AME Case Reports最新文献

Background: Sinoatrial nodal reentrant tachycardia (SANRT) is a rare form of focal atrial tachycardia, often linked with structural or congenital heart disease. Due to its electrocardiographic similarities with other supraventricular tachyarrhythmias, it is frequently misdiagnosed. Understanding its clinical presentation and effective management strategies is crucial for appropriate patient care.

Case description: We present a case of a 45-year-old female with severe pulmonary hypertension and obstructive sleep apnea who was admitted with progressive palpitations, chest pain, and dyspnea. Initial electrocardiographic evaluation suggested atrial fibrillation with rapid ventricular response (RVR), leading to treatment with metoprolol and amiodarone. However, the tachyarrhythmia persisted, and further investigation revealed features suggestive of SANRT. The diagnosis was confirmed by telemetry findings demonstrating atrial tachycardia with a prolonged PR interval, terminating abruptly after carotid sinus massage (CSM). This immediate response to vagal stimulation solidified the diagnosis of SANRT. The patient was managed conservatively with vagal maneuver training and discharged on oral bisoprolol.

Conclusions: This case highlights the diagnostic challenges associated with SANRT and emphasizes the role of CSM as both a diagnostic and therapeutic intervention. Early recognition of SANRT is crucial, as it can mimic other supraventricular arrhythmias, leading to mismanagement. While electrophysiological studies remain the gold standard for diagnosis, non-invasive measures such as vagal maneuvers can be highly effective in terminating the arrhythmia and providing symptomatic relief.

Background: Several studies have demonstrated the effectiveness of anti-programmed death-1 (PD-1) drugs in patients suffering from deficient mismatch repair/microsatellite instability (dMMR/MSI) endometrial cancer (EC). The phase III Ruby study, showed benefit in progression-free survival (PFS) for patients with stage III-IV EC, both MSI-high/dMMR (MSI-H/dMMR) and mismatch repair proficient/microsatellite stable (pMMR/MSS), treated upfront with chemotherapy in combination with dostarlimab. Even earlier, the GARNET trial, which enrolled patients with advanced or relapsed EC with dMMR and/or MSI progressing on prior platinum therapy to receive dostarlimab, reported overall response rate (ORR) of 43.5% with a manageable safety profile. We report on the case of an elderly patient with many pathologies treated with dostarlimab.

Case description: A 75-year-old woman with EC (MSI-H) with pulmonary and bone metastasis progressed on first line chemotherapy platinum-containing, was treated with dostarlimab as monotherapy. Medical history was positive for arterial hypertension, autoimmune thrombocytopenia and allergy to amoxicillin and levofloxacin. After the second administration of dostarlimab, our patient showed a dramatic improvement of her clinical conditions. The clinical response was confirmed by radiological response on the basis of the results of a computed tomography (CT) scan performed in March 2023 that showed a reduction of the pelvic mass and pulmonary secondaries. No toxicities related to autoimmune thrombocytopenia occurred. The experienced grade 2 infusion reaction, resolved with the suspension of the drug and the administration of an antihistaminic drug; then we resumed dostarlimab doubling the administration time.

Conclusions: The administration of dostarlimab is safe and feasible in elderly people with multiple pathologies and multiple allergies with recurrent dMMR/MSI EC. The drug is well tolerated and able to give a good quality of life to patients.

Background: Tuberculous myelitis is a form of central nervous system tuberculosis (TB) that can be associated with intracranial involvement but rarely presents with extensive longitudinal involvement of more than one segment. We are reporting a case with tuberculous meningitis and long-segment myelitis in a previously undiagnosed patient with TB.

Case description: A 53-year-old hypertensive male, presented with subacute lower limbs weakness, sensory level below his nipples, and urine retention. Erythrocyte sedimentation rate (ESR) was above 112 mm/hour. Magnetic resonance imaging (MRI) spine showed a long segment of hyperintense signal seen on the T2-weighted image (T2WI) images in the spinal cord extending from C6 to D3 vertebral segments, with heterogeneous post-contrast enhancement. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis with high protein and low glucose, and polymerase chain reaction (PCR) for Mycobacterium tuberculosis (MBTB) was positive. The patient received intravenous methylprednisolone daily for 5 days and standard anti-TB medications [rifampicin, isoniazid (INH), pyrazinamide, and ethambutol] for 12 months. However, repeated CSF analysis 3 months after starting anti-TB medications showed a negative PCR for MBTB, normal cell count, and glucose with slightly elevated protein. Still, the patient did not show any clinical improvement.

Conclusions: Long-segment tuberculous myelitis (LSTM) is a rare form of central nervous system TB that can be accompanied by tuberculous meningitis. It must be considered a differential diagnosis of neuromyelitis optica spectrum disorder (NMOSD), especially in endemic areas of TB, as the management approach is completely different.

Background: Pancreatic hepatoid carcinoma (PHC) is an extremely uncommon neoplasm of pancreas that resembles hepatocellular carcinoma (HCC). The morphological and immunohistochemical features of PHC are similar to those of HCC. The lack of specificity on clinical features of PHC makes it easy to be ignored in clinical diagnosis. And there is currently no standardized treatment for PHC.

