Miller-Fisher Syndrome Unveiled in the Presence of Cholangiocarcinoma.

Miller-Fisher syndrome (MFS) is a rare variant of Guillain-Barré syndrome, characterized by ataxia, areflexia, ophthalmoplegia, and possible facial, swallowing and limb weakness alongside respiratory failure. Variations within MFS may include respiratory and limb weakness and Bickerstaff brainstem encephalitis (BBE), marked by altered consciousness, ataxia, ophthalmoparesis, and paradoxical hyperreflexia. MFS can emerge in both children and adults, often following bacterial or viral illness. While autoimmune-driven nerve damage occurs, most MFS patients recover within six months without specific treatment, with a low risk of lasting neurological deficits or relapses. Rarely fatal, MFS's co-occurrence with cholangiocarcinoma (CCA) presents unique management challenges. CCA, primarily affecting bile ducts, has a bleak prognosis; surgical resection offers limited cure potential due to late-stage detection and high recurrence rates. Advances in CCA's molecular understanding have led to novel diagnostic and therapeutic approaches, requiring a comprehensive interdisciplinary care approach for optimal MFS and CCA management outcomes. Herein, we present a 50-year-old male with a complex medical history who was admitted to the hospital due to abdominal discomfort, nausea, vomiting, and ascites. Imaging revealed pneumonia and secondary bacterial peritonitis. Later, he developed neurological symptoms, including weakness, gait abnormalities, and brainstem symptoms, leading to the diagnosis of MFS. Despite treatment efforts, his condition deteriorated, leading to acute liver failure and unexplained anasarca. N-acetyl cysteine was initiated for liver issues. Neurologically, he showed quadriparesis and areflexia. Intravenous immunoglobulin (IVIG) treatment improved his neurological symptoms but worsened gastrointestinal issues, including ileus and elevated CA19-9 levels, suggesting a potential carcinoma. A liver biopsy was performed. After IVIG treatment, he experienced widespread discomfort, emotional unresponsiveness, swallowing difficulties, and aspiration risk, ultimately leading to his demise.

Simultaneous Thoracic Spine Metastatic Melanoma and Pre-existing Prostate Adenocarcinoma: A Unique Case Presentation and Literature Review.

In melanoma patients, distant metastases frequently manifest in the skin, lung, brain, liver, bone, and intestine. Notably, bone metastasis predominantly occurs within the axial skeleton, with the lumbar and thoracic spines being the most affected regions. Conversely, prostate cancer often disseminates to the bone, lung, liver, pleura, and adrenal glands. The spinal column, particularly the lumbar region, frequently harbors metastases in prostate cancer cases. Given the proximity of axial lesions to the spinal cord, patients commonly experience pain, weakness, and urinary dysfunction. This article presents a compelling case report of a patient initially diagnosed with metastatic prostate cancer, who later exhibited a metastatic lesion in the thoracic spine, subsequently identified as originating from acral melanoma on the plantar surface of the right foot. Histopathological examination confirmed the presence of acral melanoma in both the spine and the right foot. The patient received comprehensive treatment for advanced melanoma from a multidisciplinary team comprising medical and radiation oncologists. Considering the overlapping pathophysiology of prostate cancer and melanoma, simultaneous screening for both diseases in cases where one is detected could yield significant benefits, including enhanced morbidity and mortality outcomes and the facilitation of early detection for secondary malignancies.

COVID-19-Associated Disseminated Intravascular Coagulopathy Presenting As Inferior ST-Segment Elevation Myocardial Infarction.

Disseminated intravascular coagulopathy (DIC) is infrequently associated with COVID-19 infection. COVID-19 infection can predispose to thrombotic events through inflammation and microvascular injury. DIC is rarely associated with coronary artery disease, especially myocardial infarction (MI). In this case report, we present an uncommon case of a patient with concurrent DIC and MI in the setting of COVID-19 infection. A 73-year-old male patient with no known cardiovascular risk factor presented with syncope. Assessment in the field by emergency medical service (EMS) showed the patient had a third-degree atrioventricular block and a heart rate of 40 beats per minute. He was given atropine and transcutaneously paced. Upon admission, he was found to have an inferior wall ST-elevation myocardial infarction (STEMI) and tested positive for COVID-19. Cardiac catheterization was performed urgently and revealed triple vessel disease. Attempts to revascularize the vessels were unsuccessful. He subsequently developed cardiogenic shock. He was started on multiple pressor support. Laboratory workup was suggestive of DIC, and he later developed multiorgan failure. Continuous renal replacement therapy was initiated but failed due to persistent thrombosis of the dialysis access. Despite all measures, the patient developed cardiac arrest and passed away on the third day of hospitalization. Our understanding of COVID-19 and its complications has grown exponentially since the beginning of the pandemic. The pro-inflammatory state induced by the disease creates a hypercoagulable state that may result in thrombotic complications, including MI. In severe cases, a consumptive coagulopathy may develop, leading to DIC. This unique case report seeks to highlight the importance of staying vigilant about the potential complications of MI and DIC induced by COVID-19 so that prompt diagnosis can be made to reduce morbidity and mortality in these patients.

Malignant Pleural Effusion As the Initial Presentation of Renal Cell Carcinoma: A Case Report and Literature Review.

