Thyrotoxic Dysphagia in an 82-Year-Old Male

Dysphagia is a common problem in elderly patients and a rare manifestation of Graves' disease. We report a case of an 82-year-old male who presented with a 4-week history of dysphagia and weight loss. Workup for his dysphagia with upper endoscopy, MRI brain, electromyography, acetyl-cholinesterase receptor antibodies, and voltage-gated calcium channel antibodies were negative. Modified Barium swallow test showed oropharyngeal dysphagia. Thyroid function tests that revealed hyperthyroidism and antibodies to TSH-receptor were positive. Based on the above findings, we considered Graves' disease as the most likely diagnosis. Patient was treated with methimazole and beta-blockers and subsequently his dysphagia resolved. This paper highlights the importance to clinicians of considering thyrotoxicosis as possible diagnosis in an elderly patient presenting with unexplained dysphagia

Case Report Thyrotoxic Dysphagia in an 82-Year-Old Male

Dysphagia is a common problem in elderly patients and a rare manifestation of Graves' disease. We report a case of an 82-yearold male who presented with a 4-week history of dysphagia and weight loss. Workup for his dysphagia with upper endoscopy, MRI brain, electromyography, acetyl-cholinesterase receptor antibodies, and voltage-gated calcium channel antibodies were negative. Modified Barium swallow test showed oropharyngeal dysphagia. Thyroid function tests that revealed hyperthyroidism and antibodies to TSH-receptor were positive. Based on the above findings, we considered Graves' disease as the most likely diagnosis. Patient was treated with methimazole and beta-blockers and subsequently his dysphagia resolved. This paper highlights the importance to clinicians of considering thyrotoxicosis as possible diagnosis in an elderly patient presenting with unexplained dysphagia

Review article: new treatments for advanced differentiated thyroid cancers and potential mechanisms of drug resistance

The treatment of advanced, radioiodine refractory, differentiated thyroid cancers (RR-DTCs) has undergone major advancements in the last decade, causing a paradigm shift in the management and prognosis of these patients. Better understanding of the molecular drivers of tumorigenesis and access to next generation sequencing of tumors have led to the development and Food and Drug Administration (FDA)-approval of numerous targeted therapies for RR-DTCs, including antiangiogenic multikinase inhibitors, and more recently, fusion-specific kinase inhibitors such as RET inhibitors and NTRK inhibitors. BRAF + MEK inhibitors have also been approved for BRAF-mutated solid tumors and are routinely used in RR-DTCs in many centers. However, none of the currently available treatments are curative, and most patients will ultimately show progression. Current research efforts are therefore focused on identifying resistance mechanisms to tyrosine kinase inhibitors and ways to overcome them. Various novel treatment strategies are under investigation, including immunotherapy, redifferentiation therapy, and second-generation kinase inhibitors. In this review, we will discuss currently available drugs for advanced RR-DTCs, potential mechanisms of drug resistance and future therapeutic avenues

Therapeutic Potential of Ralimetinib, a p38/MAPK14 Inhibitor, in Anaplastic Thyroid Cancer

View full abstracthttps://openworks.mdanderson.org/leading-edge/1028/thumbnail.jp

Characterization of Altered immunity in Anaplastic Thyroid Cancer

View full abstracthttps://openworks.mdanderson.org/leading-edge/1033/thumbnail.jp

UnUsUal presentation of endoCarditis with nUtritional variant streptoCoCCi Case presentation

Case presentation We describe a 61 year-old caucasian male who presented to our hospital complaining of sudden onset diplopia which lasted over 24-hour period. He had become aware of double images while working at his computer the previous night. There were no other associated symptoms like orbital pain, headache, neck stiffness, fever, chills, night sweets, skin rash, lightheadedness, dizziness, weakness or paresthesias. Review of systems was only positive for 30 pounds weight loss over the previous six-month period. He denied head trauma, recent dental procedures or intravenous drug use. The patient's past medical history was significant for a lumbar epidural abscess 6 months before this presentation. He underwent lumbar decompression, bone and facet removal due to complete erosion and drainage of the epidural abscess. The pathology only showed reactive periostitis and cultures of bacteria and fungi were both negative. Trans-thoracic echocardiogram did not reveal any vegetation. He was discharged home on intravenous Ceftriaxone to complete an 8 weeks course. Follow up MRI of the lumbar region showed no evidence of recurrent or persistent infection. On physical examination the patient was a middleaged man in no apparent distress. His vital signs were within normal limit. There were no conjunctival hemorrhages, splinter hemorrhages, Janeway lesions or Osler nodes noted. Heart examination revealed an old grade 3/6 systolic murmur best heart over the apex, with no radiation. His neurological exam was normal except for the following ocular findings: binocular diplopia, the adduction of the right eye was impaired while the abduction was intact. The majority blood work was essentially normal ruling out the common infectious agents, except for erythrocyte sedimentation rate (ESR) which was 60 (normal values <15). Soon after the admission, imaging of the head was performed with computer tomography (CT) scan, followed by an magnetic resonance imaging (MRI) of the brain and both tests failed to reveal any focal abnormalities of the brain that could explain the symptoms and the physical findings. The ultrasound of the carotids showed no significant stenosis on either side. Meningitis was ruled out with a lumbar puncture which failed to reveal any infectious process in the central nervous system (CNS) The culture, the Lyme antibody and Herpes polymerase chain reaction (PCR) obtained from the cerebrospinal fluid were all negative. The trans-thoracic echocardiogram was performed to rule out endocarditis and it revealed a mobile echogenic structure attached to the anterior mitral valve leaflet. The echocardiodiogram was followed by a trans-esophageal echocardiogram (TEE) and blood cultures to confirm the diagnosis. TEE showed a mobile mass very suggestive for endocarditi

