Caucasian Man Research Articles

Traumatic Macular Hole and Uveitis: A Case Report

Introduction: Blunt ocular trauma may be associated with a variety of complications, including traumatic macular holes (TMH) and uveitis. Concerning the TMH, there is no standard treatment protocol. There have been reports of spontaneous closure and of the use of certain medications and surgical techniques. Our purpose is to present a case of bilateral blunt ocular trauma with TMH in the right (OD) and uveitis in the left eye (OS) in a 24-year-old Caucasian man.
 Case presentation: The patient had complaints of decreased vision in OD and redness and discomfort in OS. Three days previously, he had sustained trauma to both eyes with an exercise resistance band. The diagnosis was made with a thorough ophthalmic exam and optical coherence tomography (OCT). The best-corrected visual acuity (BCVA) of OD was 20/40 and of OS – 20/20. The intraocular pressure was within normal limits. There was a TMH in OD and iridocyclitis in OS. The therapy included prednisolone with an initial dose of 60 mg q.d. PO, a lutein/zeaxanthin supplement, and additional topical treatment for OS – dexamethasone and cyclopentolate. The TMH in OD had improved significantly within 6 days. BCVA of OD recovered to 20/20 in a month.
 Conclusion: We observed closure of the TMH with complete recovery of vision in the affected eye, most likely spontaneous, and with full resolution of the uveitis in the other, in the setting of short-term prednisolone therapy. The uveitis in OS was also treated with topical dexamethasone and cyclopentolate.

Failure of diltiazem to prevent 1:1 conduction of atrial flutter: a case report

BackgroundAtrial flutter with 1:1 conduction to the ventricles is a dangerous cardiac arrhythmia. Contemporary guidelines recommend atrioventricular nodal blocking agents should be co-administered with class 1C anti-arrhythmics, as prophylaxis against 1:1 flutter. No guidance is provided on the type or strength of atrioventricular nodal blockade required, and in practice, these agents are frequently prescribed at low dose, or even omitted, due to their side effect profile.Case presentationA 62 year old Caucasian man with a history of paroxysmal atrial fibrillation treated with flecainide, presented with atrial flutter with 1:1 conduction to the ventricles and was cardioverted. Diltiazem was added to prevent this complication and he again presented with atrial flutter with 1:1 conduction to the ventricles, despite prophylaxis with coadministration of diltiazem.ConclusionsThis case report demonstrates failure of diltiazem to prevent 1:1 flutter in a patient chronically treated with flecainide for paroxysmal atrial fibrillation.

Extracorporeal hemoadsorption therapy as a potential therapeutic option for rapid removal of Apixaban in high risk-surgical patients: a case report

BackgroundApixaban is a non-vitamin K antagonist oral anticoagulant (NOACs) recently emerged as an effective alternative to conventional vitamin K antagonists (VKAs) in the treatment of several thromboembolic disorders. However, in case of overdose or in patients requiring emergency surgery there is a high bleeding rate and severe adverse side effects due to the absence of an antidote. There is promising data from in vitro and clinical studies, that certain antithrombotic agents (that is Rivaroxaban and Ticagrelor) have been successfully removed by the extracorporeal hemoadsorption therapy CytoSorb. Here, we present the case of a patient successfully treated with CytoSorb as a kind of antidote to enable emergency surgery for bilateral nephrostomy.Case presentationA 82-year-old Caucasian man was admitted to the Emergency Room with acute kidney injury (AKI) in the context of severe bilateral hydroureteronephrosis. The patient’s medical history included chronic obstructive pulmonary disease, arterial hypertension, atrial fibrillation (anticoagulated with Apixaban) and a locally advanced prostate adenocarcinoma treated with trans-ureteral resection of the bladder and radiotherapy in the previous months. The indication for a bilateral nephrostomy could not be considered immediately given the major bleeding risk due to Apixaban, which was discontinued and replaced with calciparin. After 36 hours of continuous renal replacement therapy (CRRT), the Apixaban blood level was still elevated and it was decided to install CytoSorb into the running CRRT to accelerate the drug clearance. After 2 hours 30 minutes, there was good reduction of Apixaban from 139 to 72 ng/ml (reduction rate of 48.2%) registered, and this allowed for an easy placement of bilateral nephrostomies without complications. Four days after surgery renal function parameters further normalized, the patient did not require additional dialysis treatments and Apixaban therapy was prescribed again once the patient returned home.ConclusionsIn this case we report the findings of a patient with post-renal AKI requiring emergency nephrostomy placement while on chronic anticoagulation with Apixaban therapy. Combined treatment with CRRT and CytoSorb was associated with the rapid and effective removal of Apixaban allowing for prompt and urgent surgery while simultaneously ensuring the low risk of bleeding as well as an uneventful post-operative course.

