Federal Practitioner

Background

Choroidal malignant melanoma is a relatively rare condition, yet it remains the most common primary intraocular malignancy in adults, affecting approximately 5 individuals per million each year in the United States. Associated risk factors include fair skin, light-colored eyes, ocular melanocytosis, and BAP1 genetic mutations. While 13% of patients presenting with choroidal melanoma are asymptomatic, some symptoms can include photopsia, floaters, blurred vision, and progressive visual field loss.

Case Presentation

We present a case of choroidal melanoma in a 57-year-old male with a past medical history of hypertension, hyperlipidemia, major depressive disorder, and alcohol use disorder. This patient presented to the clinic following a detoxification admission, reporting one week of progressive vision loss in the left eye. Upon initial physical examination, the patient exhibited left superior quadrantanopia, with a visual acuity of 20/40 measured in the left eye. Initial imaging with CT head identified an intraocular hyperdensity within the left globe, raising concerns for potential retinal detachment. Urgent ophthalmologic evaluation revealed an afferent pupillary defect and a large choroidal lesion adjacent to the optic nerve head. Ultrasonography showed a low internal reflectivity mass (5.36 mm by 9.05 mm), and a subsequent dilated fundus examination confirmed a classic dome-shaped choroidal melanoma (11.5 mm by 16.5 mm). Gene expression profiling demonstrated a class 1b uveal melanoma with PRAME positivity and mutations in GNAQ and SF3B1. Comprehensive staging scans were negative for metastatic disease. The patient received four treatment sessions of proton beam therapy, which resulted in rapid improvements in his visual fields. For long-term management, he was scheduled for close ophthalmologic follow-up and regular imaging of the chest and abdomen every six months to monitor for recurrence.

Conclusions

This case highlights the challenges of diagnosing choroidal melanoma in the primary care setting and the importance of multidisciplinary involvement, multimodal imaging, and gene expression profiling in facilitating early diagnosis and treatment.

Background

Choroidal malignant melanoma is a relatively rare condition, yet it remains the most common primary intraocular malignancy in adults, affecting approximately 5 individuals per million each year in the United States. Associated risk factors include fair skin, light-colored eyes, ocular melanocytosis, and BAP1 genetic mutations. While 13% of patients presenting with choroidal melanoma are asymptomatic, some symptoms can include photopsia, floaters, blurred vision, and progressive visual field loss.

Case Presentation

We present a case of choroidal melanoma in a 57-year-old male with a past medical history of hypertension, hyperlipidemia, major depressive disorder, and alcohol use disorder. This patient presented to the clinic following a detoxification admission, reporting one week of progressive vision loss in the left eye. Upon initial physical examination, the patient exhibited left superior quadrantanopia, with a visual acuity of 20/40 measured in the left eye. Initial imaging with CT head identified an intraocular hyperdensity within the left globe, raising concerns for potential retinal detachment. Urgent ophthalmologic evaluation revealed an afferent pupillary defect and a large choroidal lesion adjacent to the optic nerve head. Ultrasonography showed a low internal reflectivity mass (5.36 mm by 9.05 mm), and a subsequent dilated fundus examination confirmed a classic dome-shaped choroidal melanoma (11.5 mm by 16.5 mm). Gene expression profiling demonstrated a class 1b uveal melanoma with PRAME positivity and mutations in GNAQ and SF3B1. Comprehensive staging scans were negative for metastatic disease. The patient received four treatment sessions of proton beam therapy, which resulted in rapid improvements in his visual fields. For long-term management, he was scheduled for close ophthalmologic follow-up and regular imaging of the chest and abdomen every six months to monitor for recurrence.

Conclusions

This case highlights the challenges of diagnosing choroidal melanoma in the primary care setting and the importance of multidisciplinary involvement, multimodal imaging, and gene expression profiling in facilitating early diagnosis and treatment.

Background

Choroidal malignant melanoma is a relatively rare condition, yet it remains the most common primary intraocular malignancy in adults, affecting approximately 5 individuals per million each year in the United States. Associated risk factors include fair skin, light-colored eyes, ocular melanocytosis, and BAP1 genetic mutations. While 13% of patients presenting with choroidal melanoma are asymptomatic, some symptoms can include photopsia, floaters, blurred vision, and progressive visual field loss.

Case Presentation

We present a case of choroidal melanoma in a 57-year-old male with a past medical history of hypertension, hyperlipidemia, major depressive disorder, and alcohol use disorder. This patient presented to the clinic following a detoxification admission, reporting one week of progressive vision loss in the left eye. Upon initial physical examination, the patient exhibited left superior quadrantanopia, with a visual acuity of 20/40 measured in the left eye. Initial imaging with CT head identified an intraocular hyperdensity within the left globe, raising concerns for potential retinal detachment. Urgent ophthalmologic evaluation revealed an afferent pupillary defect and a large choroidal lesion adjacent to the optic nerve head. Ultrasonography showed a low internal reflectivity mass (5.36 mm by 9.05 mm), and a subsequent dilated fundus examination confirmed a classic dome-shaped choroidal melanoma (11.5 mm by 16.5 mm). Gene expression profiling demonstrated a class 1b uveal melanoma with PRAME positivity and mutations in GNAQ and SF3B1. Comprehensive staging scans were negative for metastatic disease. The patient received four treatment sessions of proton beam therapy, which resulted in rapid improvements in his visual fields. For long-term management, he was scheduled for close ophthalmologic follow-up and regular imaging of the chest and abdomen every six months to monitor for recurrence.

Conclusions

This case highlights the challenges of diagnosing choroidal melanoma in the primary care setting and the importance of multidisciplinary involvement, multimodal imaging, and gene expression profiling in facilitating early diagnosis and treatment.

Background

Immune related adverse events (irAE) are a well-known complication in the treatment of nonsmall cell lung cancer (NSCLCA) with checkpoint inhibitors and have been shown to improve overall survival (OS) and progression free survival (PFS) across multiple studies. However, studies have shown that the prognosis of NSCLCA differs depending on the type of immune related adverse event and the grade of the irAE. For instance, patients who experienced endocrine irAEs like thyroid, or adrenal insufficiency tended to have an improved OS and PFS, whereas patients who developed pneumonitis that required discontinuation of checkpoint inhibitors had worse OS and PFS. While the literature describes the prognostic impacts of irAEs on NSCLCA, there is still a dearth of information on the implications of HLA supertypes on the prognosis of NSCLCA following irAEs.

Case Presentation

To address this point and to ask a question, we would like to share the case of a patient with a 10-year history of inflammatory arthropathy related to HLA-B27 antigen prior to his diagnosis of T2bN2M1b adenosquamous lung cancer with liver metastases. The tumor was 100% PD-L1 expressive and the patient was treated with pembrolizumab. The patient developed central adrenal insufficiency 10 months after pembrolizumab was initiated which was treated with physiologic dosing of hydrocortisone. The patient later developed a grade 3 pneumonitis 62 months after initiation of pembrolizumab and was treated with systemic glucocorticoids. Due to recurrent hospitalizations for pneumonitis, pembrolizumab was discontinued at 70 months post initiation. At the time of discontinuation PET was positive. However, there was a decrease in hyperactivity of the primary tumor at 4 months post discontinuation of pembrolizumab and there have been serial negative PETS from 7 months to 13 months post discontinuation. This led us to ask the question of whether HLA-B27 is protective of the poor prognostic immune related pneumonitis in this patient?

Background

Immune related adverse events (irAE) are a well-known complication in the treatment of nonsmall cell lung cancer (NSCLCA) with checkpoint inhibitors and have been shown to improve overall survival (OS) and progression free survival (PFS) across multiple studies. However, studies have shown that the prognosis of NSCLCA differs depending on the type of immune related adverse event and the grade of the irAE. For instance, patients who experienced endocrine irAEs like thyroid, or adrenal insufficiency tended to have an improved OS and PFS, whereas patients who developed pneumonitis that required discontinuation of checkpoint inhibitors had worse OS and PFS. While the literature describes the prognostic impacts of irAEs on NSCLCA, there is still a dearth of information on the implications of HLA supertypes on the prognosis of NSCLCA following irAEs.

