Immune Checkpoint Inhibitor-Induced Colitis: How Long Does the Threat Last?

Delayed immune-related events (DIRE) occur after ≥90 days of discontinuation of immunotherapy. Pembrolizumab is a monoclonal antibody that targets the programmed cell death protein 1 (PD-1) receptor of lymphocytes and is used frequently in the management of multiple cancers. Immunotherapy-related adverse events (irAE) are common; most occur six to seven weeks after starting immunotherapy. However, DIRE could also arise months after the stopping therapy. Although many cases of immunotherapy-induced colitis have been reported, data on colitis DIRE is limited. We present the case of a 76-year-old gentleman with bladder cancer who received pembrolizumab and developed significant diarrhea after four months of discontinuation of immunotherapy. His workup included a sigmoidoscopy with a biopsy showing evidence of immune-related colitis. In addition, the patient received steroids achieving complete resolution of diarrhea.

Complete Genome Sequences of Actinobacteriophages Anaysia and Caviar.

Anaysia and Caviar are temperate siphoviruses isolated from soil using Gordonia terrae 3612 and Mycobacterium smegmatis mc2155, respectively. Anaysia's 52,861-bp genome carries 102 genes, while Caviar's 47,074-bp genome carries 79 genes. Based on gene content similarity, Anaysia and Caviar are assigned to phage clusters A15 and A3, respectively.

Diabetes, Active Disease, and Afternoon Serum Cortisol Levels Predict Cushing's Disease Mortality: A Cohort Study.

CONTEXT: Cushing's disease (CD) is a life-threating disease, with increased mortality in comparison with the general population. OBJECTIVE: This study aimed to evaluate standardized mortality ratios (SMRs) in CD patients. We also analyzed independent risk factors related to increased mortality. DESIGN: We conducted a longitudinal cohort study in a 3rd level specialty center, from 1979 to 2018, in patients with CD. RESULTS: From 1375 cases with a pathology diagnosis of pituitary adenoma, 191 cases had the confirmed diagnosis of CD (14%). A total of 172 patients completed follow-up, with a mean age at diagnosis of 33 ±â€…11 years, female predominance (n = 154, 89.5%), majority of them with microadenoma (n = 136, 79%), and a median follow-up of 7.5 years (2.4-15). Eighteen patients (10.5%) died, 8 of them (44%) were with active CD, 8 (44%) were under remission, and 2 (11%) were under disease control. Estimated all-cause SMR = 3.1, 95% confidence interval (CI) 1.9-4.8, P < 0.001. Cardiovascular disease was the main cause of death (SMR = 4.2, 1.5-9.3, P = 0.01). Multivariate Cox regression models adjusted for potential cofounders showed that diabetes (HR = 5.2, IC 95% 1.8-15.4, P = 0.002), high cortisol levels after 1600 hours at diagnosis (3.4, 2.3-7.0, P = 0.02), and active CD (7.5, 3.8-17.3, P = 0.003) significantly increased the risk of mortality. CONCLUSIONS: Main cause of CD mortality was cardiovascular disease. Main risk factors for mortality were uncontrolled diabetes, persistently high cortisol levels after 1600 hours at diagnosis, and active disease at last follow-up.

Dyshidrotic Eczema: A Common Cause of Palmar Dermatitis.

Dyshidrotic eczema (DE) or acute palmoplantar eczema is a common cause of hand and foot dermatitis in adults. It is a recurrent vesicular eruption affecting the soles, palms, or both. It is very pruriginous and generally appears suddenly. It creates vesicles that, on physical examination, can look similar to "tapioca pudding", which is the characteristic clinical feature of this disorder. It is more common in young adults and affects men and women equally. In this report, we present the case of a 56-year-old man with no relevant past medical history who presented to the hospital with vesicular lesions in his hands and maculopapular lesions in his arms and legs. The patient had characteristic lesions in his right hand consistent with DE and negative workup for bullous pemphigoid, scabies, and bacterial, fungal, and viral infections.

Bile Cast Nephropathy Secondary to Hemophagocytic Lymphohistiocytosis With Liver Failure.

Acute kidney injury (AKI) is a common complication seen in patients with hemophagocytic lymphohistiocytosis (HLH). More than half of patients with HLH require renal replacement therapy (RRT). There are four main causes of kidney dysfunction in HLH, which include acute tubular necrosis (ATN), hypoperfusion, tumor lysis syndrome (TLS), and HLH-related glomerulopathies. Bile cast nephropathy (BCN) is a known cause of kidney injury in patients with liver failure and hyperbilirubinemia. We present the case of a 58-year-old man who presented to the hospital with painless jaundice, choluria, acholia, and generalized malaise and was found to have hyperbilirubinemia and kidney injury in the setting of HLH, who underwent a renal biopsy showing bile salt casts with degenerating tubular lining cells consistent with BCN. This case highlights the importance of considering BCN as a cause of kidney injury when a patient with HLH presents with liver failure and elevated bilirubin levels.