Presentation of new onset type 1 diabetes with diabetic ketoacidosis and hyperosmolar hyperglycaemia after a single dose of nivolumab and ipilimumab.

A Caucasian man in his 60s with recent diagnosis of metastatic renal cell carcinoma presented to the emergency department with a 5-day history of severe polyuria, polydipsia and fatigue and 1-day history of confusion, abdominal pain, nausea and vomiting. Investigations revealed an overlap of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS). He had received the first dose of immunotherapy with nivolumab and ipilimumab 3 weeks prior to this attendance. New-onset type 1 diabetes (T1DM) was confirmed based on the clinical features at presentation, seropositivity for glutamic acid decarboxylase antibodies and significant insulin deficiency. He is currently on a multiple daily injections of insulin and uses intermittent-scanned glucose monitoring. Given the irreversible impact on beta-cell function and clinical response with insulin resulting in improved diabetes control, immunotherapy was resumed for his metastatic cancer with good radiological response. Although rare, new-onset T1DM can present with DKA and HSS overlap after a single dose of nivolumab/ipilimumab in individuals without pre-existing history of diabetes. Although rare, new onset of T1DM after immunotherapy can present with DKA and HSS overlap after a single dose of nivolumab/ipilimumab in individuals without pre-existing history of diabetes and normal glycaemic parameters. Due to the irreversible destruction of beta-cells, treatment with steroids is not indicated in contrast to other settings such as immunotherapy-induced hypophysitis. Presence of low c-peptide levels post-acute presentation is indicative of an irreversible impact on beta-cell function and supports resuming immunotherapy given the significant benefits on cancer prognosis. Clinicians must maintain a high index of suspicion in regards to diagnosis and management of new-onset type 1 diabetes and advice patients on reporting symptoms suggestive of diabetes and/or diabetes-related hyperglycaemic emergencies.

Stereotactic ablative body radiation therapy for isolated pulmonary metastases from pancreatic cancer after metastectomy with positive margins: a case report

BackgroundIsolated pulmonary oligometastases as the first site of dissemination after initial resection of pancreatic ductal adenocarcinoma (PC) is a rare event, and the treatment in this subgroup is challenging. Recurrence in the lung after initial primary tumour resection is associated with the most long-term survivors of patients with metastatic PC. Stereotactic ablative body radiation therapy (SABR) or metastectomy for pulmonary oligometastases from PC is becoming more common. However, patients with close or positive margins after metastectomy for isolated pulmonary metastatic PC are at high risk for recurrence. This requires a treatment capable of achieving high rates of local control and improved quality of life by delaying the need for systemic chemotherapy. In other settings, SABR has been shown to achieve these goals, allowing safe dose escalation with excellent conformity and short duration of treatment.Case presentationWe report the case of a 48-year old Caucasian man with a history of locally advanced PC initially treated with neoadjuvant chemotherapy followed by Whipple’s resection in August 2016. After a disease-free interval of 3 years, he developed three isolated pulmonary metastases which were treated with local resection. In the setting of microscopically positive resection margins (R1), adjuvant lung SABR was delivered to all three sites. His treated lung disease remained radiologically stable for up to twenty months after SABR. Treatment was well tolerated. In January 2021, he developed a malignant pre-tracheal node which was treated with conventionally fractionated radiotherapy and remained controlled for the duration of follow-up. A year later, he developed widespread metastatic disease including pleura, bone and adrenal gland, together with presumed progression in one of the original lung lesions, receiving palliative radiotherapy for right chest wall pain. He was later found to have an intracranial metastasis and died in February 2022, 5½ years after initial treatment.ConclusionWe present the case of a patient treated with SABR after R1 resection of 3 isolated pulmonary metastases from PC, with no treatment toxicities and durable local control. For well-selected patients in this setting, adjuvant lung SABR may be a safe and effective treatment option.

