Acquired Factor VIII Deficiency in Chronic Myeloid Leukemia: A Case Report.

Factor VIII deficiency is mostly seen in hemophilia A, an X-linked recessive disorder. Patients would have a past medical history of bleeding diathesis or a family history of bleeding disorder. Acquired deficiencies of factor VIII are rare; some cases have been reported in solid malignancies. We present this case of acquired factor VIII deficiency in chronic myeloid leukemia (CML). A 72-year-old man was incidentally found to have leukocytosis at 31,000 and a platelet count of 3.2 million on a routine complete blood count (CBC). Prothrombin time (PT), international normalized ratio (INR), and partial thromboplastin time (PTT) showed an isolated elevation of PTT at 38.1 and a low factor VIII activity level at 39. The patient did not have any history or physical examination suggestive of bleeding diathesis. A bone marrow biopsy confirmed the BCR/ABL mutation, a diagnosis of CML was made, and the patient was started on dasatinib for one month. His PTT normalized after treatment for CML, suggesting a deficiency of factor VIII likely related to CML. The aim of this study is to highlight a case with acquired factor VIII deficiency due to CML and to emphasize the importance of coagulation workup in all newly diagnosed CML patients.

In-hospital mortality of heparin-induced thrombocytopenia in end-stage kidney disease. A retrospective national population-based cohort study.

AIM: Heparin induced thrombocytopenia (HIT) and end stage kidney disease (ESKD) are independent conditions associated with increased mortality and morbidity, however, whether ESKD is an independent risk factor for increased mortality in HIT admissions is not well studied. Therefore, we aimed to compare in-hospital mortality in HIT admissions based on their ESKD status. METHODS: This is a retrospective cohort study of HIT hospitalizations aged 18 and older using the 2016-2019 national inpatient sample (NIS) database. RESULTS: From 2016 to 2019 we had 12 161 admissions for HIT among 28 484 087 total hospitalizations. The annual incidence rate for HIT admissions per 100 000 admissions were: 47, 46, 41.1, and 36.6, respectively (p < .001) in 2016, 2017, 2018, and 2019 respectively. Among HIT admissions, the mean age was 64.3 years, 46.8% were females, 68% were Whites and 16% were Blacks. Black patients have a significantly higher likelihood of in-hospital mortality than White patients (aOR 1.25; 95% CI: 1.06, 1.48; p = .007). Patients who did not have any insurance or self-pay had higher mortality compared to Medicare (aOR 1.64; 95% CI: 1.13, 2.38; p = .009). ESKD status was not associated with higher or lower in-hospital mortality among HIT admissions (aOR 1.002; 95% CI: 0.84, 1.19; p = .981) after adjusting for age, sex, race, and insurance status. CONCLUSION: There are no higher or lower odds of in-hospital mortality in the ESKD subgroup in HIT admissions in adults. Decreasing incidence of HIT hospitalizations was seen over the years from 2016 to 2019.

Sex-based disparities and in-hospital outcomes of patients hospitalized with atrial fibrillation with and without dementia.

Study objective: We sought to evaluate the sex-based disparities and comparative in-hospital outcomes of principal AF hospitalizations in patients with and without dementia, which have not been well-studied. Design: This is a non-interventional retrospective cohort study. Setting and participants: We identified principal hospitalizations of AF in the National Inpatient Sample in adults (≥18 years old) between January 2016 and December 2019. Main outcome measure: In-hospital mortality. Results: Of 378,230 hospitalized patients with AF, 49.2 % (n = 186,039) were females and 6.1 % (n = 22,904) had dementia. The mean age (SD) was 71 (13) years. Patients with dementia had higher odds of in-hospital mortality {adjusted odds ratio (aOR): 1.48, 95 % confidence interval (CI): 1.34, 1.64, p < 0.001} and nontraumatic intracerebral hemorrhage (aOR: 1.60, 95 % CI: 1.04, 2.47, p = 0.032), but they had lower odds of catheter ablation (0.39, 95 % CI: 0.35, 0.43, p < 0.001) and electrical cardioversion (aOR: 0.33, 95 % CI: 0.31, 0.35, p < 0.001). In patients with AF and dementia, compared to males, females had similar in-hospital mortality (aOR: 1.00, 95 % CI: 0.93, 1.07, p = 0.960), fewer gastrointestinal bleeds (aOR: 0.92, 95 % CI: 0.85, 0.99, p = 0.033), lower odds of getting catheter ablation (aOR: 0.79, 95 % CI: 0.76, 0.81, p < 0.001), and less likelihood of getting electrical cardioversion (aOR: 0.78, 95 % CI: 0.76, 0.79, p < 0.001). Conclusions: Patients with AF and dementia have higher mortality and a lower likelihood of getting catheter ablation and electrical cardioversion.

