Metabolic syndrome is independently associated with improved overall survival to first-line therapy with immune checkpoint inhibitors in non-small cell lung cancer.

Background: Many co-existing medical conditions may affect the outcome in patients treated with immune checkpoint inhibitors for advanced cancer. There is currently not any information on whether metabolic syndrome (MetS) impacts the clinical outcome in patients treated with immune checkpoint inhibitors (ICIs) for advanced non-small cell line cancer (NSCLC). Methods: We carried out a single-center retrospective cohort study to determine the effects of MetS on first-line ICI therapy in patients with NSCLC. Results: One hundred and eighteen consecutive adult patients who received first-line therapy with ICIs and had adequate medical record information for the determination of MetS status and clinical outcomes were included in the study. Twenty-one patients had MetS and 97 did not. There was no significant difference between the two groups in age, gender, smoking history, ECOG performance status, tumor histologic types, pre-therapy use of broad-spectrum antimicrobials, PD-L1 expression, pre-treatment neutrophil:lymphocyte ratio, or proportions of patients who received ICI monotherapy or chemoimmunotherapy. With a median follow-up of 9 months (range 0.5-67), MetS patients enjoyed significantly longer overall survival (HR 0.54, 95% CI: 0.31-0.92) (p = 0.02) but not progression-free survival. The improved outcome was only observed in patients who received ICI monotherapy and not chemoimmunotherapy. MetS predicted for higher probability of survival at 6 months (p = 0.043) and 12 months (p = 0.008). Multivariate analysis indicated that, in addition to the known adverse effects of use of broad-spectrum antimicrobials and the beneficial effects of PD-L1 (Programmed cell death-ligand 1) expression, MetS was independently associated with improved overall survival but not progression-free survival. Conclusions: Our results suggest that MetS is an independent predictor of treatment outcome in patients who received first-line ICI monotherapy for NSCLC.

Hydroxychloroquine and Cardiovascular Events in Patients with Rheumatoid Arthritis.

INTRODUCTION: Cardiovascular disease (CVD) is the leading cause of mortality in patients with rheumatoid arthritis (RA). Some studies have reported a decrease in CVD in patients with RA using hydroxychloroquine (HCQ). Most of these have had fewer participants and have analyzed only composite outcomes. We aimed to identify the association between the use of HCQ in patients with RA and the incidence of major adverse cardiac events (MACEs), cerebral infarction, and AMI. METHODS: This was a retrospective observational study using the TriNetX Diamond Network. Propensity score matching (PSM) was used to equilibrate the cohorts. The dependent variables in our study were MACE, cerebral infarction, and AMI. RESULTS: A total of 2,261,643 patients with RA were identified. Approximately 6% had been prescribed HCQ. Of those prescribed HCQ, 80% (112,743) were females, while of those not prescribed HCQ, 72.5% (1,536,937) were females. HCQ was associated with lower rates of MACE (HR 0.827, 95%CI 0.8,0.86), cerebral infarction (HR 0.824, 95% CI 0.78,0.87), and AMI (HR 0.9, 95% CI 0.85,0.96). These associations were not seen in patients taking biologics. HCQ was associated with lower MACE in all other subgroups. CONCLUSION: In conclusion, HCQ was slightly beneficial in decreasing MACE and cerebral infarction in patients with RA. These associations were significantly lower in patients taking methotrexate or biologics. Although there was a significant decrease in the risk of AMI in all patients with RA, these results were not replicated in subgroup analyses, and there was an apparent increased risk of AMI with the use of HCQ in patients using biologics.

Fournier's Gangrene in an HIV-Positive Patient on Empagliflozin for the Treatment of Diabetes Mellitus.

Fournier's gangrene is a severe polymicrobial infection that results in necrosis of the perineal and genital fasciae with rapid progression. This case report describes a 55-year-old male with a past medical history of HIV, type 2 diabetes, and hypertension who was diagnosed with Fournier's gangrene after the administration of empagliflozin (Jardiance). The patient presented with a worsening ulcer of the right groin and was diagnosed with Fournier's gangrene based on clinical and radiographic findings. He underwent surgical debridement of the wound. The patient was treated with empiric vancomycin, piperacillin-tazobactam, and clindamycin. Wound cultures grew Streptococcus anginosus and Staphylococcus epidermidis. His antibiotic regimen was simplified to ampicillin-sulbactam. The patient required reconstructive surgery for wound closure after debridement. He received an additional 18 days of augmentin therapy with the resolution of the infectious process. At the time of Fournier's gangrene onset, the patient's last HbA1C level was 8.2%, despite treatment with glipizide and empagliflozin. This case suggests an association between empagliflozin and Fournier's gangrene in the setting of active HIV infection.

Small Fiber Neuropathy Associated With the Moderna SARS-CoV-2 Vaccine.

