Placental and Breast Metastasis of Squamous Cell Carcinoma in a Patient With Recurrent Respiratory Papillomatosis.

Recurrent respiratory papillomatosis (RRP), which is usually benign, is an intractable disease characterized by recurrent papillomas (wart-like lesions). Although it most commonly involves the mucosal epithelial lining of the upper respiratory tract, on rare occasions, it can also involve lung parenchyma. RRP carries the risk of malignant transformation, most often to non-small-cell squamous lung cancer. Here, we present the case of a 32-year-old pregnant female with a past medical history of RRP who developed mild respiratory distress during her immediate postpartum period. This prompted imaging of the chest which revealed right lower lobe hypodensities with extensive hilar and perihilar lymphadenopathy. Histopathology of the bronchial specimen showed squamous cell carcinoma with 100% programmed death-ligand 1 (PD-L1) expression. Gross examination of the patient's placenta showed multiple tan-colored nodules which was confirmed on histopathological examination as multifocal regions of squamous cell carcinoma metastatic from the lung. The patient underwent a staging positron emission tomography (PET) scan which showed hypermetabolic regions in the right middle and lower lobes of the lung, with avidity in the right paratracheal region and an enhancing lesion in the left breast. Biopsy from the breast lesion was also positive for squamous cell carcinoma and PD-L1. She was diagnosed with Stage IVB (T1c, N3, M1c) non-small-cell squamous lung cancer and was started on pembrolizumab. Carboplatin and paclitaxel were added after an initial mixed response to therapy. The patient was non-compliant with her updated treatment regimen as well as with outpatient follow-up visits. A restaging PET scan demonstrated an inadequate response to the amended immunotherapy/chemotherapy regimen. Ultimately, she passed away within one and a half years of her initial diagnosis. Malignant transformation of papillomatous lesions into squamous cell cancer is infrequent, and the occurrence of metastasis to the breast and/or placenta is exceptionally rare. To our knowledge, this is the first reported case of placental and breast metastasis of squamous cell lung cancer in a patient with RRP.

Severe Epistaxis Secondary to Dabrafenib and Trametinib Toxicity in Non-small Cell Lung Carcinoma With Small Bowel Metastasis.

BRAF mutations are estimated to be present in 2-4% of non-small cell lung carcinoma (NSCLC) cases. BRAF inhibitor (dabrafenib) and MEK inhibitor (trametinib) are currently approved to treat NSCLC harboring the BRAF V600E mutation. However, the use of this new combined targeted therapy can be associated with severe and life-threatening toxicities. Here, we describe the case of a 77-year-old male with a history of BRAF-positive lung adenocarcinoma with metastasis to the brain, adrenals, and small bowel (jejunum), currently on dual therapy with dabrafenib and trametinib, who presented with refractory epistaxis. The dual therapy regimen was started one month prior to his presentation. After initial stabilization with anterior nasal packing, intravenous and nebulized tranexamic acid (TXA) in the emergency department (ED), he suddenly developed respiratory decompensation. He needed emergent intubation for acute hypoxic respiratory failure and airway protection secondary to profuse bleeding. He was extubated 24 hours later as the epistaxis was manageable, and the nasal packing was removed. Shortly after extubating, he started coughing copious amounts of blood and developed respiratory distress with stridor requiring re-intubation. A large blood clot was noted to be partially occluding the vocal cords on laryngoscopy and was removed during intubation. An emergent flexible fiberoptic bronchoscopy was performed with the retrieval of a large blood clot extending from the oropharynx down into the distal trachea. There was no evidence of acute bleeding within the lung after the clot was removed. Workup to explore the cause of his bleeding included a coagulation profile, which was unrevealing. His bleeding was most likely consistent with a side effect of his treatment with dabrafenib and trametinib. Life-threatening bleeding has been reported as a side effect of the combination therapy with dabrafenib and trametinib in metastatic melanoma. Also, in the phase 2 clinical trial (BRF113928) of dabrafenib plus trametinib in patients with previously untreated BRAF V600E-mutant metastatic NSCLC, 3.2% of subjects developed a grade III or IV hemorrhage. Our case aims to raise physicians' awareness of one of the significant side effects of this combination therapy especially since this combination is being used more frequently and now also in lung cancer.

Idiopathic linear IgA bullous dermatosis treated with prednisone.

We present a case of a 43-year-old man with a medical history of paroxysmal atrial fibrillation that presented with acute onset generalised vesiculobullous rash of 1-week duration. The rash was initially noticed on his groin and then spread to his hands, feet and mucosal surfaces. Laboratory tests were unremarkable, including an extensive infection aetiology work-up. Punch biopsies were obtained of a fresh lesion and were stained with H&E and sent for direct immunofluorescence. Light microscopy and immunofluorescence study demonstrated a subepidermal blister with predominant neutrophilic infiltrates and a linear band of IgA at the dermoepidermal junction, respectively. The patient was diagnosed with linear IgA bullous dermatosis and was subsequently treated with 0.5 mg/kg of prednisone daily following previous case reports. At 1-week follow-up as an outpatient, the bullae became crusted, and the rash was nearly completely regressed.

Scombroid pancreatitis from mahi-mahi consumption.

A 61-year-old woman with no significant previous medical history presented to an urgent care facility with generalised rash, flushing and abdominal pain after eating mahi-mahi. She was diagnosed with an allergic reaction and discharged home. Later she experienced severe acute abdominal pain and multiple episodes of vomiting, which prompted her to go to the hospital. On admission, the patient had an elevated white count, lipase, amylase and C reactive protein with normal liver enzymes and bilirubin. Imaging showed acute pancreatitis that was suspected to be secondary to scombroid poisoning. This was confirmed by elevated immunoglobulin E and histamine levels. The acute pancreatitis was treated with pain management and supportive treatment. Scombroid poisoning is a well-recognised disease, however, acute pancreatitis secondary to this is rare as only two cases have been reported in the literature, one with codfish and the second an unknown type of fish.