All-cause and in-hospital mortality after aspirin use in patients hospitalized with COVID-19: a systematic review and meta-analysis.

Background: With the results of the largest randomized controlled trial (RECOVERY) and the most extensive retrospective cohort study on coronavirus disease 2019 (COVID-19) recently published, we performed a meta-analysis on the association of aspirin with mortality of COVID-19. We aimed to investigate the role of aspirin in COVID-19 hospitalizations. Materials and Methods: We searched PubMed, EMBASE and Cochrane databases for studies from 1 January 2020 until 20 July 2022, that compared aspirin versus non-aspirin use in hospitalized COVID-19 patients. We excluded case reports, review articles and studies on non-hospitalized COVID-19 infections. We used the inverse variance method and random effects model to pool the individual studies. Results: Ten observational studies and one randomized controlled trial met the criteria for inclusion. There were 136 695 total patients, of which 27 168 were in the aspirin group and 109 527 were in the non-aspirin group. Aspirin use was associated with a 14% decrease in all-cause mortality compared with non-aspirin use in patients hospitalized with COVID-19 [relative risk (RR) 0.86, confidence interval (95% CI) 0.76-0.97; P = 0.002; I 2 =64%]. Among subgroups of studies reporting in-hospital mortality in COVID-19 hospitalizations, aspirin use was associated with a 16% decrease in in-hospital mortality compared with non-aspirin use (RR 0.84, 95% CI 0.71-0.99; P = 0.007; I 2 =64%). Conclusion: Our study shows that aspirin decreases in-hospital mortality in patients hospitalized with COVID-19. Further studies are needed to assess which COVID-19 patient populations benefit most, such as patients on aspirin for primary versus secondary prevention of atherosclerotic disease. In addition, significant bleeding also needs to be considered when assessing the risk-benefit of aspirin use.

Meta-analysis examining phosphodiesterase-5 inhibitors in heart failure with preserved ejection fraction.

Patients with heart failure with preserved ejection fraction have reduced cyclic guanosine 3',5'-monophosphate (cGMP) levels compared to those with reduced ejection fraction. Phosphodiesterase-5 inhibitors may play a cardioprotective role by potentiating the cGMP pathway. To address this question, we conducted a systematic search for randomized trials using the electronic databases of PubMed, Embase, and Google Scholar and used RevMan (version 5.4) for the data analysis. We included 221 subjects in the phosphodiesterase group (mean age 69.2 ± 3.43 years; 58.82% male) and 202 subjects in the control group (mean age 70.4 ± 4.96 years; 53.46% male). The mean follow-up duration was 5.85 ± 3.43 months. The pooled results showed no significant differences in peak oxygen consumption, 6-minute walking distance, mitral annular E/e' ratio, left ventricular ejection fraction, mean pulmonary artery pressure, pulmonary artery systolic pressure, and pulmonary vascular resistance between the phosphodiesterase group and the control group.

Immune Thrombocytopenic Purpura (ITP) Following Natural COVID-19 Infection.