Renal cell carcinoma is the most common renal neoplasm. Its presentation is often very occult, and it may be discovered incidentally. It may present with the classic symptoms of back pain, flank pain, hematuria, or hypertension. Renal cell carcinoma may also present with malignant pleural effusion at diagnosis; however, it is very rare. In this case report and literature review, we describe a 77-year-old male who was diagnosed with renal cell carcinoma after presenting with a malignant pleural effusion - an extremely rare phenomenon. An analysis of the literature yielded 13 case reports, including ours, where the diagnostic presentation of renal cell carcinoma was a malignant pleural effusion. Our patient presented with left-sided chest pain. Imaging was suggestive of pleural effusion. CT and MRI imaging demonstrated masses in the upper and lower poles of the right kidney suggestive of renal cell carcinoma. CT imaging also showed lung nodules that were suggestive of pulmonary metastases. Biopsy and immunostaining of pleural tissue were positive for clear cell renal cell carcinoma. Therapeutic thoracentesis was performed. Despite this, the patient developed recurrent large-volume pleural effusions requiring drainage and placement of a pleural catheter. Our patient's extremely rare presentation of malignant pleural effusion as the diagnostic presentation of renal cell carcinoma along with recurrent, large-volume effusions requiring drainage has only been reported in the form of case reports in the literature.

Complete Resolution of Paraneoplastic Membranous Nephropathy Following Curative Therapy of Triple-Negative Breast Cancer.

A paraneoplastic syndrome, which includes glomerulopathy, is a manifestation of malignancy unexplained by direct tumor burden. Membranous nephropathy (MN) may be associated with malignancies that are primarily solid tumors of the lung, prostate and gastrointestinal tract. It is rarely associated with breast cancer. To our knowledge, we herein report the first case of MN associated with triple-negative carcinoma of the breast. The patient initially presented with MN as a paraneoplastic nephrotic syndrome. Treatment resulting in a complete pathological response of the breast cancer also resolved the MN. Neither has recurred after a 48-month follow-up. The patient exhibited autoantibodies against phospholipase A2 receptor and was also antinuclear antibody (ANA) and anti-Smith (anti-Sm) antibody positive. These results suggest that the neoplasm evoked an autoimmune response, which resolved with treatment. ANA and anti-SM positivity closely correlated with the neoplasm activity supporting this hypothesis.

Polycythemia Vera Presenting With Normal Hemoglobin and Hematocrit: A Rare Variant.

Polycythemia vera (PV) is a myeloproliferative neoplasm, and its diagnosis requires elevated hemoglobin level (>16.5 mg/dL in men and >16 mg/dL in women), bone marrow characteristics of PV (hypercellularity for age with trilineage growth), and presence of JAK2 (Janus kinase 2) mutations or subnormal erythropoietin level if JAK2 mutation is not present. There exists a subset of patients with normal hemoglobin and hematocrit due to either from dilution of the blood or from coincidental blood loss anemia but these patients still might have underlying PV. These patients have masked PV, which is a variant of overt PV. We present a case of masked PV presenting with venous thrombosis as a first presentation and with normal blood counts. A 42-year-old male with past medical history of portal vein thrombosis and portal hypertension presented with nausea and vomiting presumably secondary to viral gastroenteritis. He was not an alcoholic nor a smoker. He was diagnosed with portal vein thrombosis six years ago which was treated with warfarin but was never investigated for a cause. His physical exam was within normal limits except he had splenomegaly. His laboratory values on admission showed hemoglobin of 14.1 g/dL, white blood count of 7.4 x109/L, and platelet count of 164 x109/L. His liver function test and renal function tests were within normal limits. His viral gastroenteritis improved within 48 hours. Extensive workup to rule out myeloproliferative neoplasm, thrombophilia, antiphospholipid syndrome, and paroxysmal nocturnal hemoglobinuria was arranged. Final results revealed JAK2V617F genetic mutation with a subsequent bone marrow analysis revealing a hypercellular marrow with increased trilineage hematopoiesis, consistent with primary PV. It is rare for myeloproliferative neoplasms to present with normal blood counts. There is a subgroup of patients with JAK2-positive PV presenting with normal hemoglobin and hematocrit. The prognosis of these subgroups seems to be poor especially when present in the older age group and with associated leukocytosis. Our case emphasizes two important points: first, need for extensive workup in a patient with unusual site thrombosis including JAK2 analysis and second, investigating for myeloproliferative neoplasm if presented with thrombosis even with normal blood counts.

A Rare Case of Pembrolizumab-Induced Reactivation of Hepatitis B.

Hepatitis B virus (HBV) infection is common across the world, especially in Asia, Africa, Southern Europe, and Latin America. The association of HBV infection in patients suffering from different oncological conditions is well established. Many cases of HBV reactivation have been reported in patients on immunosuppressive chemotherapy and in patients undergoing hematopoietic bone marrow transplantations. Only one case has been reported so far of HBV reactivation in a patient treated with programmed cell death receptor 1 (PD-1) checkpoint inhibitors in the setting of HIV status. We report a case of a 51-year-old male, former smoker, diagnosed with stage IV poorly differentiated adenocarcinoma of the lung, and started on pembrolizumab, who developed reactivation of chronic hepatitis requiring antiviral therapy.