#3741 A CASE OF PODOCYTIC INFOLDING GLOMERULOPATHY WITH DIABETES MELLITUS, NEPHROTIC RANGE PROTEINURIA AND POSITIVE ANTI-PLA2R IN SERUM

Abstract Background and Aims Podocytic infolding glomerulopathy (PIG) is a rare glomerular abnormality which was first proposed as a new disease entity in 2008. It is characterized by glomerular basement membrane (GBM) bubbling viewable by light microscopy, due to extensive trapping of podocytic cytoplasm fragments and cell membrane projections within the GBM. Electron microscopy reveals podocyte infolding and invagination into the glomerular basement membranes (GBMs). Most of the cases reported worldwide, indicate that PIG usually co-exists with autoimmune diseases. In this case we present a diabetic patient with no other autoimmune disease in his medical history, whose biopsy was characterized as PIG. Method A 60-year-old Caucasian man with a 5-year history of type II diabetes mellitus, hyperlipidemia, hypertension, hyperuricemia and benign colon polyps, was noted by his family physician to have proteinuria. He had been treated with an angiotensin II receptor blocker, statin, and allopurinol for 5 years and he was well regulated. At the point of admission, his 24-h urine collection showed 4,5gr of urine protein. His creatinine at the time was normal (0,89mg/dl), no hypoalbuminemia, no edema or deregulation of hyperlipidemia was noted. His fundoscopy at this point had no diabetic lesions. In the immunological work up, we found normal values of autoantibodies ANA, anti-dsDNA, anti-ENA, complement screening C3, C4, serum and urine protein electrophoresis - immunofixation. Everything was within normal limits except from serum autoantibodies to Phospholipase A2 Receptor of podocytes which was tested with ELISA and valued 35 RU/mL (<20RU/mL). In the following 9 months his proteinuria remained at the same levels. Due to the persistent nephrotic range proteinuria (>3.5gr/24h) a kidney biopsy was performed. Biopsy was evaluated under light microscope (histochemistry for Congo-Red and immunohistochemistry for C4d, PLA2R and DNAJB9 included), immunofluorescence and electron microscope. Results The renal biopsy included 8 glomeruli, 3 of them globally sclerosed (37.5%), the rest enlarged with mild to moderate mesangial matrix increase and thickening of the GBMs, without spikes, pin holes or reduplications. Immunohistochemistry for C4d, PLA2R and DNAJB9 was negative. Immunofluorescence revealed nothing noticeable (no staining of IgG, IgA, IgM, C3, C1q, C4, κ-λ chains) apart from a moderate linear albumin staining. Without electron microscopy the whole picture was rather reminiscent of mild to moderate lesions of diabetic nephropathy. On electron microscopy, no classical electron-dense deposits were found. Effacement of podocytes’ foot processes was multi-segmental. More importantly, podocytic cytoplasmic processes invaginating into the GBMs were observed, accompanied by scattered endomembranous, partially microspherular microstructures, sometimes with adjacent unclear small pyknotic areas. The biopsy report concluded that although light microscopy and immunofluorescence findings could indicate diabetic nephropathy, the electron microscopy lesions suggest the diagnosis of PIG. Conclusion To our knowledge, this is the first reported case with PIG and anti-PLA2R antibodies detected in the serum, without clear histological evidence of membranous nephropathy. Our patient was diabetic for five years with no diabetic lesions in fundoscopy. Although PIG has been reported mainly in the context of autoimmune diseases, the coexistence with diabetes or its possible role in PIG's pathogenesis has not been addressed. The treatment of this peculiar morphologically disease, still remains an open query for physicians.

Amiodarone-induced blue man syndrome: a case report

BackgroundAmiodarone is one of the most commonly used and effective antiarrhythmic drugs to treat ventricular and supraventricular arrhythmias. Besides its advantages, this drug has side effects like liver, digestive, pulmonary, thyroid, neural, skin, optical, hematologic, psychiatric, and cardiac complications. Blue-gray cutaneous discoloration, also known as blue man syndrome, is an undesirable and unusual side-effect of chronic amiodarone therapy in less than 3% of patients.Case presentationThis report presents a 51-year-old Caucasian man treated for the past 3 years with amiodarone and implantable cardioverter defibrillators due to his ventricular arrhythmia and cardiomyopathy, without any follow-up visit to his doctor. He was referred to the medical center for blue-gray discoloration on his nose and cheeks, which had started to appear in the last 3 weeks.ConclusionConsidering the findings obtained in this report and the numerous side effects of amiodarone, the blue-man syndrome is a rare yet important finding of this drug which may influence the patient’s daily life. It is recommended that all patients under treatment with this drug be notified about its side effects and visit their doctors regularly. Regarding the high therapeutic value of this drug, the lack of any association between blue man syndrome and other complications, and the related aesthetic problems, the role of the caregiver becomes much more critical in the prescription of amiodarone.

A 48-year-old Caucasian man with unilateral "smudge" in inferior visual field.