Efforts of controlling viral transmission began soon after the first cases of coronavirus disease 2019 (COVID-19) infections were identified. Initial efforts were related to contact precautions, hand hygiene, and mask-wearing; however, it was soon evident that a robust global immunization drive was the most effective way to curb disease transmission. In the United States, the first doses of COVID-19 vaccines were rolled out soon after the FDA granted emergency use authorization for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. What this also meant was that many of the routine phases that any new drug or vaccine goes through before being released publicly were bypassed. Over the past two years, various side effects and reactions have been seen after COVID-19 vaccine administration, the most common being local injection site events (e.g., pain, redness, swelling) and systemic effects (e.g., fatigue, headaches, myalgias). We report the case of a 64-year-old female who developed bilateral lower extremity numbness and tingling within weeks of receiving the third dose of Moderna SARS-CoV-2 vaccine. The patient underwent extensive testing to ascertain the diagnosis. She had negative autonomic testing and normal nerve conduction study/electromyography (EMG), which did not reveal large fiber neuropathy. Eventually, the patient underwent a skin biopsy, which revealed small fiber neuropathy. This case report highlights the importance of keeping a broad differential for rare side effects, such as small fiber neuropathy, that are currently being seen and reported in the literature.

An Early Catch: Multisystem Inflammatory Syndrome in Adults (MIS-A) in a Young Adult Male With COVID-19 Exposure.

While severe acute respiratory syndrome (SARS) is the most common presentation of coronavirus disease 2019 (COVID-19) infection, several short- and long-term complications from COVID-19 infection are also being recognized. One such complication with life-threatening consequences is known as multisystem inflammatory syndrome in adults (MIS-A). While the phenomenon of multisystem inflammatory syndrome in children (MIS-C) is more recognized, the pathophysiology of both presentations remains a mystery currently. Several theories have been put forward however no consensus has been established yet. We present the case of a 20-year-old male who was admitted to the intensive care unit for a multisystem illness characterized by severe biventricular failure, profound shock, and acute liver and kidney injuries. The severity of illness necessitated the treatment with mechanical ventilation, extracorporeal membrane oxygenation (ECMO), vasopressors, and continuous veno-venous hemofiltration (CVVH). The patient was treated with one dose of intravenous immune globulin (IVIG). In association with the foregoing treatment, the patient made dramatic recovery and came off pulmonary, hemodynamic, and renal support within a week and made remarkably quick and full recovery. This case highlights a rare presentation of a COVID-19 complication that requires prompt recognition, supportive care, and empiric treatment that led to a favorable outcome in this case.

Piperacillin/Tazobactam and Meropenem Use Increases the Risks for Acute Graft Rejection Following First Kidney Transplantation.

Many broad-spectrum antibiotics (BSA) alter the intestinal microbiome that regulates adaptive immune responses. We hypothesized that BSA use before and early after kidney transplant may affect acute graft rejection (AGR). We carried out a retrospective cohort study on all patients who underwent kidney transplants in our institution. Patient demographics, clinical data, diagnosis, and treatment history were collected. Antibiotic use within 2 months prior to transplant and during the hospital admissions for transplant, as well as antibiotic types were recorded. A total of 357 consecutive first transplants were included for analysis. Median age was 52 years (range 7-76). A total of 67 patients received living donor and 290 deceased donor kidneys. A total of 19 patients received BSA within two months prior to transplant and 55 patients during the hospital admission for the transplant. With a median follow-up of 1270 days, 38 episodes of biopsy-proven AGR were recorded. There was no difference in the AGR rates during the first year between patients who received BSA and those who did not. However, the use of piperacillin/tazobactam or meropenem (PM) was associated with increased risks for the development of AGR, irrespective of the source of the donor grafts. Time to development of AGR was also shorter. Our data, therefore, suggest that the use of PM BSA prior to and immediately after kidney transplant increases the risks for AGR.

Diagnosing Spinal Gout: A Rare Case of Back Pain and Fever.

Gout is a common inflammatory arthritis that has a high prevalence worldwide. It is characterized by monosodium urate deposition, usually affecting the joints and soft tissue of the lower extremities. Urate deposition in the axial skeleton resulting in spinal gout is rare. However, it seems to be more prevalent than usually thought, largely because it is underdiagnosed. Imaging findings are, for the most part, nonspecific and often mimic infectious etiologies. Definitive diagnosis requires pathological examination. Thus, it can be easily missed. We present a 41-year-old male with a seven-year history of untreated gout who came in with severe back pain, fevers, and radiculopathy. He was initially diagnosed with vertebral osteomyelitis. However, after a biopsy, spinal gout was confirmed. Spinal gout can be misdiagnosed as vertebral osteomyelitis given the similarities in presentation and imaging findings. This case report highlights the importance of keeping spinal gout as a differential of vertebral osteomyelitis, especially in patients with long-standing or uncontrolled gout with tophi.