JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
DISSEMINATED HERPES ZOSTER MENINGOENCEPHALITIS ON TOFACITINIB C. Naccari, MD; C. McLeod, MD; W. Davis, MD Department of Internal Medicine, Ochsner Medical Center, New Orleans
ATYPICAL METASTASIS OF RENAL CELL CARCINOMA TO THE UVULA
P. Khade, MD; S. Devarakonda, MD Department of Medicine, LSU Health Sciences Center - Shreveport
Case: A 55-year-old woman with a history of stage 3(T3aN0M0) renal cell carcinoma s/p nephrectomy 3 years prior, presented with persistent headaches, as well as vertical diplopia on upward gaze. MRI showed a well circumscribed mass, intensely enhancing mass 2.3cm in diameter in the left nasal cavity, bulging into the left maxillary sinus. The patient underwent stereotactic CT-guided endoscopic sinus surgery, which showed mass extended into the left maxillary sinus. Frozen sections confirmed RCC of the left ethmoids and nasal cavity. She then underwent intensity-modulated radiation therapy to the ethmoid sinus area via tomotherapy for a total dose of 3900 cGy, and started on Sutinib, which was stopped based on a predicted lack of response on CARIS testing results, and later Everolimus, which was stopped due to grade 3 fatigue and severe mucositis. Approximately 1 year after left ethmoid sinus metastectomy, our patient presented with symptoms of a foreign body sensation at the back of her throat and oropharyngeal examination revealed uvular erythematous mass with vascularity. Uvular biopsy and complete excision were performed, which revealed metastatic renal cell carcinoma. Palate biopsy was negative and revealed only squamous mucosa with mild chronic inflammation. The patient was restarted on a lower dose of Everolimus, which was continued until recent disease progression, with new lung metastases visualized on CT. Patient was then switched to Pazopanib. Discussion: Renal cell carcinoma is a common malignancy with high metastatic potential, primarily due to its extensive vascularity. Common sites of metastasis include lungs, bone, lymph nodes, liver, and brain. However, there have been rare cases ofmetastasis toother sites including inguinal lymphnodes, peritoneum/mesentery, and orbit published in the literature. To our knowledge, there is only one other documented case of RCC metastasis to the uvula in the literature.
Introduction: Tofacitinib is an oral Janus Kinase (JAK) inhibitor approved for rheumatoid arthritis in 2012. Meningoencephalitis is a rare but potentially life threatening complication of varicella herpes zoster for patients taking tofacitinib. Case: A 66-year-old woman with a history of seropositive erosive rheumatoid arthritis and secondary sjogren syndrome previously treated with numerous conventional and biologic disease modifying anti-rheumatic drugs and corticosteroids experienced a reduction in rheumatoid arthritis disease activity on tofacitinib. After four months of therapy she presented with a five day history of altered mental status and hallucinations about one week after stopping tofacitinib for impending ankle surgery. Review of systems revealed right lateral hip pain associated with vesicular rash, subsequently found to be multi- dermatomal shingles. One year previous, she had an episode of altered mental status which was diagnosed as pachymeningitis that clinically responded to treatment with corticosteroids. On admission, the patient was found to be afebrile, heart rate of 78, respiratory rate of 18, blood pressure of 153/82mmHg and saturating 100%on roomair. Physical examinationwas pertinent for disorientation, with delayed response to questions. Blood work was pertinent for erythrocyte sedimentation rate of 155 mm/Hr, mild hyponatremia of 131 mmol/L and hemoglobin of 11 g/dL. Computed tomography showed no acute intracranial abnormalities. Magnetic resonance imaging showed trace residual diffuse pachymeningeal enhancement significantly improved from prior. Lumbar puncture showed lymphocytic pleocytosis and elevatedprotein consistent with viral meningitis. Varicella zoster polymerase chain reaction of cerebral spinal fluid was positive. The patient was started on a three week course of intravenous acyclovir with gradual improvement in her mental status. Discussion: Varicella zoster virus reactivates to cause herpes zoster and in patients with decreased cell mediated immunity, this process can be complicated by post herpetic neuralgia, vasculopathy or meningoencephalitis. In pooled analysis the crude incidence rate of herpes zoster with treatment of tofacitinib was 4.0 events per 100 patient years of tofacitinib. While the majority of reported cases were non serious, 25 cases of disseminated or multidermatomal herpes zoster, correlating to an incidence rate of 0.149 events per 100 patient- years were reported. This case of varicella meningoencephalitis demonstrates a rare complication of tofacitinib therapy.
58 J La State Med Soc VOL 170 MARCH/APRIL 2018
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