persistent headaches irrespective of multiple pain medications. No neck stiffness or other meningeal signs were appreciated but because of high clinical suspicion, lumbar puncture was done which showed WBCs elevated to 2335 with 83% neutrophils, elevated protein of 154 and glucose of 50 which was suggestive of bacterial meningitis. After LP, the patient was started on Vancomycin, ceftriaxone, ampicillin and acyclovir. Blood and CSF cultures were negative. VDRL, HSV1,HSV2, CSF cryptococcal antigen, AFB culture, CSF viral culture and India ink stain of CSF
were negative. Antibiotics were then tailored down to ceftriaxone and ampicillin for a duration of 14 days and the patient’s symptoms drastically improved. Discussion: Systemic or localized infections increase the risk of thrombosis by 2 to 20 times. Even though infection related thrombosis is associated with increased mortality, which is extensively mentioned in the existing literature, there have been no reports of exact mortality rates and need to be further studied.
CHECKPOINT INHIBITOR INDUCED MYOPERICARDITIS PRESENTING AS TAMPONADE Ernest Philon, Carl Haupt, Graham Unis; Department of Medicine, Ochsner Medical Center, New Orleans, LA.
Introduction: Checkpoint inhibitor immunotherapy has rapidly progressed to become a vital role in the treatment of a variety of malignancies. Checkpoint inhibitor therapies are engineered to target transmembrane proteins and that serve to modulate immune system function. Certain malignancies have the capacity to exploit these proteins in order to evade destruction by the immune system. The favorable effect of immunotherapy has been repeatedly demonstrated in numerous studies by decreasing mortality and progression of disease. However, there exist a host of undesirable effects known as immune-related adverse events (iAE). With the increased use of checkpoint inhibitors, better understanding of these adverse events is vital. Here we report a case of cardiotoxicity associated with combination anti-PD1 and anti-CTLA-4 checkpoint inhibitors in a patient with metastatic renal cell carcinoma. Case: A 64-year-old male with severe aortic stenosis, bicuspid aortic valve, and renal cell carcinoma with metastasis to the pancreas treated with nivolumab and ipilimumab, who presented to the emergency department with the chief complaint of pleuritic chest pain and associated shortness of breath. Initial testing was notable for troponin
elevated to 0.028, ESR 43, CRP 36, and an EKG with nonspecific ST-T changes. Cardiology was consulted and while undergoing an echocardiogram the patient became lethargic and suffered PEA arrest. ROSC was achieved after brief compression and epinephrine. Hemodynamics necessitated the use of dobutamine. The echocardiogram was concerning for tamponade so the patient underwent left subclavian Swan-Ganz catheterization and pericardiocentesis with 400cc removed followed by pericardial drain placement. Fluid had 16,000 WBC with a neutrophilic predominance and was negative for malignancy or infectious process. The patient received weight-based methylprednisolone per iAE protocol and made a full recovery. Discussion: Checkpoint inhibitors have revolutionized the field of oncology and their widespread use further necessitates the need for recognition of iAE and prompt treatment. The risk of myopericarditis with these agents is less than 1% however it can occur at any time during the course of treatment. As their use becomes more widespread for the maintenance of advanced malignancies, clinicians must be trained to consider iAEs due to their broad range of manifestations.
USE OF CORTICOSTEROID THERAPY IN A CASE OF WEST NILE VIRUS ENCEPHALITIS James Kuo, Ryan Chan, Gary Guidry; Department of Medicine, LSU Health Sciences Center, Lafayette, LA.
Introduction: West Nile Virus (WNV) is the most common mosquito-borne illness in the United States. Fortunately, most infections are asymptomatic. About 1 in 5 patients experience minor symptoms, usually consistent with West Nile
Fever, while approximately 1 in 150 experience a severe neuroinvasive illness including encephalitis, meningitis, or flaccid paralysis. Neuroinvasive disease predominantly occurs in the elderly population, most often in the Great Plains and Rocky Mountain 34
Made with FlippingBook Digital Publishing Software