Sudden Cardiac Death in a Patient with Anomalous Origin of Right Coronary Artery with Concomitant Sinus of Valsalva Aneurysm.

Anomalous origin of right coronary artery (ARCA) arising from the left sinus of Valsalva (a congenital cardiac abnormality) and sinus of Valsalva aneurysm (SOVA) are rare and often have asymptomatic conditions. However, symptoms could range from chest pain, shortness of breath, palpitations, syncope to sudden cardiac death (SCD). The co-existence of these two anomalies (ARCA + SOVA) could lead to potential adverse outcomes in the absence of early intervention. The presence of these two conditions together increases the risk of SCD as reported in our case of a young male who presented to the emergency department with chest pain.

A Rare Case of Ipilimumab-induced Reversible Hypophysitis and Permanent Primary Hypothyroidism.

Ipilimumab is a monoclonal antibody targeting the cytotoxic T-lymphocyte antigen-4 receptor, which was originally approved for the treatment of metastatic melanoma. It is the first immune checkpoint inhibitor to enter clinical practice. Immune toxicity due to ipilimumab causing colitis, hepatitis, and dermatitis are well-described in literature. We report a case of hypophysitis resolving with corticosteroid treatment, following which the patient developed long-term primary thyroid impairment. This highlights the importance of vigilance for rarer immune-related toxicities as clinical utilization of ipilimumab becomes more widespread.

A bimodal approach to thymic carcinoma with pericardial sac invasion.

Thymic carcinoma is a rare tumour of the thymus, representing less than 1% of thymic malignancies. 1 It has an annual incidence of 0.15-0.32 per 1 00 000 person-years. 2 It is found incidentally in 30% of the patients as an opacity on chest X-ray or with non-specific complaints of persistent cough, chest pain, fatigue, shortness of breath, arm and facial swelling, and upper airway congestion related to tumour extension. We present the case of a 59-year-old man with a history of Graves' disease status post radiation treatment presenting with cough and left lingual opacity on chest X-ray, confirmed to be thymic carcinoma with pericardial invasion and lymph node metastasis. We aim to discuss the presentation, treatment modalities and outcome associated with this rare tumour.

A case of panitumumab containing chemotherapy causing interstitial lung disease: early recognition and treatment resulting in a good outcome.

Panitumumab is a recombinant human IgG2 monoclonal antibody which is used for the treatment of patients with metastatic colorectal cancer (mCRC) with disease progression on or following FOLFIRI (fluoropyrimidine, oxaliplatin and irinotecan) containing chemotherapy regimen. We report a case of an 83-year-old Hispanic man, non-smoker, with KRAS/NRAS wild-type mCRC of the liver who was treated with 9 cycles of FOLFOX4 (fluorouracil, leucovorin and oxaliplatin) and cetuximab. Follow-up abdominal imaging showed progression of CRC, requiring initiation of panitumumab in addition to FOLFIRI. After 2 cycles of this combination chemotherapy, he presented with acute hypoxaemic respiratory failure. Pulmonary imaging showed new onset of interstitial lung disease (ILD). He was treated with systemic corticosteroids with marked improvement of ILD. We aim to highlight the risk of severe life-threatening ILD associated with panitumumab. Early recognition of this serious adverse event helps avoid unnecessary administration of systemic antibiotics and prevent mortality.

Denosumab causing severe, refractory hypocalcaemia in a patient with chronic kidney disease.

Denosumab is a fully human monoclonal antibody that is being increasingly used for the treatment of osteoporosis and prevention of skeletal-related events (SREs) in bone metastases from primary tumours. It has improved efficacy, better tolerability and convenient administration via subcutaneous route, in comparison with bisphosphonates; however, it has been reported to cause severe hypocalcaemia in certain high-risk individuals. We report the case of a 71-year-old man with a history of haemodialysis-dependent end-stage renal disease who developed severe hypocalcaemia with electrocardiographic changes after being started on denosumab for prevention of SREs from a recently diagnosed metastatic prostate cancer. He was admitted to the hospital for close monitoring and received multiple doses of intravenous calcium gluconate, along with haemodialysis with high calcium bath. We aim to highlight the risk of severe, life-threatening hypocalcaemia associated with denosumab and to recognise patients at risk of developing this serious adverse effect, so that prompt treatment and preventive strategies can be implemented.