Immune thrombocytopenic purpura (ITP) has been linked to the COVID-19 vaccine series as a rare adverse event but has recently emerged in the literature as a sequela of natural COVID-19 infection. ITP is a diagnosis of exclusion where a diagnosis is made by having isolated thrombocytopenia (platelet count <100,000/µL) and no other identifiable etiology for the thrombocytopenia. We share the case of a young male without any history of hematological or immunological disorders presenting with severe, symptomatic thrombocytopenia following a natural COVID-19 infection. Patients should be made aware of the potential risk of adverse events with not only vaccination but also even mild cases of natural infection with COVID-19. An emphasis should be placed on the fact that the benefits of vaccination continue to outweigh the potential risks of adverse events, even in those with a pre-existing diagnosis of ITP.

A unique case of tachycardia-mediated cardiomyopathy in a patient misusing anabolic steroids.

A 54-year-old male patient with history of anabolic androgenic steroid (AAS) misuse presented to the emergency department with new-onset atrial fibrillation and severely reduced ejection fraction. Cardiac catheterization revealed normal coronaries. He underwent cryo-balloon ablation with subsequent conversion to sinus rhythm. After appropriate guideline-directed medical management, ejection fraction improved on follow-up.

Vaping-Induced Sepsis and Rapidly Evolving Pleural Effusion in a Young, Otherwise Healthy Male.

There have been increasing reports of electronic cigarette (e-cigarette) or vaping use-associated lung injury (EVALI), and the evolving literature demonstrates that the solvents used to dissolve flavors, including vitamin E, may be responsible, at least in part, for the injuries associated with this form of smoking. We present the case of a 26-year-old, otherwise healthy, African American male with a history of heavy use-cigarette use who presented with pleuritic chest pain. He was found to be septic and developed a rapidly accumulating pleural effusion with loculations during his hospitalization. He eventually underwent a thoracotomy due to his deteriorating respiratory status. This case highlights the importance of physician awareness regarding the growing evidence base suggesting that electronic cigarettes and vaporized tobacco products are not as safe as they have been perceived to be. Physicians should screen for and advise patients regarding the risks associated with the use of such products.

Restrictive versus Liberal Blood Transfusion Strategy in Patients With Acute Myocardial Infarction: A Meta-Analysis of Randomized Clinical Trials.

Background: A meta-analysis of observational studies comparing differences in outcomes between restrictive blood transfusion (RBT) and liberal blood transfusion (LBT) in patients with acute myocardial infarction (AMI) reported that LBT is associated with higher all-cause mortality. Few randomized clinical trials (RCTs) have compared RBT to LBT in patients with AMI and anemia, but no meta-analysis of RCTs was performed to date. Aim: To assess the clinical effect of RBT compared to LBT in patients with AMI and anemia regarding was all-cause mortality, recurrent MI, revascularization, and heart failure exacerbation. Methods: The electronic databases Ovid MEDLINE, EMBASE, Cochrane Central, Scopus, and Google Scholar, were systematically searched to identify eligible studies published before June 19th, 2021. RCTs that assessed the effect of RBT compared to LBT were included. The primary endpoint was all-cause mortality. Secondary endpoints included recurrent MI, revascularization, and heart failure exacerbation. Results: Three RCTs with 821 patients were included (421 received RBT, and 400 received LBT). The mean age was 75.9 ± 6.1 years, and 56% were male. Our meta-analysis showed that RBT was not associated with reduced all-cause mortality (RR = 1.61; 95% CI = 0.38-6.96, p = 0.52), recurrent MI (RR = 0.98; 95% CI = 0.48-1.96, p = 0.94), revascularization (RR = 1.18; 95% CI = 0.26-5.44, p = 0.83) and heart failure exacerbation (RR = 0.86; 95% CI = 0.23-3.22, p = 0.82) when compared to LBT. Conclusion: RBT was not associated with reduced all-cause mortality, recurrence of MI, need for revascularization, or heart failure exacerbation in patients with AMI and anemia compared to LBT. A larger RCT is required to confirm the above findings.

Electrolyte Abnormalities Associated With the Use of Atezolizumab - A Systematic Review.