Case Presentation

To address this point and to ask a question, we would like to share the case of a patient with a 10-year history of inflammatory arthropathy related to HLA-B27 antigen prior to his diagnosis of T2bN2M1b adenosquamous lung cancer with liver metastases. The tumor was 100% PD-L1 expressive and the patient was treated with pembrolizumab. The patient developed central adrenal insufficiency 10 months after pembrolizumab was initiated which was treated with physiologic dosing of hydrocortisone. The patient later developed a grade 3 pneumonitis 62 months after initiation of pembrolizumab and was treated with systemic glucocorticoids. Due to recurrent hospitalizations for pneumonitis, pembrolizumab was discontinued at 70 months post initiation. At the time of discontinuation PET was positive. However, there was a decrease in hyperactivity of the primary tumor at 4 months post discontinuation of pembrolizumab and there have been serial negative PETS from 7 months to 13 months post discontinuation. This led us to ask the question of whether HLA-B27 is protective of the poor prognostic immune related pneumonitis in this patient?

Background

Immune related adverse events (irAE) are a well-known complication in the treatment of nonsmall cell lung cancer (NSCLCA) with checkpoint inhibitors and have been shown to improve overall survival (OS) and progression free survival (PFS) across multiple studies. However, studies have shown that the prognosis of NSCLCA differs depending on the type of immune related adverse event and the grade of the irAE. For instance, patients who experienced endocrine irAEs like thyroid, or adrenal insufficiency tended to have an improved OS and PFS, whereas patients who developed pneumonitis that required discontinuation of checkpoint inhibitors had worse OS and PFS. While the literature describes the prognostic impacts of irAEs on NSCLCA, there is still a dearth of information on the implications of HLA supertypes on the prognosis of NSCLCA following irAEs.

Case Presentation

To address this point and to ask a question, we would like to share the case of a patient with a 10-year history of inflammatory arthropathy related to HLA-B27 antigen prior to his diagnosis of T2bN2M1b adenosquamous lung cancer with liver metastases. The tumor was 100% PD-L1 expressive and the patient was treated with pembrolizumab. The patient developed central adrenal insufficiency 10 months after pembrolizumab was initiated which was treated with physiologic dosing of hydrocortisone. The patient later developed a grade 3 pneumonitis 62 months after initiation of pembrolizumab and was treated with systemic glucocorticoids. Due to recurrent hospitalizations for pneumonitis, pembrolizumab was discontinued at 70 months post initiation. At the time of discontinuation PET was positive. However, there was a decrease in hyperactivity of the primary tumor at 4 months post discontinuation of pembrolizumab and there have been serial negative PETS from 7 months to 13 months post discontinuation. This led us to ask the question of whether HLA-B27 is protective of the poor prognostic immune related pneumonitis in this patient?

Background

Vitamin B12 deficiency is a well-recognized cause of megaloblastic anemia. In severe cases, it can lead to neuropsychiatric symptoms, hemolytic anemia, and pancytopenia.

Case Presentation

A 60-year-old male presented due to multiple falls and confusion. On presentation, he was markedly altered and unable to provide a history. His spouse reported a one-day history of incoordination and confusion. Physical examination revealed an ill-appearing male who was unable to follow commands with non-purposeful movements of all extremities. Initial labs showed a WBC 0.5 x103/μL, Hgb 3.6 g/dL, MCV 118.8 fL, platelets 7 x 103/μL, lymphocytes 50%, atypical lymphocytes 2%, and total bilirubin of 2.1 mg/dL (direct bilirubin 0.8 mg/dL). Further evaluation showed a reticulocyte count of 7.8 x109/L, reticulocyte 1%, and reticulocyte index of 0.7. Iron studies were unremarkable. Lactate dehydrogenase was elevated at 796 U/L and haptoglobin was undetectably low (< 20 mg/dL). Peripheral smear showed macrocytic anemia, anisopoikilocytosis, leukopenia with hypersegmented neutrophils, and thrombocytopenia; no schistocytes were noted. Additional labs showed folate of 3.8 ng/mL and an undetectably low vitamin B12 level (< 159 pg/mL). Anti-parietal cell and intrinsic factor blocking antibodies were negative. Infectious workups and serum protein electrophoresis were negative. The patient was diagnosed with severe vitamin B12 deficiency resulting in pancytopenia, hemolytic anemia secondary to intramedullary hemolysis, and neuropsychiatric changes. He was started on daily intramuscular (IM) cyanocobalamin (1000 mcg) and supportive transfusions. Over the hospitalization, his mentation returned to baseline and his cell counts stabilized.

Discussion

Vitamin B12 is an important co-factor needed for the synthesis of DNA and myelin. Vitamin B12 deficiency most commonly presents with megaloblastic anemia but neuropsychiatric manifestations can occur in severe cases. Pancytopenia occurs in ~5% of patients with B12 deficiency, whereas hemolytic anemia occurs in only ~1.5% of patients. Hemolytic anemia secondary to B12 deficiency is thought to be due to ineffective erythropoiesis causing intramedullary hemolysis. Prompt diagnosis and B12 supplementation can lead to rapid clinical recovery.

Conclusions

This case highlights the importance of considering vitamin B12 deficiency in patients with unexplained pancytopenia, hemolytic anemia, and neuropsychiatric symptoms. Early diagnosis and treatment can lead to significant and rapid clinical improvement.

Background

Vitamin B12 deficiency is a well-recognized cause of megaloblastic anemia. In severe cases, it can lead to neuropsychiatric symptoms, hemolytic anemia, and pancytopenia.

Case Presentation

A 60-year-old male presented due to multiple falls and confusion. On presentation, he was markedly altered and unable to provide a history. His spouse reported a one-day history of incoordination and confusion. Physical examination revealed an ill-appearing male who was unable to follow commands with non-purposeful movements of all extremities. Initial labs showed a WBC 0.5 x103/μL, Hgb 3.6 g/dL, MCV 118.8 fL, platelets 7 x 103/μL, lymphocytes 50%, atypical lymphocytes 2%, and total bilirubin of 2.1 mg/dL (direct bilirubin 0.8 mg/dL). Further evaluation showed a reticulocyte count of 7.8 x109/L, reticulocyte 1%, and reticulocyte index of 0.7. Iron studies were unremarkable. Lactate dehydrogenase was elevated at 796 U/L and haptoglobin was undetectably low (< 20 mg/dL). Peripheral smear showed macrocytic anemia, anisopoikilocytosis, leukopenia with hypersegmented neutrophils, and thrombocytopenia; no schistocytes were noted. Additional labs showed folate of 3.8 ng/mL and an undetectably low vitamin B12 level (< 159 pg/mL). Anti-parietal cell and intrinsic factor blocking antibodies were negative. Infectious workups and serum protein electrophoresis were negative. The patient was diagnosed with severe vitamin B12 deficiency resulting in pancytopenia, hemolytic anemia secondary to intramedullary hemolysis, and neuropsychiatric changes. He was started on daily intramuscular (IM) cyanocobalamin (1000 mcg) and supportive transfusions. Over the hospitalization, his mentation returned to baseline and his cell counts stabilized.

Discussion

Vitamin B12 is an important co-factor needed for the synthesis of DNA and myelin. Vitamin B12 deficiency most commonly presents with megaloblastic anemia but neuropsychiatric manifestations can occur in severe cases. Pancytopenia occurs in ~5% of patients with B12 deficiency, whereas hemolytic anemia occurs in only ~1.5% of patients. Hemolytic anemia secondary to B12 deficiency is thought to be due to ineffective erythropoiesis causing intramedullary hemolysis. Prompt diagnosis and B12 supplementation can lead to rapid clinical recovery.