To report an increasingly prevalent fundoscopic manifestation of syphilitic uveitis. Case report of a patient with acute retinal necrosis secondary to syphilis. A 48-year-old man presented with decreased vision, anterior segment inflammation, and a wedge-shaped retinal lesion in the superior periphery, with a diaphanous leading edge extending down towards the superior arcade. The patient was HIV+ and poorly compliant with therapy. The top three differential diagnoses were herpetic necrotizing retinitis, syphilis, and lymphoma. An extensive lab workup was positive for syphilis. The patient was treated with IV penicillin G and demonstrated improvement in visual acuity and exam. There have been an increasing number of reports of syphilis patients, especially in the population of men who have sex with men, who present with fundus findings similar to acute retinal necrosis. These findings include a characteristic ground glass, translucent appearance of unifocal or multifocal lesions, primarily affecting the inner retina and sometimes associated with co-localizing occlusive vasculitis. Treatment with IV penicillin G is warranted and has demonstrated good visual recovery.

P393 EDOXABAN: NEW PERSPECTIVE IN A PATIENT WITH CANCER–ASSOCIATED THROMBOSIS COMPLICATED BY BRAIN METASTASES. A RARE CLINICAL CASE

Abstract Herein, we present the case of a 58 y–o Caucasian man with unremarkable cardiovascular history and a strong family history for cancer. He was diagnosed with lung adenocarcinoma IVb (pleura, pleural effusion, lymph nodes), PDL1: 2% TPS and absence of actionable driver mutations on DNA and RNA NGS (only ERBB2 mutation). Started first–line chemotherapy with cisplatin–pemetrexed regimen and immunotherapy with pembrolizumab. He developed common/superficial femoral and popliteal deep vein thrombosis (DVT) and pulmonary embolism (PE). The patient started low–molecular–weight heparin (LMWH) namely enoxaparin 1 mg/kg x 2/d (weight: 65 Kg). After 1 mo, CT showed PE resolution. Due to DVT persistence and patient’s preference for oral administration, LMWH was replaced with direct oral anticoagulant (DOAC) namely edoxaban 60 mg 1 cp/d. After 2 mo, resolution of common femoral and popliteal vein thrombosis with partial recanalization of superficial femoral DVT were detected. However, he developed brain metastases treated with WB radiotherapy. We decided for edoxaban full dose long–term anticoagulant treatment with monthly cardioncological surveillance. After 6 mo since cancer diagnosis, the patient was still adherent to DOAC therapy, although in a maintenance combined regimen pemetrexed–pembrolizumab based, without both drug–drug interactions and brain bleeding. Conclusions Thromboembolism is the second leading cause of death in malignancy. In this clinical case, a man with advanced lung cancer developed extended cancer–associated thrombosis (CAT). However, the appearance of brain metastases has posed a clinical dilemma: to continue or to withdraw the anticoagulant therapy and, also, which drug to choose between LMWH and DOAC. Literature is limited on the use of DOACs in cancer patients with brain metastases. Besides, current guidelines neither advocate contraindication to DOAC, nor suggest caution as requested for gastrointestinal and genitourinary sites of cancer. We decided to proceed with edoxaban therapy, despite chemotherapy combined to immunotherapy were still ongoing and the concurrent appearance of brain metastases, with good results in efficacy, patient’s adherence and, mostly, safety. In conclusion, in regard to our clinical experience, we point out DOAC as a reliable and manageable therapeutical choice in CAT, also in active cancer patients with brain metastases receiving chemo–immunotherapy.

P134 RECURRENT SCAD IN A PATIENT WITH BICUSPID AORTIC VALVE AND ANOMALOUS CORONARY ORIGIN

Abstract Spontaneous coronary artery dissection (SCAD) is recently emerging as an increasingly frequent cause of myocardial infarction and among the main triggering factors we found hypertension, pregnancy, fibromuscular dysplasia and connective tissue diseases (e.g. Marfan syndrome). Recent studies also suggest that even bicuspid aortic valve may be a predisposing condition for the development of spontaneous coronary artery dissection. We report the case of a 45–year–old Caucasian man with no cardiovascular risk factors; his clinical history begins in August 2019, when he was hospitalized for acute coronary syndrome (NSTEMI). Echocardiography showed preserved left ventricular ejection fraction, bicuspid aortic valve (fusion of right and left cusps) with mild to moderate regurgitation without stenosis and mild dilatation of the aortic bulb (38 mm). The coronary angiography showed no significant stenoses and an anomalous origin of the right coronary artery from the common trunk. The patient was discharged two days later with a diagnosis of MINOCA and an indication to perform a coronary CT scan, which confirmed the anomalous origin of the right coronary artery with a retro–aortic course, and a cardiac MRI, which showed myocardial edema of the infero–lateral wall, mainly with sub–endocardial distribution and LGE in the same sites, compatible with ischemic damage. In September 2022 there was a new hospitalization for inferior–posterior–lateral STEMI with coronarographic finding of a large marginal branch collateral stenosis, with recovery of distal caliber. The angiographic pattern was consistent with type II SCAD (no intracoronary imaging has been performed because of vascular tortuosity and lesion distality). A retrospective comparative analysis of the 2019 angiography allowed to find a distal occlusion of the same branch, now healed, also compatible with SCAD. The patient was discharged on single antiplatelet therapy after one week of DAPT with acetylsalicylic acid and clopidogrel and indication to perform a genetic test for connective tissue diseases. The case described prompts the cardiologists to suspect an uncommon etiology (connective tissue disease, bicuspid aortic valve) in case of SCAD detection, especially if associated with anomalous origin of the coronary arteries.

