2023: Vol 10 No 7

Dasatinib is a tyrosine kinase inhibitor used for treatment of some specific types of leukaemia. The development of pleural effusion is a known adverse effect of dasatinib and chylothorax is exceptional. No case has been reported beyond 5 years of treatment and extensive search for an alternative diagnosis is currently suggested in such scenario. The underlying mechanism is not currently clear. We describe a woman on dasatinib treatment for more than 10 years who developed chylothorax. Drug withdrawal resolved the chylous pleural effusion. We were able to find 14 additional cases of dasatinib-related chylothorax reported up until now.

This report describes a rare case of oligometastatic renal disease in a 69 year-old Caucasian male with non-small cell lung cancer (NSCLC). Diagnosed with Stage IIIb, NSCLC he completed chemoradiotherapy followed by 1 year of immunotherapy. Surveillance CT scans after nearly three years showed an ill-defined lesion in the left kidney.
Biopsy results were consistent with metastasis from the known lung carcinoma. Following neo-adjuvant Pembrolizumab (200mg, q3w), the patient underwent a left radical nephrectomy, without complications. One year post-operatively, CT of the thorax, abdomen and pelvis (TAP) did not identify any recurrence.
Renal metastases were historically demonstrated predominantly by autopsy studies^[1]. Any mass manifesting in the kidney in the context of previous NSCLC warrants comprehensive investigations. The combination of immunotherapy followed by definitive treatment appears to be a promising management strategy^[2]. With regards to local curative options, the advantages and disadvantages of surgery and radiotherapy have been well described^[3-4].

A 57-year-old male with heart failure and decompensated alcoholic liver cirrhosis presented with recurrent haematochesia due to rectal varices. After multiple failed therapy with endoscopic band ligation and surgical sclerotherapy, a discussion with an interventional radiologist was arranged. A transjugular intrahepatic portosystemic shunt (TIPS) was deferred due to a history of heart failure. A shared decision to proceed with transhepatic Gelfoam® slurry embolisation with coiling was made. During the procedure, a variant anatomy of the superior rectal vein was identified. The superior rectal vein was found to drain directly into the left portal vein with no connectivity between the inferior mesenteric vein and the rectal varices. As planned, Gelfoam slurry embolisation and coiling was done to the left and right superior rectal vein along with the common trunk it drains. The patient did not develop any further episodes of gastrointestinal bleeding or worsening ascites on follow-up after 6 months. This case represents a successful treatment of bleeding rectal varices when TIPS is contraindicated.

Remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) syndrome has been reported in patients treated with dipeptidyl peptidase-4 inhibitors (DPP-4i). We experienced a case of RS3PE syndrome in a 73-year-old man with a history of type 2 diabetes, who developed RS3PE as a side effect of vildagliptin. Further to this, the patient developed polymyalgia rheumatica (PMR), the first such case associated with long-term DPP-4i use.

Introduction: Visual seizure is one of the rare complications of poorly controlled chronic hyperglycaemia. This condition can be debilitating for patients. Early recognition and careful control of hyperglycaemia is vital.
Case description: A middle-aged female was found collapsed at her home after missing insulin for several days. She was found to have diabetes ketoacidosis (DKA) and she was started on treatment for DKA. She reported visual hallucinations in the right side of her visual field for a week. Further assessment with EEG and brain MRI suggested an occipital seizure consistent with metabolic disturbances. She was initially started on antiepileptic medication. After strict diabetes control, her symptoms resolved, and she no longer needed antiepileptic treatment.
Conclusion: Experiencing diabetes-related seizures can be terrifying both for patients and their family. Early recognition and quick control of hyperglycaemia is important in treating these patients.

Introduction: Rhabdomyosarcoma is a high-grade malignant neoplasm with skeletal muscle differentiation; a common soft tissue sarcoma in children but considered one of the rarest in adults.
Case description: We report a case of 35-year-old male with a chronic productive cough and haemoptysis for five days. A CT scan of the nasopharynx revealed a blocked left maxillary and ethmoid sinus with bone destruction. These findings raised a suspicion of a tumour, and trans-nasal endoscopic sinus surgery was performed.
Discussion: Nasal rhabdomyosarcoma is a rare adult malignant tumour. Most patients have lymphatic metastasis or skull base tumour infiltration at the time of the initial diagnosis and treatment, which poses a challenge to the diagnosis and management.
Conclusion: Nasal acinar rhabdomyosarcoma, one of the histopathological types of rhabdomyosarcoma, has rapid disease progression and high mortality. Therefore, the treatment of rhabdomyosarcoma requires a combination of surgery, chemotherapy, radiotherapy, and immunotherapy to work together to achieve the best care for the patient.