Conclusions

This case highlights the importance of considering vitamin B12 deficiency in patients with unexplained pancytopenia, hemolytic anemia, and neuropsychiatric symptoms. Early diagnosis and treatment can lead to significant and rapid clinical improvement.

Background

Vitamin B12 deficiency is a well-recognized cause of megaloblastic anemia. In severe cases, it can lead to neuropsychiatric symptoms, hemolytic anemia, and pancytopenia.

Case Presentation

A 60-year-old male presented due to multiple falls and confusion. On presentation, he was markedly altered and unable to provide a history. His spouse reported a one-day history of incoordination and confusion. Physical examination revealed an ill-appearing male who was unable to follow commands with non-purposeful movements of all extremities. Initial labs showed a WBC 0.5 x103/μL, Hgb 3.6 g/dL, MCV 118.8 fL, platelets 7 x 103/μL, lymphocytes 50%, atypical lymphocytes 2%, and total bilirubin of 2.1 mg/dL (direct bilirubin 0.8 mg/dL). Further evaluation showed a reticulocyte count of 7.8 x109/L, reticulocyte 1%, and reticulocyte index of 0.7. Iron studies were unremarkable. Lactate dehydrogenase was elevated at 796 U/L and haptoglobin was undetectably low (< 20 mg/dL). Peripheral smear showed macrocytic anemia, anisopoikilocytosis, leukopenia with hypersegmented neutrophils, and thrombocytopenia; no schistocytes were noted. Additional labs showed folate of 3.8 ng/mL and an undetectably low vitamin B12 level (< 159 pg/mL). Anti-parietal cell and intrinsic factor blocking antibodies were negative. Infectious workups and serum protein electrophoresis were negative. The patient was diagnosed with severe vitamin B12 deficiency resulting in pancytopenia, hemolytic anemia secondary to intramedullary hemolysis, and neuropsychiatric changes. He was started on daily intramuscular (IM) cyanocobalamin (1000 mcg) and supportive transfusions. Over the hospitalization, his mentation returned to baseline and his cell counts stabilized.

Discussion

Vitamin B12 is an important co-factor needed for the synthesis of DNA and myelin. Vitamin B12 deficiency most commonly presents with megaloblastic anemia but neuropsychiatric manifestations can occur in severe cases. Pancytopenia occurs in ~5% of patients with B12 deficiency, whereas hemolytic anemia occurs in only ~1.5% of patients. Hemolytic anemia secondary to B12 deficiency is thought to be due to ineffective erythropoiesis causing intramedullary hemolysis. Prompt diagnosis and B12 supplementation can lead to rapid clinical recovery.

Conclusions

This case highlights the importance of considering vitamin B12 deficiency in patients with unexplained pancytopenia, hemolytic anemia, and neuropsychiatric symptoms. Early diagnosis and treatment can lead to significant and rapid clinical improvement.

Background

Pulmonary large-cell neuroendocrine carcinoma (LCNEC) is a rare, aggressive lung cancer subtype, comprising ~3% of lung malignancies. It commonly affects older, heavy smokers and presents at an advanced stage. Prognosis is poor, with a 5-year survival rate of 15–25% in metastatic disease.

Case Presentation

A 33-year-old previously healthy male presented with a month of abdominal and lower back pain, along with significant weight loss. Lab tests revealed elevated lipase (378), and he was initially treated for acute pancreatitis. Imaging revealed a 1.9 cm pancreatic head mass and three hypodense hepatic lesions. MRI confirmed these findings but remained inconclusive. An incidental 8 mm right lower lobe pulmonary nodule led to chest CT, identifying a dominant left lower lobe mass and mediastinal lymphadenopathy, raising suspicion for primary lung malignancy. The patient was discharged but returned three days later with worsening symptoms and a lipase of 754. Endoscopic biopsy of the pancreatic mass was deferred due to ongoing pancreatitis. A liver biopsy revealed neuroendocrine differentiation, positive for CK AE1/AE3, CK7, CK19, and synaptophysin. Molecular profiling showed PD-L1 (TPS 50%), low tumor mutational burden, microsatellite stability, and high loss of heterozygosity. Bronchoscopy revealed a left hilar mass, and lymph node biopsy confirmed LCNEC (CK7+, chromogranin+, TTF- 1+, synaptophysin+), establishing a diagnosis of stage IV pulmonary LCNEC with pancreatic and liver metastases. The patient began treatment with bevacizumab, paclitaxel, carboplatin, and atezolizumab, resulting in improvement in hilar, hepatic, and pancreatic lesions on further imagings. The patient was continued on chemoimmunotherapy.

Discussion

This case highlights an uncommon presentation of LCNEC in a young, non-smoking male, initially manifesting as pancreatitis due to pancreatic metastasis. The absence of pulmonary symptoms complicated the diagnosis. Histopathology and immunohistochemistry were essential. While no standardized treatment exists for LCNEC, platinum-based chemotherapy with immunotherapy remains the mainstay. PD-L1 expression may guide immunotherapy decisions.

Conclusions

Pulmonary LCNEC should be considered in metastatic neuroendocrine tumors, even in young, non-smoking patients without pulmonary symptoms. Early tissue diagnosis and molecular profiling are key to guiding management.

Background

Pulmonary large-cell neuroendocrine carcinoma (LCNEC) is a rare, aggressive lung cancer subtype, comprising ~3% of lung malignancies. It commonly affects older, heavy smokers and presents at an advanced stage. Prognosis is poor, with a 5-year survival rate of 15–25% in metastatic disease.

Case Presentation

A 33-year-old previously healthy male presented with a month of abdominal and lower back pain, along with significant weight loss. Lab tests revealed elevated lipase (378), and he was initially treated for acute pancreatitis. Imaging revealed a 1.9 cm pancreatic head mass and three hypodense hepatic lesions. MRI confirmed these findings but remained inconclusive. An incidental 8 mm right lower lobe pulmonary nodule led to chest CT, identifying a dominant left lower lobe mass and mediastinal lymphadenopathy, raising suspicion for primary lung malignancy. The patient was discharged but returned three days later with worsening symptoms and a lipase of 754. Endoscopic biopsy of the pancreatic mass was deferred due to ongoing pancreatitis. A liver biopsy revealed neuroendocrine differentiation, positive for CK AE1/AE3, CK7, CK19, and synaptophysin. Molecular profiling showed PD-L1 (TPS 50%), low tumor mutational burden, microsatellite stability, and high loss of heterozygosity. Bronchoscopy revealed a left hilar mass, and lymph node biopsy confirmed LCNEC (CK7+, chromogranin+, TTF- 1+, synaptophysin+), establishing a diagnosis of stage IV pulmonary LCNEC with pancreatic and liver metastases. The patient began treatment with bevacizumab, paclitaxel, carboplatin, and atezolizumab, resulting in improvement in hilar, hepatic, and pancreatic lesions on further imagings. The patient was continued on chemoimmunotherapy.

Discussion

This case highlights an uncommon presentation of LCNEC in a young, non-smoking male, initially manifesting as pancreatitis due to pancreatic metastasis. The absence of pulmonary symptoms complicated the diagnosis. Histopathology and immunohistochemistry were essential. While no standardized treatment exists for LCNEC, platinum-based chemotherapy with immunotherapy remains the mainstay. PD-L1 expression may guide immunotherapy decisions.

Conclusions

Pulmonary LCNEC should be considered in metastatic neuroendocrine tumors, even in young, non-smoking patients without pulmonary symptoms. Early tissue diagnosis and molecular profiling are key to guiding management.

Background

Pulmonary large-cell neuroendocrine carcinoma (LCNEC) is a rare, aggressive lung cancer subtype, comprising ~3% of lung malignancies. It commonly affects older, heavy smokers and presents at an advanced stage. Prognosis is poor, with a 5-year survival rate of 15–25% in metastatic disease.

