Delay in diagnosis of PD-1 Inhibitor induced Secondary adrenal Insufficiency

Introduction: Immune checkpoint inhibitors including PD-1 inhibitors, were initially approved for the treatment of metastatic melanoma but are now increasingly being used for different types of solid organ malignancies. Despite the important clinical benefits, they are associated with immune-related adverse events. The most critical endocrinopathy associated with PD -1 inhibitor is adrenal insufficiency (AI), which requires prompt diagnosis and management to avoid fatality. Case presentation: We present the case of a 78-year-old woman with colon adenocarcinoma treated with Nivolumab (PD-1 inhibitor) after her pulmonary metastases progressed on chemotherapy. She presented to the hospital with progressive generalized weakness, fatigue, headache, lightheadedness, nausea, myalgia, reduced oral intake. She had 2 prior hospitalizations on account of similar symptoms with workup negative for cancer progression or gastrointestinal obstruction. Her laboratory values showed Na 128mmol/L, K 3.4mmol/L, Cr 0.52mg/dL and blood sugar 42mg/dL. Morning cortisol was low at 2.2µg/dL and ACTH stimulation test was positive. She was diagnosed with AI secondary to Nivolumab use and was started on Hydrocortisone while Nivolumab was discontinued. Conclusion: Immune checkpoint inhibitors have a unique side effect profile of immune-related adverse events, the most critical of which is AI. However, the non-specific manifestations of AI can lead to misdiagnosis or delay in diagnosis. Therefore, it is important for physicians to have high index suspicion for AI in acutely ill patients on PD-1 inhibitors for prompt recognition, diagnosis and treatment of AI which is important to prevent life-threatening adrenal crisis

Effectiveness of an Oral Health Care Training Workshop for School Teachers: A Pilot Study

Background: School teachers play key roles in imparting appropriate and up-to-date knowledge to pupils and students. However, most teachers in developing countries like Nigeria have poor knowledge and motivation about oral health which may be due to inadequate training in the area of oral health. This might be one of the reasons for the poor oral hygiene among them and their students.Objectives: To evaluate the effectiveness of an oral health care training programme organized for teachers in Eruwa, Oyo state, Nigeria. Methods: An intervention study was conducted among 40 school teachers who attended a two day oral health training workshop at Eruwa, headquarters of Ibarapa East Local Government Area. Training methods included lectures and demonstrations on aetiology, clinical features, treatment and prevention of common oral diseases. Pre- and post- evaluation written tests were administered to the participants to assess the effectiveness of the training. The knowledge scores were rated as poor, fair and good knowledge scoring <50.0%, 50.0-60.0% and > 60.0% respectively. Frequencies, percentages and means of relevant variables were generated. Paired t-test was used to compare means at P<0.05.Result: The mean age of the teachers was 40.13 ±7.24 years. There were 16 (40.0%) males and 24 (60.0%) females. Twenty (50.0%) of the participants had poor pre-training knowledge as compared to 7 (17.5%) after the training. Thirteen (32.5%) had fair pre-training knowledge as compared to 17 (42.5%) post training. Only (2.5%) of the participants had good pre-training knowledge as compared to 18 (45.0%) post training. The mean scores of the pre- and post-evaluation tests were 31.70 ±11.31 and 48.20 ±11.16 respectively. There was a statistically significant difference between the mean scores of the pre and post evaluations P<0.05.Conclusions: The training workshop improved the knowledge of school teachers regarding oral health.Keywords: Effectiveness, Oral health training, Teachers

