stage I patients (P = 0.053). No effect was found on RFS for stage II or III patients. Alternatively, opioid consumption was a risk factor for OS for stage I patients (P = 0.036), whereas no effect was noted for stage II or III patients. Intraoperative opioid use is associated with decreased OS in stage I but not stage II-III NSCLC patients. Until randomized controlled studies explore this association further, opioids should continue to be a key component of balanced anesthesia.

Perioperative beta-blocker use and survival in lung cancer patients.

STUDY OBJECTIVE: To assess the effect of perioperative beta blockers on recurrence and overall survival after non-small cell lung cancer surgery. DESIGN: Retrospective study. SETTING: Academic medical center. MEASUREMENTS: The medical records of patients with stage 1, 2, and 3a non-small cell lung cancer were divided into three different groups: those patients who never received beta blockers perioperatively, those receiving nonselective beta blockers within 60 days of surgery, and those taking selective beta blockers within 60 days of surgery. Recurrence-free survival and overall survival were the main clinical endpoints. Univariate log-rank tests and multivariate Cox proportional hazards models were used to assess the effects of selective beta blockers, nonselective beta blockers, or no beta blockers on recurrence-free survival and overall survival. MAIN RESULTS: The analysis included records of 435 patients. Univariate analyses showed that the use of both selective and nonselective beta blockers was associated with decreased recurrence-free survival (P = 0.014) and overall survival (P = 0.009). However, these findings were not sustained after adjusting for possible confounding variables in the multivariate analysis. The hazard ratios for recurrence-free survival (selective beta blockers vs no beta blocker use were: 1.304; 95% confidence intervals [CI] 0.973 - 1.747; P = 0.075; for nonselective beta blockers vs no beta blockers: 0.989; 95% CI 0.639 - 1.532; P = 0.962. The hazard ratios for overall survival were: selective beta blocker use vs no beta blockers: 1.335; 95% CI 0.966 - 1.846; P = 0.080; nonselective beta blocker use vs no beta blocker use: 1.108; 95% CI 0.678 - 1.812; P = 0.682. CONCLUSION: Administration of beta blockers during the perioperative period did not improve recurrence-free or overall survival in patients undergoing resection of non-small cell lung cancer.

Effects of postoperative epidural analgesia on recurrence-free and overall survival in patients with nonsmall cell lung cancer.

STUDY OBJECTIVE: To determine whether postoperative epidural analgesia is associated with better recurrence-free survival and overall survival after lung cancer surgery. DESIGN: Retrospective study. SETTING: Academic hospital. MEASUREMENTS: Data of patients with stage 1, stage 2, and stage 3 nonsmall cell lung cancer, who underwent tumor resection surgery, were studied. Patient data were grouped into three different postoperative pain management interventions: intravenous patient-controlled analgesia, patient-controlled epidural analgesia, and their combination. Univariate and multicovariate Cox proportional hazards models were applied to assess the effects of covariates of interest on overall survival and recurrence-free survival. MAIN RESULTS: The type of postoperative analgesia used for patients who underwent surgery for nonsmall cell lung cancer did not affect recurrence-free survival or overall survival. However, certain variables, including age ≥ 65 years, male gender, body mass index ≥ 25 kg/m(2), ASA physical status 4, and the need for preoperative blood transfusions, pneumonectomy, and postoperative radiation, were associated with decreased recurrence-free survival and overall survival. CONCLUSIONS: The type of postoperative analgesia used after surgery for nonsmall cell lung cancer is not associated with better 2-year or 5-year recurrence-free survival or overall survival rates.