Dileep Unnikrishnan

A case of fatal Guillain–Barre syndrome from anti-PD1 monoclonal antibody use

on ventilator support. Unfortunately, her clinical condition did not improve and she was extubated after 11 days. She expired in hospice care within a few hours. Immune checkpoint inhibitors modulate the immune system and may cause immune-related adverse events (irAE) (Naidoo et al. 2015). Neurologic manifestations of irAE’s are extremely rare. A few cases of ipilimumab-induced Guillain–Barré syndrome (GBS) have been reported in the literature (Gaudy-Marqueste et al. 2013; Wilgenhof and Neyns 2011). To our knowledge, this is the first case of nivolumab-induced GBS. Immune response directed against the myelin or axon of the peripheral nerve is implicated in the pathogenesis of GBS (Yuki and Hartung 2012). Nivolumab can cause disruption in normal immune checkpoint molecule function resulting in decreased peripheral tolerance to ganglioside-related epitopes and unchecked immune responses (Csurhes et al. 2005). With increasing use of nivolumab in advanced malignancies, physicians should be aware of rare adverse events like GBS, which can be effectively treated with rapid initiation of corticosteroids, IVIG or plasma exchange along with discontinuation of anti-PD1 antibody therapy.

Silent myocardial infarction secondary to cardiac autonomic neuropathy in a patient with rheumatoid arthritis

An 83-year-old female patient with rheumatoid arthritis and hypertension presented to the emergency department with fever and chills of 1 day duration. On examination, temperature was 100.9 F, heart rate 111/min and she had orthostatic hypotension. Laboratory tests showed elevated blood urea nitrogen and white cell count. The patient underwent treatment for symptomatic urinary tract infection and while her fever and leucocytosis resolved, tachycardia persisted. An EKG done showed T inversions in leads II, III, arteriovenous fistula, V2 and V3. Troponin-I was elevated. Nuclear stress test revealed apical wall motion abnormality confirming myocardial infarction. Ewings tests were carried out at bedside and these diagnosed severe autonomic neuropathy. Rheumatoid arthritis can cause cardiac autonomic neuropathy from chronic inflammation. This case entails the importance of assessing and detecting cardiac autonomic neuropathy in chronic inflammatory conditions, and the need to be cautious of acute coronary events in these patients, even for minimal or no symptoms.

Fever of Unknown Origin as a Sole Presentation of Subacute Thyroiditis in an Elderly Patient: A Case Report with Literature Review

An 80-year-old Caucasian male presented with fever of 3-week duration. Outpatient workup for infectious etiologies was negative and due to persistent fever, he was hospitalized for further evaluation of fever of unknown origin (FUO). Physical examination and laboratory studies remained unremarkable; however a follow-up CT scan of chest, abdomen, and pelvis with contrast done to rule out malignancy as an underlying cause of FUO revealed heterogeneous thyroid gland with surrounding hazy changes suggestive of thyroiditis. Thyroid function tests confirmed the diagnosis of subacute thyroiditis. The patient was started on prednisone with good response in his symptoms and was eventually discharged to home. The importance of our case lies in the fact that diagnosing subacute thyroiditis in the absence of classical symptoms of neck pain can be challenging and a physician should have a very high index of suspicion especially in an elderly patient where FUO can be the sole presentation.

STEMI in a Young Male after Use of Synephrine-Containing Dietary Supplement

A twenty-two-year-old male with no significant past medical history who presented with chest pain was found to have ST-segment elevation in leads II, III, aVF, and V4–V6. On subsequent EKGs, patient had new ST-segment elevations in anterolateral leads with dynamic changes. Cardiac catheterization showed acute dissection with thrombosis of the distal left main coronary artery leading into the ostial left anterior descending artery. The patient had no cardiac risk factors including hypertension, hyperlipidemia, diabetes, or family history of early cardiac disease. On further inquiry, the patient was found to be on two separate performance-enhancing supplements which contained synephrine, a sympathomimetic chemical which was later attributed as the cause of his acute coronary syndrome. Synephrine acts on alpha-1 adrenergic receptors causing peripheral and coronary vasoconstriction, hypertension, and hyperglycemia. Increased hemodynamic stress on the coronary arteries can lead to fatal dissections. Ours is an atypical case of synephrine-induced nonatherosclerotic spontaneous coronary artery dissection which helps caution the physicians about the importance of dietary supplement use in the history and possible side effects of such performance-enhancing additives.

Case of acute paraspinal pyomyositis in an elderly diabetic secondary to spread from urinary tract infection

A 73-year-old woman with medical history of diabetes and hypertension presented with right-sided back pain and night sweats of 1 month duration. On physical examination, there was costovertebral angle tenderness and her urinalysis was indicative for urinary tract infection. She was admitted and managed with intravenous antibiotics. On initial imaging, there was a right-sided retroperitoneal mass adjacent to right kidney. This was investigated further with MRI, which showed diffuse inflammation of right paraspinal muscles with two loculated abscesses. The abscesses were aspirated and the culture sent grew Streptococcus agalactiae (Group B Streptococcus) and the patient was treated with 6-week course of intravenous antibiotics.

A case of tricuspid valve non-bacterial thrombotic endocarditis presenting as pulmonary embolism in a patient with antiphospholipid antibody syndrome

A 47-year-old woman with a medical history of Raynaud’s phenomenon presented with fever, cough and shortness of breath. She was found to have left lower lobe consolidation and pleural effusion and was treated as a case of pneumonia. During the hospital course, her respiratory status worsened, and she was intubated on the third hospital day. To investigate the high A–a gradient, a Computerized Tomographic Pulmonary Embolism (CTPE) study was done which identified a large left lower pulmonary artery embolism. She was also found to have a new murmur, and an echocardiogram demonstrated a large lesion on tricuspid valve. However, multiple sets of her blood cultures came back consistently negative. Alternative diagnoses for culture-negative endocarditis were considered, and a full set of rheumatological workup was done. Laboratory tests were suggestive of antiphospholipid syndrome, hence the diagnosis of tricuspid valve Libman-Sacks endocarditis was made.

Intracardiac metastasis of high-grade sarcoma of the neck causing right ventricular outflow obstruction.

A 71-year-old man with a medical history significant for high-grade pleomorphic undifferentiated soft tissue sarcoma of the neck and multiple lung metastases presented to the emergency room, with exertional dyspnoea. He was actively receiving palliative radiation at the time of presentation as his tumour was deemed untreatable by his oncologist. Physical examination revealed a cachectic man in mild respiratory distress, at rest. A firm, non-tender 8×8 cm mass was palpated in the suboccipital area of his neck. On auscultation, there were bilateral scattered rhonchi, but no crackles. Cardiovascular examination revealed a grade 3/6 ejection systolic murmur, heard loudest in the pulmonic area, which worsened on inspiration but did …

A Huge Abdominal Mass due to Metastatic Leimyosarcoma

A 32-year-old female was diagnosed with high-grade uterine leiomyosarcomas and undergone a hysterectomy and subsequent debulking surgery. She failed to respond to chemotherapy with docetaxel and gemcitabine. CT abdomen without contrast showed a 20 cm x 19.8 cm x 20.4 cm heterogeneous mass, which was a conglomerate of all her abdominal metastatic lesion.