A Rare Case of Pembrolizumab Associated Encephalopathy.

We present a unique case of a 55-year-old man with confusion thought to be due to pembrolizumab which he was receiving for renal cell carcinoma. His workup for other possible etiologies for encephalopathy was negative. He was treated with high dose intravenous methylprednisolone followed by prednisone taper and intravenous immunoglobulin with gradual improvement in his mentation.

A Rare Case of Idiopathic Systemic Capillary Leak Syndrome.

Idiopathic systemic capillary leak syndrome (SCLS) is characterized by an increased capillary hyperpermeability with subsequent hemoconcentration, hypoproteinemia, and hypovolemia. Patients present with diffuse swelling, weight gain, low blood pressure, and shock. We present our case of idiopathic SCLS in a 50-year-old man presenting with prodromal flu-like illness associated with shock that was complicated by compartment syndrome requiring four limb fasciotomies, disseminated intravascular coagulation, acute kidney injury requiring dialysis, and cardiac arrest.

Brain Stem Encephalitis in a Patient With Recurrent Small Cell Lung Cancer Treated With Immune Checkpoint Inhibitor: Case Presentation and Review of the Literature.

Immunotherapy with checkpoint inhibitors (CPIs) has revolutionized the management of advanced cancer including advanced small cell lung cancer (SCLC). Unfortunately, those agents are not without adverse effects. Immune imbalance through enhanced cellular immune response may result in impaired endogenous immunological tolerance mechanisms that can result in a wide spectrum of immunological side effects also known as immune-related adverse events (irAEs). Scarce data are currently available about neurological immune-related adverse events (neuro irAEs), mainly obtained from clinical trials, case reports, or small case series. Most reported cases presented with nonspecific symptoms. It is important to recognize and promptly treat neuro irAEs, as it may be serious and even potentially fatal. We present a rare case of nivolumab induced brain stem encephalitis in a patient with advanced SCLC presented 10 months after starting treatment with symptoms of nystagmus, gait disturbance, and blurry vision. Nivolumab was held and the patient was started on oral steroids with tapering dose. The patient's symptoms gradually improved over a few weeks. Re-challenging with nivolumab six weeks later resulted in recurrence of symptoms and again the patient was prescribed oral steroids with tapering dose. She maintained response off treatment for six months. This case report is aimed to highlight the importance of clinically suspecting and promptly treating neurological irAE, when managing a patient with CPIs.

A Rare Case of Pseudo-Meigs' Syndrome With Ovarian Metastasis Presenting as Meigs' Syndrome.

Pseudo-Meigs' syndrome is defined as malignant ovarian tumor leading to ascites or/and pleural effusion, whereas Meigs' syndrome is a triad of ascites, pleural effusion, and benign ovarian tumor. The removal of an underlying tumor leads to rapid improvement in patient symptoms in both conditions. It is a rare phenomenon, and only 1% of ovarian tumors account for Meigs' syndrome. We report a case of a 70-year-old female presented with complaints of shortness of breath, vaginal bleeding, bloating, and increased abdominal girth. X-ray and lab workup revealed pleural effusion and raised CA 125 (cancer antigen 125), which along with clinical presentation raised suspicion for Meigs' syndrome, but on exploratory laparotomy ovarian serous carcinoma was diagnosed. Diagnosis of pseudo-Meigs' syndrome was established instead of Meigs' syndrome, which was initially suspected. Pseudo-Meigs' syndrome can mimic many other pathologies, which makes it a diagnostic challenge.

Recurrent nonbacterial thrombotic endocarditis and stroke on anticoagulation.

We present a rare case of recurrent nonbacterial thrombotic endocarditis (NBTE) and stroke despite anticoagulation. A 48-year-old man with history of antiphospholipid syndrome, prior nonbacterial aortic valve endocarditis status post valve replacement and prior stroke was found to have acute ischemic stroke while on apixaban and nonbacterial thrombotic endocarditis of mitral valve. This was initially managed conservatively with therapeutic dose of enoxaparin, but the patient later underwent mitral valve replacement. Unfortunately, the patient later passed away with hemorrhagic stroke while on enoxaparin.