P119 WHEN THE ELECTROCARDIOGRAM CHANGES YOUR DIAGNOSIS

Abstract Sarcomeric hypertrophic cardiomyopathy is among the most common genetic cardiovascular diseases.Clinical,electrocardiographic and echocardiographic evaluation plays a crucial role in the diagnosis and initial framing of the hypertrophic phenotype. A 51–year–old Caucasian man with multiple myeloma,previous autologous transplant,undergoing chemotherapy for disease recurrence,without cardiovascular risk factors or family history of MCV or MCI came to our outpatient clinic for a follow–up visit.At another center,cardiac amyloidosis was diagnosed due to the echocardiogram finding of concentric left ventricular hypertrophy. Patient asymptomatic for angor,NYHAI dyspnea,heart palpitation,syncope,presented with rhythmic cardiac action,2/6 systolic murmur at centrum and tip,no central or peripheral stasis.On ecg sinus bradycardia at fc57 bpm,PR202 msec,high QRS V4–V6 voltages with negative T waves in infero–lateral site,suggestive for left ventricular hypertrophy. On echocardiogram:concentric left ventricular hypertrophy with posterolateral papillary hypertrophy,preserved contractile function,FE 62%,grade I diastolic dysfunction,no signs of elevated filling pressures,left atrium and right ventricle in normal range;tripartite aortic valve in absence of gradients,prolapse of the LAM(A1–A2)with mild grade insufficiency,mild tricuspid insufficiency. At cardiac MRI:non–dilated left ventricle with concentric hypertrophy,maximum thickness 16mm at basal SIV level,apical inferior wall,15mm anterior wall,anterolateral media,apex systolic obliteration 14mm,FE 64%.Right ventricle and atria in normal.T2–STIR sequences tenuous hyperintensity at infero–lateral media wall,inferior apical wall and lateral,increased T2 mapping in relation to myocardial edema. Subendocardial LGE of middle infero–lateral,apical lateral and postero–medial papillary wall,slight increase in native T1 mapping,ECV 27%,picture of sarcomeric hypertrophic heart disease.Holter ecg showed no arrhythmias;at HCM score low risk,no indication for ICD implantation. The patient was undergoing genetic screening test for HCM.The presence of left ventricular hypertrophy may mimic different forms of hypertrophic cardiomyopathy,leading to misdiagnosis or delayed diagnosis.Differential diagnosis,ecg and specific use of imaging tests are of paramount importance.

Thyrotoxic periodic paralysis in a Caucasian man without identifiable genetic predisposition: a case report

BackgroundThyrotoxic periodic paralysis (TPP) is a rare condition characterized by muscle paralysis, thyrotoxicosis, and hypokalemia. It presents with paralysis of both proximal and distal musculature in upper and lower limbs and may affect respiratory musculature and the cardiac conduction system. Early diagnosis is essential, as the condition is potentially reversible by oral or intravenous potassium treatment, leading to rapid resolution without lasting weakness. Overlooking the diagnosis may result in respiratory failure and cardiac arrhythmias including QT prolongation, Torsades de points, and ventricular arrhythmias.Case presentationA 19-year-old Caucasian man was admitted acutely with paralysis in upper and lower limbs and tachycardia. Over several months, he had experienced anxiousness, sweating more than usual, had daily palpitations, shortness of breath on exertion, and loose stools, and had lost 21 kg over the last year. Initial blood gas showed very low potassium of 1.4 mM, and blood tests showed decreased Thyroid-stimulating hormone (TSH) < 0.01 × 10− 3 IU/L, elevated free thyroxine (fT4) of 63.5 pM (reference interval (RI): 12.0–22.0 pM), and elevated total triiodothyronine (T3) of 8.2 nM (RI: 1.0–2.6 nM). He was diagnosed with TPP and treated with liquid oral potassium chloride (30 mmol every 30 minutes) and propylthiouracil (initial dose of 400 mg followed by 200 mg three times daily). TSH-receptor antibodies (TRAB) and thyroid-peroxidase antibodies (TPO-ab) were highly elevated. Thyroid ultrasound showed a normal-sized gland and color Doppler sonography showed increased vascularity throughout the gland, compatible with Graves’ disease. He was discharged on day 4 with a normal potassium level and followed in the outpatient clinic where he received standard care for Graves’ disease. Genetic testing using whole-genome sequencing found no genetic variants in genes previously associated with TPP.ConclusionTPP is very rare in Caucasians but more often affects young men in East Asian populations. The case presents a Caucasian man with TPP where genetic testing of CACNA1S, KCNJ18, SCN4A, KCNJ2, KCNE3, and ABCC8 shows no pathogenic variants in genes previously associated with TPP.