High Molecular Weight ACTH-Precursor Presence in a Metastatic Pancreatic Neuroendocrine Tumor Causing Severe Ectopic Cushing's Syndrome: A Case Report.

Ectopic ACTH-secretion causing Cushing's syndrome is unusual and its diagnosis is frequently challenging. The presence of high-molecular-weight precursors throughout pro-opiomelanocortin (POMC) translation by these tumors is often not reported. We present the case of a 49-year-old woman with a 3-month history of proximal muscular weakness, skin pigmentation, and weight loss. Upon initial evaluation, she had a full moon face, hirsutism, and a buffalo hump. Laboratory workup showed hyperglycemia, hypokalemia and metabolic alkalosis. ACTH, plasma cortisol, and urinary free cortisol levels were quite elevated. Serum cortisol levels were not suppressed on dexamethasone suppression testing. An octreo-SPECT scan showed enhanced nucleotide uptake in the liver and pancreas. Transendoscopic ultrasound-guided biopsy confirmed the diagnosis of a pancreatic ACTH-secreting neuroendocrine tumor (NET). Surgical excision of both pancreatic and liver lesions was carried out. Western blot analysis of the tumor and metastases revealed the presence of a high-molecular-weight precursor possibly POMC (at 30 kDa) but not ACTH (normally 4.5 kDa). ACTH-precursor secretion is more frequent in ectopic ACTH-secreting tumors compared with other causes of Cushing's syndrome. Hence, the measurement of such ACTH precursors warrants further evaluation, especially in the context of ACTH-dependent hypercortisolism.

Tumor Lysis Syndrome Caused by Unrecognized Richter's Transformation of Chronic Lymphocytic Leukemia: Treatment With Venetoclax for Suspected Disease Progression.

Richter's transformation (RT) is defined as the transition of chronic lymphocytic leukemia (CLL) or small lymphocytic leukemia (SLL) into an aggressive lymphoma. The conversion generally leads to diffuse large B-cell lymphoma (DLBCL), but more aggressive forms such as Hodgkin lymphoma (HL) can also occur. RT is a rare complication of CLL. RT can be confused with CLL progression. Its identification is crucial because the management of lymphoma and CLL differ from each other. Furthermore, the use of certain agents for CLL such as venetoclax increases the risk of tumor lysis syndrome (TLS) in neoplasms with rapid replication such as DLBCL or CLL with hyperleukocytosis (blast crisis). We present the case of a 76-year-old man with a history of CLL on chemotherapy who developed fatigue, malaise, night sweats, chills, and unintentional weight loss for which he was started on treatment with venetoclax due to suspected clinical progression of his disease. The patient developed TLS, requiring hospitalization, and he was found to have an acute blast crisis. Also, his CLL was found to have been transformed into an aggressive DLBCL. This case highlights the importance of differentiating a true progression of CLL from RT into an aggressive lymphoma given that treatment would be different for the two and the prognosis with the transformation is worse.

Leukocytoclastic Vasculitis: An Early Skin Biopsy Makes a Difference.

Leukocytoclastic vasculitis (LCV) is an uncommon condition with a broad differential diagnosis. Although the clinical history, physical examination, and laboratory workup are pivotal when formulating a differential diagnosis of LCV, a skin biopsy is required in most cases to elucidate the cause. The diagnostic yield of a skin biopsy increases within the first 24 to 48 hours of the lesion onset indicating the importance of obtaining a prompt skin sample. We present the case of a 60-year-old man who presented to the emergency department with a three-day history of fevers, headaches, and a painful skin rash. He endorsed rhinorrhea and sore throat a week ago. Physical examination was notable for an erythematous papular rash with palpable violaceous purpura located mainly at the distal right leg and thigh. He also complained of painful bilateral hand edema. His complete blood count and chemistries were unremarkable. His C-reactive protein was 147 mg/L (normal value <8 mg/L), and sedimentation rate was 51 mm (normal value <15 mm). Immunoglobulin A was 509 mg/dL (normal value 82-460 mg/dL). Further workup including viral hepatitis serologies, antinuclear antibodies, complements, antineutrophil cytoplasmic antibodies, cryoglobulins, rheumatoid factor, and blood cultures yielded negative results. Therefore, it was believed that his rash was likely associated with his recent upper respiratory infection. A skin biopsy done on the first day of admission was positive for LCV without immunoglobulin A deposition. He was managed with prednisone and anti-inflammatory medications with improvement of his rash.

Spontaneous Tumor Lysis Syndrome Due to Endometrial Carcinoma.

Spontaneous tumor lysis syndrome (TLS) is a rare condition in solid tumors, particularly in endometrial carcinoma. Spontaneous TLS occurs without the use of cytotoxic therapy but is observed particularly in hematologic malignancies. Given the high morbidity and mortality associated with spontaneous TLS, it is crucial to identify and treat it promptly. There have been only four cases of spontaneous TLS reported to date in the literature from a uterine source. We present a 59-year-old female with a recently diagnosed endometrial carcinoma with neuroendocrine features by dilation and curettage who presented to the hospital with somnolence, decreased oral intake, and lower abdominal pain of three days duration. She was found to have sepsis secondary to endometritis and spontaneous tumor lysis syndrome by clinical and laboratory definitions (hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia). Signs of disease progression were found such as worsening retroperitoneal lymphadenopathy that corresponded with the suspected increased tumoral activity. We report the case of a solid tumor (endometrial) presenting with spontaneous TLS, which highlights the importance of the early identification and initiation of treatment.