Legionnaires Disease Presenting as Diarrhea: A Case Report.

Legionnaires disease is primarily a pneumonic illness with possible multisystem involvement. Major risk factors include immunodeficiency, smoking, alcoholism and chronic obstructive pulmonary disease among others. We report a peculiar case of Legionnaires disease presenting with diarrhea as the chief complaint and no respiratory symptoms throughout the course of disease. The patient had no risk factors for the disease and had no recent travel history or sick contacts. Acute diarrhea is not an uncommon manifestation of Legionnaires disease, although isolated diarrhea symptoms with the absence of concurrent respiratory symptoms and no risk factors for Legionella makes this case a diagnostic challenge, leading to possible delay in appropriate management. We are presenting this case to inform physicians of the possibility of Legionnaires disease presenting as an isolated gastrointestinal involvement with no clinical symptoms of pneumonia at presentation.

Superior Mesenteric Artery Syndrome: A Classic Presentation of a Rare Entity.

A 32-year-old female with a past medical history of constipation (predominant irritable bowel syndrome (IBS) and gastro-esophageal reflux disease (GERD)) presented with a complaint of pain in the lower abdomen. She lost 20 pounds in three months with a current body mass index (BMI) of 19.5 kg/m2 (ref: normal level 18.5-24.9). Computed tomography (CT) of the abdomen with contrast showed very little intra-abdominal fat, enlarged proximal duodenum, and decreased aorto-mesenteric angle of 15.40 suggestive of superior mesenteric artery (SMA) syndrome. Per general surgery, the patient was managed conservatively: initially Nil Per Os (NPO), slowly transitioned to a clear liquid diet, soft diet, and solid diet. She tolerated the diet, improved clinically, and was discharged home.

An Unusual Case of Evolving Localized Tetanus Despite Prior Immunization and Protective Antibody Titer.

Centers for Disease Control and Prevention has reported that tetanus infection in a fully immunized person with the last dose within 10 years is extremely rare. The prevalence of localized tetanus in such a scenario is unknown. Only two case reports of localized tetanus in previously immunized patients have been reported so far, making this the third one. Also, this is the first case of its kind to demonstrate evolving localized tetanus. Our patient is a 19-year-old man who presented with shortness of breath, pain in right upper extremity, shoulder, and neck. His chest X-ray and creatine kinase were normal. The patient was sent home. He presented again to our hospital two days later with difficulty swallowing and speaking as well as chest tightness. Routine blood tests, electrocardiogram, CT angiography of the chest, and transthoracic echocardiogram were normal. He gave a history of a cut in the right middle finger while removing the carpet a week before his presentation. His immunization history was complete with documented last tetanus shot nine years and two months ago. He was treated with tetanus vaccine and penicillin. His tetanus antitoxoid titer came out protective.

Obstructive Sleep Apnea: Risk Factor for Arrhythmias, Conduction Disorders, and Cardiac Arrest.

Background Obstructive sleep apnea (OSA) has been described as a risk factor for cardiac arrhythmias. Its association with atrial fibrillation has been established. However, relationships with other arrhythmias and conduction disorders have not been fully studied. Methods We used the National Inpatient Sample database from 2009 to 2011 to explore the relationship between OSA and arrhythmias and conduction disorders. The presence of diagnosis was determined based on the International Classification of Disease-9 (ICD-9) codes. Univariate and multivariate logistic regressions were used to establish mortality risks among all groups. Results Multivariate logistic regression showed increased mortality in patients with OSA in comparison to patients without OSA and patients across all categories of arrhythmias and conduction disorders. One significant finding was the increased association of cardiac arrest in patients with OSA versus patients without OSA (OR: 95.72; CI: 89.13-105.81, p < 0.001). Conclusions OSA is significantly associated with non-atrial fibrillation arrhythmias, conduction disorders, and sudden cardiac arrest. Awareness regarding this association is important for early screening for OSA in obese patients to prevent cardiovascular morbidity and mortality. The use of continuous positive airway pressure (CPAP) might be beneficial against all kinds of arrhythmias and sudden cardiac death.