Postmortem Biochemistry and Immunohistochemistry in Anaphylactic Death Due to Hymenoptera Sting: A Forensic Case Report

Postmortem assessment of anaphylactic death is a challenge for forensic pathologists. One of the most frequent elicitors of anaphylaxis is insect venom. Here, a case of anaphylactic death due to Hymenoptera stings is reported to highlight the contribution of postmortem biochemistry and immunohistochemistry in assessing the cause of death. A 59-year-old Caucasian man working on his farm was presumably stung by a bee and died. He had a history of previous sensitization to insect venom. The autopsy revealed no signs of insect puncture, mild edema of the larynx, and foamy edema in the bronchial tree and lungs. Routine histology showed endo-alveolar edema and hemorrhage, bronchospasm, and scattered bronchial obstruction due to mucus hyperproduction. Biochemical analysis was performed, and serum tryptase was equal to 189 µg/L, total IgE was 200 kU/L, and specific IgE dosage was positive for bee and yellow jacket species. Immunohistochemistry for tryptase detection was carried out, revealing mast cells and degranulated tryptase expression in the larynx, lungs, spleen, and heart. These findings led to the diagnosis of anaphylactic death due to Hymenoptera stings. The case highlights that the role of biochemistry and immunohistochemistry in the postmortem assessment of anaphylactic reactions should be stressed by forensic practitioners.

Treatment of Medication-Resistant Neuropathic Pain in a Tetraplegic Patient Using Repetitive Transcranial Magnetic Stimulation (rTMS): A case report (P9-6.009)

<h3>Objective:</h3> N/A <h3>Background:</h3> Transcranial magnetic stimulation (TMS) is a non-invasive method of neuromodulation currently FDA-approved for the treatment of depression, but has also shown promising results in treating neuropathic pain. Given the risks of invasive neuromodulation and the dangers of long-term opioid use, especially in the face of an opioid crisis, it is imperative to find an effective treatment with minimal side effects. <h3>Design/Methods:</h3> The patient is a 74-year old tetraplegic Caucasian man who suffers from severe medication-resistant neuropathic pain following a spinal cord injury. TMS treatment was initiated, using a two-part protocol consisting of high-frequency (10 Hz) stimulation of the left dorsolateral prefrontal cortex (DLPFC) followed by low-frequency (5 Hz) stimulation of the primary motor (M1) cortex. Patient received daily treatment for the first week and decreased in frequency as treatment continued. Pain was measured using the Visual Analog Scale and tracked over 13 weeks (currently ongoing). <h3>Results:</h3> Patient’s pain level before beginning treatment was 6.35/10. Within the first week of treatment, his baseline pain level was reduced to 4.19/10. The lowest pain immediately following treatment was 1.9/10, a 70.1% decrease in pain scores. During the initial week of treatments, the patient reported that pain relief lasted for a few hours immediately following treatment. As treatment continued, he reported experiencing progressively longer relief, and also decreased his dosage of opioids due to the pain relief from the rTMS treatment. <h3>Conclusions:</h3> The pain protocol reduced medication-resistant neuropathic pain in our patient, as measured by the Visual Analog Scale as well as a decrease in opioid usage. Analgesic effects were additive with continual treatment. TMS treatment is non-invasive and could be administered without moving the patient from his wheelchair. The significant, lasting decrease in pain reported by the patient supports the need for further clinical studies of combined M1-rTMS and DLPFC-rTMS treatment for neuropathic pain. <b>Disclosure:</b> Miss Li has nothing to disclose. Dr. Kuluva has received personal compensation in the range of $50,000-$99,999 for serving as an officer or member of the Board of Directors for Piedmont Neuroscience Center. Ms. Paras has nothing to disclose. Mr. Mohammad has nothing to disclose.