Acute Polyarthritis as a Harbinger of Recurrent Non-Hodgkin Lymphoma

Background: Non-Hodgkin lymphoma (NHL) commonly presents with painless lymphadenopathy, splenomegaly, hepatomegaly, and constitutional symptoms of fever, night sweats, or weight loss. Skeletal involvement is possible, but it is rarely the first complaint. NHL may lead to a diagnostic dilemma when it presents solely with small joints involvement, mimicking Rheumatoid Arthritis. We present a patient with relapse of NHL manifesting as symmetrical polyarthritis. Case Presentation: A 69-year-old woman with prior history of NHL who achieved remission with chemotherapy presented to the Emergency Room (ER) three years later with progressively worsening pain in the small joints of both hands, associated with stiffness and swelling. She had associated fatigue and occasional night sweats but no fever, lymphadenopathy, skin rash, or oral ulcers. Physical examination revealed dactylitis of the right thumb and index finger; and synovitis of all the PIP, MCP, and metatarsophalangeal joints. She had multiple ER visits and failed treatments with steroids and opioids. She received presumptive diagnoses of Rheumatoid arthritis, acute gout, and carpal tunnel syndrome. Her inflammatory markers and autoimmune workup were unremarkable. Table 1 X-rays of her hands showed cystic changes; a Positron Emission Tomography (PET) scan revealed increased uptake in a periarticular and peripheral osseous distribution. Bone marrow biopsy did not reveal malignant cells, but histopathology of calcaneal bone confirmed infiltration by large B-cell Lymphoma. Due to her poor functional status, she was no longer a candidate for curative chemotherapy at the time of diagnosis, and she declined palliative radiotherapy or steroid. Conclusion: This case reflects the dilemma of physicians managing patients with seronegative symmetric polyarthritis. Physicians should always consider a broad list of differentials that include malignancy and promptly get a bone biopsy if destructive bone lesions are present on imaging because bone marrow biopsy can be unrevealing in NHL. Delayed diagnosis may lead to poor outcomes Keywords: Non-Hodgkin Lymphoma, polyarthritis, Rheumatoid arthritis Table 1: Laboratory results Test (Units) Result Reference range White blood cells (*10E3/uL) 4.8 4.8 – 10.8 Hemoglobin (g/dL) 13.3 12.0 – 16.0 Platelet (*10E3/UL) 176 130 - 400 Sodium (Meq/L) 139 136 - 145 Potassium (Meq/L) 3.6 3.5 – 5.1 Creatinine (mg/dL) 0.87 0.6 – 1.3 Blood Urea Nitrogen (mg/dL) 16 7 - 25 Calcium (mg/dL) 9.9 8.6 – 10.3 25 hydroxy Vitamin D (ng/mL) 44.7 \u3c20.0 Parathyroid hormone (pg/mL) 44 12 - 88 C-reactive protein (ng/dL) 0.32 \u3c1.00 Sedimentation rate (mm/hr) 35 0 - 20 Ferritin (ng/ml) 107 27 - 300 Rheumatoid factor (IU/mL) 14.0 Anti- cyclic citrullinated peptide (U/mL) \u3c0.5 \u3c3.0 Antinuclear antibody 1:40 Anti-double stranded DNA Negative Anti-smith antibody Negative Antineutrophil Cytoplasmic antibody (U/mL) \u3c0.3 Uric acid (mg/dL) 4.8 2.3 – 6.6 Lactate dehydrogenase (IU/L) 221 140 - 271 Lyme disease IgM antibody Negative Lyme disease IgG antibody Negative Parvovirus B19 IgG Antibody (IV) 4.53 Parvovirus B19 IgM Antibody (IV) 0.15 Ebstein-Barr Virus IgM antibody Negative Ebstein-Barr Virus IgM antibody Negativ

Delay in diagnosis of PD-1 Inhibitor induced Secondary Adrenal Insufficiency

Introduction Immune checkpoint inhibitors, including PD-1 inhibitors, were initially approved to treat metastatic melanoma but are now increasingly being used for many different types of solid organ malignancies. Despite the significant clinical benefits, they are associated with immune-related adverse events, including dermatologic, gastrointestinal, hepatic, and endocrine diseases. The most critical endocrinopathy associated with PD -1 Inhibitor is adrenal insufficiency, and it requires prompt diagnosis and management to avoid fatality. Case presentation We present the case of a 78-year-old woman with a history of gastric bypass, alcohol use, and stage III (T3N1bM0) colon adenocarcinoma status post hemicolectomy and adjuvant Capecitabine with metastatic recurrence in the lungs. She was treated with Nivolumab after her pulmonary metastases progressed on FOLFOX chemotherapy. She had been hospitalized multiple times on account of worsening dry heaving, reduced oral intake, and fatigue with workup negative for cancer progression or gastrointestinal obstruction. She again presented to the hospital with progressive generalized weakness, fatigue, headache, lightheadedness, nausea, myalgia, and reduced oral intake. Her vitals: blood pressure 171/88mmHg, pulse 83/minute, temperature 36.4 °C, and oxygen saturation of 98% in room air. Her laboratory results showed Na 128mmol/L, K 3.4mmol/L, Cr 0.52mg/dL and blood sugar 42mg/dL. Her chemotherapy was withheld. However, morning cortisol was low at 2.2µg/dL, and the ACTH stimulation test was positive (baseline cortisol 1.4µg/dL, 7.0 µg/dL at 30 minutes, and 9.7µg/dL at 60 minutes). A diagnosis of adrenal insufficiency possibly secondary to Nivolumab use was made. She was started on Hydrocortisone, and Nivolumab was discontinued. At her follow-up visit, her symptoms had resolved. Conclusion Immune checkpoint inhibitors have a unique side effect profile of immune-related adverse events, the most critical of which is adrenal insufficiency. Prompt recognition, diagnosis, and treatment of adrenal insufficiency are essential to prevent life-threatening adrenal crises. Physicians need to have a high index of suspicion for adrenal insufficiency in patients on PD-1 inhibitors presenting with nonspecific nausea, vomiting, and fatigue to prevent life-threatening complications