Quality of life is significantly impaired in both secretory and non-functioning pituitary adenomas.

OBJECTIVE: To evaluate the quality of life (QoL) in patients with pituitary adenomas in comparison with healthy Mexican population QoL scores. DESIGN & MEASUREMENTS: Cross-sectional study using the short form 36 questionnaire (SF-36) in 175 patients with pituitary adenomas grouped by adenoma subtype and disease activity, and compared them with the healthy Mexican population normative QoL scores. PATIENTS: A total of 44 patients with non-functioning pituitary adenomas (NFPA), 48 with acromegaly, 53 with prolactinomas and 30 with Cushing disease (CD) were enrolled in this study. RESULTS: Mental and physical components scores (MCS & PCS) of SF-36 questionnaire were lower in patients with active disease in all adenoma subtypes (P < 0.03). A significant negative relationship between prolactin levels and MCS (r = -0.30, P < 0.01) and PCS (r = -0.41, P < 0.01) were found in prolactinomas. Patients with CD showed 24 hours urine-free cortisol levels negatively correlated with MCS (r = -0.43, P < 0.01) but not with PCS. No significant correlation was found between IGF-1 ULN and QoL scores in acromegaly. NFPA patients had lower QoL scores than patients with controlled CD, acromegaly or prolactinoma (P < 0.02). Active CD and prolactinoma have lower QoL scores in comparison of NFPA (P < 0.05). Having an adenoma, secretory or non-functioning, decrease QoL scores in comparison of results in the healthy Mexican population register. Using an adjusted-multivariate model, we confirmed that disease activity in all secretory adenomas is an independent risk factor, reducing SF-36 scores significantly. CONCLUSION: Activity in all secretory pituitary adenomas' patients decrease mental and physical QoL. However, independently of disease activity, secretory and NFPA significantly decrease QoL in comparison with healthy Mexican population QoL register.

Evolución del proceso de afrontamiento y adaptación en adultos hospitalizados que experimentaron un trauma músculo esquelético por accidentes de tránsito / The evolution of coping and adaptation in hospitalised adults who have suffered traffic accident-related musculoskeletal trauma

Objetivo: Explorar la evolución del proceso de afrontamiento y adaptación de 11 casos de adultos que experimentaron un trauma músculo esquelético, por accidentes de tránsito, durante la estancia hospitalaria en la Clínica Universidad de la Sabana en 2015. Método: Estudio de casos que permitió describir y comparar el proceso de afrontamiento y adaptación en 11 personas. Se aplicó la Escala de medición del proceso de afrontamiento y adaptación versión abreviada en español, al ingreso y al egreso hospitalario. En esta investigación se tuvo en cuenta los principios éticos correspondientes, se obtuvo el consentimiento informado de los participantes y las autorizaciones de la Subcomisión de Investigación de la Facultad de Enfermería y Rehabilitación de la Universidad de la Sabana y de la Clínica donde se llevó a cabo el estudio. Resultado: Los hallazgos de este estudio muestran para ocho de los once casos una tendencia a mantenerse en nivel alto de afrontamiento o a pasar de nivel medio a alto desde el ingreso hasta el egreso hospitalario. Conclusión: La mayoría de los casos tuvo un proceso de afrontamiento y adaptación dirigido al problema, donde se encontró interés por resolver dudas relacionadas con la situación antes de actuar, utilización de experiencias pasadas consideradas como útiles, adopción de nuevas habilidades para afrontar las situaciones difíciles y el uso de soluciones alternativas y recursos (AU)

Objective: Exploring the evolution of coping and adaptation strategies by 11 cases of adults who had suffered traffic accident-related musculoskeletal trauma during their stay in hospital at Clínica Universidad de la Sabana during 2015. Methods: Studying the aforementioned cases enabled describing and comparing the 11 patients' coping and adaptation strategies. The abridged Spanish version of Roy's Coping Adaptation Processing Scale (CAPS) was used for measuring such strategies; it was used on patient admission to and discharge from hospital. This research took the relevant ethical principles into account; the patients gave their written informed consent and the Universidad de la Sabana and its hospital where the study was carried out authorised the study (i.e. the Faculty of Nursing and Rehabilitation's Research Subcommittee). Results: This study's findings showed that eight of the eleven cases maintained a high coping ability, or improved from moderate (on admission to hospital) to high level ability (on discharge). Conclusion: Problem-centred coping and adaptation strategies were involved in most cases. Patients approached this through resolving situation-related questions before acting, using past experiences considered useful, adopting new skills to cope with difficult situations and using alternative solutions and resources (AU)