Case Presentation

A 33-year-old previously healthy male presented with a month of abdominal and lower back pain, along with significant weight loss. Lab tests revealed elevated lipase (378), and he was initially treated for acute pancreatitis. Imaging revealed a 1.9 cm pancreatic head mass and three hypodense hepatic lesions. MRI confirmed these findings but remained inconclusive. An incidental 8 mm right lower lobe pulmonary nodule led to chest CT, identifying a dominant left lower lobe mass and mediastinal lymphadenopathy, raising suspicion for primary lung malignancy. The patient was discharged but returned three days later with worsening symptoms and a lipase of 754. Endoscopic biopsy of the pancreatic mass was deferred due to ongoing pancreatitis. A liver biopsy revealed neuroendocrine differentiation, positive for CK AE1/AE3, CK7, CK19, and synaptophysin. Molecular profiling showed PD-L1 (TPS 50%), low tumor mutational burden, microsatellite stability, and high loss of heterozygosity. Bronchoscopy revealed a left hilar mass, and lymph node biopsy confirmed LCNEC (CK7+, chromogranin+, TTF- 1+, synaptophysin+), establishing a diagnosis of stage IV pulmonary LCNEC with pancreatic and liver metastases. The patient began treatment with bevacizumab, paclitaxel, carboplatin, and atezolizumab, resulting in improvement in hilar, hepatic, and pancreatic lesions on further imagings. The patient was continued on chemoimmunotherapy.

Discussion

This case highlights an uncommon presentation of LCNEC in a young, non-smoking male, initially manifesting as pancreatitis due to pancreatic metastasis. The absence of pulmonary symptoms complicated the diagnosis. Histopathology and immunohistochemistry were essential. While no standardized treatment exists for LCNEC, platinum-based chemotherapy with immunotherapy remains the mainstay. PD-L1 expression may guide immunotherapy decisions.

Conclusions

Pulmonary LCNEC should be considered in metastatic neuroendocrine tumors, even in young, non-smoking patients without pulmonary symptoms. Early tissue diagnosis and molecular profiling are key to guiding management.

Background

Immune checkpoint inhibitors (ICI) have changed the landscape of cancer therapy. Pembrolizumab is an ICI which targets programmed cell death protein-1 on T-cells and acts to release inhibition of the T-cell antitumor response. Pembrolizumab is approved for the treatment of multiple malignancies. However, ICI therapy may precipitate immune-related adverse events (IRAEs). We describe a unique presentation of irAE-cardiotoxicity.

Case Discussion

A 70-year-old female with a history of uterine cancer previously treated with pembrolizumab (discontinued in January) presented to the emergency department with acute onset nausea and vomiting. On arrival, she was afebrile, tachycardic, normotensive, and saturated well in room air. Labs were notable for troponin of 20, normal TSH, elevated proBNP, ESR and CRP. EKG revealed atrial fibrillation with rapid ventricular response and subtle ST changes in leads II, aVF, V4-V6. She was started on diltiazem infusion for rate control and was subsequently transitioned to oral amiodarone. Given the concern for pericarditis, NSAIDs were initiated. Transthoracic echocardiogram was notable for an ejection fraction of 58% with moderate circumferential pericardial effusion without tamponade. Given her recent ICI exposure and evolving clinical course, she was diagnosed with pembrolizumab- induced pericarditis with associated atrial fibrillation and pericardial effusion. High-dose corticosteroids and colchicine were initiated for stabilization and symptomatic improvement.

Discussion

IRAEs usually occur within 3 months of therapy but may develop later. They are classified as low-grade (1-2), high-grade (3-4), or lethal (5). Anti- PD1 therapy is frequently associated with minor IRAEs, which develop in ~70% of patients; dermatologic IRAEs are most common. Major IRAEs develop in 10-15% of patients, and lethal IRAEs may develop in up to 3%. Cardiac IRAEs are infrequent but significant. Presentation is variable and may involve the myocardium, pericardium, or conductive system. In the case of pericardial disease, high-dose IV methylprednisolone with oral steroid taper should be considered. Re-challenge with ICI therapy should only be considered if clinically stable and pericarditis or myocarditis are excluded.

Conclusions

Our patient illustrates a rare but significant IRAE associated with ICI with improvement following immunosuppressive and rate-control therapy.

Background

Immune checkpoint inhibitors (ICI) have changed the landscape of cancer therapy. Pembrolizumab is an ICI which targets programmed cell death protein-1 on T-cells and acts to release inhibition of the T-cell antitumor response. Pembrolizumab is approved for the treatment of multiple malignancies. However, ICI therapy may precipitate immune-related adverse events (IRAEs). We describe a unique presentation of irAE-cardiotoxicity.

Case Discussion

A 70-year-old female with a history of uterine cancer previously treated with pembrolizumab (discontinued in January) presented to the emergency department with acute onset nausea and vomiting. On arrival, she was afebrile, tachycardic, normotensive, and saturated well in room air. Labs were notable for troponin of 20, normal TSH, elevated proBNP, ESR and CRP. EKG revealed atrial fibrillation with rapid ventricular response and subtle ST changes in leads II, aVF, V4-V6. She was started on diltiazem infusion for rate control and was subsequently transitioned to oral amiodarone. Given the concern for pericarditis, NSAIDs were initiated. Transthoracic echocardiogram was notable for an ejection fraction of 58% with moderate circumferential pericardial effusion without tamponade. Given her recent ICI exposure and evolving clinical course, she was diagnosed with pembrolizumab- induced pericarditis with associated atrial fibrillation and pericardial effusion. High-dose corticosteroids and colchicine were initiated for stabilization and symptomatic improvement.

Discussion

IRAEs usually occur within 3 months of therapy but may develop later. They are classified as low-grade (1-2), high-grade (3-4), or lethal (5). Anti- PD1 therapy is frequently associated with minor IRAEs, which develop in ~70% of patients; dermatologic IRAEs are most common. Major IRAEs develop in 10-15% of patients, and lethal IRAEs may develop in up to 3%. Cardiac IRAEs are infrequent but significant. Presentation is variable and may involve the myocardium, pericardium, or conductive system. In the case of pericardial disease, high-dose IV methylprednisolone with oral steroid taper should be considered. Re-challenge with ICI therapy should only be considered if clinically stable and pericarditis or myocarditis are excluded.

Conclusions

Our patient illustrates a rare but significant IRAE associated with ICI with improvement following immunosuppressive and rate-control therapy.

Background

Immune checkpoint inhibitors (ICI) have changed the landscape of cancer therapy. Pembrolizumab is an ICI which targets programmed cell death protein-1 on T-cells and acts to release inhibition of the T-cell antitumor response. Pembrolizumab is approved for the treatment of multiple malignancies. However, ICI therapy may precipitate immune-related adverse events (IRAEs). We describe a unique presentation of irAE-cardiotoxicity.

Case Discussion

A 70-year-old female with a history of uterine cancer previously treated with pembrolizumab (discontinued in January) presented to the emergency department with acute onset nausea and vomiting. On arrival, she was afebrile, tachycardic, normotensive, and saturated well in room air. Labs were notable for troponin of 20, normal TSH, elevated proBNP, ESR and CRP. EKG revealed atrial fibrillation with rapid ventricular response and subtle ST changes in leads II, aVF, V4-V6. She was started on diltiazem infusion for rate control and was subsequently transitioned to oral amiodarone. Given the concern for pericarditis, NSAIDs were initiated. Transthoracic echocardiogram was notable for an ejection fraction of 58% with moderate circumferential pericardial effusion without tamponade. Given her recent ICI exposure and evolving clinical course, she was diagnosed with pembrolizumab- induced pericarditis with associated atrial fibrillation and pericardial effusion. High-dose corticosteroids and colchicine were initiated for stabilization and symptomatic improvement.