Case description: We presented a case of PHC with specific clinical examinations and treatments. The patient reported that he suffered from a history of chronic viral hepatitis B, laboratory tests showed elevated serum alpha-fetoprotein (AFP) levels. No significant liver mass was found on imaging, the contrast-enhanced abdominal computed tomography revealed a slightly nodular low-density shadow in the head of the pancreas. The patient received neoadjuvant chemotherapy combined with programmed cell death protein 1 (PD-1) antibody and he underwent radical resection of pancreatic cancer. The post-operative histopathological examination of the resection specimen revealed a diagnosis of poorly differentiated PHC. Half a month after the surgery, this patient's serum AFP dropped to within the normal range. The patient recovered without complications, and regular reexaminations showed no signs of tumor recurrence and metastasis.

Conclusions: We analyzed the previous PHC-related literature to enhance the understanding of PHC and persistently improve PHC treatment strategies for clinicians.

Background: Pulmonary mucormycosis (PM) is an acute suppurative lung disease caused by any fungus in the order Mucorales. PM is characterized by its propensity for vascular invasion, rapid progression, and destructiveness, leading to a high mortality rate.

Case description: A 39-year-old male patient was diagnosed with PM and complicated by bronchial obstruction. Although surgical debridement of mucormycosis and antifungal therapy are generally preferred treatment, our patient presented with a high burden of invasive disease and was deemed ineligible for surgery. We therefore had to compromise and palliate his bronchial obstruction with a bronchial stent while continuing intravenous, nebulized, and bronchoscopically applied antifungals. The intervention markedly alleviated the patient's symptoms of chest tightness and dyspnea. However, given the advanced stage at presentation, the prognosis was already poor. Despite these measures, the aggressive underlying infection continued to progress, ultimately leading to erosion into a major vessel and catastrophic hemoptysis.

Conclusions: The implantation of bronchial stents in patients with PM can effectively alleviate severe bronchial obstruction caused by mucormycosis infection, improve pus drainage, and promote infection resolution. However, as a complete surgical resection of the lesion was not performed, the patient remains at risk of potentially catastrophic hemoptysis due to the possibility of pulmonary vascular invasion by mucormycosis. The potential increase in hemoptysis risk associated with stent implantation warrants further investigation.

Background: Colorectal choriocarcinoma is a rare condition with a poor prognosis, and no standard chemotherapy regimen has been established. A combination of cetuximab, encorafenib, and binimetinib as adjuvant chemotherapy may be effective for colorectal choriocarcinoma. This treatment approach has not been previously reported for this rare malignancy.

Case description: We describe the case of a 59-year-old woman who underwent right hemicolectomy for a transverse colon perforation and was diagnosed with primary colorectal adenocarcinoma with choriocarcinoma differentiation. Adjuvant chemotherapy with folinic acid, fluorouracil, and oxaliplatin (FOLFOX) and bevacizumab was administered for colorectal adenocarcinoma, but disease progression was observed. The patient had a BRAF V600E mutation, tested negative for human chorionic gonadotropin (hCG), and was switched to a combination of encorafenib, cetuximab, and binimetinib. The treatment response was monitored through regular imaging studies and tumor marker measurements. The patient has been alive for 34 months with no metastases or recurrence, and with continued reduction in the size of the lymph nodes and peritoneal lesions.

Conclusions: Standard chemotherapy for the treatment of choriocarcinoma and colorectal adenocarcinoma has been applied to colorectal choriocarcinoma. In patients with a BRAF V600E mutation and decreased hCG levels, a combination of encorafenib, cetuximab, and binimetinib may be a useful chemotherapeutic option when treating patients with colorectal choriocarcinoma.

Background: Incident development of Raynaud phenomenon (RP) in older adults raises concern for secondary etiologies. Malignancy is an important, yet underrecognized, cause of RP. In particular, paraneoplastic acral vascular syndrome (PAVS) describes a spectrum of secondary vascular disorders including RP and has been described in a variety of malignancies. However, presentations with squamous cell histology are uncommon, particularly in the esophagus.

Case description: A 61-year-old Caucasian male with a history of alcohol use disorder, hypertension, and hyperlipidemia presented with 3 months of progressive dysphagia and digital ischemia. RP had developed concomitantly with dysphagia and progressed to digital ischemia prior to admission. Evaluation for rheumatologic causes of secondary RP was notable for positive antinuclear antigen with high titer. Cross-sectional imaging for evaluation of occult malignancy revealed circumferential thickening of the distal esophagus with upper abdominal lymphadenopathy. Endoscopic evaluation identified a large ulcerating mass in the distal esophagus and pathology confirmed squamous cell carcinoma (SCC). These findings resulted in a diagnosis of metastatic esophageal SCC with paraneoplastic RP.

Conclusions: Although paraneoplastic RP occurs most often in cases of adenocarcinoma, this case highlights the importance of considering malignancy in the evaluation of secondary RP even with underlying squamous cell histology.