A Sporadic Case of Disseminated Fusobacterium Causing Pylephlebitis and Intracranial and Hepatic Abscesses in a Healthy Young Patient.

Fusobacterium species is known for being a causative agent for Lemierre's syndrome, which is characterized by thrombophlebitis of the jugular vein. However, Fusobacterium species causing Lemierre's variant gastrointestinal syndrome has only been reported in case reports. We present a case of Fusobacterium causing hepatic vein pylephlebitis, multiple brain abscesses, and hepatic abscess. To the best of our knowledge, there have only been four other case reports of Fusobacterium causing hepatic abscesses with associated septic pylephlebitis in the literature.

Diffuse exanthematous drug eruption associated with intravenous immunoglobulin.

Diffuse exanthematous drug eruption due to intravenous immunoglobulin (IVIg) is a rare adverse event reported only in case reports. We present a case of a 71-year-old woman with a diffuse maculopapular rash 5 days after receiving an IVIg infusion for treatment of chronic inflammatory demyelinating polyneuropathy. She was managed conservatively with antihistamines; she was already receiving prednisone 25 mg daily as part of treatment for the neuropathy. The rash resolved over 2 weeks.

Yearly trend of acute venous thromboembolism in patients admitted with heart failure in the United States.

Introduction: Heart failure (HF) patients are at risk for venous thromboembolism (VTE) during the hospital stay. We aim to study the recent trend of deep vein thrombosis (DVT), pulmonary embolism (PE), and VTE in heart failure patients from years 2000-2013. Methods: We utilized the National (Nationwide) Inpatient Sample database and selected non-pregnant patients over the age of 18 years for this purpose. We selected HF, DVT, PE, and VTE based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). We used STATA for analysis. Results: We noted an increase in prevalence of DVT, PE and composite VTE among HF hospitalizations from 0.55%, 0.17% and 0.76% in 2000 to 0.96%, 0.4% and 1.46%, respectively, in 2013 and a decrease in trend of mortality among HF hospitalizations associated with DVT, PE and VTE from 8.95%, 16.36% and 10.80% in 2000 to 6.78%, 7.92% and 7.20%, respectively, in 2013. Conclusion: Increasing prevalence of VTE is concerning and suggests that we still need to work on delivering prophylaxis to all HF inpatients.

Acute generalized exanthematous pustulosis: a rare side effect of clindamycin.

Introduction: Acute generalized exanthematous pustulosis (AGEP) is a rare adverse effect of clindamycin characterized by widespread papules and pustulosis 1 - 3 weeks of its use. Case description: We present a case of a 71-year-old woman diagnosed with AGEP after clindamycin use for a tooth infection. She had been started on empiric prednisone without benefit. She did not have any systemic involvement and had an unremarkable blood work . Her rash resolved completely in a month.

Influence of abnormal potassium levels on mortality among hospitalized heart failure patients in the US: data from National Inpatient Sample.

Background: Abnormalities in serum potassium levels have been associated with variable mortality risk among hospitalized patients with heart failure (HF). We aim to use a large database study to further characterize risk of mortality, demographic factors, and associated comorbidities among heart failure inpatients. Methods: Our sample population was from the US National Inpatient Sample database from the year 2009-2011. The inclusion criteria used to identify patients was those with a diagnosis of heart failure as per ICD-9 classification. Other demographic factors considered in data collection included income, and cardiac risk factors. Taking these factors into consideration, a univariate association of potassium level and mortality was performed, as well as multivariable logistic regression controlling for demographic factors and associated conditions. Results: Of the 2,660,609 patients who were discharged with a diagnosis of heart failure during this time period, patients with hypokalemia during hospitalization had increased mortality risk (OR: 1.96, 95% CI: 1.91-2.01) when compared with those with hyperkalemia who had decreased inpatient mortality risk OR: 0.94,95% CI: 0.91-0.96) versus those not coded for potassium abnormalities. This finding was significant even regardless of the etiology of the hypokalemia while the hyperkalemic patients were noted to have no difference or a decreased risk in all subtypes and groups. Conclusion: Unlike heart failure patients with hyperkalemia, those with hypokalemia are at an increased inpatient mortality risk. Whether our mortality findings translate to longer-term outpatient settings where significantly less monitoring is possible is a matter for further study.