Discussion

IRAEs usually occur within 3 months of therapy but may develop later. They are classified as low-grade (1-2), high-grade (3-4), or lethal (5). Anti- PD1 therapy is frequently associated with minor IRAEs, which develop in ~70% of patients; dermatologic IRAEs are most common. Major IRAEs develop in 10-15% of patients, and lethal IRAEs may develop in up to 3%. Cardiac IRAEs are infrequent but significant. Presentation is variable and may involve the myocardium, pericardium, or conductive system. In the case of pericardial disease, high-dose IV methylprednisolone with oral steroid taper should be considered. Re-challenge with ICI therapy should only be considered if clinically stable and pericarditis or myocarditis are excluded.

Conclusions

Our patient illustrates a rare but significant IRAE associated with ICI with improvement following immunosuppressive and rate-control therapy.

Background

Sickle cell disease (SCD) patients often present with pain and fever, commonly attributed to vaso-occlusive crises (VOC), which can delay the diagnosis of other conditions. This highlights the need for reassessment and bias-aware clinical reasoning.

Case Presentation

A 27-year-old male with SCD, prior hip replacement, and cholecystectomy presented with whole-body pain. Labs supported VOC with anemia, elevated LDH, and reticulocytosis. Despite RUQ tenderness and a positive Murphy sign, the ultrasound was unremarkable, and he was admitted for VOC management. Persistent fever >48 hours prompted further evaluation with MRCP, revealing choledocholithiasis with common bile duct and mild biliary dilatation; later, his pain and fever resolved by ERCP, and he was discharged. However, he returned the following day with whole-body and right upper quadrant pain; lab tests showed normal hemoglobin, LDH, and reticulocyte levels, indicating no active sickling. On follow-ups, the patient started to have fever episodes again. Subsequent fevers prompted a CT scan, revealing pulmonary embolism involving the right interlobar pulmonary artery extending into the segmental and subsegmental vessels and right lower lobe pneumonia. He denied any cough or shortness of breath. Treatment with Eliquis for the embolism and antibiotics for hospital-acquired pneumonia resolved the fever and leukocytosis, but the patient persistently requested high-dose opioids despite normal sickling labs.

Discussion

This case highlights the need for diagnostic flexibility in SCD, as anchoring bias may cause clinicians to overlook other life-threatening conditions when VOC is suspected. The patient’s symptoms, initially suggestive of VOC, were later linked to choledocholithiasis, pulmonary embolism, and pneumonia, highlighting how overlapping complications can be misattributed to a single episode. The delayed diagnosis reflects cognitive and systemic factors, with few reports emphasizing the diagnostic delays when multiple SCD-related complications occur together. The stigma surrounding opioid use may also hinder timely care escalation. This case highlights the need for structured reassessment, red-flag criteria, and multidisciplinary collaboration to improve diagnostic accuracy and prevent fatal delays in complex SCD presentations.

Conclusions

This case emphasizes reassessing persistent symptoms in SCD, avoiding anchoring bias, and recognizing red flags. Multidisciplinary evaluation and bias-aware practices are key to accurate, timely care.

Background

Sickle cell disease (SCD) patients often present with pain and fever, commonly attributed to vaso-occlusive crises (VOC), which can delay the diagnosis of other conditions. This highlights the need for reassessment and bias-aware clinical reasoning.

Case Presentation

A 27-year-old male with SCD, prior hip replacement, and cholecystectomy presented with whole-body pain. Labs supported VOC with anemia, elevated LDH, and reticulocytosis. Despite RUQ tenderness and a positive Murphy sign, the ultrasound was unremarkable, and he was admitted for VOC management. Persistent fever >48 hours prompted further evaluation with MRCP, revealing choledocholithiasis with common bile duct and mild biliary dilatation; later, his pain and fever resolved by ERCP, and he was discharged. However, he returned the following day with whole-body and right upper quadrant pain; lab tests showed normal hemoglobin, LDH, and reticulocyte levels, indicating no active sickling. On follow-ups, the patient started to have fever episodes again. Subsequent fevers prompted a CT scan, revealing pulmonary embolism involving the right interlobar pulmonary artery extending into the segmental and subsegmental vessels and right lower lobe pneumonia. He denied any cough or shortness of breath. Treatment with Eliquis for the embolism and antibiotics for hospital-acquired pneumonia resolved the fever and leukocytosis, but the patient persistently requested high-dose opioids despite normal sickling labs.

Discussion

This case highlights the need for diagnostic flexibility in SCD, as anchoring bias may cause clinicians to overlook other life-threatening conditions when VOC is suspected. The patient’s symptoms, initially suggestive of VOC, were later linked to choledocholithiasis, pulmonary embolism, and pneumonia, highlighting how overlapping complications can be misattributed to a single episode. The delayed diagnosis reflects cognitive and systemic factors, with few reports emphasizing the diagnostic delays when multiple SCD-related complications occur together. The stigma surrounding opioid use may also hinder timely care escalation. This case highlights the need for structured reassessment, red-flag criteria, and multidisciplinary collaboration to improve diagnostic accuracy and prevent fatal delays in complex SCD presentations.

Conclusions

This case emphasizes reassessing persistent symptoms in SCD, avoiding anchoring bias, and recognizing red flags. Multidisciplinary evaluation and bias-aware practices are key to accurate, timely care.

Background

Sickle cell disease (SCD) patients often present with pain and fever, commonly attributed to vaso-occlusive crises (VOC), which can delay the diagnosis of other conditions. This highlights the need for reassessment and bias-aware clinical reasoning.

Case Presentation

A 27-year-old male with SCD, prior hip replacement, and cholecystectomy presented with whole-body pain. Labs supported VOC with anemia, elevated LDH, and reticulocytosis. Despite RUQ tenderness and a positive Murphy sign, the ultrasound was unremarkable, and he was admitted for VOC management. Persistent fever >48 hours prompted further evaluation with MRCP, revealing choledocholithiasis with common bile duct and mild biliary dilatation; later, his pain and fever resolved by ERCP, and he was discharged. However, he returned the following day with whole-body and right upper quadrant pain; lab tests showed normal hemoglobin, LDH, and reticulocyte levels, indicating no active sickling. On follow-ups, the patient started to have fever episodes again. Subsequent fevers prompted a CT scan, revealing pulmonary embolism involving the right interlobar pulmonary artery extending into the segmental and subsegmental vessels and right lower lobe pneumonia. He denied any cough or shortness of breath. Treatment with Eliquis for the embolism and antibiotics for hospital-acquired pneumonia resolved the fever and leukocytosis, but the patient persistently requested high-dose opioids despite normal sickling labs.

Discussion

This case highlights the need for diagnostic flexibility in SCD, as anchoring bias may cause clinicians to overlook other life-threatening conditions when VOC is suspected. The patient’s symptoms, initially suggestive of VOC, were later linked to choledocholithiasis, pulmonary embolism, and pneumonia, highlighting how overlapping complications can be misattributed to a single episode. The delayed diagnosis reflects cognitive and systemic factors, with few reports emphasizing the diagnostic delays when multiple SCD-related complications occur together. The stigma surrounding opioid use may also hinder timely care escalation. This case highlights the need for structured reassessment, red-flag criteria, and multidisciplinary collaboration to improve diagnostic accuracy and prevent fatal delays in complex SCD presentations.

Conclusions

This case emphasizes reassessing persistent symptoms in SCD, avoiding anchoring bias, and recognizing red flags. Multidisciplinary evaluation and bias-aware practices are key to accurate, timely care.

Background

Lung cancer, primarily non-small cell lung cancer (NSCLC), typically presents at an advanced stage with a five-year survival rate below 5%. Treatment includes platinum-based chemotherapy and targeted therapies for specific mutations, with immunotherapy significantly improving outcomes for patients with high PD-L1 expression.

