Pembrolizumab-Induced Rhabdomyolysis in a Clear Cell Renal Cell Carcinoma Patient: A Case Report.

Pembrolizumab is one of the approved treatments for many types of cancer including clear cell renal cell carcinoma (ccRCC). It has improved the prognosis of renal cell carcinoma, yet has many possible immune-related side effects. We discuss a rare case of rhabdomyolysis in an ccRCC patient treated with pembrolizumab. The case was complicated with acute kidney injury and severe hypothyroidism, which can be attributed to pembrolizumab.

An In-Depth Analysis of Medullary Strokes at a Tertiary Care Stroke Center: Incidence, Clinical and Radiological Characteristics, Etiology, Treatment, and Prognosis.

Introduction Medullary infarctions (MI) are a rare medical entity that is classified mainly as the more commonly lateral medullary infarcts (LMI) and the less common medial medullary infarcts (MMI). Lateral medullary syndrome, also known as Wallenberg syndrome, results when the medulla oblongata is affected and predominantly occurs secondary to atherosclerotic occlusion of the vertebrobasilar arteries. Previous studies have focused more on the anatomical, clinical, and topographical aspects of medullary infarcts. We describe the incidence of their presentation, radiological findings, etiology, treatment, and outcome at our comprehensive stroke center. Material and method This is a retrospective cohort study of 108 medullary stroke patients with confirmed clinical and radiological diagnoses of MI at Hamad General Hospital, Doha, between January 1, 2018 and December 31, 2020. We evaluated the electronic medical records of all stroke patients. Result During the selected period, a total of 2,912 ischemic strokes were reported. Of these, 843 (28.8%) were posterior circulation strokes. Only 108 (3.7%) patients had medullary strokes. Commonly encountered neurological features were dizziness (94.4%), limb ataxia (84.3%), dysarthria (44.4%), ipsilateral facial sensory loss (32.4%), headache (32.4%), contralateral limb sensory loss (25%), ipsilateral hemiparesis (24%), dysphagia (19.4%), and hiccups (13%). Most strokes reported were either minor (73% with National Institutes of Health Stroke Scale [NIHSS] 1-4) or moderate (26% with NIHSS 5-15). LMIs (87.9%) were the most common, followed by medial paramedian MI (10%). Twenty-five percent had extramedullary involvement, predominantly of the cerebellum (17.6%). Out of the total number of patients, 44 (40.7%) had large vessel atherosclerotic disease, followed by 41 (37.6%) whose stroke was due to small vessel disease, 15 (13.8 %) due to undetermined etiology, and 6 (5.5%) due to arterial dissection. Twenty-eight patients (25.4%) underwent 48-hour Holter monitoring, which detected atrial fibrillation in two patients (1.85%). The majority of patients (98.2%, or 106 patients) received antiplatelet therapy, while 68.5% (74 patients) received single antiplatelet therapy (SAPT), and 29.6% (32 patients) received dual antiplatelet therapy (DAPT). Noteworthy is that only 2.7% (three patients) received thrombolysis as an acute reperfusion therapy. Forty-seven percent (51 patients) were discharged home (mRS 0-2), and 51.9% (56 patients) were transferred to rehabilitation facilities. Follow-up assessments were performed at the stroke clinic for 57.4% (62) of the patients. The assessments found that 46 of the follow-up patients were functionally independent at that time (mRS 0-2). Conclusion This is the first large local study of medullary strokes to determine their frequency, presentation, etiology, treatment, and clinical outcome. Medullary strokes represent 3.7% of total ischemic strokes at our comprehensive stroke center. MI is rare and could present with a variety of neurological and non-specific symptoms that mimic common benign conditions. Prompt and early recognition with a high index of suspicion, the use of posterior NIHSS (POST-NIHSS), and urgent MRI-diffusion-weighted imaging (DWI) of the brain in acute settings can improve early diagnosis and the rate of reperfusion therapy. Further studies are needed to enable the early recognition and treatment of medullary infarcts.

Post-COVID-19 Vaccine Limbic Encephalitis: A Case Report.

Limbic encephalitis (LE) diagnosis can be challenging due to its broad spectrum of clinical presentation and variety of causes. The most commonly known causes include paraneoplastic and autoimmune, but they can also occur post-vaccine. Since 2020, many people worldwide have received the coronavirus disease 2019 (COVID-19) vaccine after FDA approval. Mild self-limited neurological adverse reactions, including headache and dizziness, were reported post-vaccine. However, emerging few neurological severe events, including encephalitis, have also been reported. Herein, we present a case of a middle-aged female who presented with seizures after two days of receiving the second dose of the Moderna COVID-19 vaccine. A diagnosis of limbic encephalitis was made based on head MRI findings. It was treated with immunosuppressive agents and responded well with no additional neurological sequelae. This case is unique as it highlights a possible association between limbic encephalitis and the COVID-19 vaccine.