Hypercalcemia–leukocytosis syndrome from non-schistosomiasis-associated squamous cell carcinoma of the urinary bladder: a case report and review of the literature

BackgroundNon-schistosomiasis-associated squamous cell carcinoma of the urinary bladder is less common in the Western world. Limited information on its possible paraneoplastic syndromes exists. Leukocytosis tends to commonly be regarded by clinicians as an indication of sepsis, rather than a feature of paraneoplasia, potential surrogate marker for recurrence, and prognostic marker. Accompanying hypercalcemia may be missed entirely.Case presentationA 66-year-old Caucasian man presented with visible painless hematuria and symptomatic hypercalcemia. Investigations revealed a squamous cell carcinoma of the urinary bladder with marked leukocytosis. Hypercalcemia and leukocytosis resolved following radical cystectomy, recurred with nodal recurrence and regressed with radiotherapeutic control. Subsequently, serum leukocyte and calcium assays were included in his follow-up protocol. His survival was 20 months by the time of the report.ConclusionThis report highlights hypercalcemia–leukocytosis syndrome as a paraneoplastic manifestation of non-schistosomiasis-associated squamous cell carcinoma to reemphasize the need for clinicians to assay for calcium in the presence of leukocytosis in such patients. Prompt identification and control of the paraneoplastic derangements, with treatment of the cancer recurrence it may connote, is advocated to provide a chance for better long-term outcomes in these patients.

A stalk with no polyp-A muco-submucosal elongated polyp in the duodenum.

A 62-year-old Caucasian man was referred for upper GI endoscopy with a 6-month history of intermittent abdominal pain, nausea and bloating. Endoscopy revealed a 5-cm elongated lesion arising in D2. A pedunculated polyp (0-Ip) was suspected; however, deeper intubation revealed no polyp at the end of the stalk (Figure 1). Narrow band imaging did not reveal any adenomatous or suspicious features (Figure 2). The base of the polyp was injected with EMR solution (gelofusin, methylene blue and adrenaline 1:100,000), resected by snare cautery (Figure 3) and the defect was closed with two endoclips. Histopathology confirmed a 42 mm × 15 mm cylindrical lesion of hyperplastic duodenal mucosa with submucosal expansion by fibroconnective tissue. Histological analysis demonstrated features of a prominent submucosal vascular component with dilated lymphovascular structures, the absence of inflammatory infiltrate and the absence of significant architectural disturbance (Figure 4). These findings were consistent with a diagnosis of a muco-submucosal elongated polyp.1, 2 Muco-submucosal elongated polyp of the GIT under white light. Muco-submucosal elongated polyp of the GIT under narrow band imaging (NBI). Muco-submucosal elongated polyp of the GIT following resection. Histology section (2X) through the polyp shows architecturally normal small intestinal mucosa (yellow arrow) overlying a core of submucosa containing abundant adipose tissue (blue arrow) with submucosal vessels (green arrows). No significant inflammation is seen. Enteric muco-submucosal elongated polyps are rare, benign gastrointestinal polyps with an elongated, cylindrical ‘worm-like’ endoscopic appearance that is a hallmark of the disease.2, 3 Initially identified in the colon,1 few cases have been reported in the small bowel.3 It is hypothesised that peristaltic movements serve as mechanical traction for redundant mucosa, creating a nidus for polyp growth in these mucosal areas. They can mimic a number of other enteric lesions, in particular prolapsing mucosal folds (associated with diverticular disease) and filiform polyps (associated with inflammatory bowel disease). Immunohistochemistry demonstrates positivity for endothelial vascular markers (CD31) and endothelial lymphatic vessels (D2-40/podoplanin). Endoscopic ultrasound (EUS) can demonstrate the mucosal and submucosal layers of the polyp, with characteristic microcystic components aiding the diagnosis. Symptomatic patients can be treated by endoscopic resection, although treatment may be considered in asymptomatic cases given case reports suggesting an associated risk of intussusception,4 diverticulitis5 and non-polypoid neoplasia.6, 7 Surveillance gastroscopy 3 and 12 months post resection did not reveal any residual polyps. The authors wish to acknowledge the patients who attend, and staff who work in the Endoscopy Unit and the contribution they make to clinical research. There was no funding source for this research. The authors have no conflicts of interest to declare. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Hemangioblastoma with late leptomeningeal metastasis: a case report