The most common cause of vasoplegic shock in critical care is sepsis. However, although rarely and only in specifically sensitised individuals previously bitten by a tick, red meat may provoke a delayed allergic reaction called an alpha-gal syndrome. We present a case of a protracted life-threatening manifestation of alpha-gal syndrome, which, due to an unusual absence of typical features of anaphylaxis can masquerade as septic shock and calls attention to the premature diagnostic closure as a contributor to diagnostic error. Alpha-gal syndrome is a relatively new, but increasingly recognised health issue. We propose that alpha-gal syndrome should be considered in the differential diagnosis of vasoplegic shock of unclear aetiology even in the absence of typical allergic symptomatology and typical allergen exposure since alpha-gal is present in a wide variety of carriers.

Wells syndrome or eosinophilic cellulitis is a rare and relapsing skin disease which lacks systemic involvement. A skin biopsy is needed to establish a diagnosis. Several precipitating factors have been proposed but no proven causative link has been found. On the other hand, Churg-Strauss syndrome, also known as eosinophilic granulomatosis with polyangiitis (EGPA), an auto-immune disease, is associated with multiorgan, including cutaneous manifestations. We report a case with overlapping features of Wells and Churg-Strauss syndrome, suggesting that these syndromes could be part of the same nosological entity.

Introduction: Multicentric Castleman disease (MCD) is a lymphoproliferative disorder characterized by lymph node histopathology and systemic symptoms. To our knowledge, there are no descriptions in the literature of long-term outcomes of human herpesvirus-8 (HHV-8)-associated MCD.
Case Description: We report a case of a 70-year-old male living with human immunodeficiency virus and a history of human herpesvirus-8 (HHV-8)-associated MCD. The patient reported having had low-grade fever for two weeks. Extensive workup revealed systemic lymphadenopathy without evidence of autoimmune disease or malignancy. Lymph node biopsy was consistent with HHV-8-negative idiopathic MCD (iMCD). The patient was subsequently scheduled for anti-interleukin-6 therapy.
Discussion: The present case is the first report of probable development of iMCD after long-term follow-up for HHV-8-associated MCD. The case illustrates the possible long-term consequences of MCD, suggesting the necessity of further research on the pathogenesis of CD.
Conclusion: Given the uncertainty in the long-term outcomes of HHV-8-associated MCD, periodic surveillance of patients with a history of HHV-8-associated MCD is warranted. Prospective nationwide cohort studies comparing characteristics of HHV-8-associated MCD and iMCD would bring further insights.

Primary splenic lymphoma (PSL) is a rare disease and an improbable cause of splenomegaly or splenic nodules. On the contrary, splenic secondary involvement as part of an advanced lymphoproliferative disorder is more common.
The authors present the case of a 49-year-old woman with a primary splenic diffuse large B-cell lymphoma (PS-DLBCL), in which the absence of other organs’ involvement determined an ultrasound-guided biopsy of the spleen to achieve a definitive diagnosis.
With this case the authors intend to emphasise the extensive differential diagnosis of splenomegaly, splenic nodules or infiltrates, the usefulness of splenic biopsy in establishing the diagnosis and recall a rare disease, with non-specific presenting symptoms, in which the diagnostic workup is challenging.

We present a case of thyrotoxic periodic paralysis (TPP) presenting with stroke symptoms as a harbinger of Grave’s disease. A 61-year-old female presented with symptoms of abdominal pain and fatigue two weeks prior to admission and reported acute diarrhoea and unintentional weight loss. Investigation revealed thyrotoxicosis with undetectable thyroid stimulating hormone (TSH), elevated free T4 and elevated thyroid stimulating immunoglobulin (TSI). On the third day of admission, while undergoing physical therapy, code stroke was called on account of the onset of right-side predominant acute flaccid paralysis of upper and lower extremities, right-side facial droop, dysarthria and hyporeflexia bilaterally. The patient was alert and fully oriented with stable vitals with no increased labour in breathing at room air. An emergent head and neck CT, angiography, and magnetic resonance imaging (MRI) were negative. Serum potassium was 2.7 mmol/l, requiring prompt replacement. The patient’s paralysis and dysarthria improved over the following three days with a complete reversal of symptoms following the correction of serum potassium. Thyrotoxic periodic paralysis can occur in association with any of the causes of hyperthyroidism. It is due to a significant intracellular shift of potassium, subsequently manifesting clinically with hypokalaemia and muscle paralysis.

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is considered a rare congenital heart disease where the take-off of the left coronary artery abnormally originates from the pulmonary artery instead of left aortic sinus. It is associated with a high mortality rate in the first year of life and sudden death in adults if left untreated. We report an adult form of ALCAPA syndrome in a 20-year-old female who presented with anginal pain for the previous few months. Unfortunately, the patient was hesitant to have surgery at the time.

We present an extremely rare case of a patient with intermediate-high risk pulmonary embolism treated with percutaneous mechanical thrombectomy, complicated with stroke as a form of paradoxical embolism through a previously unknown patent foramen ovale. We reviewed the literature for indications, efficacy, and safety of this procedure, as well as for experience on this technique in patients with patent foramen ovale.