Background and objectives: In recent years, immune-checkpoint inhibitors (ICIs) particularly atezolizumab is on the rise in treating advanced malignancies. With its increased clinical use, various electrolyte abnormalities have been reported in the literature. In this review, we have addressed the question of significant electrolyte abnormalities associated with atezolizumab. Materials and methods: Following PRISMA guidelines, we performed a thorough literature search in four databases including PubMed, Cochrane Library, Embase, and Clinicaltrials.gov. We included only randomized controlled trials from 2010 till March 2021. After a comprehensive screening of 1587 articles, we selected 14 articles for our review and tabulated the results. Following MeSH terms were used: "electrolyte abnormalities", "immune checkpoint inhibitors", "atezolizumab". Results: Non-small cell lung cancer (n = 1270) and metastatic urothelial carcinoma (n = 1164) were the most common malignancies among 3160 patients. The most common electrolyte abnormality was hypomagnesemia (4.7%). Hyponatremia, hypophosphatemia, hypercalcemia and hypokalemia were found in 2.3%, 0.63%, 0.25% and 0.06% patients respectively. For patients taking atezolizumab, hypomagnesemia was most frequently found in non-small cell lung carcinoma patients (9.4%), while urothelial metastatic carcinoma patients most commonly had hyponatremia (5.15%). Hypokalemia though insignificant was observed only in patients with metastatic renal cell carcinoma (2.85%). Conclusion: Since the use of atezolizumab is on the rise for the treatment of various cancers, more studies need to be conducted to better understand its safety and toxicity profile.

In-hospital mortality and length of stay among patients with infective endocarditis and solid organ transplant: A study from National Inpatient Sample 2016-2019.

Infective endocarditis (IE) is a rare but serious complication following a Solid Organ Transplant (SOT). Due to the lack of sufficient studies, we aimed to compare in-hospital mortality and length of stay (LOS) of patients primarily admitted for IE (index or principal hospitalization) with history of SOT, including the subgroup of heart or lung transplant (HLT), to those without a history of SOT (non-SOT) or HLT (non-HLT). We used the 2016-2019 National Inpatient Sample, the largest all-payer inpatient hospital data from Healthcare Cost and Utilization Project (HCUP), including patients 18 years or older with IE, as a principal diagnosis for hospitalization. From 2016 to 2019, there were 56,330 principal or index hospitalizations for IE. Among them, 0.6 % (n = 327) were SOT recipients, 0.1% (n = 68) were HLT recipients, and 41.4% were females. The mean age was 51.9 ± 19.2 years. Compared to non-SOT controls, SOT recipients were older (mean age 59.3 vs. 51.8 years; P = 0.002) and had higher Charlson-comorbidity-index (CCI) of 3 or more (87.7% vs. 33.2%; p < 0.001). SOT status was not statistically significant for a higher or lower odds of in-hospital mortality (adjusted odds ratio (aOR) 0.7; 95% confidence interval (CI): 0.2, 2.4; p = 0.60) or increased or decreased LOS (coefficient: -0.1, 95% CI: -0.4, 0.1; p = 0.23) among index IE hospitalizations after controlling for age, sex, race, hospital-region, hospital-teaching status, income, insurance status, and CCI. HLT status was also not associated with higher or lower odds of in-hospital mortality (aOR 1.4; 95% CI: 0.2, 13.1; p = 0.77) or increased or decreased LOS (coefficient: -0.1, 95% CI: -0.3, 0.5; p = 0.59). From 2016 to 2019, the rate of index IE hospitalization trends from 37.8 to 41.4 per 100,000 overall hospitalizations (p = 0.001). We found the rate of index IE hospitalizations increasing with time. Among index IE hospitalizations, SOT, including a subgroup of HLT recipients, have similar in-hospital mortality and LOS compared to non-SOT or non-HLT groups. We need a larger sample size to comment on outcomes of IE hospitalizations with the HLT subgroup.

The Mediport Paradox: Mediastinitis and Pericardial Effusion With a Misplaced Mediport.