BackgroundHemangioblastoma of the central nervous system is an uncommon benign neoplasm, with about 25% of cases in patients with von Hippel–Lindau disease. The incidence of metastasis is rare, particularly in patients without von Hippel–Lindau disease. We report a case of hemangioblastoma with leptomeningeal dissemination as a late recurrence.Case presentationA 65-year-old Caucasian man with a history of World Health Organization grade I hemangioblastoma of the cerebellar vermis underwent gross total resection in 1997. In early 2018, he developed intracranial recurrences with diffuse leptomeningeal disease of the entire spine. The patient underwent resection of intracranial recurrence, followed by palliative craniospinal irradiation. The disease progressed quickly, and he died 8 months after recurrence.ConclusionsDespite a benign pathology, hemangioblastoma has a low risk of metastasis. The outcome for hemangioblastoma patients with metastasis is poor. Multidisciplinary care for patients with metastatic hemangioblastoma warrants further investigation, and an effective systemic option is urgently needed. Regular lifelong follow-up of at-risk patients is recommended.

Precision fluoropyrimidines dosing in a compound heterozygous variant carrier of the DPYD gene: a case report.

Fluoropyrimidines (FPs) form still nowadays the backbone of chemotherapic schemes in colorectal cancer (CRC). Inter-patient variability of the toxicity profile of FPs may be partially accounted for by variable expression of dihydropyrimidine dehydrogenase (DPD). DPD rate activity is genetically determined by its extremely polymorphic coding gene DPYD. In spite of pharmacogenetic guideline-directed-dosing of FPs based regimens treating carrier of multiple variants of DPYD gene remains still challenging. We present a case of a 48-year-old Caucasian man, compound heterozygous variant carrier of the DPYD gene (HapB3 and c.2194G>A) who had a diagnosis of adenocarcinoma of the left colon and was safely treated with a pharmacogenetic-guided 25% dose reduction of the standard CAP adjuvant treatment. Compound heterozygosis may have been responsible for an earlier over exposure to CAP resulting into low-grade toxicity with an anticipated median time to toxicity of the c.2194G>A variant to the 4th vs. 6th cycles. Some haplotypes of DPYD variants may have an advantage in terms of survival compared to wild-type patients. Our patient may also have benefitted from compound heterozygosis, as shown by no evidence of disease (NED) at 6-month follow-up. Pharmacogenetic-guided dosing of DPYD intermediate metabolizer compound heterozygous HapB3 and c.2194G>A variant carries should be managed by a multidisciplinary team with a dose reduction ranging from 25 to 50% to maintain effectiveness and close clinical monitoring for early detection of ADRs.

Concurrent syphilis, gonorrhea, and monkeypox: A case report.

Documented cases of monkeypox virus outside of Africa are rare, but as of August 22, 2022, the CDC was tracking 18,101 cases in the United States. Monkeypox rash can easily mimic other sexually transmitted infections, which may occur concurrently. This case report describes a 36-year old Caucasian man who has sex with men. The patient came in for a routine history and physical examination and disclosed a perianal rash. The patient had a medical history significant for undertreated HIV, ankylosing spondylitis, and homelessness. On examination, he had multiple perianal deep-seated ulcers that were swabbed for monkeypox and herpes simplex virus 1 and 2. Samples were also collected for syphilis, chlamydia, and gonorrhea. The swabs were positive for monkeypox and pharyngeal gonorrhea. At subsequent blood draw, he was found to have elevated titers for syphilis and a positive QuantiFERON-TB gold test. In summary, this case is a clear example of an individual with concurrent monkeypox virus and other sexually and nonsexually transmitted infections, highlighting the importance of careful identification of risk factors and testing for monkeypox virus even when the clinical presentation may depict a common sexually transmitted infection, such as the herpes simplex virus.

Treatment of HIV-Associated Lupus-like Membranous Nephropathy with Tacrolimus: A Case Report and Review of the Literature

Renal complications of HIV infection are common and histologically diverse. Besides HIV-associated nephropathy, which is the most well-defined glomerular disorder, immune-complex-mediated glomerulonephritis (HIVICK) is also encountered in the setting of HIV infection and may occasionally present with "lupus-like" features by light microscopy and immunofluorescence. Management of HIVICK remains controversial and mainly focuses on HIV viremia suppression with combined antiretroviral therapy. Immunosuppressive therapy may be used in order to mitigate the renal inflammation induced by the immune complex deposition. Data regarding the use of immunosuppressants in HIVICK are very limited, mostly including corticosteroids and mycophenolate acid analogues. Herein, we present the case of a 40-year-old HIV-infected Caucasian man with nephrotic syndrome, renal impairment, and a "lupus-like" membranous pattern in the kidney biopsy, who achieved a partial response of his proteinuria with a tacrolimus-based regimen in combination with antiretroviral therapy.