Case Presentation

A 72-year-old male, diagnosed with advanced lung adenocarcinoma in 2020 after showing symptoms of brain metastases, underwent successful surgical and CyberKnife treatments. Despite no actionable genetic targets and a high PD-L1 expression of 80%, his treatment with 3-cycles of Keytruda was cut short due to a psoriatic arthritis flare-up, though it initially decreased his CEA levels significantly. Over the following years, fluctuating CEA levels and various imaging studies indicated some concerning changes, such as potential radionecrosis or recurrence of cancer in the lung. His refusal of biopsy and a preference for avoiding invasive treatments led to only surveillance. Later, an MRI showed some metastasis, and the patient agreed to a lung biopsy, which showed poorly differentiated carcinoma of pulmonary origin. The patient only agreed to restart treatment with Keytruda 4-years later after his initial treatment with Keytruda, under close rheumatological care, and received only two doses. Afterward, the patient lost follow-ups. 3-months later, Repeated CT scans of the chest, abdomen, and pelvis showed no evidence of mass or pathological lymph nodes, and repeated CEA was 3.4.

Discussion

Managing advanced lung adenocarcinoma, especially with complications like brain metastases and psoriatic arthritis, is challenging. Pembrolizumab treatment showed promise by significantly reducing CEA levels despite early discontinuation due to autoimmune side effects, indicating effective tumor response in patients with high PD-L1 expression. The case underscores the need for balancing cancer treatment with autoimmune management and highlights the importance of patient preferences in treatment plans. Ongoing surveillance and genomic profiling remain crucial for guiding therapy.

Conclusions

This case of a 70-year-old male with advanced lung adenocarcinoma highlights the significant impact of immunotherapy, particularly PD-1/ PD-L1 inhibitors like pembrolizumab, in NSCLC. Despite a brief treatment period, the patient experienced extended disease control, demonstrating the potential of immunotherapy to enhance survival and its broad applicability in oncology.

Background

Lung cancer, primarily non-small cell lung cancer (NSCLC), typically presents at an advanced stage with a five-year survival rate below 5%. Treatment includes platinum-based chemotherapy and targeted therapies for specific mutations, with immunotherapy significantly improving outcomes for patients with high PD-L1 expression.

Case Presentation

A 72-year-old male, diagnosed with advanced lung adenocarcinoma in 2020 after showing symptoms of brain metastases, underwent successful surgical and CyberKnife treatments. Despite no actionable genetic targets and a high PD-L1 expression of 80%, his treatment with 3-cycles of Keytruda was cut short due to a psoriatic arthritis flare-up, though it initially decreased his CEA levels significantly. Over the following years, fluctuating CEA levels and various imaging studies indicated some concerning changes, such as potential radionecrosis or recurrence of cancer in the lung. His refusal of biopsy and a preference for avoiding invasive treatments led to only surveillance. Later, an MRI showed some metastasis, and the patient agreed to a lung biopsy, which showed poorly differentiated carcinoma of pulmonary origin. The patient only agreed to restart treatment with Keytruda 4-years later after his initial treatment with Keytruda, under close rheumatological care, and received only two doses. Afterward, the patient lost follow-ups. 3-months later, Repeated CT scans of the chest, abdomen, and pelvis showed no evidence of mass or pathological lymph nodes, and repeated CEA was 3.4.

Discussion

Managing advanced lung adenocarcinoma, especially with complications like brain metastases and psoriatic arthritis, is challenging. Pembrolizumab treatment showed promise by significantly reducing CEA levels despite early discontinuation due to autoimmune side effects, indicating effective tumor response in patients with high PD-L1 expression. The case underscores the need for balancing cancer treatment with autoimmune management and highlights the importance of patient preferences in treatment plans. Ongoing surveillance and genomic profiling remain crucial for guiding therapy.

Conclusions

This case of a 70-year-old male with advanced lung adenocarcinoma highlights the significant impact of immunotherapy, particularly PD-1/ PD-L1 inhibitors like pembrolizumab, in NSCLC. Despite a brief treatment period, the patient experienced extended disease control, demonstrating the potential of immunotherapy to enhance survival and its broad applicability in oncology.

Background

Lung cancer, primarily non-small cell lung cancer (NSCLC), typically presents at an advanced stage with a five-year survival rate below 5%. Treatment includes platinum-based chemotherapy and targeted therapies for specific mutations, with immunotherapy significantly improving outcomes for patients with high PD-L1 expression.

Case Presentation

A 72-year-old male, diagnosed with advanced lung adenocarcinoma in 2020 after showing symptoms of brain metastases, underwent successful surgical and CyberKnife treatments. Despite no actionable genetic targets and a high PD-L1 expression of 80%, his treatment with 3-cycles of Keytruda was cut short due to a psoriatic arthritis flare-up, though it initially decreased his CEA levels significantly. Over the following years, fluctuating CEA levels and various imaging studies indicated some concerning changes, such as potential radionecrosis or recurrence of cancer in the lung. His refusal of biopsy and a preference for avoiding invasive treatments led to only surveillance. Later, an MRI showed some metastasis, and the patient agreed to a lung biopsy, which showed poorly differentiated carcinoma of pulmonary origin. The patient only agreed to restart treatment with Keytruda 4-years later after his initial treatment with Keytruda, under close rheumatological care, and received only two doses. Afterward, the patient lost follow-ups. 3-months later, Repeated CT scans of the chest, abdomen, and pelvis showed no evidence of mass or pathological lymph nodes, and repeated CEA was 3.4.

Discussion

Managing advanced lung adenocarcinoma, especially with complications like brain metastases and psoriatic arthritis, is challenging. Pembrolizumab treatment showed promise by significantly reducing CEA levels despite early discontinuation due to autoimmune side effects, indicating effective tumor response in patients with high PD-L1 expression. The case underscores the need for balancing cancer treatment with autoimmune management and highlights the importance of patient preferences in treatment plans. Ongoing surveillance and genomic profiling remain crucial for guiding therapy.

Conclusions

This case of a 70-year-old male with advanced lung adenocarcinoma highlights the significant impact of immunotherapy, particularly PD-1/ PD-L1 inhibitors like pembrolizumab, in NSCLC. Despite a brief treatment period, the patient experienced extended disease control, demonstrating the potential of immunotherapy to enhance survival and its broad applicability in oncology.

Background

Warm autoimmune hemolytic anemia (wAIHA) is traditionally treated with immunosuppresimmunosuppression, and management of refractory disease is often a challenge. The anti-CD38 antibody daratumumab is emerging as a promising treatment for refractory wAIHA, as it targets autoantibody-producing plasma cells. Here, we present the first reported case of daratumumab used in conjunction with an erythropoiesisstimulating agent (ESA) to salvage refractory wAIHA in a patient with AIDS and bone marrow suppression.

Case Presentation

A middle aged man with HIV (undetectable viral load on antiretroviral treatment but CD4 persistently < 200, requiring chronic antimicrobial prophylaxis) was diagnosed with classic wAIHA in late 2021. The disease initially responded to corticosteroids, but relapsed repeatedly and eventually required IVIG, rituximab, danazol, and three immunosuppressive agents, none of which induced remission. Hemolysis worsened by fall 2024, with hemoglobin 5-6 g/dL despite high-dose corticosteroids and IVIG. Bone marrow biopsy was unrevealing, and he underwent splenectomy. However, recovery was complicated by cutaneous nocardiosis, iron overload, liver injury, and continued hemolysis. Eventually, reticulocytosis also ceased, and hemoglobin declined to 4-5 g/dL. Due to failure of standard therapies and to minimize further immunosuppression, weekly daratumumab injections were initiated, with weekly darbepoetin injections added to aid in compensatory hematopoiesis. With this combination, hemolysis indices improved, reticulocytosis picked up, and hemoglobin increased to 8-9 g/dL. However, the patient continued to struggle with infections, and he succumbed to drug-resistant bacterial sepsis in spring 2025.