Thyroid Acropachy: A rare manifestation of Graves disease

Background: Thyroid acropachy is a rare manifestation of Graves disease characterized by periosteal new bone formation and digital clubbing. Patients may be asymptomatic, but some present with disabling small-joint pain, skin tightness, and soft tissue swelling. It is common in smokers and patients with advanced ophthalmopathy or dermopathy; early recognition is important to prevent unnecessary tests and treatment. Case Presentation: 58-year-old woman with an 18-year history of Graves disease status post thyroidectomy, thyroid eye disease s/p oculoplastic surgery and radiation therapy, post-surgical hypothyroidism treated with levothyroxine, osteoporosis, and tobacco use who presented to the Emergency Room with four months history of worsening pain In both hands and feet with associated swelling, early morning stiffness and curving of her nails. She had no oral ulcers, photosensitivity rash, or fatigue. She had normal vital signs, but her physical examination revealed exophthalmos, generalized soft tissue swelling of hands and feet, tenderness in the metacarpophalangeal and distal interphalangeal (DIP) joints of both hands, grade 4 finger clubbing, and thickening of the skin over the dorsum of both feet and ankles. The laboratory data showed normal TSH and free T4, elevated Thyroid Stimulating Immunoglobulin 2.7( She had a right foot skin biopsy; pathology revealed verrucous skin and no myxoedema. She was diagnosed with thyroid acropachy, received three weeks of treatment with Prednisone 20mg daily, and was switched to weekly Methotrexate and folic acid. Her pain and swelling improved with steroids, but finger clubbing persisted. At a recent follow-up visit, she reports being pain-free on Methotrexate. Conclusion: Graves acropachy is rarely seen in the absence of dermopathy or ophthalmopathy. Diagnosis is often clinical; however, an X-ray of the affected limb often provides a more accurate diagnosis. There is no specific treatment, but high dose ste=roids, Rituximab, and other immunomodulators have been used