Clinical characteristics and outcomes of immune checkpoint inhibitor-induced pancreatic injury

Abstract Background Immune checkpoint inhibitor (ICI)-induced pancreatic injury (ICIPI) is not well documented in the literature. We aimed to describe the clinical characteristics and outcomes of patients who developed ICIPI. Methods We reviewed the medical records of consecutive patients who had a confirmed diagnosis of ICIPI (Common Terminology Criteria for Adverse Events grade ≥ 3 lipase elevation with or without clinical symptoms) from April 2011 through April 2018. Results Among the 2,279 patients received ICI and had lipase values checked thereafter, 82 (4%) developed ICIPI. Overall, 65% of patients received inhibitors of programmed death protein-1 or its ligand. Compared with asymptomatic presentation, patients who had clinical symptoms of pancreatitis (n = 32) had higher levels of lipase (P = 0.032), more frequent imaging evidence of pancreatitis (P = 0.055), and more frequent hospitalization (P < 0.001) and received intravenous fluids (P < 0.001) and steroids more frequently (P = 0.008). Twelve patients (15%) developed long-term adverse outcomes of ICIPI; three had chronic pancreatitis, four had recurrence of ICIPI, and six had subsequent diabetes. Among 35 patients who resumed ICI therapy, four (11%) had recurrence of lipase elevation. Logistic regression revealed that smoking and hyperlipidemia were associated with increased risk for long-term adverse outcomes of ICIPI, and intravenous fluids were associated with reduced risk. Patients who resumed ICI therapy survived longer than patients who discontinued ICI therapy permanently, statistically not significant (P = 0.0559). Patients who developed long-term adverse outcomes of ICIPI survived significantly longer than those who did not (P = 0.0295). The highest proportion of patients (6/21, 29%) developed long-term adverse outcomes of ICIPI was among those without typical symptoms of pancreatitis, continued ICI therapy after ICIPI, and did not receive intravenous fluids. Conclusion ICIPI can present as typical acute pancreatitis, with risk of the development of a pseudocyst, diabetes, and chronic pancreatitis. ICI resumption after ICIPI may lead to recurrence of lipase elevation without increased risk of long-term adverse outcomes, and can increase survival duration. Intravenous fluids may prevent long-term adverse outcomes, but steroids do not appear to affect outcomes of ICIPI. Asymptomatic ICIPI presentation may lead to undertreatment of ICIPI owing to underestimation of its degree, and therefore, intravenous fluid administration could potentially could potentially be benificial to prevent long-term adverse outcomes even in asymptomatic patients

Early introduction of selective immunosuppressive therapy associated with favorable clinical outcomes in patients with immune checkpoint inhibitor–induced colitis

Abstract Background Current treatment guidelines for immune-mediated colitis (IMC) recommend 4 to 6 weeks of steroids as first-line therapy, followed by selective immunosuppressive therapy (SIT) (infliximab or vedolizumab) in patients who do not respond to steroids. We assessed the effect of early SIT introduction and number of SIT infusions on clinical outcomes. Methods We performed a retrospective review of patients with IMC who received SIT at The University of Texas MD Anderson Cancer Center between January and December 2018. Logistic regression analyses were used to assess associations between clinical outcomes and features of IMC. Results Of the 1459 patients who received immune checkpoint inhibitors, 179 developed IMC of any grade; 84 of these 179 patients received SIT. Of the 84 patients who received SIT, 79% were males, and the mean age was 60 years (standard deviation, 14). Compared with patients who received SIT > 10 days after IMC onset, patients who received early SIT (≤10 days) required fewer hospitalizations (P = 0.03), experienced steroid taper failure less frequently (P = 0.03), had fewer steroid tapering attempts (P < 0.01), had a shorter course of steroid treatment (P = 0.09), and had a shorter duration of symptoms (P < 0.01). Patients who received one or two infusions of SIT achieved histologic remission less frequently (P = 0.09) and had higher fecal calprotectin levels after SIT (P = 0.01) compared with patients who received three or more infusions. Risk factors for IMC recurrence after weaning off steroids included: 1) needing multiple hospitalizations, 2) experiencing steroid taper failure after SIT, 3) receiving infliximab rather than vedolizumab, 4) receiving fewer than three infusions of SIT, 5) having higher fecal calprotectin levels after SIT, and 6) receiving a longer course of steroids, hospitalization and IMC symptoms. Unsuccessful weaning from steroids after SIT was associated with high IMC grades; multiple hospitalizations; steroid-resistant IMC; long interval from IMC to SIT initiation; and long duration of steroids, IMC symptoms, and hospitalization. Conclusion SIT should be introduced early in the disease course of IMC instead of waiting until failure of steroid therapy or steroid taper. Patients who received three or more infusions of SIT had more favorable clinical outcomes