Totally implantable subcutaneous devices (TISDs) have become excellent options for patients requiring long-term chemotherapy, parenteral nutrition, and fluid replacement. As with all invasive devices and procedures, they come with their inherent risks, which may manifest immediately or at a later point in time. We present the case of a 74-year-old female with a history of hypertension, chronic obstructive pulmonary disease (COPD), ischemic stroke, breast cancer, and lung cancer who had mediport placement for chemotherapy administration. She received several infusions of pembrolizumab through her mediport and developed progressive dyspnea over four weeks. Upon evaluation at our institution, she was found to have a misplaced mediport with mediastinitis and pericardial effusion due to direct mediastinal exposure to immunotherapy. This case highlights the importance of systematic imaging review, regardless of suspected pathology, and encourages providers to have a low threshold to re-evaluate patients after device placement or immunotherapy commencement.

Emergent Hemodialysis Followed by Continuous Renal Replacement Therapy: A Management Challenge in a Patient With Life-Threatening Metabolic Acidosis of Multifactorial Etiology.

Metabolic acidosis is a frequently encountered laboratory finding in daily clinical practice. Rapid pH correction is almost always preferred and necessary while performing workup to identify the causative factors. We present the case of a 73-year-old male presenting with progressive dyspnea and severe metabolic acidosis. He had a pH of 6.6, bicarbonate of 1.8 mg/dL, lactic acid of 18.1 mg/dL, and pCO2 of 14.1 mmHg. The intensivist and nephrologist made a joint decision to rapidly correct the pH using bicarbonate and emergent hemodialysis. Subsequently, continuous renal replacement therapy (CRRT) was started, leading to a favorable outcome. Our patient's most likely etiology of lactic acidosis was metformin because he had a very high lactic acid, high anion gap metabolic acidosis, and acute renal failure on presentation. From our case and literature review, we suggest using hemodialysis, CRRT, and bicarbonate replacement for a better prognosis in patients with critical acidosis in view of frank renal failure and concurrent metformin use.

The efficacy and safety of roxadustat for the treatment of anemia in non-dialysis dependent chronic kidney disease patients: An updated systematic review and meta-analysis of randomized clinical trials.

BACKGROUND: Roxadustat (ROX) is a new medication for anemia as a complication of chronic kidney disease (CKD). Our meta-analysis aims to evaluate the efficacy and safety of ROX, especially on the cardiovascular risks, for anemia in NDD-CKD patients. METHODS: Electronic databases were searched systematically from inception to July 2021 to look for randomized control trials (RCTs) that evaluated ROX NDD-CKD patients. Hemoglobin level and iron utilization parameters, including ferritin, serum iron, transferrin saturation (TSAT), total iron-binding capacity (TIBC), transferrin, and hepcidin were analyzed for efficacy. Pooled risk ratios (RRs) and standardized mean differences (SMDs) were calculated and presented with their 95% confidential intervals (CIs). RESULTS: Nine RCTs included a total of 3,175 patients in the ROX group and 2,446 patients in the control group. When compared the control group, ROX increased Hb level significantly (SMD: 1.65; 95% CI: 1.08, 2.22; P< 0.00001) and improved iron utilization parameters by decreasing ferritin (SMD: -0.32; 95% CI: -0.51, -0.14; P = 0.0006), TSAT (SMD: -0.19; 95% CI: -0.32, -0.07; P = 0.003), and hepcidin (SMD: -0.74; 95% CI: -1.09, -0.39; P< 0.0001) and increasing TIBC (SMD: 0.99; 95% CI: 0.76, 1.22; P< 0.00001) and transferrin (SMD: 1.20; 95% CI: 0.70, 1.71; P< 0.00001). As for safety, ROX was associated with higher serious adverse effects (RR: 1.07; 95% CI: 1.01, 1.13; P = 0.01), deep venous thrombosis (DVT) (RR: 3.80; 95% CI: 1.5, 9.64; P = 0.08), and hypertension (HTN) (RR: 1.37; 95% CI: 1.13, 1.65; P = 0.001). CONCLUSION: We concluded that ROX increased Hb level and improved iron utilization parameters in NDD-CKD patients, but ROX was associated with higher serious adverse effects, especially DVT and HTN. Our results support the use of ROX for NDD-CKD patients with anemia. However, higher-quality RCTs are still needed to ensure its safety and risk of thrombosis.