Acute Tubulointerstitial Nephritis: A Case Report on Rare Adverse Effect of Pembrolizumab.

Pembrolizumab is a novel immune checkpoint inhibitor approved for use in non-small cell lung carcinoma. There have been a few cases that have associated adverse renal outcomes with pembrolizumab. We present a case of acute kidney injury in a patient on pembrolizumab who was noted to have acute tubulointerstitial nephritis on renal biopsy. Pembrolizumab was discontinued and the patient was started on long-term corticosteroids with a taper. Her renal function improved partially with treatment.

Takotsubo Cardiomyopathy Associated with Polycythemia Vera.

Takotsubo cardiomyopathy is characterized by transient apical ballooning with preserved basal ventricular function triggered by physical or emotional stressors. We present a case of a 75-year-old man referred to our facility for the management of acute myocardial infarction later diagnosed as takotsubo cardiomyopathy. We believe platelet-mediated adrenaline release from massive thrombocytosis might have been the precipitating factor for the pathogenesis of takotsubo cardiomyopathy.

Daptomycin associated eosinophilic pneumonia: case report and differential diagnoses.

Daptomycin is a bactericidal antibiotic approved for treatment of gram-positive skin and soft tissue infections. We present a case of an 89-year-old man who presented with fever, shortness of breath and nonproductive cough on week 4 of starting daptomycin for infective endocarditis. Computerized tomography scan showed bilateral interstitial infiltrates predominantly affecting the lower lobes. He also had peripheral eosinophilia of 6%. He was diagnosed with eosinophilic pneumonia secondary to daptomycin use. His symptoms improved with discontinuation of daptomycin and initiation of corticosteroids. Clinical correlation of pneumonia-like presentation with recent use of daptomycin should make physicians rule out this rare adverse effect for early institution of correct treatment.

Multifactorial aetiology for non-uremic calciphylaxis: a case report.

Calciphylaxis is commonly associated with end-stage renal disease patients on haemodialysis. We present a rare case of calciphylaxis in a non-uremic patient. The diagnosis was made clinically and confirmed with skin biopsy showing calcification of the dermal and subcutaneous tissues in the von Kossa stain. We believe that the combination of uncontrolled diabetes mellitus, a non-functioning paraganglioma and vitamin D deficiency in a susceptible female patient was responsible for causing calciphylaxis in our patient. An index of suspicion should be maintained by clinicians for calciphylaxis even in patients without uremia.

A Rare Case of Spontaneous Empyema by Clostridium perfringens.

Empyema caused by clostridial infections is rare especially in the absence of invasive thoracic procedures. We present the case of an 81-year-old man without a history of preceding trauma who presented with shortness of breath and nonproductive cough and grew Clostridium perfringens only in the pleural cavity. He was predisposed to the infection due to his swallowing dysfunction. He was treated with penicillin and chest tube placement for drainage and subsequently improved.

Association between thyroid abnormalities and hypertension among hospitalized US patients: data from the National Inpatient Sample.

Abnormalities of thyroid, namely hyperthyroidism and hypothyroidism, are both associated with increased risk of hypertension. We utilized the National Inpatient Sample from the years 2012-2014 to explore the risk of thyroid disorders in relation to those without a thyroid diagnosis. We found that hypertension was more commonly associated with hyperthyroidism (odds ratio: 1.18; 95% confidence interval: 1.16-1.21, P<0.0001) than with hypothyroidism (odds ratio: 1.06; 95% confidence interval: 1.06-1.07, P<0.0001) when both were compared with hypertension without a thyroid diagnosis.