Background: Recombinant human interferon α2b (rhIFN-α2b) is a widely used antiviral and immune-modulating agent. However, its potential to interfere with immunoassays, particularly human chorionic gonadotropin (hCG) tests, has not been extensively documented. This case report highlights the challenges of interpreting hCG assay results in the context of rhIFN-α2b therapy.

Case description: A 24-year-old female presented with amenorrhea for over 40 days, and tested positive for urine hCG using the colloidal gold method (124 IU/L). However, her serum β-hCG measured by electrochemiluminescence was <0.200 IU/L, and her progesterone was 29.3 nmol/L. A further analysis across platforms revealed that the Roche, Beckman, and Mindray chemiluminescence methods were unaffected by rhIFN-α2b, while the colloidal gold urine hCG, quantitative immunochromatography, and Abbott chemiluminescence assays were affected by rhIFN-α2b. This interference likely stems from the immunomodulatory effects of rhIFN-α2b, which can cause non-specific binding to assay antibodies.

Conclusions: This case underscores the importance of using multiple testing platforms and conducting thorough clinical assessments to avoid false-positive results. It also highlights the need for assay developers to consider epitope targeting in reagent design to minimize interference. Clinicians and laboratory professionals should be aware of the potential for rhIFN-α2b to cause assay interference and collaborate closely to ensure accurate interpretation of test results. This case calls for further research into the prevalence of rhIFN-α2b-induced hCG assay interference and the development of strategies to mitigate its impact on clinical diagnostics.

Background: Omalizumab is a monoclonal humanized antibody used as a third-line treatment for chronic spontaneous urticaria (CSU). While it has shown significant efficacy in controlling urticaria symptoms, it is also associated with various adverse effects. Cutaneous side effects of omalizumab have been reported, but the mechanisms underlying these reactions are not fully understood. This case report describes a patient who developed a maculopapular rash after receiving the 8th dose of omalizumab, which has not been previously reported.

Case description: The patient in this case was a 46-year-old male with CSU who had been receiving omalizumab injections every four weeks. After the 8th dose, he developed a generalized itchy erythematous skin eruption six days after the injection. The rash progressively worsened over a two-week period. Interestingly, the patient had experienced a milder skin reaction after the 6th dose, which resolved on its own. A skin biopsy showed mild interstitial edema in the dermis with a mild perivascular infiltrate of lymphocytes and eosinophils, consistent with a drug-induced eruption. The patient was advised to hold the next dose of omalizumab and was managed with topical steroids. Significant improvement and resolution of the lesions were observed, and no recurrence or relapse was reported after the patient resumed omalizumab.

Conclusions: This case adds to the existing literature by reporting a pityriasis rosea-like eruption as an adverse reaction to omalizumab, which has not been extensively documented. The delayed onset and progressive nature of the rash after the 8th dose, as well as the milder previous reaction after the 6th dose, highlight the importance of considering omalizumab as a potential cause of various cutaneous reactions. Physicians should be vigilant in monitoring patients receiving omalizumab for any signs of skin eruptions or other adverse effects. Further research is needed to understand the mechanisms underlying cutaneous reactions to omalizumab and to establish guidelines for their management. This case emphasizes the need for ongoing attention to potential side effects or reactions in patients receiving omalizumab.

Background: This case report describes a rare and severe instance of osimertinib-induced interstitial lung disease (ILD) requiring intubation and mechanical ventilation during postoperative adjuvant therapy following lung cancer resection. This is the most severe reported case, necessitating intensive care. While severe ILD during adjuvant therapy is uncommon, its incidence may increase as osimertinib use expands.

Case description: A 68-year-old nonsmoking female with no history of ILD underwent left lower lobectomy for epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (stage IIB, pT3N0M0). Following adjuvant cisplatin and vinorelbine chemotherapy, osimertinib (80 mg/day) was initiated. Thirty-five days later, she developed acute respiratory distress and hypoxemia [saturation of percutaneous oxygen (SpO2) 78% on room air], rendering her unable to walk without assistance. Chest computed tomography (CT) revealed diffuse ground-glass opacities across both lungs. Osimertinib was discontinued, and methylprednisolone (500 mg/day) was started; however, oxygenation rapidly deteriorated, leading to intubation and mechanical ventilation the following day. The patient was diagnosed with severe grade IV ILD induced by osimertinib. After 5 days of methylprednisolone, treatment was switched to prednisolone (60 mg/day), but oxygenation worsened, and pulmonary infiltrates reappeared on CT. Methylprednisolone (500 mg/day) was reintroduced for 5 days. The partial pressure of oxygen in the arterial blood (PaO2)/fraction of inspired oxygen (FiO2) ratio then improved, and prednisolone was gradually tapered from 1 mg/kg with a weekly reduction of 10 mg based on clinical and radiologic improvement. The patient was discharged on day 72 with prednisolone 30 mg/day. Although respiratory symptoms improved significantly, she required long-term home oxygen therapy due to residual hypoxemia during exertion.

Conclusions: This case underscores the potentially life-threatening nature of osimertinib-induced ILD in adjuvant therapy. Careful patient selection, thorough risk assessment, and vigilant monitoring are crucial for early detection and management. Given the increasing use of osimertinib in postoperative settings, further research is needed to better understand and mitigate the risks associated with this therapy.