Discussion

The patient had very complicated chronic and acute comorbidities, and some simplification was required in order to provide this summary. However, we hope this case adds to the literature on daratumumab as an effective new agent in refractory wAIHA, and also present a novel duo of therapies for patients who may struggle with bone marrow suppression in addition to autoimmune hemolysis. To our knowledge, this is the first reported case of the combination used in this manner.

Conclusions

Daratumumab is an effective and less immunosuppressive alternative for the treatment of heavily pretreated refractory wAIHA. Its combined use with ESA in patients with inadequate reticulocytosis should be studied further to clarify the efficacy and safety in this setting.

Background

Warm autoimmune hemolytic anemia (wAIHA) is traditionally treated with immunosuppresimmunosuppression, and management of refractory disease is often a challenge. The anti-CD38 antibody daratumumab is emerging as a promising treatment for refractory wAIHA, as it targets autoantibody-producing plasma cells. Here, we present the first reported case of daratumumab used in conjunction with an erythropoiesisstimulating agent (ESA) to salvage refractory wAIHA in a patient with AIDS and bone marrow suppression.

Case Presentation

A middle aged man with HIV (undetectable viral load on antiretroviral treatment but CD4 persistently < 200, requiring chronic antimicrobial prophylaxis) was diagnosed with classic wAIHA in late 2021. The disease initially responded to corticosteroids, but relapsed repeatedly and eventually required IVIG, rituximab, danazol, and three immunosuppressive agents, none of which induced remission. Hemolysis worsened by fall 2024, with hemoglobin 5-6 g/dL despite high-dose corticosteroids and IVIG. Bone marrow biopsy was unrevealing, and he underwent splenectomy. However, recovery was complicated by cutaneous nocardiosis, iron overload, liver injury, and continued hemolysis. Eventually, reticulocytosis also ceased, and hemoglobin declined to 4-5 g/dL. Due to failure of standard therapies and to minimize further immunosuppression, weekly daratumumab injections were initiated, with weekly darbepoetin injections added to aid in compensatory hematopoiesis. With this combination, hemolysis indices improved, reticulocytosis picked up, and hemoglobin increased to 8-9 g/dL. However, the patient continued to struggle with infections, and he succumbed to drug-resistant bacterial sepsis in spring 2025.

Discussion

The patient had very complicated chronic and acute comorbidities, and some simplification was required in order to provide this summary. However, we hope this case adds to the literature on daratumumab as an effective new agent in refractory wAIHA, and also present a novel duo of therapies for patients who may struggle with bone marrow suppression in addition to autoimmune hemolysis. To our knowledge, this is the first reported case of the combination used in this manner.

Conclusions

Daratumumab is an effective and less immunosuppressive alternative for the treatment of heavily pretreated refractory wAIHA. Its combined use with ESA in patients with inadequate reticulocytosis should be studied further to clarify the efficacy and safety in this setting.

Background

Warm autoimmune hemolytic anemia (wAIHA) is traditionally treated with immunosuppresimmunosuppression, and management of refractory disease is often a challenge. The anti-CD38 antibody daratumumab is emerging as a promising treatment for refractory wAIHA, as it targets autoantibody-producing plasma cells. Here, we present the first reported case of daratumumab used in conjunction with an erythropoiesisstimulating agent (ESA) to salvage refractory wAIHA in a patient with AIDS and bone marrow suppression.

Case Presentation

A middle aged man with HIV (undetectable viral load on antiretroviral treatment but CD4 persistently < 200, requiring chronic antimicrobial prophylaxis) was diagnosed with classic wAIHA in late 2021. The disease initially responded to corticosteroids, but relapsed repeatedly and eventually required IVIG, rituximab, danazol, and three immunosuppressive agents, none of which induced remission. Hemolysis worsened by fall 2024, with hemoglobin 5-6 g/dL despite high-dose corticosteroids and IVIG. Bone marrow biopsy was unrevealing, and he underwent splenectomy. However, recovery was complicated by cutaneous nocardiosis, iron overload, liver injury, and continued hemolysis. Eventually, reticulocytosis also ceased, and hemoglobin declined to 4-5 g/dL. Due to failure of standard therapies and to minimize further immunosuppression, weekly daratumumab injections were initiated, with weekly darbepoetin injections added to aid in compensatory hematopoiesis. With this combination, hemolysis indices improved, reticulocytosis picked up, and hemoglobin increased to 8-9 g/dL. However, the patient continued to struggle with infections, and he succumbed to drug-resistant bacterial sepsis in spring 2025.

Discussion

The patient had very complicated chronic and acute comorbidities, and some simplification was required in order to provide this summary. However, we hope this case adds to the literature on daratumumab as an effective new agent in refractory wAIHA, and also present a novel duo of therapies for patients who may struggle with bone marrow suppression in addition to autoimmune hemolysis. To our knowledge, this is the first reported case of the combination used in this manner.

Conclusions

Daratumumab is an effective and less immunosuppressive alternative for the treatment of heavily pretreated refractory wAIHA. Its combined use with ESA in patients with inadequate reticulocytosis should be studied further to clarify the efficacy and safety in this setting.

Background

Merkel cell carcinoma (MCC) is a rare and aggressive primary cutaneous neuroendocrine carcinoma. The disease is associated with Merkel cell polyomavirus, immunosuppression, and ultra-violet radiation. Clinical presentation is highly varied and MCC is not suspected in majority of cases initially. It is rapidly growing and has a poor prognosis with a high mortality rate.

Case 1

A 75-year-old male initially presented with a cutaneous left facial lesion which on biopsy was confirmed to be Merkel cell carcinoma. He underwent wide local excision of the lesion with sentinel lymph node biopsy and was monitored. Six months later he was found to have palpable left parotid nodule, and underwent left parotidectomy and left neck lymph node dissection. The parotid nodule itself was of benign etiology; however, one of the cervical lymph nodes was positive for Merkel cell carcinoma with extranodal extension and lymphovascular invasion. Patient received adjuvant radiation to the site. A year after patient was noted to have bone lesions and other lesions concerning for visceral metastasis on surveillance imaging which were also confirmed to be recurrent MCC by biopsy. Patient was started on immunotherapy afterwards.

Case 2

A 60-year-male patient originally presented with a left inguinal mass. Pathology from the initial biopsy was noted to be small cell neuroendocrine carcinoma of unknown primary. Patient received six cycles of cisplatin and etoposide followed by radiation. Four months later patient was found to have local recurrence and underwent surgical resection, followed by five cycles of cyclophosphamide, doxorubicin, and vincristine. Five months later, the patient had a second recurrence in the surgical bed in addition to multiple subcutaneous nodules in the abdominal wall and lower extremity. A repeat biopsy was performed with Merkel cell polyomavirus testing by immunohistochemistry, which resulted as positive. Patient was started on immunotherapy afterwards.

Discussion

The above two cases represent how Merkel cell carcinoma can have varying presentations either on diagnosis or on progression. Thus, it is important to have a low threshold for biopsy or rebiopsy. Additionally, neuroendocrine carcinomas of unknown primary may benefit from additional Merkel cell IHC testing on diagnosis.

Background

Merkel cell carcinoma (MCC) is a rare and aggressive primary cutaneous neuroendocrine carcinoma. The disease is associated with Merkel cell polyomavirus, immunosuppression, and ultra-violet radiation. Clinical presentation is highly varied and MCC is not suspected in majority of cases initially. It is rapidly growing and has a poor prognosis with a high mortality rate.

Case 1

A 75-year-old male initially presented with a cutaneous left facial lesion which on biopsy was confirmed to be Merkel cell carcinoma. He underwent wide local excision of the lesion with sentinel lymph node biopsy and was monitored. Six months later he was found to have palpable left parotid nodule, and underwent left parotidectomy and left neck lymph node dissection. The parotid nodule itself was of benign etiology; however, one of the cervical lymph nodes was positive for Merkel cell carcinoma with extranodal extension and lymphovascular invasion. Patient received adjuvant radiation to the site. A year after patient was noted to have bone lesions and other lesions concerning for visceral metastasis on surveillance imaging which were also confirmed to be recurrent MCC by biopsy. Patient was started on immunotherapy afterwards.