The Effect of Vasopressin and Methylprednisolone on Return of Spontaneous Circulation in Patients with In-Hospital Cardiac Arrest: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

INTRODUCTION: Cardiac arrest is often fatal if not treated immediately by cardiopulmonary resuscitation to restore a normal heart rhythm and spontaneous circulation. We aim to evaluate the clinical benefits of vasopressin and methylprednisolone versus placebo for patients with in-hospital cardiac arrest. DATA SOURCES: We searched PubMed, EMBASE, Scopus, Web of Science, Cochrane Central, and Google Scholar from inception to October 17, 2021, by using search terms included "Vasopressin" AND "Methylprednisolone" AND "Cardiac arrest". STUDY SELECTION AND DATA EXTRACTION: We included randomized controlled trials (RCTs) that compared vasopressin and methylprednisolone to placebo. The main outcomes were the return of spontaneous circulation (ROSC) and survival to hospital discharge. DATA SYNTHESIS: A total of three RCTs, with a total of 869 patients, were included. The pooled risk ratios (RRs) were calculated along with their 95% confidence intervals (CIs). Our result showed an increase in ROSC in patients who received vasopressin and methylprednisolone (RR = 1.32; 95% CI = [1.18, 1.47], p < 0.00001) when compared with the placebo group. However, there was no difference between both groups regarding survival to hospital discharge (RR = 1.76; 95% CI = [0.68, 4.56], p= 0.25). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: The current guidelines recommend epinephrine for patients with in-hospital cardiac arrest. Our meta-analysis updates clinicians about using vasopressin and methylprednisolone besides epinephrine, providing them with the best available evidence in managing patients with in-hospital cardiac arrest. CONCLUSION: Among patients with in-hospital cardiac arrest, administration of vasopressin and methylprednisolone besides epinephrine is associated with increased ROSC compared with placebo and epinephrine. However, high-quality RCTs are necessary before drawing a firm conclusion regarding the efficacy of vasopressin and methylprednisolone for patients with in-hospital cardiac arrest.

The cardiovascular outcomes of finerenone in patients with chronic kidney disease and type 2 diabetes: A meta-analysis of randomized clinical trials.

Recently, a few randomized control trials (RCTs) suggested that finerenone has been shown to reduce cardiovascular events in patients with CKD and DM-2. We aimed to analyze the cardiovascular benefits of using finerenone in patients with CKD and DM-2. Electronic databases were systematically searched to identify only RCTs comparing finerenone versus placebo. Pooled risk ratios (RR) and their 95% confidence intervals (CI) were calculated using random-effects models. Three RCTs were included, with a total of 13,847 patients. Compared with the placebo group, the use of finerenone was associated with significantly lower rates of cardiovascular events (RR: 0.88; 95% CI: 0.80, 0.96; p < 0.01), which was mainly driven by lower hospitalizations for heart failure (RR: 0.79; 95% CI: 0.66, 0.94; p = 0.01). However, there were no significant differences between groups in terms of cardiovascular death (RR: 0.88; 95% CI: 0.76, 1.02; p = 0.09), non-fatal myocardial infarction (RR: 0.91; 95% CI: 0.74, 1.12; p = 0.38), non-fatal stroke (RR: 0.99; 95% CI: 0.80, 1.22; p = 0.90).

Aortic valve insufficiency due to myxomatous degeneration: a case report and literature review.

