Anal Cancer with Mediastinal Lymph Node Metastasis.

Squamous cell carcinoma of the anal canal remains rare, with metastatic disease even less commonly reported. We present a case of a patient with both a prior history of squamous cell carcinoma of the anal canal as well as breast cancer, who was without evidence of disease for 1 year. She was subsequently found to have FDG-avid mediastinal lymphadenopathy, initially assumed to be related to her more recent breast cancer. However, a biopsy confirmed recurrent anal cancer, with HPV infection. This represents a novel site of spread for anal cancer, one not yet reported in the literature.

EVALI and the Pulmonary Toxicity of Electronic Cigarettes: A Review.

Electronic cigarettes are a novel and emerging product increasingly used by the general public. However, despite their popularity, they remain poorly studied and with likely serious health risks. EVALI, or "electronic cigarette or vaping product use-associated lung injury," is a recently described entity at the forefront of current investigations. Though EVALI has been linked to vitamin E acetate, a constituent of THC vaping products, electronic cigarettes likely pose a host of other pulmonary toxicities. The presentation, diagnostic work-up, treatment, and pathophysiology of EVALI are herein described, as well as the general pulmonary toxicity profile of electronic cigarettes.

Ketogenic Weight Loss Diet Rapidly Unmasks an Insulinoma.

The ketogenic diet, a diet high in fat and extremely low in carbohydrates, has recently gained momentum and is increasingly employed by patients in order to lose weight. We report a case of an otherwise healthy 47-year-old male who developed seizures and hypoglycemia shortly after initiating this diet. Biochemical testing confirmed hyperinsulinemic hypoglycemia and a subsequent abdomen MRI showed a pancreatic mass. The tumor was ultimately excised with pathology confirming an insulinoma. It was felt that his abrupt decrease in carbohydrate consumption led to the rapid unmasking of this tumor.

Disseminated Strongyloidiasis in Association with Nephrotic Syndrome.

Strongyloidiasis is a well-known parasitic infection endemic in tropical and subtropical areas of the world. While most infected individuals are asymptomatic, strongyloidiasis-related glomerulopathy has not been well documented. We present a case of disseminated strongyloidiasis in a patient with minimal change nephrotic syndrome treated with high-dose corticosteroids. The remission of nephrotic syndrome after treatment of strongyloidiasis suggests a possible causal relationship between Strongyloides and nephrotic syndrome.

Isolated Left Ventricular Metastasis from Renal Cell Carcinoma: Diagnostic and Therapeutic Dilemma.

BACKGROUND: The treatment of metastatic renal cell carcinoma (RCC) has been radically changed by the advent of tyrosine kinase inhibitors (TKIs). However, few reports have described their role in cardiac metastases. We present a case of a left ventricular metastasis from RCC that was managed with pazopanib therapy. CASE REPORT: A 74-year-old male with stage I RCC underwent right nephrectomy in 2004 and right lung metastasis resection in 2009. He was well till March 2016, when he presented with chest pain. Cardiac catheterization revealed a highly vascular mass in the apex. Cardiac magnetic resonance imaging revealed a left ventricular mass with full-thickness involvement of the myocardium, and the open cardiac biopsy was consistent with metastatic RCC. The patient was initially treated with pazopanib with response but later developed therapy-related side effects, and the dose was reduced. Due to tumor progression, he is currently on nivolumab instead and is stable. CONCLUSION: RCC with cardiac metastasis poses unique challenges with regard to diagnosis as well as treatment. The use of TKI therapy is associated with cardiotoxicity and has not been adequately studied in cardiac metastasis. Choosing the right treatment for this subgroup of patients continues to pose an ongoing dilemma.

Amiodarone, lidocaine, magnesium or placebo in shock refractory ventricular arrhythmia: A Bayesian network meta-analysis.

Recent evidence challenges, the superiority of amiodarone, compared to other anti-arrhythmic medications, as the agent of choice in pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF). We conducted Bayesian network and traditional meta-analyses to investigate the relative efficacies of amiodarone, lidocaine, magnesium (MgSO4) and placebo as treatments for pulseless VT or VF. Eleven studies [5200 patients, 7 randomized trials (4, 611 patients) and 4 non-randomized studies (589 patients)], were included in this meta-analysis. The search was conducted, from 1981 to February 2017, using MEDLINE, EMBASE and The Cochrane Library. Estimates were reported as odds ratio (OR) with 95% Credible Interval (CrI). Markov chain Monte Carlo (MCMC) modeling was used to estimate the relative ranking probability of each treatment group based on surface under cumulative ranking curve (SUCRA). Bayesian analysis demonstrated that lidocaine had superior effects on survival to hospital discharge, compared to amiodarone (OR, 2.18, 95% Cr.I 1.26-3.13), MgSO4 (OR, 2.03, 95% Cr.I 0.74-4.82) and placebo (OR, 2.42, 95% Cr.I 1.39-3.54). There were no statistical differences among treatment groups regarding survival to hospital admission/24 h (hrs) and return of spontaneous circulation (ROSC). Probability analysis revealed that lidocaine was the most effective therapy for survival to hospital discharge (SUCRA, 97%). We conclude that lidocaine may be the most effective anti-arrhythmic agent for survival to hospital discharge in patients with pulseless VT or VF.

Yellow Fever in an Unvaccinated Traveler to Peru.

We present a case of an unvaccinated traveler who traveled from New York to Peru and contracted yellow fever. He likely acquired the infection while visiting the Amazon River, with a point of exit of Lima, Peru. Our case illustrates the dramatic course that yellow fever may take, as well as the importance of pretravel vaccination.