ABSTRACT
Pembrolizumab is an immune checkpoint inhibitor being increasingly used as immunotherapy for a multitude of cancers. With the increasing use of these agents, various immune-related adverse events are being recognized. Lichenoid reaction, pruritus, and eczema are well-established cutaneous side effects of pembrolizumab, but bullous pemphigoid (BP) is a rare side effect of the drug. It is difficult to establish this diagnosis because it needs a detailed history of the timeline of the evolution of symptoms and careful ruling out of other etiologies, especially other drugs. Here, we present the case of a 66-year-old male who developed BP after receiving pembrolizumab therapy for non-small-cell lung cancer. Discontinuation of pembrolizumab and the use of topical and systemic steroids led to the complete resolution of symptoms. Physicians should be aware of this potential complication and keep it on their differential diagnosis when treating patients on immune checkpoint inhibitors.
ABSTRACT
Pituitary apoplexy (PA) is an expansion of a pituitary adenoma due to infarction or hemorrhage of the gland. The term apoplexy usually describes larger bleeds leading to a sudden onset of symptoms. Although it is a rare condition, it can be a life-threatening emergency. PA usually presents with severe headache, nausea, vomiting, visual acuity, and field defects, frequently involving the cranial nerves directly adjacent to the pituitary gland, including third (oculomotor) cranial nerve, fourth (trochlear) cranial nerve, ophthalmic and maxillary branches of the fifth (trigeminal) cranial nerve, and, less commonly, the sixth (abducens) cranial nerve. Here, we present the case of a 36-year-old male who presented with a one-week history of worsening headache associated with double vision. On physical examination, the patient was noted to have left abducens nerve palsy. MRI brain showed anterior right T1 hyperintensity in the pituitary representing blood products. The patient was treated with analgesics and hormonal therapy with improvement in symptoms and eventual resolution of PA without the need for surgical intervention. PA is an unusual cause of acute isolated abducens nerve palsy which should be identified promptly as it is a life-threatening emergency that can be treated immediately with hormonal replacement followed by a decision to manage conservatively or surgically. The long-term follow-up includes endocrine assessment, visual assessment, and imaging surveillance.
ABSTRACT
Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by multiple episodes of venous and arterial thromboses or recurrent fetal losses in the presence of antiphospholipid antibodies against ß2GP1, frequently accompanied by moderate thrombocytopenia. Catastrophic APS (CAPS) is a severe manifestation of APS. COVID-19 may have an intense hypercoagulable state in critically ill patients. SARS-CoV2 may potentiate pathogenic APS effects, including the activation of endothelial cells, monocytes, platelets, and complement, resulting in a proinflammatory state and prothrombotic events. The endothelial tropism of SARS-CoV2 may also modify the clinical presentation of COVID-19 in susceptible individuals and trigger flares of underlying vascular diseases. We report a case of a 64-year-old woman with a history of triple-positive APS who had multiple thrombotic and bleeding episodes after being found to have a COVID-19 infection temporally associated with CAPS development that was successfully treated with eculizumab, preventing further macro- and microvascular thrombotic events at 1 month follow-up. Our case highlights the need for more research regarding the mechanism by which COVID-19 may potentiate APS and lead to the development of CAPS.
ABSTRACT
Type 1 interferons, especially interferon-beta, has been reported to be effective in COVID-19 patients in multiple randomized controlled trials. The aim of our meta-analysis and systematic review is to assess efficacy of subcutaneous IFN-beta in regards to mortality and discharge rate. Prospective, retrospective and randomized controlled trials were included. Primary outcomes measured were 28-day mortality and discharge rate. Secondary outcomes measured were mean hospital stay and post-intervention intubation rate. A thorough literature search was conducted in Medline, PubMed, Ovid journals, Google Scholar, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews from 1 April 2020 to 28 February 2021. Relative risk was calculated using both the Mantel-Haenszel method (fixed-effects model) and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test, based upon inverse variance weights. 7 studies were included in the meta-analysis and systematic review. The IFN-beta group did not improve the 28-day mortality (RR = 1.276; 95% CI: 1.106-1.472, p = 0.001) or the discharge rate (RR = 0.906; 95% CI = 0.85-0.95, p = < 0.001). The mean hospital stay was 11.95± 2.5 days in the interferon-beta group and 11.43 ± 3.74 days in the traditional treatment group. Likewise, interferon-beta did not add any advantage to post-intervention intubation rate (RR = 0.92; 95% CI = 0.7841-1.0816, p = 0.3154). Our findings revealed that use of subcutaneous interferon-beta is futile in COVID-19.
ABSTRACT
Typhlitis, also known as neutropenic enterocolitis, is a rare but serious condition characterized by inflammation of the cecum causing right lower quadrant (RLQ) pain and fever. It typically affects immunocompromised patients with neutropenia, hematologic malignancies, AIDS, or those on immunosuppressive therapy. This is an entity that should be considered in any differential for a patient with febrile RLQ pain, not just those with obvious immunosuppression.
ABSTRACT
Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that is used as one of the first-line antihypertensive medications. Necrotizing pancreatitis induced by the use of ACE inhibitors is an extremely rare occurrence. Although an uncommon risk factor, our aim is to further highlight that patients with chronic use of lisinopril can develop such complications and should be considered among the list of differential diagnoses for pancreatitis. A 53-year-old Caucasian male with a history of hypertension treated with lisinopril presented with a one-day history of nausea, vomiting, and severe epigastric pain. On physical examination, there was tenderness to palpation in the epigastric region and left lower quadrant without rebound tenderness or guarding. A complete blood count showed a slight increase in white blood cell count to 12,000 cells/mm3 and serum lipase level was elevated at 1028 U/L. A subsequent CT scan of the abdomen with contrast revealed findings supporting necrotizing pancreatitis. The patient was treated with conservative medical management with goal-directed intravenous fluid support, early enteral feeding, and pain control. His condition resolved, and he was found doing well on follow-up visits.