A Case of Macrophage Activation syndrome Heralding The Diagnosis of SLE

Background Macrophage activation syndrome (MAS) is a form of hemophagocytic lymphohistiocytosis that occurs primarily in patients with juvenile idiopathic arthritis or other Rheumatologic diseases but rarely in SLE. It is characterized by an aggressive and life-threatening syndrome of excessive immune activation and presents as an acute or subacute febrile illness associated with multiple organ involvement and often diagnosed late due to its rarity. We present a case of MAS precipitated by Ehrlichia infection leading to the diagnosis of SLE in a young male. Case Presentation A 26-year-old male with a history of chronic ITP and nephrolithiasis who presented to the ER with complaints of fever, fatigue, generalized weakness, and presyncope. He reported unintentional weight loss of 30 pounds in three months and two months history of fatigue, malaise, night sweats, polyarthralgia, and episodic swelling in fingers and toes. He has a family history of SLE in his mother and maternal aunt. His vital signs in the ER: Temperature 38.7oc, HR 111/min, BP 122/75mmhg and RR 20cpm, SPO2 98% on RA. He had tenderness in the small joints of the hands and bilateral axillary and inguinal lymphadenopathy on physical examination. His initial laboratory work-up revealed pancytopenia, transaminitis, low fibrinogen, elevated D-dimer, troponin, and lipase. He had wall motion abnormality, low ejection fraction, and pericardial effusion on Transthoracic Echocardiogram. CT Chest/Abdomen/Pelvis showed hepatomegaly, inguinal and axillary lymphadenopathy, and findings suggestive of acute pancreatitis. The top differential diagnoses were autoimmune disease and malignancy. Immunologic work-up revealed positive Anti-nuclear antibody, anti-double-stranded DNA, anti-smith antibody, anticardiolipin, and B2-glycoprotein antibodies. He also had low complement levels, elevated ferritin, and ESR. An extensive infectious screen revealed a positive Erhilichia IgM antibody. Table 1. Flow cytometry and Axillary lymph node pathology were negative for malignancy. He met the diagnostic criteria for SLE (5 of 11 ACR criteria) and had an HScore of 228 points (96-98% probability of hemophagocytic syndrome). He was treated with high-dose steroid and hydroxychloroquine and completed ten days of doxycycline. Conclusion This case is a rare presentation of MAS in a young man with previously undiagnosed SLE. Prompt diagnosis and treatment are important to prevent an adverse outcome. Table 1: Laboratory tests(units) Result Normal Range White cell count (X 103/uL) 2.38 4.8 - 10.8 Platelet (X 103/uL) 53 130 - 400 Hemoglobin(g/dL) 10 14.0 - 17.5 ESR (mm/hr) 40 0-15 CRP (mg/dl) 0.4 \u3c1.00 Fibrinogen(mg/dL) 218 193 - 488 Blood protein electrophoresis Polyclonal Hypergammaglobulinemia; increased alpha 1 globulin and hypoalbuminemia Ferritin(ng/mL) 7500 24 - 336 Triglyceride(mg/dL) 408 \u3c175 Creatinine(mg/dL) 0.64 0.60 - 1.30 Troponin(ng/mL) 0.1 \u3c=0.06 D-dimer(ug/ml) 5 \u3c0.50 LDH (units/L) 289 140- 280 Lipase (IU/L) 306 11 - 82 Haptoglobin(mg/dL) 213 20-200 Procalcitonin(ng/mL) 1.07 \u3c0.50 Anti-double stranded DNA antibody 1:40 1:10 Anti-Smith \u3e8 \u3c1 Cardiolipin 1:38 \u3c=14 ANA 1:640(homogenous pattern) \u3c40 DRVVT (Dilute Russell\u27s viper venom time) Positive Negative DRVVT (Dilute Russell\u27s viper venom time) 175 \u3c=45 Cardiolipin Ab IgG 38 \u3c=14 Cardiolipin Ab IgA \u3c11 \u3c=11 Cardiolipin Ab IgM 32 \u3c=12 Beta 2 glycoprotein 1 IgG(SGU) 23 \u3c=20 Beta 2 glycoprotein 1 IgA(SAU) 45 \u3c=20 Beta 2 glycoprotein 1 IgM (SMU) 60 \u3c=20 PhosSerine IGG 46 \u3c10 C3(mg/dL) 29 90-180 C4(mg/dL) 6 15-45 Mitochondrial antibodies Negative Negative Smooth Muscle antibody Negative Negative ANCA Screening Negative Negative Anti-liver/kidney microsomal antibodies (Anti-LKM-1) Negative Negative Ehrlichia chaffeensis IgM Ab 1:40 \u3c1:20 Ehrlichia chaffeensis IgG Ab \u3c1:64 \u3c1:6

Arrhythmia With Lithium Toxicity Requiring Urgent Dialysis: A Case Report.

Lithium has been widely used as a mood stabilizer. With its narrow therapeutic index, systemic side effects, primarily neurological are a concern. Cardiotoxic effects of lithium are rare, reported as non-specific T-wave flattening, prolonged QT interval, sinus node dysfunction, ventricular tachycardia, cardiomyopathy, and myocardial infarction. We report an interesting case of a young female patient with schizoaffective disorder on lithium who developed life-threatening cardiotoxicity secondary to lithium requiring urgent dialysis

The Journey From Knee to Heart: A Case of Methicillin-Sensitive Staphylococcus aureus Infective Endocarditis Secondary to Septic Prepatellar Bursitis.

Staphylococcus aureus is a cause of life-threatening gram-positive bacteremia and the most common causative organism of septic bursitis. Although there are several case reports of infective endocarditis complicated with septic bursitis and other rheumatic complications, there are very few cases reports of septic bursitis leading to infective endocarditis (IE). We present a patient with a history of recurrent prepatellar bursitis requiring catheter drainage, who presented with sepsis and IE