Myxomatous degeneration is a non-inflammatory degenerative process leading to disruption of the fibrosa layer of the valve with acid mucopolysaccharide accumulation. This type of degeneration commonly affects the mitral valve leading to mitral regurgitation; however, few cases have been reported regarding myxomatous degeneration of the aortic valve leading to acute decompensated heart failure. We report a case of myxomatous degeneration of the aortic valve as an etiology of acute decompensated heart failure to highlight the importance of considering myxomatous degeneration as an underlying etiology of symptomatic aortic insufficiency. A 64-year-old female presented with progressively worsening dyspnea, cough, and peripheral edema over a one-month duration. Clinical evaluation and imaging studies revealed aortic valve regurgitation (AVR). Subsequent aortic valve replacement was performed. The histopathology report was consistent with myxomatous degeneration of the aortic valve. Upon symptom improvement, the patient was discharged home. Subsequent transesophageal echocardiogram demonstrated a normal hemodynamic profile across the bioprosthetic valve without aortic regurgitation or paravalvular leak. We highlight a unique presentation of heart failure secondary to myxomatous degeneration of the aortic valve. Furthermore, a review of available literature on myxomatous degeneration of the aortic valve was conducted to illustrate the importance of early diagnosis and proper treatment to improve the patients' quality of life.

Light Chain (AL) Cardiac Amyloidosis: A Diagnostic Dilemma.

Amyloidosis is a clinical condition characterized by amyloid fibril deposition into different organ systems. The most common types are light chain (AL) amyloidosis and transthyretin amyloidosis (ATTR) amyloidosis. Amyloidosis involves the heart with an incidence of 1.38 to 3.69 per 100,000 person-years and a prevalence of 14.85 per 100,000 person-years between 2004 and 2018. Diagnosis of cardiac amyloidosis can be made through cardiac imaging, including cardiac magnetic resonance imaging (CMR) and 99mTc-labeled pyrophosphate (PYP) cardiac scan. However, a tissue biopsy is frequently needed to confirm the diagnosis. Herein, we report such a case of cardiac amyloidosis. The patient presented with pericardial effusion and acute kidney injury as the initial presentation. The presumptive diagnosis was ATTR amyloidosis, but the endomyocardial biopsy confirmed the diagnosis of AL amyloidosis. The patient was started on bortezomib, cyclophosphamide, and dexamethasone therapy. We aimed to highlight the different diagnostic modalities of cardiac amyloidosis and the importance of obtaining tissue biopsy to confirm the amyloidosis type before starting the treatment.

Ipilimumab and Nivolumab induced ventricular tachycardia in a patient with metastatic renal cell carcinoma.

The immune checkpoint inhibitor (ICIs) as Nivolumab and Ipilimumab is a novel class of medication used in the management of several metastatic malignancies. ICIs can cause immune-related adverse events due to autoreactive T cell activation. Cardiovascular complications comprised myocarditis, conduction abnormalities, ventricular storm, and cardiomyopathy. Cardiomyopathy is one of the significant side effects highlighted in some of the case reports. The physicians should include autoimmune toxicities as the potential differential diagnosis in patients presenting with an unusual presentation and receiving ICIs. We report a case of a 66-year-old female with advanced renal cell carcinoma who developed cardiomyopathy and ventricular tachycardia from nivolumab and ipilimumab therapy.

Outpatient Management of COVID-19 With Monoclonal Antibody Therapy in a Young Renal Transplant Patient.

At baseline, solid organ transplant recipients are at an increased risk for infectious complications due to the complex immunosuppressive regimens. The available data in renal transplant patients who contract coronavirus disease 2019 (COVID-19) demonstrates dangerously high mortality rates (33%) in those who require hospitalization and/or ICU level care. Interestingly, the data for transplant patients who do not require hospitalization shows significantly lower mortality (3%) despite being on an immunosuppressive regimen. We present the case of a young male patient with a history of renal transplant who tested positive for COVID-19; he was mildly symptomatic with cough, sinusitis, and headache, was worked up as an outpatient, and treated as an outpatient with bamlanivimab monotherapy with no adjustment to his immunosuppressive regimen. This case aims to highlight the possibility of safely managing mild cases of COVID-19 in solid organ transplant patients receiving immunosuppression as an outpatient with monoclonal antibody (mAb) therapy.