A Case of Anterior Choroidal Artery Occlusion and Stroke Secondary to External Compression.

The anterior choroidal artery (AChA) is a small artery commonly arising from the supraclinoid segment of the internal carotid artery (ICA). The significance of the AChA is related to its strategic supply to various important structures of the brain, such as the optic tract, the posterior limb of the internal capsule, the cerebral peduncle, the lateral geniculate body, medial temporal lobe, medial area of pallidum, and the choroid plexus [J Neurol. 1988;235:387-91]. The AChA syndrome in its complete form consists of the triad of hemiplegia, hemisensory loss, and hemianopia. However, incomplete forms are more frequent in clinical practice [Stroke. 1994;25:837-42]. Isolated infarction in the AChA territory is relatively rare. The presumed pathogenic mechanisms of AChA infarction are cardiac emboli, large-vessel atherosclerosis, dissection of the ICA, small-vessel occlusion, or other determined or undetermined causes [Stroke. 1994;25:837-42 and J Neurol Sci. 2009;281:80-4].

Invasive Klebsiella pneumoniae Syndrome in Qatar: A Case Report.

Klebsiella pneumoniae (K. pneumoniae) is a Gram-negative bacteria that can infect most of the body's organs, from the lungs to the central nervous system. It is notorious for causing pneumonia in alcoholic, diabetic, and hospitalized patients. It is now emerging as a cause of abscesses involving multiple organs. Invasive K. pneumoniae is most commonly observed in the Asian population but has been reported in other geographical areas as well. We present a case of invasive K. pneumoniae. The patient was initially admitted with diabetic ketoacidosis (DKA); further investigations showed multiple abscesses involving the liver, lungs, brain, and muscles. K. pneumoniae was identified in blood and liver abscess cultures. The patient was managed for DKA as per protocol, and was administered broad-spectrum antibiotics with percutaneous drainage of liver abscess for invasive K. pneumoniae syndrome. In this paper, we highlight the invasive nature of K. pneumoniae, which may aid clinicians in diagnosing and managing similar cases, thereby preventing the associated high morbidity and mortality.

Hepatosplenic Bartonellosis in an Immunocompetent Teenager: An Atypical Presentation of Cat-Scratch Disease.

Infection with Bartonella henselae,a gram-negative coccobacillus, most frequently presents as cat-scratch disease (CSD) and often accompanies a recent history of cat bite or scratch. As compared to adults, teenagers and children or immunocompromised patients are predominantly affected by CSD. In immunocompetent individuals, CSD is typically a self-limiting clinical syndrome with complete resolution of febrile illness in two to four weeks with or without antimicrobial therapy. While most cases present with fever of unknown origin (FUO), previous reports have also documented atypical clinical presentation or systemic symptoms in few cases, including reports of hepatosplenic involvement. We present a case of visceral bartonellosis in an immunocompetent 15-year-old female, who presented with a six-week history of fever and abdominal pain with hepatosplenomegaly. She recovered completely after prolonged antibiotic treatment for six weeks with doxycycline and amikacin. We emphasize that in the workup of FUO, it may be pertinent to include bartonellosis as a differential especially in cases exhibiting hepatosplenomegaly on examination along with hepatosplenic lesions on imaging.

Multiple Microbleeds: A Serious Neurological Manifestation in a Critically Ill COVID-19 Patient.

Coronavirus disease 2019 (COVID-19) is a viral illness caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). There is worldwide emerging evidence of multisystem involvement including different neurological manifestations in COVID-19 patients. As a result, healthcare systems worldwide are not only experiencing diagnostic but also therapeutic and prognostic challenges with COVID-19-related complications. Cerebral microbleeds and leukoencephalopathy have been described in COVID-19 patients; although the mechanism remains unknown, possibilities include endotheliitis with thrombotic microangiopathy, excessive inflammation, prolonged respiratory failure, and hypoxemia. We describe here the clinical, radiological, and laboratory findings as well as the 90-day outcome of a 72-year-old gentleman who presented with severe SARS-CoV-2 infection, leading to diffuse cerebral microhemorrhages and ischemic infarct causing severe morbidity. He was tested positive for COVID-19 confirmed by reverse transcriptase polymerase chain reaction.