Case 2

A 60-year-male patient originally presented with a left inguinal mass. Pathology from the initial biopsy was noted to be small cell neuroendocrine carcinoma of unknown primary. Patient received six cycles of cisplatin and etoposide followed by radiation. Four months later patient was found to have local recurrence and underwent surgical resection, followed by five cycles of cyclophosphamide, doxorubicin, and vincristine. Five months later, the patient had a second recurrence in the surgical bed in addition to multiple subcutaneous nodules in the abdominal wall and lower extremity. A repeat biopsy was performed with Merkel cell polyomavirus testing by immunohistochemistry, which resulted as positive. Patient was started on immunotherapy afterwards.

Discussion

The above two cases represent how Merkel cell carcinoma can have varying presentations either on diagnosis or on progression. Thus, it is important to have a low threshold for biopsy or rebiopsy. Additionally, neuroendocrine carcinomas of unknown primary may benefit from additional Merkel cell IHC testing on diagnosis.

Background

Merkel cell carcinoma (MCC) is a rare and aggressive primary cutaneous neuroendocrine carcinoma. The disease is associated with Merkel cell polyomavirus, immunosuppression, and ultra-violet radiation. Clinical presentation is highly varied and MCC is not suspected in majority of cases initially. It is rapidly growing and has a poor prognosis with a high mortality rate.

Case 1

A 75-year-old male initially presented with a cutaneous left facial lesion which on biopsy was confirmed to be Merkel cell carcinoma. He underwent wide local excision of the lesion with sentinel lymph node biopsy and was monitored. Six months later he was found to have palpable left parotid nodule, and underwent left parotidectomy and left neck lymph node dissection. The parotid nodule itself was of benign etiology; however, one of the cervical lymph nodes was positive for Merkel cell carcinoma with extranodal extension and lymphovascular invasion. Patient received adjuvant radiation to the site. A year after patient was noted to have bone lesions and other lesions concerning for visceral metastasis on surveillance imaging which were also confirmed to be recurrent MCC by biopsy. Patient was started on immunotherapy afterwards.

Case 2

A 60-year-male patient originally presented with a left inguinal mass. Pathology from the initial biopsy was noted to be small cell neuroendocrine carcinoma of unknown primary. Patient received six cycles of cisplatin and etoposide followed by radiation. Four months later patient was found to have local recurrence and underwent surgical resection, followed by five cycles of cyclophosphamide, doxorubicin, and vincristine. Five months later, the patient had a second recurrence in the surgical bed in addition to multiple subcutaneous nodules in the abdominal wall and lower extremity. A repeat biopsy was performed with Merkel cell polyomavirus testing by immunohistochemistry, which resulted as positive. Patient was started on immunotherapy afterwards.

Discussion

The above two cases represent how Merkel cell carcinoma can have varying presentations either on diagnosis or on progression. Thus, it is important to have a low threshold for biopsy or rebiopsy. Additionally, neuroendocrine carcinomas of unknown primary may benefit from additional Merkel cell IHC testing on diagnosis.

Background

Anal squamous cell carcinoma is a rare cancer which usually has locoregional spread. We report a case of distant metastasis of primary anal squamous cell carcinoma to the posterior mediastinal lymph node without lung involvement.

Case Presentation

A 63-year-old female presented with a painful anal mass, bleeding, and fluid leakage for around six months. The patient was found to have a near-circumferential fungating anal mass with bilateral inguinal lymphadenopathy. MR imaging revealed an 8.7 x 5.9 cm anal mass extending beyond the mesorectal fascia, with lymphadenopathy involving inguinal, pelvic sidewall, and iliac regions. A biopsy of the mass confirmed anal squamous cell carcinoma (ASCC). Initial treatment included diverting colostomy followed by definitive chemoradiotherapy with Mitomycin and 5-Fluorouracil. Colonoscopy post-treatment revealed tubular adenomas and a hyperplastic polyp, with no malignancy detected. The patient demonstrated a strong therapeutic response, with resolution of the anal mass and improved symptoms. However, one year later, new FDG-avid mediastinal lymph node were detected on the CT/PET scan with no pulmonary involvement. Metastatic ASCC of the Mediastinal lymph node was confirmed by biopsy. Salvage chemotherapy with Carboplatin and Paclitaxel every three weeks for six cycles achieved complete resolution of metastases.

Conclusions

This case underscores the importance of a multidisciplinary approach in managing advanced ASCC and highlights the efficacy of salvage chemotherapy in addressing metastases. Close monitoring of disease progression following surgery and chemotherapy is crucial due to the risk of recurrence.

Background

Anal squamous cell carcinoma is a rare cancer which usually has locoregional spread. We report a case of distant metastasis of primary anal squamous cell carcinoma to the posterior mediastinal lymph node without lung involvement.

Case Presentation

A 63-year-old female presented with a painful anal mass, bleeding, and fluid leakage for around six months. The patient was found to have a near-circumferential fungating anal mass with bilateral inguinal lymphadenopathy. MR imaging revealed an 8.7 x 5.9 cm anal mass extending beyond the mesorectal fascia, with lymphadenopathy involving inguinal, pelvic sidewall, and iliac regions. A biopsy of the mass confirmed anal squamous cell carcinoma (ASCC). Initial treatment included diverting colostomy followed by definitive chemoradiotherapy with Mitomycin and 5-Fluorouracil. Colonoscopy post-treatment revealed tubular adenomas and a hyperplastic polyp, with no malignancy detected. The patient demonstrated a strong therapeutic response, with resolution of the anal mass and improved symptoms. However, one year later, new FDG-avid mediastinal lymph node were detected on the CT/PET scan with no pulmonary involvement. Metastatic ASCC of the Mediastinal lymph node was confirmed by biopsy. Salvage chemotherapy with Carboplatin and Paclitaxel every three weeks for six cycles achieved complete resolution of metastases.

Conclusions

This case underscores the importance of a multidisciplinary approach in managing advanced ASCC and highlights the efficacy of salvage chemotherapy in addressing metastases. Close monitoring of disease progression following surgery and chemotherapy is crucial due to the risk of recurrence.

Background

Anal squamous cell carcinoma is a rare cancer which usually has locoregional spread. We report a case of distant metastasis of primary anal squamous cell carcinoma to the posterior mediastinal lymph node without lung involvement.

Case Presentation

A 63-year-old female presented with a painful anal mass, bleeding, and fluid leakage for around six months. The patient was found to have a near-circumferential fungating anal mass with bilateral inguinal lymphadenopathy. MR imaging revealed an 8.7 x 5.9 cm anal mass extending beyond the mesorectal fascia, with lymphadenopathy involving inguinal, pelvic sidewall, and iliac regions. A biopsy of the mass confirmed anal squamous cell carcinoma (ASCC). Initial treatment included diverting colostomy followed by definitive chemoradiotherapy with Mitomycin and 5-Fluorouracil. Colonoscopy post-treatment revealed tubular adenomas and a hyperplastic polyp, with no malignancy detected. The patient demonstrated a strong therapeutic response, with resolution of the anal mass and improved symptoms. However, one year later, new FDG-avid mediastinal lymph node were detected on the CT/PET scan with no pulmonary involvement. Metastatic ASCC of the Mediastinal lymph node was confirmed by biopsy. Salvage chemotherapy with Carboplatin and Paclitaxel every three weeks for six cycles achieved complete resolution of metastases.

Conclusions

This case underscores the importance of a multidisciplinary approach in managing advanced ASCC and highlights the efficacy of salvage chemotherapy in addressing metastases. Close monitoring of disease progression following surgery and chemotherapy is crucial due to the risk of recurrence.